BACKGROUNDTranscatheter closure of patent ductus arteriosus (PDA) has been established as a safe and effective treatment for pediatric patients. However, long-term experience in adults remains limited. Therefore, our purpose is to report our experience with this approach in Chinese adults.METHODSTwenty-five patients (mean age, 34 years) who underwent transcatheter closure of PDA in a tertiary cardiology center in Hong Kong were recruited.RESULTSThe mean PDA diameter measured by angiogram was 3.1 mm (range, 1.3 6.6 mm) and the mean pulmonary-to-systemic shunt was 1.65 (range, 1.3 1.8). All procedures were performed under local anesthesia. The average procedure and fluoroscopy times were 54 14 minutes and 14 4 minutes, respectively. The mean period of hospitalization was 4 days (range, 3 5 days). Immediate, one-month and late success rates were 96%, 92% and 84%, respectively.CONCLUSIONSPercutaneous closure of PDA in adults is a safe and feasible procedure. It should be a reasonable alternative for adult patients who are either not fit for open-chest surgery or who prefer a less invasive approach.

HomeCirculationVol. 97, No. 1Large Unruptured Aneurysm in Sinus of Valsalva Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBLarge Unruptured Aneurysm in Sinus of Valsalva An Unusual Cause of Right Ventricular Inflow and Outflow Tract Obstruction Elaine M.C. Chau, King-Loong Cheung, Alex S.B. Yip and Wing-Hing Chow Elaine M.C. ChauElaine M.C. Chau From the Department of Cardiology, The Grantham Hospital, Hong Kong, China. , King-Loong CheungKing-Loong Cheung From the Department of Cardiology, The Grantham Hospital, Hong Kong, China. , Alex S.B. YipAlex S.B. Yip From the Department of Cardiology, The Grantham Hospital, Hong Kong, China. and Wing-Hing ChowWing-Hing Chow From the Department of Cardiology, The Grantham Hospital, Hong Kong, China. Originally published13 Jan 1998https://doi.org/10.1161/01.CIR.97.1.114Circulation. 1998;97:114–115A 64-year-old man with a large cavitating squamous cell carcinoma (6×6 cm) in the right lower lobe of the lung was referred for prelobectomy cardiac assessment because of incidental finding of Q waves in leads II, III, and aVF on the ECG. Physical examination revealed an ejection systolic murmur at the left sternal edge. Cardiac size was normal on chest radiograph. A transthoracic echocardiogram revealed a large cavity at the aortic root, 5 cm in diameter, obscuring visualization of the right heart (Figs 1 and 2). Diagnostic cardiac catheterization was performed. An aortogram revealed a large (5×5 cm), unruptured aneurysm in the sinus of Valsalva arising from the right coronary sinus (Fig 3), and a coronary angiogram showed normal anatomy. A right ventricular angiogram demonstrated obstruction at the inflow and outflow tracts of the right ventricle due to compression from the aneurysm (Fig 4). There was a 20 mm Hg pressure gradient across the right ventricular outflow tract. Therefore, a large, unruptured aneurysm in the sinus of Valsalva may be an unusual cause of right ventricular inflow and outflow tract obstruction. The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner, MC 1-267, Houston, TX 77030.Download figureDownload PowerPoint Figure 1. Transthoracic echocardiogram: parasternal long-axis view showing 5×5-cm aneurysm in sinus of Valsalva arising from anterior aspect of aorta (AO) above aortic valves (AV). LA indicates left atrium; LV, left ventricle; and MV, mitral valve.Download figureDownload PowerPoint Figure 2. Transthoracic echocardiogram: apical five-chamber view, with color-flow Doppler showing blood flow from left ventricular (LV) outflow tract into aortic (AO) root and aneurysm. RV indicates right ventricle; RA, right atrium; and LA, left atrium.Download figureDownload PowerPoint Figure 3. Contrast aortogram: right anterior oblique view, showing large, unruptured aneurysm in sinus of Valsalva arising from right coronary cusp of aorta.Download figureDownload PowerPoint Figure 4. Contrast right ventricular angiogram: anteroposterior view, showing negative shadow of aneurysm causing compression on right ventricular inflow and outflow areas.FootnotesCorrespondence to Dr Elaine M.C. Chau, Department of Cardiology, The Grantham Hospital, 125 Wong Chuk Hang Rd, Aberdeen, Hong Kong, China. eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Al-Makhamreh H, Alexander P, Lee M and Nona W (2016) Sinus of Valsalva Aneurysm (SVA), Journal of Diagnostic Medical Sonography, 10.1177/8756479306287580, 22:3, (182-184), Online publication date: 1-May-2006. Rajashekar D, Subramanyam G, Panchamukheswar R, Praveen M and Guruprasad S (2016) Unruptured Sinus of Valsalva Aneurysms Manifesting as Complete Heart Block, Asian Cardiovascular and Thoracic Annals, 10.1177/021849230501300321, 13:3, (283-286), Online publication date: 1-Sep-2005. Katz E, Shah A, Rosenzweig B, Tunick P and Kronzon I (2003) Bilateral pulmonary artery compression and obstruction by tumor: Diagnosis by unusual Doppler flow patterns, Journal of the American Society of Echocardiography, 10.1067/mje.2003.42, 16:2, (185-187), Online publication date: 1-Feb-2003. Van Camp G, De Mey J, Daenen W, Budts W and Schoors D (1999) Pulmonary Stenosis Caused by Extrinsic Compression of an Aortic Pseudoaneurysm of a Composite Aortic Graft, Journal of the American Society of Echocardiography, 10.1016/S0894-7317(99)70155-0, 12:11, (997-1000), Online publication date: 1-Nov-1999. Caputo R, Rosenberg J, Fedele K and Giambartolomei A (1999) Myocardial ischemia resulting from spontaneous dissection in a patient with massive bilateral sinus of valsalva aneurysms, Catheterization and Cardiovascular Interventions, 10.1002/(SICI)1522-726X(199906)47:2<194::AID-CCD15>3.0.CO;2-C, 47:2, (194-198), Online publication date: 1-Jun-1999. January 13, 1998Vol 97, Issue 1 Advertisement Article InformationMetrics Copyright © 1998 by American Heart Associationhttps://doi.org/10.1161/01.CIR.97.1.114 Originally publishedJanuary 13, 1998 PDF download Advertisement

Objectives. This study was designed to examine the effects of destroying the posterior approaches to the atrioventricular (AV) node.Background. Surgical and catheter ablation procedures have been developed for the cure of AV junctional reentrant tachycardia.,Some of these destroy the posterior approaches to the AV node.Methods. Atrioventricular node function and electrical excitation of Koch's triangle and the proximal coronary sinus were examined in 18 dogs. Dissection of the posterior atrionodal connections was performed in 10 dogs and a sham procedure in 8. After 28 to 35 days, repeat electrophysiologic and mapping studies were performed to assess changes in AV node function and the routes of AV and ventriculoatrial (VA) conduction. The AV junction was then examined with light microscopy.Results. The compact AV node was undamaged in eight cases (80%). In two cases minor fibrosis occurred at the posterior limit of the compact node. The right-sided posterior atrionodal connections lying between the coronary sinus orifice and the tricuspid annulus were replaced by scar tissue in all cases, but the left-sided posterior connections and the anterior connections remained intact. Atrioventricular and VA conduction intervals and refractory periods were not altered. Atrioventricular junctional echoes were present in 10 dogs before and in 7 dogs after dissection (p = 0.06). Posterior (slow pathway) retrograde exits from the AV node were present in seven dogs before and in seven dogs after dissection. However, retrograde atrial excitation was altered in four of these seven dogs, so that the site of exit from the AV node was more leftward than it had been preoperatively. The node remained responsive to autonomic blocking drugs postoperatively. Double atrial electrograms similar to slow pathway potentials were found in all dogs.Conclusions. This procedure ablates the posterior atrionodal connections but rarely damages the compact AV node. Atrioventricular node function is not impaired and the node is not denervated. The mechanism of cure of AV junctional reentrant tachycardia is probably damage to the perinodal atrium. This suggests that part of the slow AV node pathway may lie outside the compact AV node. Dual AV node exits and double atrial electrograms are present in the normal canine heart.

