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We report our experience with the use of covered stents for the management of coarctation of the aorta. From December 2001 to March 2004, nine patients (seven males: median age, 31 years; mean weight, 65 ± 15 kg) underwent implantation. Indications included critical or atretic native coarctation (n = 4), patients > 50 years of age (n = 2), associated patent ductus arleriosus (n = 1) or adjacent aneurysm (n = 1), and the presence of a circumferential fracture within a previously implanted stent (n = 1). The covered balloon-expandable Cheatham-Platinum stem and the self-expandable stent graft Braile were employed. Adequate implantation was observed in all patients. Gradients were reduced from 54 ± 14 to 3 ± 8 mmHg and the coarctation site increased from 2.4 ± 2.9 to 15.9 ± 4.3 mm. The patent ductus arteriosus was immediately closed and the aneurysm excluded. Two patients > 35 years with aneurysmal ascending aorta and metallic aortic prosthesis had aneurysm formation at follow-up. with one undergoing aneurysm exclusion using a Braile stent. Although covered stents are useful in the management of selected patients with coarctation, aneurysm formation may still occur in patients with markers of aortic wall weakness. Refinements in the deployment technique and/or the stent design are needed to eliminate this risk. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate the initial clinical experience with the Helex septal occluder for percutaneous closure of atrial septal defects. METHODS: Ten patients underwent the procedure, 7 patients with ostium secundum atrial septal defects (ASD) with hemodynamic repercussions and 3 patients with pervious foramen ovale (PFO) and a history of stroke. Mean age was 33.8 years and mean weight was 55.4 kg. Mean diameter by transesophageal echocardiography and mean stretched ASD diameter were 11.33 ± 3.3mm, and 15.2 ± 3.8mm, respectively. The Qp/Qs ratio was 1.9 ± 0.3 in patients with ASD. RESULTS: Eleven occluders were placed because a patient with 2 holes needed 2 devices. It was necessary to retrieve and replace 4 devices in 3 patients. We observed immediate residual shunt (< 2mm) in 4 patients with ASD, and in those with patent foramen ovale total occlusion of the defect occurred. No complications were noted, and all patients were discharged on the following day. After 1 month, 2 patients with ASD experienced trivial residual shunts (1mm). In 1 patient, we observed mild prolapse in the proximal disk in the right atrium, without consequences. CONCLUSION: The Helex septal occluder was safe and effective for occluding small to moderate atrial septal defects. Because the implantation technique is demanding, it requires specific training of the operator. Even so, small technical failures may occur in the beginning of the learning curve, but they do not involve patient safety.

Abstract Introduction Tinnitus is considered the third worst symptom affecting humans. The aim of this article is to assess complaints by workers with tinnitus exposed to environmental and occupational noise. Methodology 495 workers went through an epidemiological survey at the Audiology Department of the Center for Studies on Workers’ Health and Human Ecology, from 2003 to 2007. The workers underwent tonal and vocal audiometry, preceded by a clinical and occupational history questionnaire. Two-factor ANOVA and Tukey were the statistical tests used. All the analysis set statistical significance at α=5%. Findings There was a higher prevalence of occupational tinnitus (73.7%), a predominance of female domestic workers (65.4%) in cases of environmental exposure, and predominance of male construction workers (71.5%) for occupational exposure. There was a significant difference in workers with hearing loss, who showed a mean speech recognition index (SRI) of 85%, as compared to healthy workers with a mean SRI greater than 93.5%. Signs and symptoms, speech perception, and interference in sound localization with the type of noise exposure (environmental versus occupational) comparisons found no significant differences. Conclusion Studied group’s high prevalence of tinnitus, major difficulties in speech recognition with hearing loss and the presence of individuals with normal hearing with both types of exposure justify the importance of measures in health promotion, prevention, and hearing surveillance. The findings highlight the importance of valuing the patients’ own perception as the first indication of tinnitus and hearing loss in order to help develop appropriate public policies within the Unified National Health System (SUS).

