Reversible complete atrioventricular block after percutaneous ASD device closure in a child <15 kg

Transcatheter device closure of atrial septal defect (ASD) in small children less than 15 kg may be associated with increased complications. Complete atrioventricular heart block (CHB) is a rare complication of ASD device closure in such a setting. We report the case of a 2-year-old girl, less than 15 kg, who underwent device closure of ASD with Amplatzer Septal Occluder and subsequently developed CHB 12 h after the procedure which resolved completely with steroid treatment on fifth day. Case report of a similar kind is rarely reported in the literature. Despite adequate postero-inferior margin CHB may still occur in small children as in our case.     

Strategy of treating secundum atrial septal defect not referred to percutaneous closure

Objective: To evaluate safety and effectiveness of intraoperative device closure for secundum atrial septal defect (ASD) not referred to percutaneous closure.
Design and Patients: From April 2010 to December 2018, 231 secundum ASD children (≤14 years) directly recommended to surgical repair were enrolled in this study. These patients were divided into two groups according to the parents’ choice based on surgeons’ recommendation. Follow-up evaluations were adopted at 2 weeks, 3 months, 6 months, and 12 months after the procedure and yearly thereafter. In Group A, 127 patients underwent an initial attempt at device closure. In Group B, 104 patients underwent a repair procedure under cardiopulmonary bypass.
Results: All patients survived. Group A had lower values of operation time, mechanical ventilation time, cardiac intensive care unit duration and amount of blood transfusion. Nevertheless, postoperative hospitalization time between two groups showed no statistical difference. In group A, 109 (85.83%) patients were successfully occluded, whereas 18 (14.17%) patients were converted to open-heart surgery. No severe complications occurred in the follow-up period.
Conclusion: Intraoperative device closure is safe, effective procedure for selected cases with secundum ASDs which were not referred to percutaneous closure because of more suitable occluder selection, no “unbutton effect” and stitching enhancement.     

Hair toxic and essential trace elements in children with autism spectrum disorder

The objective of the study was to investigate hair trace elements content in children suffering from autism spectrum disorder (ASD). A total of 74 ASD children and 74 sex- and age-matched controls divided into two age groups (2–4 and 5–9 years) were investigated. Hair trace elements content was assessed using inductively coupled plasma mass spectrometry. A general cohort of ASD children was characterized by 29 %, 41 %, and 24 % lower hair levels of chromium (Cr), iodine (I), and vanadium (V), respectively, whereas the level of selenium (Se) exceeded the respective control values by 31 %. In ASD children aged 2–4 years hair Cr, I and V content was 68 %, 36 % and 41 % lower than in the controls. Older ASD children were characterized by 45 % increase in hair Se levels. In a general cohort of ASD children hair beryllium (Be) and tin (Sn) levels were 50 % and 34 % lower than the control values. In the first age group (2–4 years) of ASD children 34 %, 42 %, and 73 % lower levels of arsenic (As), boron (B), and Be were detected. In the second age group of ASD children only a nearly significant 25 % decrease in hair lead (Pb) was detected. Surprisingly, no significant group difference in hair mercury (Hg), zinc (Zn), and copper (Cu) content was detected. Generally, the results of the present study demonstrate that children with ASD are characterized by lower values in hair of not only essential but also toxic trace elements.

     

Echocardiographic predictors of candidacy for successful transcatheter atrial septal defect closure

We reviewed pre-closure echocardiograms on all patients undergoing transcatheter atrial septal defect (ASD) closure with the Bard double-umbrella occluder device aided by simultaneous transesophageal echocardiography to determine precatheterization predictors of outcome. Transesophageal echocardiograms were performed on 28 of 132 patients (22%) undergoing device closure (age = 3–72 years, mean = 14 years; weight = 15–68 kg, mean = 35 kg). Three devices were removed because of unstable position. Of the remaining 25 patients, 21 had effective closure (residual flow diameter ≤ 3 mm) and 18 had favorable arm position (device arm on proper side of the septum and not in contact with an atrioventricular valve leaflet). Only ASD size predicted effective closure. All patients with a maximum defect size of < 13 mm had effective closure. Among the 17 patients with defects ≥ 13 mm, 10 had effective closure, 4 had significant residual flow, and 3 had devices removed for unstable position. Atrial dimensions and rim size did not predict effective closure. There were no pre-closure predictors of favorable arm position which was associated only with the size of the device implanted.     