The aim of this study was to characterize a relatively rare type of atrioventricular (AV) junctional reentrant tachycardia (AVJRT). Posterior AVJRT is a type of AV nodal tachycardia in which the site of earliest atrial activation is posterior to the AV node near the coronary sinus orifice. The mechanism of this tachycardia is not well understood. The characteristics of posterior AVJRT (n = 15) were compared with those of anterior ("common") AVJRT (n = 146) and supraventricular tachycardia using single posterior septal accessory pathways (n = 13). During posterior AVJRT, the AH interval was longer than the retrograde conduction time (His to earliest atrial activity) in 11 cases (73%), indicating that these tachycardias were not fast-slow types of AVJRT. The mean ventriculoatrial (VA) interval in posterior AVJRT (93 +/- 41 ms) was longer than in anterior AVJRT (11 +/- 20 ms; p < 0.005), but was similar to that in tachycardias using accessory pathways (106 +/- 16 ms; p = NS). The site of earliest atrial activation during posterior AVJRT was similar to that in tachycardias using accessory pathways. In all cases of accessory pathway-mediated tachycardia, atrial activation could be advanced by ventricular extrastimuli delivered coincident with the His deflection, but atrial activation was not advanced in any case of posterior AVJRT unless the extrastimulus was delivered > 80 ms before the His deflection. Anterograde conduction was similar in the posterior and anterior AVJRT groups.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVES:This study was undertaken to examine the electrophysiologic and anatomic effects of a surgical procedure that cures the anterior (common) type of atrioventricular (AV) junctional reentrant tachycardia.BACKGROUND:The procedure was designed to interrupt the reentrant circuit at the point of earliest atrial activation during AV junctional reentrant tachycardia, the anterior atrionodal connections.METHODS:Atrioventricular node function and the sequence of electrical excitation of Koch's triangle were examined in 18 dogs. Excitation of Koch's triangle was mapped using a 60-channel mapping system. Surgical dissection was performed in 10 dogs and a sham procedure in 8. After 28 to 35 days, AV node function and the atrial excitation pattern were reassessed. The AV junction was examined using light microscopy.RESULTS:Some degree of AV node damage was visible in all dogs in the dissection group, but it was minor in 40% of cases. The anterior part of the AV node was disconnected from the anterior atrionodal connections in all cases. Anterograde AV node function was mildly impaired. The median AH interval was increased (62 vs. 76 ms [interquartile ranges 48 to 72 and 64 to 104, respectively], p = 0.05), and the AV Wenckebach cycle length was increased (210 vs. 245 ms [interquartile ranges 200 to 230 and 210 to 260, respectively], p = 0.02). The degree of impairment of conduction was directly proportional to the length of dissection (p < 0.05) but not to the degree of damage to the AV node. Ventriculoatrial (VA) conduction was destroyed in 50% of dogs undergoing dissection but in none of those with a sham operation (p < 0.04). The AV node remained responsive to autonomic blocking drugs, and atrial mapping during ventricular pacing revealed that the site of exit from the AV node had been altered.CONCLUSIONS:The atrionodal connections closest to the His bundle are the preferred route of conduction through the AV node during normal AV or VA conduction. Destruction of these connections modifies AV node conduction. The surgical procedure selectively interrupts these connections, and this interruption is likely to be the mechanism of cure.

OBJECTIVES:The purpose of this study was to examine the effects of varying basic cycle lengths in a programmed stimulation protocol if up to seven extrastimuli were available at each basic cycle length.BACKGROUND:There is no uniformly accepted protocol for induction of ventricular tachycardia. Most protocols limit the number of extrastimuli to two or three but use several basic cycle lengths.METHODS:Twenty-eight patients with coronary artery disease and documented spontaneous sustained ventricular tachycardia or ventricular fibrillation were studied. In the absence of antiarrhythmic drugs, each patient underwent three inductions of ventricular tachycardia/ventricular fibrillation using sinus rhythm or right ventricular pacing at 600 or 400 ms as the basic cycle length. Up to seven extrastimuli were allowed at each basic cycle length.RESULTS:The maximal yield of clinical tachycardia (96%) was identical for each basic cycle length and was achieved using a maximum of seven, five and four extrastimuli for sinus rhythm and 600 and 400 ms, respectively. A basic cycle length of 400 ms required fewer extrastimuli (2.4 +/- 0.7) to induce ventricular tachycardia/ventricular fibrillation than did 600 ms (2.7 +/- 1.1, p = 0.014) or sinus rhythm (3.4 +/- 1.2, p < 0.001). There was no significant difference in the cycle lengths of the induced ventricular tachycardia, incidence of induced ventricular fibrillation or requirement for direct current countershock.CONCLUSIONS:The use of an adequate number of extrastimuli obviates the need for multiple basic cycle lengths for induction of ventricular tachycardia and does not increase induction of unwanted ventricular fibrillation. If only one basic cycle length is used, the ease of inducibility can be quantified in terms of the number of extrastimuli required. Fewer extrastimuli were required for induction of ventricular tachycardia if a basic cycle length of 400 ms was used. These data favor the use of ventricular pacing at a basic cycle length of 400 ms with up to at least four extrastimuli as the standard stimulation protocol for induction of ventricular tachycardia.

Midazolam has several advantages over diazepam as a sedative agent in electrophysiologic studies, but its electrophysiologic effects in humans are unknown. Therefore, its effects were studied in 20 patients undergoing electrophysiologic studies. Electrophysiologic variables were measured before and after administration of intravenous midazolam (5 mg). There were no significant changes in the electrophysiologic variables, apart from a minor decrease in sinus cycle length (711 +/- 124 vs 647 +/- 91 ms; p = 0.005). Ease of inducibility of reentrant tachycardia was not significantly altered by midazolam, and tachycardia remained inducible in all patients. The drug was well-tolerated with no significant side effects, apart from a minor reduction (mean 18 mm Hg) in blood pressure (p less than 0.001). Good amnesic effect was achieved in 16 patients, and most patients preferred it to oral diazepam for sedation during the procedure. It is concluded that midazolam can be used safely in patients undergoing electrophysiologic studies without significantly interfering with electrophysiologic variables or the inducibility of reentrant tachycardias.