BackgroundThe beneficial effects of atrial septal defect (ASD) device closure on electrical cardiac remodeling are well established. The timing at which these effects starts to take place has yet to be determined.ObjectivesTo determine the immediate and short term effects of ASD device closure on cardiac electric remodeling in children.Methods30 pediatric patients were subjected to 12 lead Electrocardiogram immediately before ASD device closure, 24 h post procedure, 1 and 6 months after. The maximum and minimum P wave and QT durations in any of the 12 leads were recorded and P wave and QT dispersions were calculated and compared using paired T test.ResultsThe immediate 24 h follow up electrocardiogram showed significant decrease in P maximum (140.2 ± 6 versus 130.67 ± 5.4 ms), P dispersion (49.73 ± 9.01 versus 41.43 ± 7.65 ms), PR interval (188.7 ± 6.06 ms versus 182.73 ± 5.8 ms), QRS duration (134.4 ± 4.97 ms versus 127.87 ± 4.44), QT maximum (619.07 ± 15.73 ms versus 613.43 ± 11.87), and QT dispersion (67.6 ± 5.31 versus 62.6 ± 4.68 ms) (P = 0.001). After 1 month all the parameters measured showed further significant decrease with P dispersion reaching 32.13 ± 6 (P = 0.001) and QT dispersion reaching 55.0 ± 4.76 (P = 0.001). These effects were maintained 6 months post device closure.ConclusionPercutaneous ASD device closure can reverse electrical changes in atrial and ventricular myocardium as early as the first 24 h post device closure.
Right pulmonary artery (RPA) to left atrium fistula (LA) is an extremely rare congenital malformation with less than 100 cases of PA-to-LA fistula reported. It causes central cyanosis and may present with heart failure. This is the first case to be closed under 2D and 3D TEE guidance inside cath lab. We present a case of a 12-year-old student who complained of exertional dyspnea and easy fatigability over the past few months. His mother reported mild cyanosis since birth which increased with exertion. On examination, he had central cyanosis with grade II clubbing in both fingers and toes, silent precordium with no audible murmur over his back). ECG showed normal sinus rhythm with no abnormality. CXR showed an abnormal shadow related to right cardiac border with prominent pulmonary artery and otherwise normal pulmonary vasculature. His complete blood count showed erythrocytosis with hemoglobin concentration of 16.4 g/dl and hematocrit value of 69.2%. Transthoracic echocardiography showed dilated left atrium with dilated right pulmonary artery. Patient was diagnosed to have a right pulmonary AV malformation. Invasive cardiac catheterization was done to identify size and number of this pulmonary AV malformation. Right pulmonary angiography showed a right pulmonary artery to left atrium fistula (type I) measuring 11 mm in its narrowest diameter with free shunting of blood. TEE guidance inside our cath lab showed normal pulmonary venous drainage into the left atrium, dilated right pulmonary artery opening into left atrium through an opening 10 mm with systolic flow across of low gradient (15 mmHg). A balloon was advanced across the fistula for sizing. Stretched diameter of fistula measured 13 mm. An Amplatzer ventricular septal occluder 14 was successfully positioned across the fistula. Right pulmonary angiography assured patent right lower pulmonary artery. TEE assured normal pulmonary veins flow into the left atrium. Patient saturation rose from 75% to 95%. Complete cure can be accomplished by transcatheter closure of direct pulmonary artery to left atrium communication. Systematic approach in assessment of patients with rare congenital anomalies can help their management despite of difficult clinical diagnosis. 2D and 3D TEE can guide RPA to LA fistula transcatheter closure as in ASD closure.
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