Spectrum of cardiac lesions associated with Isolated Cleft Mitral Valve and their impact on therapeutic choices

Abstract Background: Isolated cleft mitral valve (ICMV) may occur alone or in association with other congenital heart lesions. The aim of this study was to describe the profile of cardiac lesions associated with ICMV and their potential impact on therapeutic management. Methods: We conducted a descriptive study with data retrieved from the Congenital Heart Disease (CHD) single-center registry of our institution, including patients with ICMV registered between December 2008 and November 2014. Results: Among 2177 patients retrieved from the CHD registry, 22 (1%) had ICMV. Median age at diagnosis was 5 years (6 days to 36 years). Nine patients (40.9%) had Down syndrome. Seventeen patients (77.3%) had associated lesions, including 11 (64.7%) with accessory chordae in the left ventricular outflow tract (LVOT) with no obstruction, 15 (88.2%) had ventricular septal defect (VSD), three had secundum atrial septal defect, and four had patent ductus arteriosus. Thirteen patients (59.1%) required surgical repair. The decision to proceed with surgery was mainly based on the severity of the associated lesion in eight patients (61.5%) and on the severity of the mitral regurgitation in four patients (30.8%). In one patient, surgery was decided based on the severity of both the associated lesion and mitral regurgitation. Conclusion: Our study shows that ICMV is rare and strongly associated with Down syndrome. The most common associated cardiac abnormalities were VSD and accessory chordae in the LVOT. We conclude that cardiac lesions associated with ICMV are of major interest, since in this study patients with cardiac lesions were diagnosed earlier. The decision to operate on these patients must take into account the severity of both mitral regurgitation and associated cardiac lesions.

Outcomes and reoperations after total correction of complete atrio-ventricular septal defect

BACKGROUND: Surgical correction of complete atrio-ventricular septal defect (AVSD) achieves satisfactory results with low morbidity and mortality, but may require reoperation. Our recent operative results at mid-term were followed-up. METHODS: From June 2000 to December 2007, 81 patients (Down syndrome; n=60), median age 4.0 months (range 0.7-118.6) and weight 4.7kg (range 2.2-33), underwent complete AVSD correction. Patch closure for the ventricular septal defect (VSD; n=69) and atrial septal defect (ASD; n=42) was performed with left atrio-ventricular valve (LAVV) cleft closure (n=76) and right atrio-ventricular valve (RAVV) repair (n=57). Mortality, morbidity, and indications for reoperation were retrospectively studied; the end point 'time to reoperation' was analyzed using Kaplan-Meier curves. Follow-up was complete except in two patients and spanned a median of 28 months (range 0.4-6.1 years). RESULTS: In-hospital mortality was 3.7% (n=3) and one late death occurred. Reoperation was required in 7/79 patients (8.9%) for LAVV insufficiency (n=4), for a residual ASD (n=1), for right atrio-ventricular valve insufficiency (n=1), and for subaortic stenosis (n=1). At last follow-up, no or only mild LAVV and RAVV insufficiency was present in 81.3% and 92.1% of patients, respectively, and 2/3 of patients were medication-free. Risk factors for reoperation were younger age (<3 months; p=0.001) and lower weight (<4kg; p=0.003), and a trend towards less and later reoperations in Down syndrome (p<0.2). CONCLUSIONS: Surgical correction of AVSD can be achieved with low mortality and need for reoperation, regardless of Down syndrome or not. Immediate postoperative moderate or more residual atrio-ventricular valve insufficiency will eventually require a reoperation, and could be anticipated in patients younger than 3 months and weighing <4kg.

The transventricular-transseptal access to the aortic root: a new route for extrapleural trans-catheter aortic stent-valve implantation.

