Heterotaxy refers to the abnormal arrangement of internal organs in relation to each other. Model organism studies have shown that functions of more than eighty genes are required for normal asymmetric left-right organ development. CRELD1 has been shown to be necessary for proper heart development and mutations in CRELD1 are known to increase risk of cardiac atrioventricular septal defects (AVSD). AVSD is the most common form of heart defect associated with heterotaxy, and we have previously shown that some individuals with heterotaxy-related AVSD have mutations in CRELD1. Therefore, we propose to examine the CRELD1 gene in a large sample of patients with heterotaxy syndrome. Our goal was to determine if mutations in CRELD1 are associated with other manifestations of heterotaxy or if they only coincide with AVSD. To achieve this aim, a sample size of 126 patients with heterotaxy collected by Dr. Belmont, Baylor college of Medicine, Texas, with approximately 66% of the heterotaxy population with different types of heart defects, were used for this study. Ten exons, promoter regions, and regulatory elements in the introns of CRELD1 gene were sequenced and analyzed. In this study three different heterozygous missense mutations in CRELD1 were identified in three unrelated individuals. These three individuals were diagnosed with different forms of heart defects in addition to AVSD. All three mutations were identified in highly conserved regions of CRELD1 possibly altering the CRELD1 properties. This demonstrates that mutations in CRELD1 may increase the susceptibility of AVSD in heterotaxy population. This information can help us to find factors effecting disease susceptibility in heterotaxy patients since the heart defects are a complex trait with incomplete penetrance.

Ο σκοπός της παρούσας διδακτορικής διατριβής ήταν η μελέτη της έκφρασης των υπομονάδων του GABAΑ υποδοχέα σε τομές από τον διαφραγματικό και τον κροταφικό ιππόκαμπο αμέσως μετά την θανάτωση του ζώου και κατά την διάρκεια της ανάπτυξης των "in vitro" οξέων κυμάτων που έχουν παρατηρηθεί μόνο σε τομές του κροταφικού ιππόκαμπου. Επιπλέον, μελετήθηκε η ποσοτική και τοπογραφική κατανομή των Α1 υποδοχέων αδενοσίνης με την χρήση του ραδιενεργού ιχνηθέτη [3H]-CHA (αγωνιστής των Α1 υποδοχέων) στον κροταφικό και τον διαφραγματικό ιππόκαμπο αμέσως μετά την θανάτωση του επίμυος. Η μελέτη της κατανομής των Α1 υποδοχέων αδενοσίνης έδειξε ότι η δέσμευση της [3H]-CHA ήταν μικρότερη στον κροταφικό σε σύγκριση με τον διαφραγματικό ιππόκαμπο με την μεγαλύτερη διαφορά να εντοπίζεται στην CA1 περιοχή. Το παραπάνω αποτέλεσμα έρχεται σε συμφωνία με την υπόθεση, ότι οι συνάψεις του κροταφικού ιππόκαμπου εμφανίζουν μεγαλύτερη πιθανότητα απελευθέρωσης γλουταμινικού οξέος σε σύγκριση με αυτές του διαφραγματικού ιππόκαμπου, καθώς οι Α1 υποδοχέων αδενοσίνης εντοπίζονται στην CA1 περιοχή κυρίως προσυναπτικά όπου ελέγχουν την απελευθέρωση γλουταμινικού οξέος. Στη συνέχεια της παρούσας μελέτης δείξαμε ότι η έκφραση του mRNA και των πρωτεϊνών για τις κυριότερες υπομονάδες του GABAA υποδοχέα είναι διαφορετική μεταξύ του διαφραγματικού και του κροταφικού ιπποκάμπου. Ειδικά, στην CA1 περιοχή του ιπποκάμπου η έκφραση των α1, β2 και γ2 υπομονάδων ήταν μικρότερη, ενώ αντίθετα η έκφραση των α2 και β1 υπομονάδων ήταν μεγαλύτερη στον κροταφικό ιπποκάμπο σε σύγκριση με τον διαφραγματικό ιππόκαμπο. Σύμφωνα με προηγούμενες μελέτες που αφορούν την συνέκφραση των υπομονάδων στο σύμπλοκο του GABAA υποδοχέα τα αποτελέσματα μας υποδηλώνουν ότι ο α1β2 υποτύπος του GABAA υποδοχέα επικρατεί στον διαφραγματικό ιππόκαμπο, ενώ ο α2β1 υπότυπος κυριαρχεί στον κροταφικό ιππόκαμπο. Η διαφορετική κατανομή των υποτύπων στους δυο πόλους του ιπποκάμπου που είναι εντονότερη στην CA1 περιοχή, μπορεί να επηρεάζει τις ιδιότητες του διαύλου (αγωγιμότητα, πλάτος και διάρκεια των IPSCs), δείχνοντας ότι οι υπότυποι του GABAA υποδοχέα που εντοπίζονται στον κροταφικό ιππόκαμπο έχουν μικρότερη ανασταλτική αποτελεσματικότητα, η οποία συμφωνεί με την μικρότερη GABAA-προερχόμενη αναστολή που έχει δειχθεί στην CA1 περιοχή του κροταφικού ιππόκαμπου. Επιπλέον θα μπορούσε να εξηγήσει την μεγαλύτερη επιρρέπεια του κροταφικού ιππόκαμπου στην επιληψία. Η χαμηλότερη έκφραση του mRNA για τις α4, β3 και δ υπομονάδες του GABAA υποδοχέα στην περιοχή της οδοντωτής έλικας του κροταφικού ιπποκάμπο υποδεικνύει ότι η έκφραση του α4β3δ υποτύπου είναι μικρότερη στον κροταφικό σε σύγκριση με τον διαφραγματικό ιππόκαμπο. Καθώς έχει δειχθεί ότι ο α4β3δ υπότυπος παίζει σημαντικό ρόλο στην τονική αναστολή στα κοκκιώδη κύτταρα της οδοντωτής έλικας, τα παραπάνω αποτέλεσμα μας πιθανώς σημαίνει ότι η τονική αναστολή είναι διαφορετική στους δυο πόλους του ιππόκαμπου. Η αύξηση της έκφρασης του mRNA της α5 υπομονάδας στην CA1 περιοχή του κροταφικού ιπποκάμπου μπορεί να επηρεάζει την ικανότητα για συναπτική βραχυ- και μακρο-χρόνια πλαστικότητα η οποία έχει βρεθεί να είναι διαφορετική μεταξύ του κροταφικού και του διαφραγματικού ιπποκάμπου καθώς έχει δειχθεί ότι οι α5-υπότυποι παίζουν ρόλο σε διαδικασίες μνήμης και μάθησης. Επίσης, οι α5-υπότυποι του GABAA υποδοχέα στην CA1 περιοχή του ιππόκαμπου συμμετέχουν στην τονική αναστολή. Τα υψηλότερα επίπεδα στην έκφραση του mRNA για την α5 υπομονάδα στον κροταφικό ιππόκαμπο σε σύγκριση με τον διαφραγματικό ιππόκαμπο πιθανώς υποδεικνύουν ότι η τονική αναστολή είναι διαφορετική στην CA1 περιοχή των δυο πόλων του ιππόκαμπου. Στο δεύτερο μέρος της παρούσας διατριβής μελετήσαμε την πιθανή συσχέτιση του GABAεργικού συστήματος με την οργάνωση των "in vitro" οξέων κυμάτων η οποία έχει παρατηρηθεί, σε κανονικές "in vitro" συνθήκες, μόνο σε τομές του κροταφικού ιππόκαμπου. Για το λόγο αυτό πραγματοποιήσαμε αναλυτική μελέτη της έκφρασης του mRNA των υπομονάδων (α1, α2, α5, β1, β2, β3, γ2) του GABAΑ υποδοχέα σε διάφορα χρονικά διαστήματα κατά την κανονική "in vitro" διατήρηση των τομών (15min, 1, 3, 5 και 8h). Αρχικά μελετήσαμε την έκφραση των πρώιμων γονιδίων (c-fos, zif-268), που είναι δείκτες της νευρωνικής ενεργότητας, μετά από 5 ώρες κανονικής "in vitro" διατήρησης των τομών με σκοπό τη πιθανή συχέτιση της έκφρασης τους με την οργάνωση των "in vitro" οξέων κυμάτων. Τα αποτελέσματα μας έδειξαν και στους δυο πόλους του ιπποκάμπου παρόμοια αύξηση της έκφρασης του mRNA τόσο για το c-fos όσο και για zif-268 γεγονός που υποδηλώνει ότι γονιδιακή ενεργότητα είναι παρόμοια και όσο αφορά τα συγκεκριμένα πρώιμα γονίδια ανεξάρτητη της ανάπτυξης των "in vitro" οξέων κυμάτων. Στην CA1 περιοχή του κροταφικού ιππόκαμπου παρατηρήθηκε σημαντική αύξηση της έκφρασης του mRNA των α1, β2 και γ2 υπομονάδων του GABAΑ υποδοχέα η οποία ξεκινάει την 1η ώρα, δηλαδή πριν την οργανωμένη εμφάνιση της αυθόρμητης δραστηριότητας, γίνεται μέγιστη στις 4 ώρες παραμονής των τομών σε Τεχνητό Εγκεφαλονωτιαίο Υγρό (ΤΕΝΥ) και συμβαδίζει χρονικά με την οργάνωση των "in vitro" οξέων κυμάτων. Δεν παρατηρήθηκαν σημαντικές αλλαγές σε τομές που προέρχονται από τον διαφραγματικό ιππόκαμπο. Έχει δειχθεί ότι οι α1-υπότυποι παίζουν σημαντικό ρόλο στην ανασταλτική ικανότητα του υποδοχέα. Επίσης η παρουσία της β2 υπομονάδας στον δίαυλο χαρακτηρίζει μεγαλύτερα σε πλάτος και διάρκεια ανασταλτικά ρεύματα συγκρινόμενη με τις β1 