Cardiac catheteriztion, Oximetery study in a patient with VSDPRAVEEN GUPTA
In this ppt i am going to discuss how to do cardiac catheterisation study, oximetry study and how to analyse its data in a patient with VSD who came to our hospital
Natural history of common congenital heart diseasesRamachandra Barik
Most infants with ASDs are asymptomatic
They may present at 6 to 8 weeks of age with a soft systolic ejection murmur and possibly a fixed and widely split S2
CHF rare in the first decades of life but it can become common once the patient is older than 40 yrs
Cardiac catheteriztion, Oximetery study in a patient with VSDPRAVEEN GUPTA
In this ppt i am going to discuss how to do cardiac catheterisation study, oximetry study and how to analyse its data in a patient with VSD who came to our hospital
Natural history of common congenital heart diseasesRamachandra Barik
Most infants with ASDs are asymptomatic
They may present at 6 to 8 weeks of age with a soft systolic ejection murmur and possibly a fixed and widely split S2
CHF rare in the first decades of life but it can become common once the patient is older than 40 yrs
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
The lecture is for medical student. It is from Dr RUSINGIZA Emmanuel, MD, senior lecture at UR( UNIVERSITY OF RWANDA) .
It will help to understand heart diseases in newborn, infants and children.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
A case of ASD - Sinus Venosus type
1. AN INTERESTING CASE OF ACYANOTIC CONGENITAL HEART DISEASE Dr. Namitha Narayanan
2. CASE HISTORY Thirty six years old male admitted with C/O Palpitations -10 days HISTORY OF PRESENTING ILLNESS: Pt. was apparently normal 10 years back H/O Palpitations on and off-on moderate exertion. Increased in intensity-10 days
3. CASE HISTORY CONTD Ass with breathlessness . Relieved with rest. Not ass with chest pain/syncope/sweating. No history suggestive of Cardiac Failure. No H/O fever/joint pain/swelling/ rashes/cough with expectoration.
4. CASE HISTORY CONTD PAST H/O: No history suggestive of Recurrent Respiratory Tract Infections/Cyanotic Spells/RHD PERSONAL H/O: Chronic Alcoholic and Smoker
5. ON EXAMINATION Well Built and Nourished Conscious Comfortable Afebrile Clubbing –Grade I NO Pallor/Icterus/Cyanosis/Clubbing/ Lymphadenopathy/Pedal Edema
6. EXAMINATION CONTD Vitals –Stable JVP –Normal CVS Examn:- Trachea in midline Chest B/L Symmetrical Parasternal pulsations+ Apical Impulse –in 5th ICS lat to MCL Palpable P 2+ No THRILL .
7. CVS EXAMINATION CONTD ON AUSCULTATION:- MITRAL AREA: S1 S2+ PULMONARY AREA: S1 S2+ Loud P2& Fixed Split of S2 ESM of Grade 3/6 AORTIC AREA:S1S2+, ESM+ TRICUSPID AREA:S1S2+ Long Drawn Systolic Murmur.
8. OTHER SYSTEMS –Normal DIAGNOSIS-ACYANOTIC CONGENITAL HEART DISEASE-ASD /MOD PULMONARY HT
13. INTRODUCTION Atrialseptal defects account for about 10-15% of all congenital cardiac anomalies and are the most common congenital cardiac lesion presenting in adults. Sinus venosusatrialseptal defects account for only 10% of atrialseptal defects. The remaining atrialseptal defects are ostiumsecundum type (70%), ostiumprimum type (20%), and unroofed coronary sinus, or coronary sinus septal defects, (<1%).
14. Most children with sinus venosusatrialseptal defects are asymptomatic but may develop symptoms as they age. Excellent surgical results with a mortality rate near 0% can be expected. This is particularly true in patients who undergo repair when younger than 15 years. An atrialseptal defect was the first lesion repaired using cardiopulmonary bypass in 1954 by John Gibbon, MD, at the Mayo Clinic.
15. PATHOPHYSIOLOGY The more common sinus venosus type defect occurs in the upper atrial septum and is contiguous with the superior vena cava (SVC). The lesion is rostral and posterior to the fossaovalis (where secundum type defects occur) and is separate from it. It is almost always associated with anomalous pulmonary venous drainage of the right upper pulmonary vein into the SVC.
16.
17. Less commonly, the defect may occur at the junction of the right atrium and inferior vena cava and be associated with anomalous connection of the right lower pulmonary vein to the IVC. Rarely, sinus venosus defects occur posterior to the fossaovalis without bordering the SVC or IVC. The predominant hemodynamic consequence is a left-to-right shunt through the defect.
18.
19.