Introduction: SARS-CoV-2 infection usually presents similarly to other respiratory viral pathogens. Children and adolescents do not present as a group that is highly affected by the disease, having low infection rates. However, limited publications are associated with the findings of pneumonia in pediatric patients with COVID-19., Objective: To analyze the clinical and epidemiological aspects of children and adolescents hospitalized with SARS-CoV-2 in a pre-Amazon region., Methods: A retrospective study, carried out in four public hospitals in São Luís, Brazil where medical records of children and adolescents aged from 0 to 13 years, of both sexes, with clinical diagnosis of community-acquired pneumonia were evaluated from March 2020 to March 2021., Results: Almost 40.0% of children were aged between 1 year and 5 years. Of the 128 children who had SARS-CoV-2, 3 are of indigenous ethnicity. Additionally, 78.6% of the children had fever and there was no significant difference between COVID-19 patients and those of other respiratory viruses. Eighteen patients had chronic neurological disease, which is the most common comorbidity observed in patients with coronavirus infection. Ground glass opacity attenuation was observed in 24.8% of children and adolescents with COVID-19. Anemia and increased inflammatory response markers were related to SARS-CoV-2 infection. More than 90.0% of patients admitted to hospital, regardless of etiology, were treated with antibiotics. Eighteen patients died. Pediatric multisystem inflammatory syndrome (PMIS) was diagnosed in 17 patients., Conclusions: SARS-CoV-2 in children and adolescents is mild, but the condition of patients with PMIS is more serious, with an increase in inflammatory biomarkers which can lead to death. Therefore, rapid diagnosis and differentiation of agents causing respiratory diseases are necessary for better therapeutic decision making, since the results of this study make us question the excessive use of antibiotics without meeting well-defined clinical-epidemiological criteria.

Introduction: Although fewer children have been affected by the severe form of the coronavirus disease 2019 (COVID-19), community-acquired pneumonia (CAP) continues to be the leading global cause of child hospitalizations and deaths., Aim: This study investigated the incidence of respiratory syncytial virus (RSV) as well its subtypes (RSV A and B), adenovirus (ADV), rhinovirus (HRV), metapneumovirus (HMPV), coronavirus (NL63, OC43, 229E and HKU1), parainfluenza virus subtypes (PI1, PI2 and PI3), bocavirus and influenza A and B viruses (FluA and FluB) in children diagnosed with CAP during the COVID-19 pandemic., Methods: A total of 200 children with clinically confirmed CAP were initially recruited, of whom 107 had negative qPCR results for SARS-CoV-2 and were included in this study. Viral subtypes were identified using a real-time polymerase chain reaction in the nasopharyngeal swab samples., Results: Viruses were identified in 69.2% of the patients. RSV infections were the most frequently identified (65.4%), with type RSV B being the most prevalent (63.5%). In addition, HCoV 229E and HRV were detected in 6.5% and 3.7% of the patients, respectively. RSV type B was associated with severe acute respiratory infection (ARI) and a younger age (less than 24 months)., Conclusions: New strategies for preventing and treating viral respiratory infections, particularly RSV infections, are necessary.

Brain macrophage populations include parenchymal microglia, border-associated macrophages, and recruited monocyte-derived cells; together, they control brain development and homeostasis but are also implicated in aging pathogenesis and neurodegeneration. The phenotypes, localization, and functions of each population in different contexts have yet to be resolved. We generated a murine brain myeloid scRNA-seq integration to systematically delineate brain macrophage populations. We show that the previously identified disease-associated microglia (DAM) population detected in murine Alzheimer's disease models actually comprises two ontogenetically and functionally distinct cell lineages: embryonically derived triggering receptor expressed on myeloid cells 2 (TREM2)-dependent DAM expressing a neuroprotective signature and monocyte-derived TREM2-expressing disease inflammatory macrophages (DIMs) accumulating in the brain during aging. These two distinct populations appear to also be conserved in the human brain. Herein, we generate an ontogeny-resolved model of brain myeloid cell heterogeneity in development, homeostasis, and disease and identify cellular targets for the treatment of neurodegeneration., Competing Interests: Declaration of interests A.S. and F.G. are inventors on a patent filed, owned, and managed by A∗ccelerate technologies Pte Ltd, A(∗)STAR, Singapore, on technology related to the work presented in this manuscript., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Serrated polyposis (SPP) is characterized by the development of multiple serrated polyps and an increased predisposition to colorectal cancer (CRC). In the present study, we aimed to characterize, at a clinical and molecular level, a cohort of SPP patients with or without a family history of SPP and/or polyps/CRC (SPP-FHP/CRC). Sixty-two lesions from 12 patients with SPP-FHP/CRC and 6 patients with sporadic SPP were included. The patients with SPP-FHP/CRC presented with an older mean age at diagnosis (p=0.027) and a more heterogeneous histological pattern of lesions (p=0.032) than the patients with sporadic SPP. We identified two molecular forms of SPP-FHP/CRC, according to the preferential location of the lesions: proximal/whole-colon or distal colon. Mismatch repair (MMR) gene methylation [mutS homolog 6 (MSH6)/mutS homolog 3 (MSH3)] or loss of heterozygosity (LOH) of D2S123 (flanking MSH6) were detected exclusively in the former (p=3.0x10-7), in most early lesions. Proximal/whole‑colon SPP-FHP/CRC presented a higher frequency of O-6-methylguanine-DNA methyltransferase (MGMT) methylation/LOH, microsatellite instability (MSI) and Wnt mutations (19/29 vs. 7/17; 16/23 vs. 1/14, p=2.2x10-4; 15/26 vs. 2/15, p=0.006; 14/26 vs. 4/20, p=0.02) but a lower frequency of B-raf proto-oncogene, serine/threonine kinase (BRAF) mutations (7/30 vs. 12/20, p=0.0089) than the distal form. CRC was more frequent in cases of Kirsten rat sarcoma viral oncogene homolog (KRAS)-associated proximal/whole-colon SPP-FHP/CRC than in the remaining cases (4/4 vs. 1/8, p=0.01). Thus, SPP-FHP/CRC appears to be a specific entity, presenting two forms, proximal/whole-colon and distal, which differ in the underlying tumor initiation pathways. Early MGMT and MMR gene deficiency in the former may underlie an inherited susceptibility to genotoxic stress.