υπομονάδες. Φαίνεται λοιπόν ότι ο υπότυπος α1β2γ2, του οποίου η έκφραση αυξάνει πριν την έναρξη της οργανωμένης ρυθμικής δραστηριότητας, λόγω της συγκρότησης του από τις συγκεκριμένες υπομονάδες, έχει μεγάλη ανασταλτική αποτελεσματικότητα η οποία μπορεί να συμμετέχει στην ανάπτυξη των "in vitro" οξέων κυμάτων. Η δέσμευση της [3H]–muscimol αυξάνει σε τομές που προέρχονται μόνο από τον κροταφικό ιππόκαμπο και έχουν παραμείνει σε κανονικές "in vitro" συνθήκες για 8 ώρες σε σύγκριση με αντίστοιχες τομές που προέρχονται αμέσως μετά την θανάτωση του ζώου. Καμία αλλαγή δεν παρατηρήθηκε στην δέσμευση της [3H]–muscimol σε τομές που προέρχονται από τον διαφραγματικό ιππόκαμπο. Η αύξηση της δέσμευσης της [3H]–muscimol μόνο στις τομές που προέρχονται από τον κροταφικό ιππόκαμπο είναι σε συμφωνία με την αύξηση της έκφρασης του α1β2γ2-υποτύπου καθώς έχει δειχθεί ότι η θέση δέσμευσης της muscimol στο δίαυλο του GABAA υποδοχέα είναι μεταξύ των α1 και β2 υπομονάδων. Συμπερασματικά, η εκλεκτική αύξηση της έκφρασης του α1β2γ2-υπότυπου μόνο στην CA1 περιοχή του κροταφικού δηλώνει μεγαλύτερη ανασταλτική αποτελεσματικότητα των GABAA υποδοχέων, δεδομένου ότι ο α1β2γ2-υπότυπος προκαλεί μεγαλύτερα ανασταλτικά μετασυναπτικά ρεύματα. Το παραπάνω μπορεί να σχετίζεται με την "in vitro" εμφάνιση των οξέων κυμάτων καθώς η αυθόρμητη δραστηριότητα προέρχεται από GABAA-επαγόμενες υπερπολώσεις των πυραμιδικών κυττάρων, ενώ και η αύξηση στην έκφραση του α1β2γ2-υποτύπου συμπίπτει χρονικά με την εμφάνιση των "in vitro" οξέων κυμάτων. / The hippocampus in the rat appears grossly as an elongated structure with its long axis bending in a C-shaped manner from the septal nuclei rostrodorsally to the incipient temporal lobe caudoventrally. The long axis of the hippocampal formation is referred as the dorsoventral axis. Although hippocampus has been traditionally thought as a homogeneous structure, several studies have been demonstrated differences at several organization levels (from the behavioural to the cellular) between its dorsal (DH) and ventral (VH) pole. In the present study, we examined whether the recently reported differences in the GABA-mediated somatic inhibition between the DH and VH could be related to variations in the GABAA receptors. We therefore studied the quantitative distribution, the kinetic parameters and the subunit composition of the GABAA receptors in the two parts of hippocampus. We also studied the A1 adenosine receptors in order to examine the involvement of the adenosinergic system in the glutamate release between the two hippocampal poles. The study of [3H]-CHA binding on A1 adenosine receptors by using "in vitro" quantitative autoradiography, revealed a weaker A1 receptor binding in VH compared to DH in all regions we examined. Taken into consideration that the A1 adenosine receptors are localized in the CA1 glutamatergic terminals, these results may to some extend explain our hypothesis that synapses in the VH have greater probability of glutamate release compared to those in the DH counterpart. Recent data have demonstrated a weaker somatic GABAergic inhibition in CA1 region of VH compared to DH. We therefore examined possible differences in the GABAA receptor subunit composition and receptor binding parameters between DH and VH by using "in situ" hybridization, western blotting and the specific binding of the GABAA receptor agonist [3H]-muscimol using quantitative autoradiography and saturation experiments. The experiments demonstrated that the VH compared to DH displayed: 1) lower levels of mRNA expression for α1, β2, γ2 but higher levels for