Delayed spontaneous perforation of polyvinyl alcohol membrane—Covered atrial septal defect closure devices

Percutaneous device closure has become the first choice for secundum atrial septal defect (ASD) closure when feasible in case of favorable anatomy. The Ultrasept II ASD occluder® device (Cardia Inc, Eagan, MN) is made of two nitinol disc frames covered with polyvinyl alcohol membranes, a synthetic polymer with a large application in the biomedical field. Four relatively early malfunctions of the polyvinyl alcohol membrane were observed in a series of six consecutive patients treated with ASD Ultrasept II closure device in our institution. Operators have to be aware of this apparently rare complication that is likely to be underestimated, associated with such devices. © 2016 Wiley Periodicals, Inc.     

Atrial septal defect repair gone wrong

Isolated atrial septal defect (ASD) accounts for 13% of congenital heart disorders. The anatomic location, size, and coexistence of other cardiac anomalies determine outcomes of repair. Surgical closure was the first‐choice treatment until the 1990s and remains the only treatment for large defects. We describe a case of a 64‐year‐old woman who underwent surgical repair for an ASD as a child in 1959. She presented with dyspnea to the hospital almost 53 years after the surgery. Diagnostic cardiac imaging revealed interesting anatomy of the repair surgery. Transthoracic echocardiography showed areas of flow signal across the patch consistent with surgical perforation of the patch to reduce symptoms of superior vena cava (SVC) syndrome. Despite intervention, severe dilation of the SVC along with a thrombus is seen. CT angiography of the heart showed the ASD patch occluding the ostium of the SVC instead of patching the ASD. Transesophageal echocardiography showed malpositioned patch allowing the sinus venosus ASD to remain patent.     

Complications associated with central venous access device in children with haemophilia: a nationwide multicentre study in Finland

Children with haemophilia require venous access for regular infusion of coagulation factors. A central venous access device (CVAD) ensures long‐term access but associates with infectious and non‐infectious complications with proposed risk factors of young age at initial CVAD implantation and presence of an inhibitor. Our aim was to evaluate the incidence and risk factors for complications associated with CVAD usage in a retrospective nationwide multicentre study in five Finnish Paediatric Haemophilia Treatment Centers. Our study investigated 106 CVADs in 58 patients with 137 971 CVAD days. The median access survival was 1159 CVAD days, and most often a malfunction led to CVAD removal after a long survival (median of 1640 CVAD days). We detected a very low bloodstream infection rate (0.12/1000 CVAD days). The presence of neutralizing inhibitor was a significant risk factor for infection. Heparin vs. saline flushing did not influence the CVAD outcome. We detected a lower infection rate than previously reported, although 90% of the patients were very young (<2 years) at first insertion (median age = 1.02 year). Port access was frequent after initial implantation: six patients (10%) used the port daily for immune tolerance induction therapy and 74% at least twice weekly for prophylaxis. Young age did not increase the risk of infections, as 59% of the CVAD‐related infections were recorded in children over 6 years of age. Our national experience confirms the safety of prophylactic factor concentrate administration via ports even in very young children.     