Objective: The aim of this study was to investigate the feasibility of transventricular-transseptal approach (TVSA) for extrapleural transcatheter aortic valved stent implantation via a subxyphoidian access. Methods: In five porcine experiments (52.3 +/- 10.9 kg) the right ventricle was exposed via subxyphoidian access. Under the guidance of intracardiac echocardiography (ICE) and fluoroscopy, the transseptal access from right ventricle to left ventricle was created progressively by puncture and dilation with dilators (8F-26F). Valved stents built in-house from commercial tanned pericardium and self-expandable Nitinol stents were loaded into a cartridge. A delivery sheath was then introduced from the right ventricle into the left ventricle and then into the ascending aorta. The cartridge was connected and the valved stent was deployed in the aortic position. Then, the ventricular septal access was sealed with an Amplatzer septal occluder device and the right ventricular access was closed by tying prepared purse-string suture directly. Thirty minutes after the whole procedure, the animals were sacrificed for macroscopic evaluation of the position of valved stent and septal closure device. Result: Procedural success of TVSA was 100% at the first attempt. Mean procedure time was 49 +/- 4 min. Progressive dilatation of the transseptal access resulted in a measurable ventricular septal defect (VSD) after dilator sizes 18F and more. All valved stents were delivered at the target site over the native aortic valve with good acute valve function and no paravalvular leaks. During the procedure, premature beats (5/5) and supraventriclar tachycardias (5/5) were observed, but no atrial-ventricular block (0/5) occurred. Heart rate before (after) was 90 +/- 3 beats min(-1) (100 +/- 2 beats min(-1): p < 0.05), whereas blood pressure was 60 + 1 mm Hg (55 + 2 mm Hg (p < 0.05)). Total blood loss was 280 + 10 ml. The Amplatzer septal occluder devices were fully deployed and the ventricular septal accesses were sealed successfully, without detectable residual shunt. Conclusion: Trans-catheter implantation of aortic valved stent via extrapleural transventricular-transseptal access is technically feasible and has the potential for a simplified procedure under local anaesthesia. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B. V. All rights reserved.

Levosimendan as rescue therapy after surgery for congenital heart disease

Objectives: Levosimendan, a calcium-sensitizing agent has been reported as useful for the management of patients with low cardiac output state. We report here our experience, safety and efficacy of use of levosimendan as rescue therapy after surgery for congenital heart disease. Methods: Retrospective cohort study on patients necessitating levosimendan therapy for post operative low cardiac output or severe post operative systolic and diastolic dysfunction. Twelve patients with a mean age of 2.1 years (range 7 days - 14 years old) received levosimendan. Type of surgery: 3 arterial switch, 3 correction of complete abnormal pulmonary venous return, 3 closure of VSD and correction of aortic coarctation, 3 Tetralogy of Fallot, one correction of truncus arteriosus and one palliation for single ventricle. The mean time of ECC was 203 +/- 81min. Ten patients received levosimendan for low cardiac output not responding to conventional therapy in these cases (milrinone, dopamine and noradrenaline) in the first 6 hours following entry in the ICU and 3 patients received levosimendan 3-4 days after surgery for severe systolic and diastolic dysfunction. Levosimendan was given as a drip for 24-48 hours at the dose of 0.1-0.2 mcg/ kg/min, without loading dose. Results: Significant changes were noted on mean plasmatic lactate (3.3 +/- 1.7mmole/L vs 1.8 +/-0.6mmole/L, p+0.01), mean central venous saturation (55 +/- 11% vs 68 +/- 10%, p+0.01) and mean arterio-venous difference in CO2 (9.6 +/- 4.9mmHg vs 6.7 +/- 2.1mmHg, p+0.05) for values before and at the end of levosimendan administration. There was no significant changes on heart rate, systolic pressure or central venous pressure. No adverse effect was observed. Conclusion: Levosimendan, used as rescue therapy after surgery for congenital heart disease, is safe and improves cardiac output as demonstrated with improvement of parameters commonly used clinically.