α2 and β1 subunits in CA1, CA2 and CA3, with the differences being more pronounced in CA1 region. Western blot analysis confirmed the mRNA expression data, showing lower levels for α1, β2 and higher levels for α2 subunits’ protein. Only in the CA1 region the mRNA levels of α5 were higher, while those of α4 subunit were slightly lower; in dentate gyrus, the mRNA levels of α4, β3 and δ subunits were significantly lower in VH compared to DH presumably suggesting a lower expression of the α4/β3/δ receptor subtype; 2) lower levels of [3H]-muscimol binding in the VH, with the lowest value observed in CA1, apparently resulting from weaker affinity for GABA and not from a decreased receptor density, since the KD values were higher in VH, while the Bmax values were similar between DH and VH. In conclusion, the differences in the subunit mRNA and protein expression and the lower affinity of GABAA receptor observed predominantly in CA1 region of VH, suggest that the α1 subunit-containing GABAA receptors dominate in the DH, while the α2 subunit-containing receptors prevail in VH. This could underlie the lower GABAA mediated somatic inhibition observed in VH and, to some extent, explain: a) the higher liability of VH for epileptic activity and b) the differential involvement of DH and VH in cognitive and emotional processes. Recent electrophysiological experiments have been shown that slices from the VH of adult rats generate rhythmical activity during their maintenance in the recording chamber. This activity is fully organized during the first 3 hours of in vitro maintenance and resembles the in vivo recorded hippocampal "sharp waves", therefore called "in vitro sharp waves". The field manifestation of this spontaneous activity results from GABAA receptor-mediated hyperpolarizations in pyramidal cells. The aim of the second part of the present thesis focused on the possible relationship between the characteristics of GABAA receptors and the development of "in vitro sharp waves". Using the "in situ hybridisation" technique, we examined the mRNA expression of the alpha1/2/5,beta1/2/3 and gamma2 subunits of GABAA receptor and the binding of GABAA receptor agonist [3H]-muscimol in a time course including periods before and during the development of the "in vitro sharp waves". Six sets of transversely cut DH and VH slices were prepared: slices frozen immediately after killing the animal (naive slices), and slices maintained in vitro and frozen at different time points (15min, 1, 3, 5 and 8h) during the electrophysiological experiment. The results showed: A) Upregulation of alpha1, beta2 and gamma2 subunits mRNA in VH but not in DH slices at 1h of their maintenance, which became significant at 3h as compared to the respective naive slices; B) Increase in [3H]-muscimol binding only in VH slices, obtained at 8h compared to the respective naive ones. The upregulation of the α1β2γ2 GABAA receptor subtype (starting at 1h) in VH but not in DH presumably suggests an increase in GABAergic activity, which could be related with the appearance of "in vitro sharp waves" observed only in VH; C) Τhe similar mRNA expression of the early genes c-fos and zif-268 in the two hippocampal poles showing a comparable general gene activity in DH and VH. In conclusion, the α1β2γ2 subtype dominates in DH while the α2β2-subtype prevails in VH and this could be related to the weaker somatic inhibition observed in the CA1 region of VH, and also to the distinct involvement of DH and VH in cognitive and emotional processes. Moreover, the higher expression of the GABAA receptor subtype α4β4δ in the DG of DH compared to VH may imply a higher tonic inhibition in the former hippocampal pole. The upregulation of the α1β2γ2- subtype only in VH slices during their in vitro maintenance may reflect an increase in the impact of GABAA receptor-mediated transmission, which is required for the organization of "in vitro" sharp waves.