Use of the Griffiths mental development scale-Chinese in the assessment of children with autism spectrum disorder and global developmental delay/intellectual disability

The Griffiths Mental Development Scale-Chinese (GDS-C) is used in China to assess the development of children from birth to 8 years of age. Language disorders are a common symptom of autism spectrum disorder (ASD) and global developmental delay (GDD)/intellectual disability (ID). There is a need to identify distinct clinical characteristics in children suspected of having these 2 disorders, mainly presenting as language disorders. Here, we aimed to use the GDS-C to evaluate children presenting with language problems to identify characteristics that distinguish ASD and GDD/ID. Children with language problems were recruited between August 2018 and December 2019. A total of 150 children aged 25 to 95.2 months were enrolled (50 in the ASD group, 50 in the GDD/ID group, and 50 in the typical group). Each group was subdivided by age as follows: 24–36 months, >36–60 months, and >60–96 months. Developmental characteristics assessed using the GDS-C were analyzed and compared. Both, children with ASD and GDD/ID presented with a lower developmental level than typical children in all six subscales of the GDS-C. No significant differences were observed in the six subscale scores between the ASD and GDD/ID groups, except for the practical reasoning subscale score in the >36 to 60 months subgroups, which was significantly lower in the GDD/ID group than in the ASD group. The developmental imbalance of subscales within the ASD and GDD/ID groups identified troughs in the personal-social, language, and practical reasoning areas in children with ASD and in the language and practical reasoning areas in children with GDD/ID relative to typical children. The GDS-C is a useful, comprehensive tool for the assessment of the developmental state of children with ASD and GDD/ID. Characteristics of practical reasoning subscale help diagnose autism in >36 to 60 months old children.     

Analysis of P Wave and P Dispersion in Children with Secundum Atrial Septal Defect

Background: P maximum and P dispersion are evaluated as predictors of paroxysmal atrial fibrillation in adults. In this study, these variables are being investigated in children with secundum ASD in comparison with that of normal controls and in relation to size of ASD and the presence or absence of atrial dilation. Methods: Ninety‐four children with isolated secundum ASD (33 boys, 60 girls; mean ± SD age at diagnosis 2.9 ± 4.1 years) and 65 age‐matched controls (mean ± SD age 4.2 ± 4.2 years) were evaluated. Resting 12‐lead ECG was used to measure P waves from which P maximum and P dispersion (difference between maximum and minimum P‐wave duration) were derived. ASD children were arbitrarily subgrouped according to ASD sizes (small: 1–3 mm, moderate: 4–7 mm, large: 8 mm). The presence of right atrial dilation was noted from echocardiography. Results: Children with ASD had significantly longer mean P dispersion compared to controls (P dispersion: 30.2 ± 11.1 vs 26.4 ± 6.6 ms, P = 0.008). Mean P maximum and P dispersion were significantly prolonged with increasing ASD size (P < 0.001). Children with right atrial dilation had significantly longer P maximum (102.3 ± 15.2 vs 82.8 ‐13.4 ms, P < 0.001) and larger P dispersion (36.1 ± 12.5 vs 27.6 ± 9.4 ms, P = 0.003) compared to those without right atrial dilation. Conclusion: Prolonged atrial conduction time and inhomogeneity of atrial conduction may possibly be present in children with moderate to large sized ASD and in those with atrial dilation. A.N.E. 2001;6(4):305–309     

A late complication with the CardioSEAL ASD occluder device and need for surgical revision.

A late complication of the CardioSEAL atrial septal defect (ASD) occluder is reported. Although left atrial umbrella was completely epithelialized and occluded ASD without residual defect, the right atrial umbrella protruded toward the center of right atrium after 18 months. We believe this may be associated with the structural abnormality of the device.     

A new device to close secundum atrial septal defects: First clinical use to close multiple defects in a child

Transcatheter device closure of secundum atrial septal defects (ASD) has become an accepted treatment modality. Currently, the only device that can be used for large defects is the Amplatzer Septal Occluder. We report on a new device (Occlutech Figulla), to close multiple ASDs in a child with two large defects using 12 and 15 mm devices. © 2008 Wiley‐Liss, Inc.     

Erosion by the amplatzer septal occluder: Experienced operator opinions at odds with manufacturer recommendations?

