Following the pioneering work of King, Rashkind and their associates in the mid 1970s, a number of devices have been designed and tested in animal models and human subjects. Some devices have been discontinued and others were modified followed by further clinical trials. At the time of this writing, only one device, ASO, was approved by the FDA for general clinical use to occlude atrial defects. There are a number of other devices which are in clinical trials, including the CardioSeal/StarFlex, COD buttoned, Helex and transcatheter patch devices. The preceding paper reports on the utility of ASO in occluding atrial defects in adult patients: the results appear good with extremely rare major complication and little need re-intervention during follow-up. It is envisioned that several other devices will be approved by the regulatory authorities in the foreseeable future so that an appropriate device for a given type of atrial septal defect may be selected by the practicing interventional cardiologist.
A 3-year-old boy underwent evaluation for dextrocardia. Echocardiograms showed features of corrected transposition physiology, a perimembranous ventricular septal defect (VSD) (Fig. 1), and aneurysmal tissue beneath the pulmonary valve that caused severe subpulmonary stenosis (Figs. 2–4). Eighteen months after VSD closure and resection of the aneurysmal tissue, the patient was asymptomatic with only mild residual pulmonary outflow tract obstruction.Congenitally corrected transposition of the great arteries (TGA) is usually associated with multiple cardiac defects. The hallmark finding is atrioventricular and ventriculoarterial discordance. Because of this double discordance, the circulatory physiology is normal: systemic venous return goes to the lungs, and pulmonary venous return goes to the body.1,2 The usual anatomic arrangement is levocardia, visceroatrial situs solitus, L-loop ventricular inversion, and an anterior aorta on the left of the pulmonary artery {S,L,L}. Our patient's anatomy was rarer: dextrocardia with situs inversus, D-loop of the ventricles, and a rightward anterior aorta {I,D,D}.Prolapsing aneurysms of a membranous ventricular septum rarely cause left ventricular (LV) outflow tract obstruction (pulmonary obstruction) in patients who have normally related great vessels.2–5 However, in patients with TGA who have higher right ventricular pressure, such an aneurysm can protrude into the LV outflow tract and cause pulmonary outflow tract obstruction.6 Similarly, in patients with corrected TGA (who lack a conal septum and crista supraventricularis in the morphologic LV), even the proximity of a small aneurysm to the pulmonary valve can cause pulmonary outflow tract obstruction.Doppler echocardiography and cardiac catheterization with selective cineangiography help to define the lesions and are the diagnostic tests of choice. Surgical aneurysm resection and VSD patch closure—with care to avoid injuring the vulnerable conduction system—is recommended.2–5We thank Dr. William I. Douglas for his contribution to the clinical care of this patient.
An unusual case of total anomalous pulmonary venous connexion with physiologically and anatomically proven obstruction at the level of the superior vena cava is described.The embryological basisfor this defect is briefly discussed.The types of anatomical obstruction to supradiaphragmatic total anomalous pulmonary venous connexion are reviewed and classified.* Obtained while the infant was placed under a hood with Ioo per cent oxygen.Values in parentheses were obtained while in room air.t Obtained from a withdrawal tracing from the superior vena cava to right atrium.t Simultaneously measured.
Normal Frank and McFee Vectorcardiograms in the AdolescentI actively participated in the study of normal vectorcardiograms (VCGs) in adolescents [1].Frank and McFee VCGs of 166 normal adolescents were analyzed.Normal values in adolescents were published in 24 tables [1].The QRS and T magnitudes were higher in the male than in the female subjects; this difference was larger in 11-to 15-year-olds than in 16-to 19-year-old adolescents.This was attributed to females reaching puberty earlier than males.In addition, the male subjects achieved the maximal posterior QRS orientation much sooner than the females.The study also noted significant differences between the Frank and McFee VCG lead systems [1]. Diagnosis by Intra-cavitary Electrocardiography of Ebstein's Anomaly of the Left Atrio-ventricular Valve in Congenital Corrected Transposition of the Great Arteries (CCTGA)The diagnosis of Ebstein's anomaly of the tricuspid valve by
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