Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.

BackgroundRight ventricular (RV) volume overload increases morbidity and mortality after tetralogy of Fallot (TOF) repair. Surgical strategies like pulmonary leaflets sparing and tricuspid valve repair at time of primary repair may decrease RV overload. Our objective is to evaluate early and midterm results of pulmonary leaflets sparing with infundibular preservation and tricuspid valve repair in selected TOF patients with moderate pulmonary annular hypoplasia.MethodsFrom 2011 to 2016; 46 patients with TOF and moderate pulmonary annular hypoplasia had surgical repair with sparing of the pulmonary valve leaflets. Concomitant tricuspid valve repair was performed in 33 patients (71.8%). Mean age was 13.1 ± 4.8 months, 68% were males (n = 31) and mean weight was 9.5 ± 2.3 kg. Preoperative McGoon ratio was 1.9 ± 0.4 and pulmonary valve z-score ranges from − 2 to − 3. Preoperative pressure gradient of RVOT was 80.9 ± 7.7 mmHg and 10.9% had minor coronary anomalies (n = 5).ResultsAll repairs were performed through trans-atrial trans-pulmonary approach. 87% had pulmonary valve commissurotomy (n = 40). Mean cardiopulmonary bypass time was 71 ± 6.3 min and ischemic time 42.4 ± 4.9 min. Hospital mortality occurred in 4.3% (n = 2). Mean RVOT pressure gradient decreased significantly postoperatively (28.8 ± 7.2 mmHg, p-value< .001) and at the last follow up (23.6 ± 1.8 mmHg, p-value< .001). Pulmonary regurgitation progressed by one grade in 2 patients compared to the postoperative grade. 1 patient (2.5%) had late mortality and reintervention was required in 5 patients (12.5%).ConclusionPulmonary leaflets sparing, and tricuspid valve repair are safe for TOF repair with no added morbidity or mortality. These procedures could contribute to reducing right ventricular volume overload over time after TOF repair.

Background Three dimensional transesophageal echocardiography (3DTEE) is superior to two dimensional transesophageal echocardiography (2DTEE) as it provides all atrial septal information from a single view. Aim To evaluate 3DTEE role in analysis of atrial septal aneurysm (ASA) and in device closure guiding. Methods Three dimensional transesophageal echocardiography were recorded with Vivid*E9,GE system over 14 months. ASAs were classified into 4 types (A: with PFO, B: with one ASD, C: with 2 ASDs, and D: with multiple fenestrations). Each aneurysm was assessed according to its type, shape, dimensions, orientation, aneurysmal tissue, and the surrounding rims. All patients passed to transcatheter aneurysm closure. Results A total of 26 patients with ASAs were assessed (7 imperforated aneurysms excluded). The remaining 19 patients’ age was 12.84 ± 5.82years. Four patients had type A aneurysms, 6 had type B, 4 had type C, and 5 had type D. 3DTEE demonstrated oval aneurysms in 17 patients. The orientation was oblique in 8 patients, vertical in 7, and horizontal in 4. The ASAs dimensions were 23.5 ± 5.1, 23.2 ± 5.1, and 22.0 ± 4.0 mm for oblique, vertical, and horizontal axes. Percutaneous closure succeeded in 18 patients. Balloon sizing was used in 4 patients. Devices used were: In type A:PFO devices, in type B:ASO devices, in type C:two patients required two ASO devices in each patient and two patients required one cribriform device, and in type D:Cribriform devices used for three patients, PFO for one and ASO for one. LA, LUPV, and RUPV approaches were used. Aspirin was received for 6 months. Conclusion Three dimensional transesophageal echocardiography helps to select aneurysms suitable for transcatheter closure, select the suitable devices, and guide the transcatheter procedure.

Introduction: The systemic load on the right ventricle (RV) after Senning atrial switch leads to ventricular dysfunction. Quantitative assessment of RV contractile reserve is mandatory to anticipate the need for anti-fibrotic treatment. We aimed to quantitatively assess RV contractile reserve in Senning children by estimating speckle-based global longitudinal strain (GLS) during dobutamine stress echocardiography (DSE). Methods: This prospective study compared thirty-one post-Senning children (group I) and thirty controls (group II). In post-Senning children, echocardiographic RV systolic function using one-plane ejection fraction (RVEF), RV fractional area change (RVFAC), tricuspid annulus plane systolic excursion (TAPSE), its Z-score, and RVGLS were recorded at rest and peak DSE. Contractile reserve was defined as improvement >5% in RVEF, >2% in GLS, and/or to near normal TAPSE.

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IntroductionResidual patent ductus arteriosus (rPDAs) can occur following surgical or transcatheter treatment, and are indicated for closure because of the risks of infective endarteritis and hemolysis in addition to the hemodynamic effect of the residual left‐to‐right shunt.MethodsThis retrospective descriptive study describes our experience at two Egyptian centers (Cairo University Children's Hospital & Tanta University Hospital) with transcatheter treatment of rPDAs, from January 2009 to October 2017.ResultsTwenty cases were treated: 17/20 postsurgical and 3/20 post‐transcatheter, at a mean period of 13.4 ± 9.3 months from the initial procedure. The median rPDA size was 2 mm (range2–3.5 mm). Most common ductal anatomy was the conical shape. All rPDAs were successfully closed with either coils (13/20) or devices (6/20), except one case where the residual flow was within the device mesh material. Coils could be deployed from the antegrade or the retrograde approaches although the latter was associated with a higher incidence of late shunt occlusion. One case with a malpositioned device required simultaneous device and LPA stent deployment.ConclusionTranscatheter closure of rPDAs is feasible in most cases, but may be technically challenging.

Background: Patent ductus arteriosus constitutes 5-10% of all the congenital heart diseases. Volume overloading of the left side of the heart, risks of endocarditis, aneurysm of patent ductus arteriosus (PDA), and pulmonary vascular disease are indications for closure of the defect. Purpose: Evaluation of the efficacy and safety of PDA device closure in the paediatric age group patients. Methods: This prospective observational study included 26 children with a mean age of 30.2 ± 27.6 months and a mean weight of 12.8 ± 6.6 kg. Echocardiographic follow up was done at 24 hour, 1 week and 3 months post-intervention. Evaluation included assessment of residual shunt, left ventricle dimensions, left atrium/aorta ratio and velocity along descending aorta and left pulmonary artery. Results: Three different devices were used; the Amplatzer duct occluder (ADO-I) and its delivery system, PFM Nit-Occlud and Nit-Occlud PDA-R. All the patients were discharged safely from hospital after 24 hours of admission. Complete ductus closure was achieved in 77% of cases by 24 hours post-intervention, and in 96.15 % after three months. The left ventricular end diastolic diameter (LVEDd) Z score decreased from 2.13±2.37 pre-intervention, to 0.65±1.8 after 3 months (p<0.001) while LA/AO ratio decreased from 1.36±0.30 pre-intervention to 1.13±0.15 after 3 months (p<0.001). Although the LV showed decrease in systolic function (FS), all the patients showed improvement in symptoms. No significant obstruction along the descending aorta or left pulmonary artery was reported. No complications like thrombus formation, blood loss or infective endocarditis, in any case, were reported. Conclusion: Trans-catheter closure of PDA is effective and safe with rapid reversal of the left sided overload. Similar studies with long term follow up are needed for further evaluation of the LV systolic function pattern.

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