Objectives: To evaluate the importance of providing guidelines to patients via active telephone calls for blood pressure control and for preventing the discontinuation of treatment among hypertensive patients., Introduction: Many reasons exist for non-adherence to medical regimens, and one of the strategies employed to improve treatment compliance is the use of active telephone calls., Methods: Hypertensive patients (n=354) who could receive telephone calls to remind them of their medical appointments and receive instruction about hypertension were distributed into two groups: a) "uncomplicated" - hypertensive patients with no other concurrent diseases and b) "complicated" - severe hypertensive patients (mean diastolic ≥ 110 mmHg with or without medication) or patients with comorbidities. All patients, except those excluded (n=44), were open-block randomized to follow two treatment regimens ("traditional" or "current") and to receive or not receive telephone calls ("phone calls" and "no phone calls" groups, respectively)., Results: Significantly fewer patients in the "phone calls" group discontinued treatment compared to those in the "no phone calls" group (4 vs. 30; p<0.0094). There was no difference in the percentage of patients with controlled blood pressure in the "phone calls" group and "no phone calls" group or in the "traditional" and "current" groups. The percentage of patients with controlled blood pressure (<140/90 mmHg) was increased at the end of the treatment (74%), reaching 80% in the "uncomplicated" group and 67% in the "complicated" group (p<0.000001)., Conclusion: Guidance to patients via active telephone calls is an efficient strategy for preventing the discontinuation of antihypertensive treatment.

Background: The Transposition of the Great Arteries is the most frequent congenital cyanogenic cardiopathy in the neonatal period, corresponding to 7% of all congenital cardiopathies. Among the operations for surgical treatment, the Jatene operation, with arterial correction, is the treatment of choice. During the late postoperative evolution, some problems were observed, with the most common being the occurrence of supravalvular stenosis at the neopulmonary, regardless of the type of surgical technique used., Objective: To study and analyze the prevalence of stenosis, as well as describe the surgical treatment and propose technical maneuvers to prevent its onset., Methods: Of the 553 patients that underwent surgery, 409 were discharged from the hospital and 281 had late follow-up; 59 (20.9%) presented different degrees of supravalvular pulmonary stenosis and 21 had a mean gradient > 60 mmHg, needing surgical treatment. Depending on the location and anatomy of the stenosis, the surgical treatment consisted of the use of different techniques, such as the enlargement of stenosis areas with bovine pericardium patches, resection of stenotic areas and termino-terminal anastomosis, replacement of retracted patches and synthetic tubes., Results: Twenty patients presented good evolution and only one patient died., Conclusion: It can be concluded that the supravalvular pulmonary stenosis, post-Jatene operation for Transposition of Great Arteries, had a prevalence of 20.9%; once identified and with indication for treatment, it can be treated surgically with low mortality levels, through different surgical techniques; to prevent the occurrence of stenosis, ample dissection and release of the pulmonary branches, double anastomoses, large patches of autologous pericardium and careful reconstruction of the aorta are proposed, which prevents the compression of the neopulmonary.

Purpose: To evaluate the functional outcome and macular index in patients with macular hole who underwent surgery with internal limiting membrane removal., Methods: Fifteen eyes of 15 patients with idiopathic macular hole stages 2, 3 or 4 were enrolled in this study. All patients underwent conventional macular hole surgery with trypan blue staining to remove the internal limiting membrane. The best-corrected visual acuity and cross-sectional images of macular hole measured by optical coherence tomography (OCT) were evaluated pre- and postoperatively. The macular hole index (ratio of hole height to base diameter of the hole) was calculated and correlated with minimum diameter of the macular hole and postoperative gain in visual acuity., Results: Macular hole closure was observed in all operated patients. In 86.7%, there was a visual gain of at least three lines. Macular hole index was significantly negative correlated with the minimum diameter of the macular hole (r=0.811). There was no significant correlation between macular index and postoperative gain in visual acuity (r=0.351)., Conclusion: Functional outcomes with internal limiting membrane removal were good in this group of patients. Macular index was compatible with spatial configuration of the macular hole, however visual outcomes were not predictable.