Initial experience with hybrid surgery in congenital heart disease in a single center : P171

Introduction: A hybrid intervention is a joint procedure involving the interventional cardiologist and the cardiac surgeon. At our institution we have opted for this type of approach in congenital heart disease since 2005. We report here our initial experience. Cases: 1. A 3 year old boy with double aortic arch and multiple muscular ventricular septal defects (VSD),was readdressed for pulmonary band (PAB) removal and residual VSD closure after previous palliation. After surgical removal of the PAB, the surgeon provided a minimal transventricular access for placement of a 6mm Amplatzer® muscular VSD occluder by the cardiologist under transoesophageal guidance. The patient was extubated the same day and discharged after 5 days. 2. An 8 year old girl with Williams syndrome was followed for two large VSDs and severe peripheral pulmonary arteries (PA) stenosis. The membranous VSD was closed surgically, the muscular VSD during the same operation by direct placement of a 12 mm Amplatzer® muscular VSD occluder. During rewarming, balloon angioplasty of peripheral PA stenosis was achieved under fluoroscopy. Patient was extubated the following day and discharged after 8 days. 3. A 9 year old boy post tetralogy of Fallot repair had severe distal stenosis of the right ventricular to PA conduit.With patient on partial cardiopulmonary bypass, an incision was made on the conduit and a CP 8 Zig 16 stent placed on the stenosis. The child passed on full bypass and the definitive placement of the stent achieved. The child was extubated at the end of the intervention and discharged after 6 days. 4. A newborn presented at 2 days life with complex aortic arch anatomy: left aortic arch and right descending thoracic aorta perfused directly from a right arterial duct and left PA atresia. The arterial duct was stented with a Genesis XD stent dilated at 7mm. Two days later the cardiac surgeon made banded the right PA. The child was extubated after the operation and discharged a week later. Conclusion: Hybrid approach opens new ways of correction or palliation in congenital heart disease with encouraging results and less morbidity.

The complex SNP and CNV genetic architecture of the increased risk of congenital heart defects in Down syndrome.

Congenital heart defect (CHD) occurs in 40% of Down syndrome (DS) cases. While carrying three copies of chromosome 21 increases the risk for CHD, trisomy 21 itself is not sufficient to cause CHD. Thus, additional genetic variation and/or environmental factors could contribute to the CHD risk. Here we report genomic variations that in concert with trisomy 21, determine the risk for CHD in DS. This case-control GWAS includes 187 DS with CHD (AVSD = 69, ASD = 53, VSD = 65) as cases, and 151 DS without CHD as controls. Chromosome 21-specific association studies revealed rs2832616 and rs1943950 as CHD risk alleles (adjusted genotypic P-values <0.05). These signals were confirmed in a replication cohort of 92 DS-CHD cases and 80 DS-without CHD (nominal P-value 0.0022). Furthermore, CNV analyses using a customized chromosome 21 aCGH of 135K probes in 55 DS-AVSD and 53 DS-without CHD revealed three CNV regions associated with AVSD risk (FDR ≤ 0.05). Two of these regions that are located within the previously identified CHD region on chromosome 21 were further confirmed in a replication study of 49 DS-AVSD and 45 DS- without CHD (FDR ≤ 0.05). One of these CNVs maps near the RIPK4 gene, and the second includes the ZBTB21 (previously ZNF295) gene, highlighting the potential role of these genes in the pathogenesis of CHD in DS. We propose that the genetic architecture of the CHD risk of DS is complex and includes trisomy 21, and SNP and CNV variations in chromosome 21. In addition, a yet-unidentified genetic variation in the rest of the genome may contribute to this complex genetic architecture.

Competitor comparison: variable speed drives in pumping applications

As the world’s energy demand is increasing, a durable solution to control it is to improve the energy efficiency of the processes. It has been estimated that pumping applications have a significant potential for energy savings trough equipment or control system changes. For many pumping application the use of a variable speed drive as a process control element is the most energy efficient solution. The main target of this study is to examine the energy efficiency of a drive system that moves the pump. In a larger scale the purpose of this study is to examine how the different manufacturers’ variable speed drives are functioning as a control device of a pumping process. The idea is to compare the drives from a normal pump user’s point of view. The things that are mattering for the pump user are the efficiency gained in the process and the easiness of the use of the VSD. So some thought is given also on valuating the user-friendliness of the VSDs. The VSDs are compared to each other also on the basis of their life cycle energy costs in different kind of pumping cases. The comparison is made between ACS800 from ABB, VLT AQUA Drive from Danfoss, NX-drive from Vacon and Micromaster 430 from Siemens. The efficiencies are measured in power electronics laboratory in the Lappeenranta University of Technology with a system that consists of a variable speed drive, an induction motor with dc-machine, two power analyzers and a torque transducer. The efficiencies are measured as a function of a load at different frequencies. According to measurement results the differences between the measured system efficiencies on the actual working area of pumping are on average few percent units. When examining efficiencies at the whole range of different loads and frequencies, the differences get bigger. At low frequencies and loads the differences between the most efficient and the least efficient systems are at the most about ten percent units. At the most of the tested points ABB’s drive seem to have slightly better efficiencies than the other drives.