Background: Device erosion is a very rare but potentially fatal complication of ASD occlusion by the Amplatzer Septal Occluder (ASO). After reviewing cases of device erosion, recommendations for ASD sizing and device selection were revised by a small group of “experts” and adopted by the device manufacturer in 2004. These revisions, which recommend use of smaller devices, which do not straddle the aorta, remain controversial. Objective: The aim of our study is to help define an expanded expert consensus with respect to the causes and preventive strategies for erosions. Methods: We report a case of device erosion in which the 2004 revisions were carefully followed; and a survey of the members of the Congenital Cardiovascular Interventional Study Consortium (CCISC) soliciting experiences with and opinions about device erosion. Results: In our case, the device disk appeared to protrude into the aortic root but not straddle, and had motion independent of cardiac movement. Of 57 survey responders having a total experience of 12,006 ASO implants, 12 members reported 14 erosions among 3,010 implants. Ninety percent of erosions occurred in patients with deficit aortic rim. Of 53 patients, 38 (71.7%) responded that devices, which are undersized and do not straddle the aorta are at highest risk of erosion. Of 52 patients, 44 (84%) responded that motion of the device relative to the heart may cause erosion. Conclusion: Both the survey results and our single case experience suggest that operator opinions (and perhaps also device sizing practices) are at odds with the 2004 revisions. Further study and focus on this issue is needed. © 2009 Wiley‐Liss, Inc.     

Heart rate variability in patients with atrial septal defect and healthy children

ObjectiveHeart rate variability (HRV) measures are altered in various cardiac and non-cardiac situations in children. The autonomic nervous system is assumed to have a role in the pathophysiology of atrial septal defect (ASD). In this study, we evaluated the autonomic system by measuring HRV in children with ASD.MethodsTwenty-eight patients with ASD and 32 healthy children (mean ages: 6.6 ± 2.1 years and 6.4 ± 2.2 years, respectively) were enrolled in the study. Twenty-four-hour ambulatory electrocardiographic recordings were obtained and the seven time-domain (SDNN, SDANN, rMSSD, SD, SDNN index, PNN50, and mean RR) and four frequency-domain (VLF, LF, HF, and LF/HF ratio) indices of HRV were analyzed.ResultsA significant decrease in calculated HRV variables was observed in children with ASD as compared to controls. The HRV alteration was found in both time-domain and frequency-domain parameters.ConclusionsOur results indicate that HRV is decreased in children with ASD, which implies parasympathetic withdrawal and sympathetic predominance.     

Surgical vs. percutaneous atrial septal defect closure: Remote effects on left ventricular diastolic function

While surgical closure used to be the only treatment for atrial septal defects (ASD), recently, placement of an occluding device has become the treatment of choice for this condition. We sought to study the remote effects of surgical vs. device ASD closure on the indices of left ventricular diastolic function.Forty patients – 16 after device and 19 after surgical closure – were evaluated at least 1 year after the procedure. Mitral inflow and tissue Doppler indices were studied. The results were compared to those of 65 control subjects.The early mitral inflow velocities E were higher in controls and E/A ratios were different among all 3 groups. Late diastolic A′ TDI velocities were higher in both device and surgical group patients and more different from the controls in surgical than in device group.It appears that surgical ASD closure alters left ventricular diastolic indices more significantly than device ASD closure.     

Participation in physical activity and arterial stiffness in males with autism spectrum disorder

Selective eating and hyperphagia are frequently encountered in individuals with autism spectrum disorder (ASD). They may increase arterial stiffness, a risk factor for cardiovascular disease, via excessive sodium intake, nutritional deficiency, and obesity. Therefore, primary prevention of cardiovascular disease is an important issue in this population. To test our hypothesis that greater levels of physical activity are associated with lower levels of arterial stiffness in individuals with ASD as well as those without ASD, this study compared brachial-ankle pulse wave velocity (baPWV) in active males with and without ASD and less active males without ASD. We recruited subjects with ASD via organizations providing opportunities to play sports. Subjects without ASD were subdivided into less and more active groups based on scores from the International Physical Activity Questionnaire. Daily physical activity levels were higher in the more active control (2992 ± 681 MET min/week) and ASD (2992 ± 972 MET min/week) groups than in the less active control group (337 ± 86 MET min/week). BaPWV was lower in the more active control (10.7 ± 0.3 m/s) and ASD (9.9 ± 0.6 m/s) groups than in the less active control group (11.7 ± 0.3 m/s). There were no differences in physical activity level and baPWV between more active males with ASD and those without ASD. These results suggest that physically active males with ASD also have elastic central arteries. We would like to propose that participation in physical activities may be beneficial as a primary cardiovascular disease prevention strategy for not only for males without ASD but also those with ASD.     