Introduction: The quantity of topical treatments for leg ulcers has increased over the last 15 years., Objective: To determine the prescriptions for topical treatments and the problems in the management of leg ulcers using a questionnaire sent to general practitioners., Material and Methods: A questionnaire in 3 parts was sent to 95 general practitioners in the area working in 36 different districts with an explanatory letter. The first part was composed of 29 closed questions regarding prescription of topical treatment for leg ulcers. The second part, also closed, included 3 pictures showing a budding, a necrotic and a fibrinous ulcer. The physicians had to choose which treatment they would have prescribed and the frequency of dressings changes. The third part was composed of two open questions regarding the problems encountered. The survey started on May 1st and was closed on June 30th 2002. No reminders were sent., Results: We received 52 replies, 49 of which were exploitable. Forty-five percent (43/95) did not reply. Occlusive dressings were widely prescribed (mainly hydrocolloid 38/49 and hydrocellular 28/49). Vaseline impregnated gauze were less prescribed (14/49). Dressings with balsam of Peru were prescribed often by 10 and occasionally by 27 general practitioners. Alginate or charcoal dressings were not always used appropriately. Antiseptics were prescribed by 10 physicians. Mechanical debridement of fibrinous or necrotic wounds was rarely used even for necrotic ulcers. Topical anesthetics were prescribed in 21 out of 33 cases of mechanical debridement. Some physicians referred care (n=4), others complained about lack of compliance (n=15), cost (n=14), local intolerance (n=10) and the excessively wide variety of dressings (n=10). We drew-up a synopsis with guidelines for treatment, which was sent to all the general practitioners who had participated in the survey., Conclusion: Forty-three of the 95 physicians approached did not reply. This poor response rate, which is common in this type of survey, may include physicians who are not at ease in the management of ulcers and this may bias the results. The physicians who replied to the survey knew the subject well but complained of the costs and variety of dressings. They were all eager to receive further information and guidelines.

Introduction: Diagnosis of atopic dermatitis currently relies on diagnostic criteria scales developed by Hanifin and Rafka in 1980 and by the "United Kingdom Working party" in 1994. Some authors have proposed: "AEDS" [sM1] and "Atopiform Dermatitis", which has led to the distinction between different sub-populations and the exclusion of certain diseases from the diagnosis of atopic dermatitis. The aim of our study was to collect the criteria retained in the scientific medical literature during the year 2002 for the definition of atopic dermatitis and to try to understand not only the interest but also the questions that the various definitions lead to., Method: A PubMed research was launched with the key word "atopic dermatitis" from January to September of 2002. All the scientific articles either in French or in English were studied., Results: Hanifin and Rafka's criteria were selected in 44 p. 100 of the scientific articles, and the "United Kingdom Working Party" criteria in 12 p. 100. Personal definitions were used in 21 p. 100 of the articles; these were based on the level of total and specific IgE or on personal clinical criteria. For twenty-three p. 100 of the authors, the definition of atopic dermatitis was not specified., Discussion: There was not just one definition of atopic dermatitis. This may affect the interpretation of diagnostic or therapeutic papers concerning the disease, because there has been no proof that these definitions cover the same population of patients.

