Closure of atrial septal defects: is there still a place for surgery?

BACKGROUND: The purpose of this study is to assess the current management of atrial septal defect closure in an era of increasing feasibility of transcatheter device occlusion. METHODS: Atrial septal defect (ASD) closure was performed surgically through complete sternotomy in 165 patients (group 1) and through partial inferior sternotomy in 53 patients (group 2). Transcatheter device occlusion was achieved in 82 patients with only ASD type II and patent foramen ovale (group 3). RESULTS: Overall complications were minor and more frequent in group 1: 26.7% versus 13.2% in group 2 and 14.6% in group 3 (p = 0.04). Compared to complete sternotomy, a partial sternotomy led to less chest tube loss (7.1 +/- 2.9 versus 11.6 +/- 14.5 ml/kg) (p < 0.05) and less postoperative pericardial effusion (11.3% versus 13.5%)(p = 0.55). ASD closure was effective in 99.4% in group 1, 100% in group 2 but only in 86.6% in group 3 (p < 0.05). Two major complications of device implantation required early surgery: 1 femoral arteriovenous fistula and 1 device embolization. Hospital stay was significantly shorter in group 3, as well as in group 2 compared to group 1 (8.3 +/- 4.2 versus 5.9 +/- 1.1 versus 2.1 +/- 7.3 days) (p < 0.05). Midterm results were excellent, with only 1 non-cardiac death and 1 re-operation for residual shunt in group 1, and 1 device removal for thrombosis in group 3. CONCLUSION: Transcatheter device occlusion has become an established treatment for ASD closure, achieving optimal results in older children and adults with anatomically suited ASD type II and PFO. However, a partial inferior sternotomy offers a valuable and complementary operative approach for all ASD variants, maintaining the predictable success of surgery, with the obvious advantages of minimal access in terms of morbidity, cosmetics and hospital stay.

Effects of 2',3'-dideoxycytidine and 2',3'-dideoxycytidine 5'-triphosphate on phospholipid metabolism in permeabilized rat hepatocytes.

Both 2',3'-dideoxycytidine (ddC) and 2',3'-dideoxycytidine 5'-triphosphate (ddCTP) inhibit the synthesis of the major phospholipids phosphatidylcholine (PC) and phosphatidylethanolamine (PE) in permeabilized rat hepatocytes. For PC, this appears to be based on competitive inhibition of cholinephosphotransferase (CDPcholine:1,2-diacylglycerol cholinephosphotransferase; EC 2.7.8.2). The study was based on short-term incubations (6-12 min) of the nucleoside/nucleotide analogs with alpha-toxin permeabilized rat hepatocytes. At a concentration of 1 mM, ddC and ddCTP decreased the incorporation of radiolabelled glycerol-3-phosphate into PC by approximately 50% as compared with control. This was accompanied by a significant increase in diacylglycerol labelling. In the presence of 1 mM CDP-ethanolamine and increasing concentrations of ddC(TP) (0.01-1 mM), the incorporation of radiolabelled glycerol-3-phosphate into PE was decreased to approximately 60% of the control value. When both PC and PE synthesis were operative, the inhibition by ddC(TP) was restricted to PC synthesis. ddC and ddCTP were found to have inhibition constants (K(i)) of 496 microM and 452 microM, respectively, for the inhibition of PC synthesis from CDP-choline. Although the inhibitory concentrations of the nucleoside analog and its triphosphate ester are much higher than the in vivo plasma concentrations, the possibility is raised that the peripheral neuropathy, seen as a dose-dependent adverse effect of ddC treatment in acquired immunodeficiency syndrome therapy is, at least partly, caused by a perturbation of the phospholipid constitution of neuronal membranes.

The use of propranolol in the treatment of periocular infantile haemangiomas: a review.

Infantile haemangiomas (IH) are benign vascular tumours characterised by their very rapid growth. Although usually innocuous, periocular IH can cause serious visual loss through induction of strabismic, deprivational or anisometropic astigmatism. Common treatment modalities for these IH include intralesional and systemic oral steroids; however, both treatments are associated with potentially severe side effects. A report was published recently demonstrating the impressive effect of propranolol in the treatment of IH. This exciting finding has provoked a paradigm shift in the management of this condition. So far little has been reported in the specific ophthalmologic literature, although case reports are emerging. This review gives an overview of the recent findings and includes the authors' experience with 10 patients treated with propranol.

Percutaneous closure by a vascular plug of a fistula between the superior caval vein and the left atrium.

We report the case of a 7-year-old boy with a history of pulmonary atresia and intact septum who developed a fistula between the remnant of the ligated superior caval vein and the left atrium after bidirectional superior cavopulmonary (Glenn) anastomosis. The close proximity to the right pulmonary veins made closure by a standard occluder impossible. An Amplatzer vascular plug without rim enabled us to close the connection percutaneously without obstructing the pulmonary venous flow. The technique appeared to be easy, safe, and effective.

Is morbidity influenced by staging in the fontan palliation? A single center review.