20. Race No racial predilection is known. Sex Atrialseptal defects affect females more often than males. Female-to-male ratio is 2:1. No difference in outcome is associated with sex. Age Sinus venosusatrialseptal defects are congenital lesions present at birth. The age at presentation depends on the size of the left-to-right shunt. Atrialseptal defects in infancy are usually asymptomatic. They are usually detected by echocardiography while undergoing a cardiac evaluation.
21. CLINICAL PRESENTATION HistorySymptoms of atrialseptal defects are typically a function of the size of the associated shunt. As many as 60% of apparently asymptomatic patients may have easy fatigability and dyspnea. Such symptoms usually indicate a relatively large shunt. Adults may not come to medical attention until symptoms occur. Arrhythmias, dyspnea, and a decrease in exercise tolerance are common symptoms.
22. CLINICAL EXAMINATION A cardiac murmur secondary to increased pulmonary artery blood flow is heard over the left sternal border. The murmur is usually a grade 2-3/6 systolic ejection murmur. A prominent right ventricular impulse may also be noted along the left sternal border. A diastolic flow murmur may be present at the left lower sternal border and the tricuspid area and is indicative of a large left-to-right shunt. The second heart sound is widely split and may be fixed or may vary little with respiration. The pulmonic component of the second heart sound is usually normal in intensity but may increase in intensity if pulmonary hypertension is present.
23. CAUSES During normal embryonic development, the right horn of the sinus venosus encompasses the right SVC and IVC. If abnormal resorption of the sinus venosus occurs, an atrialseptal defect results near the orifice of either the SVC or IVC. Sinus venosusatrialseptal defects occur more often as an isolated abnormality. Other abnormalities may exacerbate an atrialseptal defect. For instance, systemic hypertension in an adult with a sinus venosusatrialseptal defect may result in left ventricular hypertrophy and reduce left ventricular compliance, which, in turn, exacerbates the atrial level left-to-right shunt. Mitral stenosis, which is either congenital or acquired, may also exacerbate the atrial level left-to-right shunt.
25. Laboratory Studies General laboratory studies are rarely helpful in sinus venosusatrialseptal defect (ASD). Imaging Studies Chest radiography Prominent right atrium Prominent main pulmonary artery Increased heart size and pulmonary vascularity
26. ECHOCARDIOGRAPHY Echocardiography reveals atrialseptal defect and most of the pulmonary vein connections in most patients and is the diagnostic modality of choice. Two-dimensional ECHO with color flow Doppler reveals the position and size of the defect and the presence of anomalous pulmonary venous drainage. It also helps identify associated anomalies and reveals the left-to-right (or right-to-left) direction of flow and the degree of right ventricular overload. In children with difficult transthoracic windows, or in older or larger patients, transesophageal echocardiography may be helpful in imaging the defect and pulmonary vein connections. Cardiac magnetic resonance angiography (MRA)/MRI may be alternatively used to complete the diagnostic information needed prior to surgery.
27. Other Tests Electrocardiogram Right ventricular hypertrophy predominates, with a lengthened PR interval and incomplete right bundle branch block (small rSR'). P wave morphology may demonstrate atrial enlargement. Cardiac MRI/MRA Atrialseptal defect size and location are shown. Excellent delineation of individual pulmonary vein connections can be identified. Right ventricle enlargement and indexing to body surface area (BSA) is available if helpful. Flow-quantification may also be performed.
28. Procedures Cardiac catheterization may be considered in the following circumstances: In any child in whom associated lesions are suspected or in whom pulmonary hypertension is suspected, catheterization is performed to measure pulmonary artery pressure and, if pulmonary resistance is elevated, the response to pulmonary vasodilators. Adults who have the potential for associated coronary atherosclerotic lesions should undergo catheterization to exclude these abnormalities before surgical repair of the sinus venosusatrialseptal defect.
29. TREATMENT Medical Care Medical care of sinus venosusatrialseptal defect (ASD) is primarily supportive and is not required for asymptomatic patients. Patients presenting in heart failure should be stabilized in anticipation of elective repair. Surgical Care Surgical correction is the mainstay of therapy.
30. Sinus venosus defects do not close spontaneously. Asymptomatic children generally undergo repair when aged 3-5 years. Adults with left-to-right shunts greater than 1.5-2:1 benefit from surgical closure. Patients with significant pulmonary hypertension and elevated pulmonary vascular resistance unresponsive to pulmonary vasodilator therapy may not be good candidates for surgical repair. Such patients may develop acute right ventricular failure if their heart no longer has the ability to shunt right to left at the atrial communication in response to increases in pulmonary vascular resistance.