Introduction: Colchicine is a treatment used for aphthous stomatitis but its efficacy has never been proved. We report the results of an open trial of 54 patients treated with colchicine for aphthous stomatitis. The aim of our study was to assess the long and short term efficacy and tolerance of this molecule in this disease., Patients and Methods: The case reports of 64 patients presenting with severe, recurrent aphthous stomatitis treated with colchicine between 1986 and 2000 were analyzed retrospectively. Only immunocompetent patients exhibiting idiopathic aphthous stomatitis or Behçet's disease were included. Ten patients were excluded: 4 cases of Behçet's disease treated with colchicine and systemic corticosteroids, 4 cases of aphthous stomatitis secondary to a hematological cause and 2 patients who were lost to follow-up after 3 month's treatment. Colchicine was prescribed at a dose of 1 to 1.5 mg/d for at least 3 months. All the patients were assessed after 3 month's treatment and all were contacted by phone in May 2000. Our end-point criteria were: the frequency and duration of the episodes, intensity of pain and impact on the quality of life of the patients., Results: Fifty-four patients were included: 39 women (mean age=44 +/- 16.8) and 15 men (mean age=49 +/- 13.5). The disease had progressed for a mean of 11.6 +/- 13.5 years. After 3 month's treatment, 12 patients (22 p. 100) no longer had aphta and were in complete remission, 22 patients (41 p. 100) were significantly improved, since the frequency and duration of the lesions had decreased by at least 50 p. 100 and the latter were no longer painful. Treatment failed or tolerance was poor in 20 patients (37 p. 100). Patients were monitored and assessed for a mean of 4.7 years (range: 6 months to 13 years). Six patients were lost to follow-up. Three patients (6 p. 100) were considered as cured, since they were still in complete remission after suspension of colchicine respectively 6, 24 and 72 months later. Fifteen patients (31 p. 100) had still improved. Among the latter, 10 continued colchicine for a mean of 27 months, and 5 patients stopped treatment, which they considered tedious, after a mean of 16 months. These 15 patients noted a significant reduction in the frequency and duration of the lesions. Moreover, the subjective end-point criteria had improved significantly for them not to wish to change treatment. Thirty patients (63 p. 100) were not improved by the treatment. Some benign adverse events were noted in 10 patients (18.5 p. 100) and led to suspension of treatment in 4 cases., Discussion: This study, which is the first in size (n=54) and duration of follow-up (4.7 years), showed that colchicine is an efficient preventive treatment of severe aphthous stomatitis for 63 p. 100 of patients after 3 month's treatment and that this improvement was lasting in 37 p. 100 of them. Colchicine should therefore be proposed in first intention in severe recurrent aphthous stomatitis, since it is effective, well tolerated and easy to use.

Background: Relapsing polychondritis is a rare autoimmune disease, characterized by recurrent inflammation of cartilaginous tissues. In some cases, many other tissues can be involved., Case Report: We describe the case of a 64 year-old man with relapsing polychondritis, whose first symptoms were papulonodular and mucosal aphthous lesions. The skin biopsy revealed vasculitis without leukocytoclasic features. The diagnostic of relapsing polychondritis was made only two years later, thanks to recurrent auricular chondritis. Since the beginning, the disease was associated with a myelodysplasia., Discussion: Dermatological manifestations are noticed in less than 50 p. 100 of cases during the evolution of relapsing polychondritis. An association with a myelodysplasia has already been reported, and it could be a particular form of relapsing polychondritis. Myelodysplasic syndromes are more frequently associated with relapsing polychondritis than with other vasculitis. It must be sought especially when cutaneous and mucosal manifestations exist.

OBJECTIVE - To report the results of percutaneous occlusion of persistent ductus arteriosus with the Amplatzer prosthesis in 2 Brazilian cardiological centers. METHODS - From May 1998 to July 2000, 33 patients with clinical and laboratory diagnosis of persistent ductus arteriosus underwent attempts at percutaneous implantation of the Amplatzer prosthesis. The median age was 36 months (from 6 months to 38 years), and the median weight was 14kg (from 6 to 92kg). Sixteen patients (48.5%) were under 2 years of age at the time of the procedure. All patients were followed up with periodical clinical and echocardiographic evaluations to assess the presence and degree of residual shunt and possible complications, such as pseudocoarctation of the aorta and left pulmonary artery stenosis. RESULTS - The minimum diameter of the arterial ducts ranged from 2.5 to 7.0mm (mean of 4.0+/-1.0, median of 3.9). The rate of success for implantation of the prosthesis was 100%. Femoral pulse was lost in 1 patient. The echocardiogram revealed total closure prior to hospital discharge in 30 patients, and in the follow-up visit 3 months later in the 3 remaining patients. The mean follow-up duration was 6.4+/-3.4 months. All patients were clinically well, asymptomatic, and did not need medication. No patient had narrowing of the left pulmonary artery or of the aorta. No early or late embolic events occurred, nor did infectious endarteritis. A new hospital admission was not required for any patient. CONCLUSION - The Amplatzer prosthesis for persistent ductus arteriosus is safe and highly effective for occlusion of ductus arteriosus of varied diameters, including large ones in small symptomatic infants.

We report new percutaneous techniques for perforating the pulmonary valve in pulmonary atresia with intact ventricular septum, in 3 newborns who had this birth defect. There was mild to moderate hypoplastic right ventricle, a patent infundibulum, and no coronary-cavitary communications. We succeeded in all cases, and no complications related to the procedure occurred. The new coaxial radiofrequency system was easy to handle, which simplified the procedure. Two patients required an additional source of pulmonary flow (Blalock-Taussig shunt) in the first week after catheterization. All patients had a satisfactory short-term clinical evolution and will undergo recatheterization within 1 year to define the next therapeutic strategy. We conclude that this technique may be safely and efficiently performed, especially when the new coaxial radiofrequency system is used, and it may become the initial treatment of choice in select neonates with pulmonary atresia and intact ventricular septum.

