Several devices are available for transcatheter occlusion of atrial septal defect. This report describes the international experience with the buttoned device. During a 4.5-year period ending in February 1993, 180 transcatheter atrial septal defect occlusions were performed with the buttoned device. Patient age varied between 0.6 and 76 years and stretched atrial defect diameter between 5 and 25 mm. The defects were closed with 25 to 50 mm devices delivered through 8F (148 patients) or 9F (32 patients) sheaths. Twelve patients were adults whose defects were closed to prevent recurrence of cerebrovascular accidents caused by presumed paradoxic embolism. In the remaining patients the atrial defect was closed to treat the left-to-right shunt. The atrial septal defects were effectively occluded as demonstrated by (1) decrease in pulmonary-to-systemic flow ratio from 2.1 +/- 0.6 (mean +/- SD) to 1.05 +/- 0.1 (p < 0.01) by oximetry; (2) normalized S2 and disappearance of the diastolic murmur by auscultation; and (3) improvement in right ventricular volume overloading by echocardiogram. However, trivial to small shunts could be detected by color Doppler studies in 76 (45%) of 168 patients in whom such data are available. Complications included unbuttoning in 13 and whole-device embolization in 1. All patients remained stable, and retrieval of the device and surgical closure of the atrial septal defect were accomplished in 10 patients. Transcatheter retrieval was used in the remaining 4 patients. The incidence of unbuttoning, a major complication of the procedure, appeared to decrease with the increasing experience of the investigators and with device modification (third-generation). The follow-up duration varied between 1 month and 4 years. Six patients required surgery during the follow-up period. In the remaining patients (n = 160), clinical examination did not reveal signs of atrial shunts. Color Doppler studies revealed either complete disappearance of the previously demonstrated shunts or further diminution of their size. The results indicate that transcatheter occlusion of the atrial septal defects with buttoned devices is feasible, relatively safe, and effective, and it appears to be a viable alternative to surgery for some patients with secundum atrial septal defect. Complications are infrequent and should improve with experience.
The embryogenesis of tetralogy of Fallot is still much debated. In particular, the dextroposition of the aorta is not considered by all pathologists as a genuine abnormality in this congenital heart disease but rather as a false impression due to an exaggeration of the normal overriding caused by dilatation of the aorta secondary to abnormal hemodynamics. We used two-dimensional echocardiography to examine the spatial position of the aortic root in 22 patients with tetralogy of Fallot (aged 5 days to 24 years, mean 6.4 years) and in 23 normal subjects (aged 1 month to 27 years, mean 7.6 years). Using the parasternal short-axis view, we determined the percent rightward displacement of the aortic root in relation to the plane of the atrial septum, and the relationship between the aortic cusps and the atrial septum. We measured the value of the angle 0, which was defined as the angle between the plane of the atrial septum and the plane of the left coronary-noncoronary commissure and leaflet appositional plane. In the control group, the aortic root was displaced to the right by only 23.6 + 7.6%; the atrial septum crossed the posterior aspect of the aortic root at the middle (n = 19) or at the right half of the posterior cusp (n = 4), and the angle 0 had a value of 43.3 + 8.8 degrees. In the 22 patients with tetralogy, the percent rightward shift of the aortic root was augmented to 55.5 + 9% (p < .001) and the atrial septum was related to the posterior commissure in 14 patients, to the left coronary cusp in two patients, and to the left fourth of the posterior cusp in six patients; the angle 0 had a value of 9.2 11.2 degrees (p < .001). In the two groups, the position of the commissure between the right coronary and left coronary aortic cusps was similar in relation to a line passed forward from the atrial septum. We conclude that the aorta is truly dextroposed in tetralogy of Fallot, with a rightward shift due to a clockwise rotation of the aortic root (looking downstream), and that the axis of this rotation is the anterior aortic commissure. Our echocardiographic findings, which confirm conclusions of previous investigators based on pathologic anatomy, support the embryologic hypothesis of the lack of conal rotation in tetralogy of Fallot and permit a quantitation of the effects of this morphogenetic mechanism. Circulation 73, No. 5, 892-899, 1986. IN THE PAST, the terms "dextroposition" and "overriding" have been used interchangeably. However, overriding of the aorta should not be confused with dextroposition. Overriding of the aorta over the right ventricle occurs in the normal heart because of the sigmoid interventricular septum' as well as in hearts with isolated infundibular perimembranous ventricular septal defect2' 3 and can be considered a normal anatomic feature.4 The term dextroposition indicates a pathologic condition with a rightward displacement of the aortic root.4' There has been considerable debate concerning whether a true dextroposition of the aorta exists in tetralogy of Fallot. Some ...
From August 1989 to April 1991, four children, 1.5 to 4 years old with type IIb tricuspid atresia underwent total right heart bypass by means of a bicaval pulmonary connection using an extracardiac conduit of pediculated pericardium between the inferior vena cava and the main pulmonary artery. The tube was made from a large rectangular flap of the patient's own pericardium, pediculated along the right border, ensuring a vascular supply. The diameter of the tube, calibrated on a Hegar probe, equals that of the inferior vena cava, and the length is adapted to bridge the gap between the inferior vena cava and the main pulmonary artery. All four patients had an uneventful postoperative course. Assisted ventilation was stopped on the next morning and the chest tubes removed on the 2nd or 3rd day. The liver was only moderately enlarged and no pleural effusions developed. Sinus rhythm was permanent. Echocardiographic monitoring 6-10 months after the hospital discharge showed patent tubes, no collapse during the cardiac cycle, and no wall thickening and a laminar flow. The advantages of the pediculated pericardial tube are that no prosthetic material is used. There is no thrombogenicity or antigenicity. These tubes retain a growth potential, and we believe that this material is suitable for use in young patients.
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