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Caffeine consumption during pregnancy is reported to increase the risk of in utero growth restriction and spontaneous abortion. In the present study, we tested the hypothesis that modest maternal caffeine exposure affects in utero developing embryonic cardiovascular (CV) function and growth without altering maternal hemodynamics. Caffeine (10 mg.[kg.sup-1].[day.sup.-1] subcutaneous) was administered daily to pregnant CD-1 mice from embryonic days (EDs) 9.5 to 18.5 of a 21-day gestation. We assessed maternal and embryonic CV function at baseline and at peak maternal serum caffeine concentration using high-resolution echocardiography on EDs 9.5, 11.5, 13.5, and 18.5. Maternal caffeine exposure did not influence maternal body weight gain, maternal CV function, or embryo resorption. However, crown-rump length and body weight were reduced in maternal caffeine treated embryos by ED 18.5 (P < 0.05). At peak maternal serum caffeine concentration, embryonic carotid artery, dorsal aorta, and umbilical artery flows transiently decreased from baseline at ED 11.5 (P < 0.05). By ED 13.5, embryonic aortic and umbilical artery flows were insensitive to the peak maternal caffeine concentration; however, the carotid artery flow remained affected. By ED 18.5, baseline embryonic carotid artery flow increased and descending aortic flow decreased versus non-caffeine-exposed embryos. Maternal treatment with the adenosine [A.sub.2A] receptor inhibitor reproduced the embryonic hemodynamic effects of maternal caffeine exposure. Adenosine [A.sub.2A] receptor gene expression levels of ED 11.5 embryo and ED 18.5 uterus were decreased. Results suggest that modest maternal caffeine exposure has adverse effects on developing embryonic CV function and growth, possibly mediated via adenosine [A.sub.2A] receptor blockade. adenosine [A.sub.2A] receptor; cardiovascular development; carotid artery; pregnancy

Unlabelled: Atrial septal defect (ASD) closure reduces symptoms and prevents ongoing congestive heart failure. However, little is known about device closure in the elderly (age > 60 years) and whether it is a safe and effective treatment. In this study, we report our results with ASD transcatheter closure in the elderly patient > 60 years of age using the Amplatzer Septal Occluder (ASO) device., Methods: Between September 1999 and March 2007, a total of 41 patients (24 females and 17 males) who were > 60 years of age (range 62-87.2 years) and had indications for ASD closure (right ventricular enlargement, clinically symptomatic dyspnea, fatigue, palpitations, exercise intolerance, transient ischemic attacks and/or stroke) underwent an attempt of transcatheter device closure using the ASO., Results: The median Qp/Qs ratio was 2.3 (range 1-7.5). The median mean pulmonary artery pressure was 26 mmHg (range 11-52 mmHg). The median size of the ASD as measured by intracardiac echocardiography (ICE) (n = 38) or transesophageal echocardiography (TEE) (n = 3) was 18.9 mm (range 8-40 mm), and the median balloon-stretched (stop-flow technique) diameter (n = 32) was 23.5 mm (range 12-40 mm). The procedure was successful in all patients. 44 devices were deployed in the 41 patients (3 patients received 2 devices each). A 6 mm fenestration was created in a 30 mm device that was placed in 2 patients with left ventricle diastolic dysfunction. The median fluoroscopy time was 10 minutes (range 4-24.8 minutes), and the median procedure time was 60 minutes (range 26-110 minutes). Complications encountered during or within 24 hours after the procedure included: hematoma at the site of catheter insertion in 4 patients, small pericardial effusion in 5, and in 1 patient, the pacemaker lead was dislodged requiring reimplantation. The complete closure rate as assessed by ICE or TEE immediately after the procedure was 82%. However, complete closure, as assessed by transthoracic echocardiography at 24 hours and 6-24 months postintervention, was 82% and 97%, respectively. Two patients did not return for follow up and 4 patients were known to have expired for reasons unrelated to their ASD closure. At a median interval of 6 months after closure, the right ventricular end-diastolic dimension decreased from 38.9 +/- 9 mm preprocedure to 26.6 +/- 7 mm (p < 0.001; n = 31) postprocedure, and 89% of the patients showed improvement in symptoms. On a median follow-up interval of 28 months (range 6-79 months), 1 patient was noted to have a femoral pseudoaneurysm. Patients were doing well with no major clinical events., Conclusion: In patients older than 60 years of age, device closure of ASDs is safe and an effective alternative to surgery. Right-heart remodeling can occur in patients > 60 years of age.