OBJECTIVE: Cardiac catheterization has begun to be employed for therapeutic purposes since the middle sixties. In this paper the authors review the current indications, technique and results related to each of the interventional procedures. It also includes a brief sample of the Instituto Dante Pazzanese experience for illustrative purpose. METHODS: The main procedures that are addressed include balloon and blade atrial septostomy (Rashkind and Park procedures), pulmonary valvuloplasty, aortic valvuloplasty, mitral valvuloplasty (for rheumatic mitral stenosis), angioplasty for coarctation of aorta with or without stent implantation, angioplasty for pulmonary artery stenosis with or without stent implantation, percutaneous occlusion of the patent ductus arteriosus, percutaneous occlusion of atrial septal defects and balloon dilation of stenosed Blalock-Taussig shunts. The authors make a review of the most important papers published in the literature about Interventional Pediatric Cardiology, including their own experience. RESULTS: Good or excelent therapeutic results are achieved for pulmonic stenosis, coarctation of aorta, patent ductus arteriosus, atrial septal defects and pulmonary branch stenosis. Satisfactory palliations are obtained for aortic stenosis, rheumatic mitral stenosis and complex congenital heart diseases that require balloon atrial septostomy. CONCLUSIONS: Due to the recent technological development, pediatric therapeutic heart catheterization makes it possible to treat or palliate about 30% of all congenital or acquired heart diseases with encouraging results, sparing some patients from the need of cardiac surgery.

OBJECTIVE - To analyze immediate and late results of percutaneous mitral valvotomy (PMV) in patients < or = 18 year. METHODS - Between August '87 and July '97, 48 procedures were performed on 40 patients. The mean age was 15.6 years; 68.7% were females four of whom were pregnant. RESULTS - Success was obtained in 91.7% of the procedures. Immediate complications were severe mitral regurgitation (6.3%) and cardiac tamponade (2.0%). Late follow-up was obtained in 88.8% of the patients (mean value=43.2+/-33.9 months). NYHA functional class (FC) I or II was observed in 96.2% of the patients and restenosis developed in five patients, at a mean follow-up of 29.7+/-11.9 months. Three patients presented with severe mitral insufficiency and underwent surgery. Two patients died. CONCLUSION - PMV represents a valid therapeutic option in young patients. In these patients, maybe because of subclinical rheumatic activity, restenosis may have a higher incidence and occur at an earlier stage than in others persons.

Purpose: To assess the results of reocclusion procedures for late residual shunts after transcatheter closure of the patent ductus arteriosus., Material and Methods: Nineteen patients underwent reocclusion procedures either with Rashkind technique (2 patients) or with coils. Mean age was 96.5 months and mean interval between the initial and the additional procedure was 15.7 months. In 5 patients, the duct was balloon-dilated prior to occlusion., Results: In 3 patients the procedure was unsuccessful because it was impossible to cross the duct using either a guide wire or a catheter. Immediate or late complete occlusion occurred in 13 patients. Two patients required a third procedure for complete closure. One patient developed severe intravascular hemolysis after coil implantation and was sent to surgery. The rate of final late residual shunting decreased from 17.1% to 6.6% (5/76) in the umbrella group and from 15.8% to 1.8% (1/56) in the coil group., Conclusions: Reocclusion procedures are indicated after one year of persistent shunting following the primary procedure. They are generally effective and reduce significantly the rate of late residual shunting. In patients with tiny shunts, the duct may need to be dilated. Coils are preferred because of their low cost.

In this report, we describe our experience with transcatheter occlusion of congenital coronary arterial fistulas in adults. From November 1992 to November 1996, 5 symptomatic patients, aged from 47 to 70 years, underwent transcatheter occlusion of fistulas using a retrograde arterial approach. All had chest pain or dyspnea on exertion. Detachable balloons were used in 4 patients, and Gianturco coils in 1. Detachable balloons were implanted through a Debrun system, while the coils were implanted through a 5 French right coronary Judkins catheter. Both were passed through an 8 French guiding catheter (Amplatz II). Each patient had a single fistula. The fistulas originated from the right coronary artery in 3 patients, and from the circumflex artery in 2. They drained into the pulmonary trunk in 3 patients, into the right atrium in 1, and into a bronchial artery in the other. All fistulas were occluded completely in the catheterization laboratory, and the procedures were uncomplicated. At follow up, 3 patients underwent coronary angiography, and there was no evidence of recanalization. Transcatheter embolization in adults of single congenital coronary fistulas with detachable balloons and coils is safe and effective and can be regarded as an acceptable alternative to surgery.

