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Cardiac tamponade occurring late after interventional closure of defects within the oval fossa is a very rare but life-threatening complication. We describe such an occurrence after use of a Cardioseal device to close an interatrial communication. Two arms of the device had perforated left atrial wall. The device was removed at surgery, and the defect closed uneventfully. All available means should be used to identify this complication.

Introduction: One of the main features of vibroacoustic disease (VAD) is the proliferation of the extra-cellular matrix which induces cardiovascular morphological and dynamic changes, and has been evaluated through echo-Doppler. While all subjects exposed to large pressure amplitude (> or =90 dB SPL) and low frequency (< or =500 Hz) (LPALF) for at least 15 yr have thickening of some cardiac structure, most frequently the pericardium, no significant diastolic changes accompany these observations. Echocardiography has become the diagnostic method of choice for the VAD. However, there have been no studies relating the echo-images of pericardial thickening to gross anatomy., Methods: We present the histology and ultrastructure of the pericardia of four patients who underwent cardiac surgery., Results: The most important findings concern the real thickening of the pericardium (values: 1.11, 1.35, 2.19, and 2.33 mm vs. norm: < or = 0.5 mm), the dynamic arrangements of mesothelial cells in the serosa layer, and the plasticity of the cells found among the multifascicular waveform collagen fibers. We found that the fibrosa of VAD patients has three layers: sandwiched between two thickened layers of normal fibrosa there is a loose tissue layer with vascular, nervous, and adipose structures., Conclusion: These features may partially explain why no important diastolic changes are observed in VAD patients in spite of the pericardium thickening.

A 16-year-old boy was submitted to a cardiac examination after an episode of faintness. A transthoracic echocardiogram was performed, which revealed a very mobile multicystic tumor attached to the mitral valve. A small solid mass adherent to the cysts was better defined by transesophageal echocardiography. The patient was submitted to cardiac surgery consisting of tumor resection and a mitral prosthesis implant. The surgery was successful. The tumor consisted of three bright red tense cysts with hematic content, each 1 to 2 cm in diameter. The cysts were coalescent and adherent to a solid mass attached to the posterior papillary muscle head. Histopathologic examination revealed a hamartoma with a cystic part composed of the proliferation of myofibroblast cells in a stroma with vessels, collagen, and elastin fibers. Valvular hamartoma with blood cysts is a very rare cardiac tumor both for its histopathology and its localization.

A 3.5-year-old boy with stroke secondary to embolization of a primary cardiac tumor is presented. The diagnosis was made by two-dimensional echocardiography and confirmed intraoperatively. A papillary fibroelastoma was identified histologically. It is a rare condition and a diagnostic challenge, as patients are asymptomatic before embolization. In view of the severe consequences, prompt surgery is recommended.

Background: Volume loading is commonly used to adjust preload and optimise cardiac output. It is difficult to monitor preload at the bedside because filling affects ventricular diastolic function and consequently end diastolic pressure, which is the variable used to monitor preload., Objective: To assess the effects of gradual volume loading on the different components of left ventricular diastolic function---filling velocities, relaxation, and chamber compliance---to identify how excessive loading produces diastolic dysfunction., Methods and Results: Eight mongrel dogs, anaesthetised and mechanically ventilated with both the chest and the pericardium closed, were studied during basal conditions (B), during gradual volume loading with physiological saline---5 ml/kg (VL5), 10 ml/kg (VL10), and 15 ml/kg (VL15)---and during infusion of isosorbide dinitrate (10 g/kg/min) started after the VL15 load was achieved. Dogs were monitored haemodynamically and by transthoracic Doppler echocardiography to assess peak modal velocities of the E and A waves, E/A ratios, and the deceleration time of the E wave. M mode recordings of aligned mitral and aortic valve motion were also obtained to calculate the isovolumic relaxation time. Effects of volume loading on ventricular diastolic function seemed to occur in two phases. Small and moderate volume loads (VL5 and VL10) promoted early ventricular filling, increasing E wave velocities, improving the mean (SD) E/A ratio from 1.95 (0.3) (B) to 2.0 (0.27) (VL5) and 2.6 (0.3) (VL10) (P < 0.00005), prolonging the E wave deceleration time, and only slightly increasing ventricular diastolic pressures. These changes suggest an improvement in ventricular compliance. Extreme volume loads (VL15) produced an abrupt reduction in early ventricular filling, which was transfered to late in diastole, by decreasing E wave velocity, by increasing A wave velocity, and by decreasing E/A ratio from 2.6 (0.3) (VL10) to 0.8 (0.05) (VL15) (P < 0.00005). The E wave deceleration time was shortened and left ventricular diastolic pressures were much increased, all suggesting a deterioration in chamber compliance. All these restrictive changes were promptly reversed by the perfusion of isosorbide dinitrate. The isovolumic relaxation time steadily increased with volume loading., Conclusions: Small and moderate volume loads improved ventricular diastolic function by promoting early ventricular filling and increasing ventricular compliance. Extreme volume loads promptly induced a diastolic restrictive pattern, transferring filling to the second part of diastole (increasing dependence on atrial contraction) and reducing ventricular compliance. These changes in ventricular diastolic function were independent of simultaneously measured haemodynamic systolic performance and were promptly reversed by isosorbide dinitrate, which after extreme loading promoted early filling, myocardial relaxation, and improved chamber compliance.