Doppler indexes have been used successfully to determine the severity of aortic regurgitation (AR) in adults but have not been evaluated in children. To determine the accuracy of pulsed, color, and continuous-wave (CW) Doppler echocardiographic indexes in assessing the degree of AR in children, the correlation between the non-invasive measurements and angiographic grading of the regurgitant flow (1+ to 4+) was examined in 14 children (mean age 11 +/- 3 years) with chronic AR. Forward and reverse flows in the aortic arch were evaluated from the suprasternal notch using pulsed Doppler. Aortic time-velocity integrals (TVI) were measured during systole (forward flow) and diastole (reverse flow), and the ratio of reverse to forward TVI (%) was calculated. Doppler color flow mapping was used to detect and assess the severity of AR (which appears as mosaic turbulent signals extending in the left ventricular outflow tract during diastole) by using four color Doppler grades of severity. The envelope of the flow velocity pattern in diastole was recorded from the CW Doppler signal of AR with the transducer in the lower sternal border to determine the peak flow velocity and deceleration slope (alpha) indexes. The ratio of reverse to forward aortic TVI and color flow mapping grading showed strong correlation with angiographic grade (r=0.92 and r=0.86, respectively) but AR slope (alpha) and peak flow velocity did not correlate well with the angiographic grade (r=-0.039 and r=0.74, respectively). We concluded that the severity of AR in children as determined by angiographic grading can be estimated with reasonable accuracy by noninvasive technique based on color and pulsed wave Doppler. Use of these indexes may obviate the need for angiography to detect the severity of AR in children.

Origin of the left main coronary artery from the pulmonary trunk is an extremely rare, fatal, but potentially treatable anomaly. Left ventricular perfusion with desaturated blood with low pressure from the pulmonary artery results in early death. Associated pulmonary hypertension can help to prevent ischemia. We present a four-month-old boy with this anomaly associated with patent ductus arteriosus and pulmonary hypertension.

Valvar aortic stenosis is a common congenital heart defect for which surgical procedures can be done with low risk except in infants whose conditions are seriously compromised. The purpose of this report was to present our experience with the results of surgical aortic valvotomy for congenital valvar aortic stenosis performed at our hospital. The study group consisted of 24 patients, 3 females and 21 males, with ages ranging from 1 to 15.5 years (mean age 8.5 years), who underwent aortic valvotomy for valvar aortic stenosis. The case records of all the patients were retrospectively reviewed. They were followed for 1-10.5 years (mean 5.02+/-2.38 years) after relief of aortic stenosis, and were scheduled for reevaluation. Sixteen of the 24 patients were recatheterized and 15 (93.7%) were found to have aortic regurgitation on angiography. Peak systolic pressure gradients (mean+/-SD) were 65.9+/-19.5 mmHg before and 36.7+/-14.8 mmHg (p<0.05) after the operatilon. Of the 24 patients, 45.8% had a new postoperative diastolic murmur. Twenty patients (83.3%) had residual stenosis and three (12.5%) had recurrent stenosis. Two patients (8.3%) had undergone reoperation six to seven years after the initial aortic valvotomy, and most of the others will require reoperation in the future. No sudden deaths occurred in this series. Timely relief of obstruction prevents sudden death and produces symptomatic improvement in valvar aortic stenosis, but aortic valvotomy is only a palliative measure.