In a retrospective study of 32 consecutive patients undergoing a total cavopulmonary connection (TCPC), we tried to determine if the trend for decreasing age at Fontan completion and reducing the intervals between the staged procedures during the past decade was associated with a change in morbidity and outcome. In 8 patients the Fontan circulation was completed in one stage and in 24 patients an intermediate step by hemi-Fontan or bidirectional cavopulmonary anastomosis was performed before Fontan completion. Mean age at TCPC and mean interval since the previous palliation have decreased significantly during the past decade. Although major complications were significantly reduced over time the occurrence and duration of postoperative pleural effusions were not. Decreasing age as well as intervals in staged Fontan palliation have beneficial influence on major complications and outcome, without significantly affecting the duration of pleural effusions at Fontan completion.

Inactivated hepatitis A vaccine: reactogenicity, immunogenicity, and long-term antibody persistence.

This trial evaluated the reactogenicity, kinetics of antibody induction, and long-term immunogenicity of a 720 enzyme-linked immunosorbent assay units (EL.U.) antigen dose of an inactivated hepatitis A vaccine (Havrix, SmithKline Beecham Biologicals, Rixensart, Belgium). One hundred six healthy adult volunteers were enrolled to receive vaccine intramuscularly according to a 0, 1, and 6-month schedule. The vaccine was well tolerated. The most frequently reported local symptom was soreness, observed following 37.1% of all doses. Headache was the most frequently reported general symptom observed following 12.9% of documented vaccine doses. The administration of one vaccine dose induced seropositivity (anti-hepatitis A virus [HAV] > or = 20 mIU/ml) in 91% of all vaccinees 1 month later. The second vaccine dose resulted in seropositivity of the remaining vaccinees at month 2. All subjects remained seropositive for HAV antibodies at month 6, at which time the booster vaccine dose was given. At month 7, all vaccinees had anti-HAV titres > 200 mIU/ml. Serological results obtained at months 12, 18, 24, and 36 showed that antibodies against HAV induced by the vaccine booster dose persist for at least 30 months following its administration. All 49 subjects followed up until month 36 had antibody titres > or = 20 mIU/ml. The geometric mean titre (GMT) decreased by 60% from month 7 to month 12; between month 12 and 36, the GMT decreased by approximately 14% per period of 12 months. According to the vaccine-induced antibody kinetics and the magnitude of antibody level decrease over time, the predicted duration of antibody persistence is estimated to be at least 20 years.

Palmitoyl-CoA synthetase on the external surface of isolated rat hepatocytes.

After incubating isolated rat hepatocytes with [1-14 C]palmitic acid, CoA and ATP (+MgCl2), a significant amount of [1-14 C]palmitoyl-CoA was found in the incubation medium. There was no correlation between its rate of synthesis and the degree of intactness of the cells. The results indicate that there is a long-chain fatty acyl-CoA synthetase active on the external surface of the hepatocyte plasma membrane. The activity of this enzyme was negligible in primary cultures of rat hepatocytes, suggesting that the exofacial long-chain acyl-CoA synthetase is an artifact of the collagenase perfusion technique used to prepare the hepatocytes.

Prevention of vertical transmission of hepatitis B virus infection. Is there a standard policy in Flanders (Belgium)?

The perinatal transmission of hepatitis B virus (HBV) from mother to child can be effectively prevented by the combined administration of hepatitis B immunoglobulins (HBIg) and hepatitis B vaccine (HB vaccine) immediately after birth. This requires prenatal screening of all pregnant women for HBsAg. In Belgium, a standard prevention policy does not exist. This study evaluated the current prevention policy of paediatricians in Flanders, regarding the prevention of vertical transmission of HBV, and their knowledge regarding the reimbursement of the HB vaccine for neonates of HBsAg-positive mothers. Ninety-one percent out of 134 participants administered both HBIg and HB vaccine. The recommended timing, within 12 hours post-partum, was observed in 60.0% for HBIg and in 50.3% for HB vaccine. Twenty-five percent of the respondents answered not to be well informed regarding the reimbursement of the HB vaccine. A preliminary study in Flanders among gynaecologists showed that 27 out of 29 routinely screened pregnant women for HBV, but the type of serology tested and the timing of this prenatal screening were very heterogeneous. We conclude that a standard policy regarding the prevention of vertical transmission of HBV is currently lacking in Flanders.

Pros and cons of an illicit drug users' registration system by means of judicial data in Flanders (Belgium).

The main objective of this study was to evaluate the advantages and shortcomings of a new kind of registration of illicit drug users in Flanders, Belgium. Data about the profile of drug users who have come into contact with the law were collected by examining the records kept by the District Courts. On the one hand, published data on illicit drug users in Flanders are scarce. On the other hand, a lot of unused judicial information is available. All District Courts in Flanders (n=13) and Brussels (n=1) participated in the study. The data show that a simple registration of verbalised drug users with a short questionnaire can provide useful information for prevention campaigns and police investigation and shows the importance of prevention programmes starting at school. Notwithstanding some shortcomings, the illicit drug users' registration system by means of judicial data in Flanders forms a solid basis upon which an integrated registration of illicit drug use can be built.