To determine whether diastolic ventricular interdependence mechanisms would act in the presence of an open pericardial sac, as during cardiac surgery, moderate acute right ventricle afterload increases were applied to eight dogs with the chest and pericardium open while left ventricular filling dynamics were being assessed by Doppler echocardiography. Dogs were studied under basal conditions and after acute banding of the main pulmonary artery tightened to produce a 100% increase in right ventricular systolic pressure. With banding, the left ventricular filling velocity ratio (E/A), as assessed by Doppler echocardiography of mitral inflow, changed from a baseline value of 1.32 +/- 0.05 to 1.16 +/- 0.03 (p < 0.02), suggesting a restrictive pattern to early left ventricular filling, which is differed to that during the second half of diastole. Isovolumic relaxation time, measured as the time interval between aortic valve closure and mitral valve opening, assessed by M-mode echocardiography of both valves, was prolonged, though not significantly, from 63.3 +/- 2.5 ms to 69.4 +/- 2.9 ms, by banding of the pulmonary artery. E wave deceleration time, a filling variable influenced by chamber pressure/volume relations, was shortened by pulmonary artery banding, changing from 75.1 +/- 1.7 ms to 68.0 +/- 1.8 ms (p < 0.01). It was concluded that pressure loads applied to the right ventricle restricted early left ventricular filling. Prolonged relaxation and altered pressure-volume chamber relations were the diastolic interdependence mechanisms involved that proved to be acting even under open pericardium conditions.

Objective: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA)., Design of the Study: Prospective study of case series between March 1991 and December 1994., Setting: Referral-based Paediatric Cardiology Department of a Tertiary Care Center., Patients and Methods: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed., Results: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram., Conclusions: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

Study Objective: To review our eleven year experience in the implantation and follow-up of permanent Pacemakers in the paediatric age group., Design: Retrospective study., Setting: Children submitted to permanent cardiac Pacing implantation and accompanied in the Pacing Center of the Hospital de Santa Maria., Patients: Children from both sexes, aged from neonate to 14 years old, with brady-dysrhythmia and indication for permanent cardiac Pacing implantation., Material and Methods: From November 1980 to September 1991, 16 children had permanent Pacemaker implantation. We describe the clinical and electrocardiographic characteristics of the population, mode of Pacing used, technical data from the implantation and evolution., Results: One children died due to associated cardiac defect not related to the Pacemaker. The other 15 children remain in follow-up with normofunctioning Pacemakers and free of symptoms. We had to perform 11 reinterventions in 8 children due to generator or electrode problems (28,2 months reintervention interval)., Conclusions: Improvements in Pacemaker technology and a careful technique of implantation can significantly reduce the morbidity associated to permanent pacemaker implantation in this age group.

"Cor triatriatum dexter" (CTD) is an unusual cyanotic cardiac defect in which the right atrium is subdivided into two distinct chambers due to the persistence of the "sinus venosus" valve. Two patients with CTD ho were evaluated and treatment in 1979 and 1992 are described: the first one, had total anomalous pulmonary venous return to the coronary sinus or "cor triatriatum sinister" as preoperative diagnosis based on M-mode echocardiographic findings. The presence of a membrane inside the right atrium was suspected on cineangiogram. The other one had a preoperative diagnosis of CTD. Anatomic relationships and physiological effects were established by two dimensional and Doppler ultrasonography and confirmed at cardiac catheterization and surgery. High resolution two dimensional echocardiography coupled with Doppler ultrasonography has a definite role in the study of this heart defect.

This is a report of an acute myocardial infarction complicated with rupture of the free wall of the left ventricle. Some comments concerning diagnosis and therapy are added, with emphasis in the correct communication of community hospitals with the centers of cardiac surgery.