Previsão da requeima da batateira

Com o objetivo de adequar um sistema de previsão para uso criterioso do controle químico da requeima da batateira (Solanum tuberosum), foram instalados ensaios em condição de campo, seguindo-se o delineamento experimental em blocos ao acaso, com sete tratamentos e quatro repetições, com a cultivar Bintje. Os fungicidas dimetomorfe, cimoxanil, mancozeb e clorotalonil foram associados com diferentes esquemas de pulverização baseados no sistema de previsão modificado de Wallin (1962) e no sistema tradicional de controle da requeima. Os tratamentos consistiram de : 1) aplicação de dimetomorfe de acordo com VSD-12 + clorotalonil semanalmente; 2) aplicação de dimetomorfe de acordo com VSD-14 + clorotalonil semanalmente; 3) aplicação de dimetomorfe de acordo com VSD-16 + clorotalonil semanalmente; 4) aplicação dos fungicidas protetores mancozeb, clorotalonil e oxicloreto de cobre alternados a cada sete dias; 5) aplicação dos fungicidas mancozeb, dimetomorfe, clorotalonil e cimoxanil, alternados a cada sete dias; 6) aplicação de dimetomorfe + clorotalonil de acordo com VSD-12; e 7) testemunha (sem aplicação). O uso do sistema de previsão conforme os tratamentos 1, 2 e 3 apresentou eficiência comparável ao calendário semanal (tratamento 5) de pulverização no controle da requeima da batateira. Os tratamentos baseados no acúmulo de 12 e 14 VSD's apresentaram maior eficiência em prever a ocorrência de epidemias da requeima. Apenas o sistema de previsão 2, permitiu reduzir o número de pulverizações com fungicida sistêmico, sem que houvesse perda significativa na produção.

Controle da requeima em tomateiro industrial com fungicidas e silicato de potássio

O objetivo deste trabalho foi avaliar o efeito da aplicação de fungicidas e silicato de potássio, no controle da requeima (Phytophthora infestans), em tomateiro industrial. Os fungicidas foram aplicados com base no sistema de previsão de Wallin e calendário fixo de pulverizações. Empregou-se o delineamento em blocos casualizados com 6 tratamentos e 4 repetições. Os tratamentos (T) foram: T1 - testemunha; T2 - dimetomorfe + clorotalonil (valores de severidade da doença (VSD = 10) + metiram; T3 - metalaxil-M + clorotalonil (VSD = 10) + metiram (o metiram foi aplicado somente na semana onde o VSD não atingiu o valor requerido para o tratamento); T4 - calendário fixo: dimetomorfe + clorotalonil, mancozeb, metalaxil-M + clorotalonil e clorotalonil, alternados semanalmente; T5 - silicato de potássio (5 g/L) e T6 - silicato de potássio (15 g/L). A severidade foi avaliada utilizando-se uma escala descritiva variando de 0 a 100 %. A severidade final foi: 100; 2,6; 12,3; 5,5; 97,6 e 96 %, respectivamente, nos tratamentos T1, T2, T3, T4, T5 e T6. A severidade foi em média, 93 % menor nos tratamentos que receberam aplicações de fungicidas em relação a testemunha. Dentre os tratamentos que empregaram sistema de previsão o 2 apresentou melhor resultado do que o 3. O tratamento 2 apresentou eficiência comparável ao calendário semanal (tratamento 4), apresentando produtividades de 62.103,73 e 52.473,33 kg/ha, respectivamente, sendo superiores aos demais tratamentos. Aplicações de silicato de potássio nas duas doses testadas não diferiram significativamente da testemunha, indicando a ineficiência do produto em controlar a requeima.