Comparative analysis of right heart chamber remodeling after surgical and device secundum atrial septal defect closure in adults

Background

To determine differences in right heart remodeling for patients with ASD who underwent surgical compared to device closure.

Methods

Retrospective analysis of echo data of 121 adult patients with ASD from 2005 to 2015 performed prior to closure and within 6‐8 weeks, 6 months, and 1 year post closure.

Results

121 patients with median age of 39 were studied. Patients who underwent device closure were older (46 vs 37 years, P < 0.05) with smaller mean ASD size (1.9 cm vs 2.3 cm, P < 0.05). We observed a similar and significant reduction in right heart parameters and PASP for both surgical and device closure groups on serial echos up to 1 year. Device closure was associated with preservation of TAPSE compared to surgical closure (reduction of 0.2 cm vs 0.6 cm, P < 0.001). Younger adults with ASD intervention (<40 years) had lower baseline PASP (33 mmHg vs 40 mmHg, P < 0.05) compared to older adults (>40 years). This difference persisted up to 1 year with no difference in rate of right heart remodeling. The effects of device closure with better preservation of TAPSE and S’ compared to surgery were consistent within both groups of younger and older adults.

Conclusion

Device and surgical closure of ASD both result in similar improvements in right heart parameters. However, device closure is associated with better preservation of TAPSE at 1 year post intervention. Intervention for older adults with ASD, when compared to younger ones, did not result in a difference in rate of right heart remodeling.

     

Altered gut microbial profile is associated with abnormal metabolism activity of Autism Spectrum Disorder

ABSTRACT

Autism Spectrum Disorder (ASD) is a severe neurodevelopmental disorder. To enhance the understanding of the gut microbiota structure in ASD children at different ages as well as the relationship between gut microbiota and fecal metabolites, we first used the 16S rRNA sequencing to evaluate the gut microbial population in a cohort of 143 children aged 2–13 years old. We found that the α-diversity of ASD group showed no significant change with age, while the TD group showed increased α-diversity with age, which indicates that the compositional development of the gut microbiota in ASD varies at different ages in ways that are not consistent with TD group. Recent studies have shown that chronic constipation is one of the most commonly obvious gastrointestinal (GI) symptoms along with ASD core symptoms. To further investigate the potential interaction effects between ASD and GI symptoms, the 30 C-ASD and their aged-matched TD were picked out to perform metagenomics analysis. We observed that C-ASD group displayed decreased diversity, depletion of species of Sutterella, Prevotella, and Bacteroides as well as dysregulation of associated metabolism activities, which may involve in the pathogenesis of C-ASD. Consistent with metagenomic analysis, liquid chromatography-mass spectrometry (LC/MS) revealed some of the differential metabolites between C-ASD and TD group were involved in the metabolic network of neurotransmitters including serotonin, dopamine, histidine, and GABA. Furthermore, we found these differences in metabolites were associated with altered abundance of specific bacteria. The study suggested possible future modalities for ASD intervention through targeting the specific bacteria associated with neurotransmitter metabolism.     