31. Repair is performed most often through a standard median sternotomy. More cosmetic incisions may also be used, such as partial sternotomies, small right anterior thoracotomies, and inframammary incisions. All approaches require the use of cardiopulmonary bypass for closure of the atrialseptal defect. Transcatheter occlusion devices are not indicated for the closure of sinus venosusatrialseptal defects because of the position of the defect and because of the lack of surrounding tissue adequate to seat such an occlusion device. Such a device may obstruct SVC flow and does not achieve redirection of the anomalous right pulmonary venous flow to the left atrium.
32. A patch (synthetic material or pericardium) is used to redirect blood flow from the right superior pulmonary vein into the left atrium. This effectively closes the interatrial communication while also correcting the anomalous pulmonary venous drainage. Sometimes, to avoid creating SVC obstruction, a patch is placed on the anterior surface of the SVC. Care is taken to avoid injuring the nearby sinus node. Ligation of the azygous vein may also be required to eliminate its drainage into the left atrium and to prevent the resulting residual right-to-left shunt.
33. When the location of the anomalous venous drainage is in the high SVC and is far from the atrial-caval junction, a different surgical approach can be used to decrease the probability of cavalstenosis or pulmonary vein stenosis. As described by Warden et al, the repair consists of division of the SVC just above the take off of the anomalous pulmonary vein. The distal caval end is oversewn or patched to assure no pulmonary vein compromise. Next, the well-mobilized cava is anastomosed to the right atrial appendage after amputation of the most distal end. The atrialseptal defect is then closed by sewing a patch to cover the atrialseptal defect and divided SVC orifice, thereby baffling the anomalous vein to the left atrium.
34. This method is very effective in patients with more complicated pulmonary venous anomalies. Although a relatively recent advance in the treatment of high anomalous pulmonary venous drainage, this operation has become the procedure of choice for more difficult cases. All reported series have demonstrated excellent results with little or no pulmonary venous or SVC stenosis. In addition, concern for injury to the conduction system or sinus node have not been observed to date.
35. FOLLOW-UP Further Inpatient Care Patients with sinus venosus ASD require a brief postoperative admission to a cardiac intensive care unit. Patients in heart failure may require short-term continued support until pulmonary edema resolves, myocardial function improves, and until pulmonary vascular resistance, if elevated, normalizes.
36. Further Outpatient Care Postoperative follow-up: This usually involves an office visit with the cardiologist 1-3 weeks after hospital discharge. Echocardiography is used to effectively evaluate the repair for evidence of residual shunting, SVC or pulmonary vein obstruction, pericardial effusion, and ventricular function. The potential for late postoperative narrowing of the SVC is observed after repair of sinus venosusatrialseptal defects. Sinus node dysfunction screening should be part of outpatient follow-up care as sinus node dysfunction may become apparent years after repair of a sinus venosusatrialseptal defect.
37. INPATIENT & OUTPATIENT MEDICATIONS No long-term medication is required after repair of an uncomplicated atrialseptal defect. Some prescribe aspirin or other anticoagulation regimens for several weeks in patients in whom a prosthetic patch was used to close the defect. This allows for endothelial ingrowth over the thrombogenic surface of the patch. Long-term anticoagulation is not indicated. Antibiotic prophylaxis is not required in patients who have had atrialseptal defects repaired.
39. PROGNOSIS The prognosis is excellent for young patients who undergo repair of uncomplicated defects. Repair delayed until the third decade of life is associated with a decrease in life expectancy.
40. MORTALITY/MORBIDITY Surgical repair in the first 2 decades of life is associated with a mortality rate near zero. Life expectancy approaches that of the general population if the defect is repaired during this time. Cardiac size rapidly regresses after surgery, and the functional result is excellent. In cases of repair during adulthood, life expectancy may be decreased despite successful repair. Surgical morbidity rates are related to early postoperative pericardial effusion, pulmonary venous or systemic venous obstruction, and supraventricular arrhythmias.
41. If the baffle directing pulmonary venous blood to the left atrium is not placed correctly, it may obstruct pulmonary venous drainage. If the baffle bulges into the SVC, it may obstruct SVC inflow, necessitating the placement of an augmentation patch on the anterior surface of the SVC and right atrial junction.
42. Untreated atrialseptal defects are associated with a significantly shortened life expectancy. After age 20 years, the mortality rate is approximately 5% per decade with 90% of patients dead by age 60 years. These patients present with an increase in left-to-right shunting and occasionally with congestive heart failure with pulmonary hypertension in the fourth to sixth decades of life. Late problems in untreated patients also include the risk of paradoxical embolus as well as atrial fibrillation, pulmonary hypertension, and right heart failure.