Induction Motor Drive Energy Efficiency - Simulation and Analysis

A coupled system simulator, based on analytical circuit equations and a finite element method (FEM) model of the motor has been developed and it is used to analyse a frequency-converterfed industrial squirrel-cage induction motor. Two control systems that emulate the behaviour of commercial direct-torque-controlled (DTC) and vector-controlled industrial frequency converters have been studied, implemented in the simulation software and verified by extensive laboratory tests. Numerous factors that affect the operation of a variable speed drive (VSD) and its energy efficiency have been investigated, and their significance in the simulation of the VSD results has been studied. The dependency of the frequency converter, induction motor and system losses on the switching frequency is investigated by simulations and measurements at different speeds for both the vector control and the DTC. Intensive laboratory measurements have been carried out to verify the simulation results.

Manejo da requeima do tomateiro industrial empregando sistema de previsão

Três experimentos foram conduzidos utilizando-se o híbrido de tomateiro industrial H 7155N, em 2003 e 2004 visando adequar um sistema de previsão modificado para o uso de fungicidas no manejo da requeima causada por Phytophthora infestans. Os experimentos foram conduzidos num delineamento em blocos ao acaso com dez tratamentos e três repetições. Os fungicidas sistêmicos foram aplicados quando o valor de severidade da doença (VSD) alcançou oito, dez ou doze pontos. A alternância dos fungicidas sistêmicos com o metiram ocorreu na semana em que não foram alcançados os VSD´s. O tratamento calendário de pulverização para o controle da requeima consistiu da aplicação semanal de fungicidas após o aparecimento dos primeiros sintomas e aqueles definidos pelo sistema de previsão foram baseados nos VSD acumulados durante o experimento. A avaliação da requeima foi feita semanalmente com auxílio de uma escala descritiva de severidade e uma chave diagramática. A eficiência dos tratamentos foi comparada calculando-se a área abaixo da curva do progresso da doença, a taxa de progresso da doença (r) e produtividade de tomate. Os valores de r do melhor tratamento (dimetomorfe misturado com clorotalonil (VSD = 10) alternado com metiram variaram de 0,03 a 0,07, enquanto para o tratamento calendário semanal foi de 0,05 a 0,09 e para testemunha de 0,24 a 0,39. Dimetomorfe + clorotalonil (VSD = 10) alternado com metiram produziu em média 15,7 toneladas a mais de tomate, comparado ao tratamento calendário semanal de fungicidas. Dimetomorfe ou metalaxil-M misturado com clorotalonil (VSD = 10) baseado no sistema de previsão sem a alternância com metiram diferiu do calendário semanal baseado na severidade da doença e na produção de tomate. Os tratamentos piraclostrobina misturado com metiram (VSD = 8; VSD = 10) alternado com metiram; dimetomorfe misturado com mancozeb (VSD = 8; VSD = 10) alternado com metiram proporcionaram controle intermediário da requeima. O sistema de previsão baseado no uso de dimetomorfe misturado com clorotalonil alternado com metiram (VSD = 10) permitiu redução de uma aplicação da mistura dimetomorfe misturado com clorotalonil pulverização em dois dos três experimentos, comparados ao tratamento calendário semanal de aplicação de fungicidas, sem afetar a produção.

Savings Calculator for Centrifugal Pumps

Centrifugal pumps are one of the major energy consuming end-devices in developed coun-tries both in industrial and services sectors. According to recent studies, even 30 % of the energy used in pumping systems could be saved by more careful choosing of devices and system design. One of the most efficient and affordable ways to decrease the energy con-sumption of the pumping system is to substitute traditionally used flow control methods, like valve control, with modern variable speed drive (VSD) control. In this thesis, Microsoft Excel based program, Savings Calculator for Centrifugal Pumps (SCCP), is designed. SCCP calculates the achievable energy and financial savings when throttle control is substituted by VSD control in the pumping system. Compared to the sim-ilar existing programs, the goal is to make SCCP calculations more accurate and require less input information. Also some useful additional features are added to the designed program to make it more user friendly. The reliability of the calculations of designed program seem to vary depending on case. The results are corresponding accurately to the laboratory measurements, but there occurs high deviations in some cases, when the results are compared to the pump information specified by manufacturer. On the basis of verification in this thesis, SCCP seems to be at least as accurate as similar existing programs and it can be used as help in investment decision whether to have VSD or not.

