Percutaneous closure of ostium secundum atrial septal defect using left internal jugular vein access in a child with situs inversus and absence of inferior caval vein.

Femoral vein access is the first choice for percutaneous atrial septal defect closure, and when it cannot be used due to anatomic reasons, the alternative sites should be considered, frequently increasing the complexity of the procedure. Here we report the case of a 3-year-old boy, with situs inversus and dextrocardia, electively referred for percutaneous closure of an ostium secundum atrial septal defect. During the procedure, agenesis of the infra-hepatic segment of the inferior caval vein was diagnosed, and no double inferior caval vein or right superior caval vein were identified by ultrasound or angiography. Therefore, we opted to perform the procedure through the left internal jugular vein, with fluoroscopy and transesophageal echocardiographic guidance. Catheters were navigated through a hydrophilic guidewire, and a Stiff guidewire was positioned in the left ventricle for better support. An Amplatzer septa occluder 19 was successfully deployed without major difficulties and the patient was discharged after 24 hours in good clinical condition. Percutaneous atrial septal defect closure through alternative access sites, especially in the presence of situs inversus, may pose significant challenges to the interventional team. In this case, the left internal jugular vein has shown to be a feasible option, allowing the navigation and manipulation of devices without complications. Provided the expertise of the interventional team, and awareness of the risks involved, alternative access sites can be successfully used for paediatric structural interventions.

Adenosine for vasoreactivity testing in pulmonary hypertension: a head-to-head comparison with inhaled nitric oxide.

BACKGROUND: APVT is an invasive method recommended for symptomatic patients with PAH that permits the identification of the minority of patients (<20%) that may benefit from long-term calcium channel blockers. Adenosine has been indicated in guidelines as a vasodilator agent of choice for APVT, although it has not been directly compared with iNO, the gold standard for this test. The objective of the study was to compare adenosine with inhaled nitric oxide (iNO) for acute pulmonary vasoreactivity testing (APVT) in pulmonary arterial hypertension (PAH), in order to determine the efficacy and safety of the first in the clinical setting. METHODS: The measurements of cardiac output, pulmonary and systemic resistance were done in the basal state and with a stepwise increase of the dose of each drug until either maximum dosage (adenosine: 500 microg/kg/min or iNO: 80 ppm) or side effects observed or a positive response were reached, according to current guidelines. The order of drugs used in each test was consecutively alternated during the study. RESULTS: Six of the 39 studied patients (15%) presented a positive response to iNO; none to adenosine (p = 0.047, McNemar's test). Twenty-three patients (59%) did not reach the maximum dose of adenosine due to side effects, including bronchospasm, thoracic pain and bradycardia. CONCLUSIONS: APVT testing with adenosine was not able to detect PAH patients responsive to iNo and provoked frequent adverse effects. Adenosine should not be used as a vasodilator drug in APVT.

Diagnóstico ecocardiográfico de hematoma localizado comprimindo átrio direito em pós-operatório de cirurgia cardíaca / Echocardiographic Diagnosis of Hematoma Compressing the Right Atrium in Immediate Post-Operative Period

Uma paciente apresentou um grande hematoma comprimindo o átrio direito no pós-operatório de troca valvar e o diagnóstico pelo ecocardiograma, permitiu tratamento cirúrgico imediato, com reversäo do comprometimento hemodinâmico. O ecocardiograma é um exame näo invasivo importante no diagnóstico de complicaçöes pós-opertórias, situaçöes em que o exame transtorácico é tecnicamente dificil e o ecocardiograma transesofágico pode ser muito útil

This is a report of a patient presenting with a hematoma compresseing the right atrium in the immediate post-operative period and the diagnosis by echocardiography allowed prompt surgical treatment with reversibility of the hemodynamic failure. Echocardiography is an important tool in the diagnosis of post-operative complications and transesophageal echocardiography can be very helpful in this setting, where technically difficult transthoracic exams are the rule