Modification of Serum Galectin-3 and Reversal of Cardiac Remodeling Following Pediatric Transcatheter Atrial Septal Defect Closure

Objectives: We aimed to evaluate the effect of percutaneous atrial septal defect (ASD) closure in children using right heart indices and serum galectin-3 (Gal-3), as potential biomarkers of right heart remodeling. Methods: This case–control prospective study included 40 children with ASD and 25 control subjects. An echocardiographic evaluation was performed before the procedure, as well as 24 h, 1 month, and 6 months after intervention. Serum Gal-3 was measured before, and 1 month after the procedure. Results: Serum Gal-3 concentration, right atrial (RA) dimensions, right ventricular (RV) dimensions, indexed RA area, and right index of myocardial performance (RIMP) were significantly increased in children with ASD compared with control subjects while tricuspid annular plane systolic excursion (TAPSE) was significantly decreased. Six months after closure, RA, and RV dimensions significantly decreased and RV function improved (RIMP decreased and TAPSE increased). Gal-3 oncentration significantly decreased 1 month after ASD closure, but it did not reach normal range compared with control subjects. A positive correlation between Gal-3 and age at closure, RA area, RV dimensions, and RIMP was observed. A positive correlation was observed between the decrease in Gal-3 concentration and the decrease in RA area and RV dimensions 1 month after ASD closure. A significant negative correlation was observed between TAPSE and Gal-3 concentration before and after intervention. Conclusions: Percutaneous ASD closure can improve right-sided indices and decrease serum Gal-3 concentration. Gal-3 can be used as a sensitive biomarker of right heart remodeling, with a decrease in Gal-3 concentration suggesting reversal of maladaptive remodeling.     

Impact of Zinc Oxide Nanoparticles on the Composition of Gut Microbiota in Healthy and Autism Spectrum Disorder Children

Autism spectrum disorder (ASD) seriously affects children’s health, while the gut microbiome has been widely hypothesized to be involved in the regulation of ASD behavior. This study investigated and compared the number, diversity, and population structure of gut microbiota between healthy and ASD children and their susceptibility to zinc oxide nanoparticles (ZnONPs) based on the measurement of live cell number, living/dead bacterial staining test, flow cytometry observation and bacterial community analysis using 16S rRNA gene amplicon sequencing. The result of this present study revealed that ASD children not only significantly reduced the live cell number and the community diversity of gut bacteria, but also changed the gut bacterial community composition compared to the healthy children. In addition, this result revealed that ZnONPs significantly reduced the number of live bacterial cells in the gut of healthy children, but not in that of ASD children. In contrast, ZnONPs generally increased the gut bacterial community diversity in both ASD and healthy children, while a greater increase was found in ASD children than that of healthy children. Furthermore, this study successfully isolated and identified some representative nanoparticle-resistant bacteria based on the color, shape, and edge of colony as well as the 16S rDNA sequence analysis. The community of nanoparticle-resistant bacteria differed in between healthy and ASD children. Indeed, the representative strains 6-1, 6-2, 6-3 and 6-4 from healthy children were identified as Bacillus anthracis, Escherichia coli, Bacillus cereus and Escherichia coli with sequence similarity of 97.86%, 99.86%, 99.03% and 99.65%, respectively, while the representative strains 8-1, 8-2 and 8-3 from ASD children were identified as Bacillus cereus, with sequence similarities of 99.58%, 99.72% and 99.72%, respectively. Overall, this study demonstrated that ZnONPs caused a change in number, diversity, and species composition of gut bacteria, but differed in healthy and ASD children.     

正常儿童与继发孔型房间隔缺损患儿房间隔径的对比

目的：观察儿童时期房间隔直径及其继发孔房间隔缺损（ASD）患儿的房间隔直径的解剖特点。方法：选择正常儿童500例和单纯ASD患儿206例按照体表面积分成10组,用超声心动图常规取心尖四腔心和剑下四腔心切面测量每一例儿童房间隔直径（IAS）,结果：获得正常儿童和单纯ASD患儿不同生长发育时期的IAS,得知同一体表面积组ASD患儿较正常儿童的IAS径长,探索从胸前或剑下切面测量和观察IAS和ASD直径,ASD患儿的IAS与ASD径有相关性。结论：对儿童IAS径的测量是经导管关闭,ASD术病例选择中须考虑的重要条件。探索不同发育阶段IAS径的规律性,可帮助选择恰当的病例进行导管介入关闭ASD,减少并发症,提高成功率。