Congenital ventricular septal defects and prenatal exposure to cyclooxygenase inhibitors

Ventricular septal defects (VSDs) are common congenital abnormalities which have been reported to be associated with maternal fever and various environmental factors. The aim of the present study was to evaluate the effect of prenatal exposure to cyclooxygenase (COX) inhibitors on heart defects. A retrospective statistical analysis was performed using data collected in our laboratory during various teratological studies carried out on albino CRL:(WI)WUBR Wistar strain rats from 1997 to 2004. The observations were compared with concurrent and historic control data, as well as findings from other developmental toxicological studies with selective and nonselective COX-2 inhibitors. Despite the lack of significant differences in the frequency of VSDs between drug-exposed and control groups, statistical analysis by the two-sided Mantel-Haenszel test and historical control data showed a higher incidence of heart defects in offspring exposed to nonselective COX inhibitors (30.06/10,000). Unlike other specific inhibitors, aspirin (46.26/10,000) and ibuprofen (106.95/10,000) significantly increased the incidence of the VSD when compared with various control groups (5.38-19.72/10,000). No significant differences in length or weight were detected between fetuses exposed to COX inhibitors and born with VSD and non-malformed offsprings. However, a statistically significant increase of fetal body length and decrease of body mass index were found in fetuses exposed to COX inhibitors when compared with untreated control. We conclude that prenatal exposure to COX inhibitors, especially aspirin and ibuprofen, increased the incidence of VSDs in rat offspring but was not related to fetal growth retardation.

Design of the sensorless pressure control system for a centrifugal pump

This thesis investigates the pressure-based control of a variable-speed-driven pump system in the case of existing output pressure measurement and in the case of sensorless system, where the actual output pressure value is calculated with the steady state estimator.

Études de type structure fonction des mutations causant l’ataxie épisodique de type I sur les canaux potassiques dépendants du voltage

Les ataxies épisodiques (EA) d’origine génétique sont un groupe de maladies possédant un phénotype et génotype hétérogènes, mais ont en commun la caractéristique d’un dysfonctionnement cérébelleux intermittent. Les EA de type 1 et 2 sont les plus largement reconnues des ataxies épisodiques autosomiques dominantes et sont causées par un dysfonctionnement des canaux ioniques voltage-dépendants dans les neurones. La présente étude se concentrera sur les mutations causant l'EA-1, retrouvées dans le senseur de voltage (VSD) de Kv1.1, un canal très proche de la famille des canaux Shaker. Nous avons caractérisé les propriétés électrophysiologiques de six mutations différentes à la position F244 et partiellement celles des mutations T284 A/M, R297 K/Q/A/H, I320T, L375F, L399I et S412 C/I dans la séquence du Shaker grâce à la technique du ‘’cut open voltage clamp’’ (COVC). Les mutations de la position F244 situées sur le S1 du canal Shaker sont caractérisées par un décalement des courbes QV et GV vers des potentiels dépolarisants et modifient le couplage fonctionnel entre le domaine VSD et le pore. Un courant de fuite est observé durant la phase d'activation des courants transitoires et peut être éliminé par l'application du 4-AP (4-aminopyridine) ou la réinsertion de l'inactivation de type N mais pas par le TEA (tétraéthylamonium). Dans le but de mieux comprendre les mécanismes moléculaires responsables de la stabilisation d’un état intermédiaire, nous avons étudié séparément la neutralisation des trois premières charges positives du S4 (R1Q, R2Q et R3Q). Il en est ressorti l’existence d’une interaction entre R2 et F244. Une seconde interface entre S1 et le pore proche de la surface extracellulaire agissant comme un second point d'ancrage et responsable des courants de fuite a été mis en lumière. Les résultats suggèrent une anomalie du fonctionnement du VSD empêchant la repolarisation normale de la membrane des cellules nerveuses affectées à la suite d'un potentiel d'action.