Purpose: Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder., Methods: Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters., Results: Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disappeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27 mm (average) to 24 mm and 20 mm, one and three months after the procedure, respectively (p < 0.0076)., Conclusion: With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

Purpose: To evaluate the overall experience of our institution with percutaneous occlusion of the patent ductus arteriosus., Methods: Since December/92, 150 patients underwent 178 procedures (85-Rashkind technique; 87-Gianturco coils; 6-Duct Occlud). Median age was 6.5 years (1 to 57). Mean minimum ductal diameter was 3.05 +/- 1.24 mm (1 to 8). Clinical and echocardiographic evaluations were performed periodically., Results: Adequate implantation was achieved in 143 (95.3%) patients. Prevalence of immediate residual shunting was 52.1%, falling to 15.9% during follow-up. This figure decreased to 5.2% after new additional procedures. Umbrella and coil embolization occurred in 1 and 12 procedures, respectively. Hemolysis and mild stenosis of left pulmonary artery were observed in one patient each. There was no mortality., Conclusion: This therapeutic modality is safe and efficacious with good follow-up results.

We report on a case of successful percutaneous closure of two atrial septal defects and a persistent ductus arteriosus using two Amplatzer septal occluders and a Gianturco coil in a 9-year-old child.

We report a rare case of a 21 month old child with a coronary sinus atrial septal defect associated with perimembranous ventricular septal defect and no left superior vena cava. The diagnosis was made by transthoracic echocardiogram and confirmed by angiography. The patient was operated on uneventfully, both defects were closed with bovine pericardial patches and the flow from the coronary veins was directed towards the left atrium. An echocardiogram revealed complete closure of both defects.

Purpose: To evaluate our initial experience with percutaneous closure of secundum type atrial septal defects (ASD) with the Amplatzer septal occluder., Methods: Seven patients underwent occlusion by anterograde approach, under general anesthesia and transesophageal echocardiography (TEE) guidance. One child had 2 ASD and a patent ductus arteriosus (PDA). The ASD size ranged from 8.7 to 20 mm as measured by TEE. A transthoracic echocardiogram was performed in the morning after the procedure., Results: Eight devices were successfully implanted in 7 patients and the PDA was occluded with a Gianturco coil at the same session. In this patient, there was an episode of supraventricular tachycardia during the occlusion of one ASD which was reverted with adenosin. All patients were discharged the day after, with complete occlusion of all defects., Conclusion: The procedure is safe, effective and versatile. It can be applied as an initial alternative to the treatment of selected patients with ASD.

Purpose: To evaluate the results of percutaneous balloon valvuloplasty (PBV) for membranous subaortic stenosis (MSAS)., Methods: Seven patients with MSAS were submitted to PBV using the retrograde approach. Hemodynamic and angiographic studies were performed before and after the procedure. The balloon/annulus ratio varied between 0.9 to 1.05., Results: The systolic gradient (SG) between the left ventricle (LV) and aorta was reduced from 57.8 +/- 11.6 to 22.0 +/- 8.6 mmHg (p < 0.001) and the LV systolic pressure from 154.5 +/- 30.3 to 118.7 +/- 18.4 mmHg (p < 0.001). One patient had arterial occlusion and was submitted to surgical embolectomy and another one showed severe mitral regurgitation combined with aortic insufficiency (AI) and required surgical valvuloplasty. There was no mortality. Four patients had a 11 +/- 10 month follow up: the SG measured by echocardiogram was 34 +/- 7 mmHg and no patient showed worsening of the AI., Conclusion: PBV is an effective procedure to reduce the subaortic SG, with an acceptable morbidity and persistence of the results in the short term follow up. PBV is a valid alternative as an initial mode of therapy in the management of patients with MSAS.

The association of pulmonary valve stenosis and patent ductus arteriosus is uncommonly found in clinical practice of pediatric cardiology. The authors describe 2 patients with this association that were successfully treated in the same procedure by interventional cardiology: first case, a 14 month old boy was submitted to percutaneous pulmonary valvoplasty with reduction of systolic gradient between pulmonary artery and right ventricle from 71 to 3 mmHg. The 2.0 mm of diameter and conical shape duct was successfully occluded using a 38-5-5 coil; second case, a 20 month old girl was submitted to percutaneous pulmonary valvoplasty with reduction of systolic gradient between pulmonary artery and right ventricle from 60 to 5 mmHg. An attempt to close the 3.5 mm of diameter and concial shape duct using coil was performed, but the device embolized into the pulmonary artery. After immediate retrieval, a 12 mm Rashkind umbrella was implanted. Indication of treatment of both conditions, technical aspects and complications related to the procedures, and patients follow up are also discussed.

The authors report their experience with the percutaneous closure of the patent ductus arteriosus with the Rashkind technique. They performed 42 procedures with a success of 97.6% and one embolization episode. The mean age was 8.7 +/- 6.7 years, the mean weight was 25.0 +/- 15.8 Kg and the minimum diameter of the ductus was 4.0 +/- 1.3 mm. The immediate overall prevalence of residual shunt was 48.8% falling to 21% in a mean follow-up of 17 +/- 13 months in 29 cases. Two patients underwent late reocclusion: one with a new umbrella and the other with a coil. Another patient had an immediate severe residual shunt and it was reoccluded in the same procedure with a coil. The anatomical type and minimum internal diameter of the ductus, age and weight, size of the umbrella and the rotation of the umbrella were not predictors of residual shunt. There were no deaths, hemolysis, endarteritis or fracture of the umbrella's arms. One patient remained with a slight gradient in the left pulmonary artery. The authors conclude that the Rashkind technique is safe and efficient and has good long term results. It should be considered as the first line therapeutic modality in the treatment of selected patients with persistent ductus arteriosus.

Six days old neonate with pulmonary atresia and intact ventricular septum is reported in which a communication was established between the right ventricle and the pulmonary artery. The membraneous atresia was perforated with a special radiofrequency catheter 2F connected to a Hat 200S radiofrequency generator (Osypka). The energy necessary to perforation was 15W. After perforation of the atresia, balloon dilation was performed (balloon diameter: 2, 3, 4mm of coronary angioplasty and 5, 8mm Penta Medi-tech). The valve was completely opened giving the continuity between right ventricle and pulmonary artery.

Purpose: To evaluate the late hemodynamic and angiographic results of 52 patients who underwent mitral valvoplasty by the double balloon technique in the treatment of the rheumatic mitral stenosis., Methods: The mean follow-up was of 18 months and the patients had a Doppler-echocardiogram and cardiac catheterization one year after dilatation. Of the 52 patients 84.6% were female and the mean age was 21.9% years. Eighty one percent were in NYHA class I whereas 5.7% had atrial fibrillation at the end of 18 months., Results: Immediately after valvoplasty 46 patients (88.5%) had a valvar area larger, and 6 (11.5%) smaller than 1.5 cm2. The first group had a good clinical outcome with maintenance of the clinical, echocardiographic and angiographic results in the late follow-up, including the diastolic gradient and the valvar area. Of the 6 cases with mitral area smaller than 1.5 cm2, 2 had a good clinical evolution, 2 were re-dilated, 1 was scheduled for surgery and the last one is under clinical management but with poor hemodynamic results. Three (5.7%) cases developed an atrial septal defect after the procedure, with hemodynamic repercussion in 1. Mitral regurgitation developed in 16 cases (+ in 8, +/++ in 8) without changes during the follow-up period., Conclusion: Double balloon mitral valvoplasty is a safe effective method in the treatment of the rheumatic mitral stenosis, and offers a better evolution in patients with a valvar area larger than 1.5 cm2 after the dilatation.

White male patient, 14 years old, who developed a severe subaortic stenosis in the late postoperative period of a total correction of atrioventricular septal defect. Clinical diagnosis was confirmed by echocardiography and cardiac catheterization. The patient underwent reoperation for treatment of the new condition, with resection of subaortic stenosis. Atrioventricular septal defects show a narrow and deformed left ventricle outflow tract, susceptible to obstruction before or after operation. It is, therefore, advisable to investigate a possible obstruction before the operation at the operation room and in the late postoperative period.

Fifty eight year old man, with dyspnea, fatigue and progressive angina underwent cinecoronarography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to occlude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronarography 6 months later showed the maintainance of the initial results.

Purpose: To analyse the actual contribution of digital angiography in the angioplasty setting and to assess its utility to optimize angioplasty results., Methods: One hundred patients with single vessel coronary artery disease, without previous angioplasty or coronary artery bypass graft surgery, who underwent angioplasty from January to December 1990. Views were obtained in standard films and also in digitized angiograms. The latter was acquired before angioplasty in order to precisely quantify the stenosis and also to measure the reference diameter of the artery that was used and to choose the balloon catheter for each case. New acquisitions were done during and after the end of the procedure to confirm the residual stenosis and to measure the final diameter., Results: The mean stenosis pre angioplasty was 78.2%, the mean reference diameter 2.8 mm and the mean diameter at the stenotic site 0.8 mm. The balloon artery relation was 0.9:1. After angioplasty the residual stenosis was 13.6% and the dilated segment had a final diameter of 2.6 mm. There were no complications in any patient., Conclusion: Digital angiography is a useful method for laboratories devoted to coronary interventions for it allows confirmation of the severity of the stenosis, optimizes the balloon/artery relation, monitors partial results and measures the residual stenosis as well as the final diameter.