Background：Aortic stenosis (AS) is the commonest valve disease in the West. Aortic valve replacement (AVR) remains the only available management for AS and results in improved symptoms and recovery of ventricular functions. In addition, it is well known that AVR results in disruption of LV function mainly in the form of reversal of septal motion as well as depression of right ventricular (RV) systolic function. The aim of this thesis was to study, in detail, the early and mid-term response of ventricular function to AVR procedures (surgical and TAVI) as well as post operative patients’ exercise capacity. Methods：We studied LV and RV function by Doppler echocardiography and speckle tracking echocardiography (STE) in the following 4 groups; (1) 30 severe AS patients (age 62±11 years, 19 male) with normal LV ejection fraction (EF) who underwent AVR, (2) 20 severe AS patients (age 79±6 years, 14 male) who underwent TAVI, (3) 30 healthy controls (age 63±11 years, 16 male), (4) 21 healthy controls (age 57±9 years, 14 male) who underwent exercise echocardiography. Results: After one week of TAVI, the septal radial motion and RV tricuspid annulus peak systolic excursion (TAPSE) were not different from before, while surgical AVR had significantly reversed septal radial motion and TAPSE dropped by 70% compared to before. The extent of the reversed septal motion correlated with that of TAPSE (r=0.78, p<0.001) in the patients as a whole after AVR and TAVI (Study I). Compared with controls, the LV twist function was increased in AS patients before and normalized after 6 months of surgical AVR. In controls, the LV twist correlated with LV fractional shortening (r=0.81, p<0.001), a relationship which became weak in patients before (r=0.52, p<0.01) and after AVR (r=0.34, p=ns) (Study II). After 6 months of surgical AVR, the reversed septal radial motion was still significantly lower than before. The septal peak displacement also decreased and its time became prolonged. In contrast, the LV lateral wall peak displacement increased and the time to peak displacement was early. The accentuated lateral wall peak displacement correlated with the septal peak displacement time delay (r=0.60, p<0.001) and septal-lateral time delay (r=0.64, p<0.001) (Study III). In 21 surgical AVR patients who performed exercise echocardiography, the LV function was normal at rest but different from controls with exercise. At peak exercise, oxygen consumption (pVO2) was lower in patients than controls. Although patients could achieve cardiac output (CO) and heart rate (HR) similar to controls at peak exercise, the LV systolic and early diastolic myocardial velocities and strain rate as well as their delta changes were significantly lower than controls. pVO2 correlated with peak exercise LV myocardial function in the patients group only, and the systolic global longitudinal strain rate (GLSRs) at peak exercise was the only independent predictor of pVO2 in multivariate regression analysis (p=0.03) (Study IV). Conclusion: Surgical AVR is an effective treatment for AS patients, but results in reversed septal radial motion and reduced TAPSE. The newly developed TAVI procedure maintains RV function which results in preservation of septal radial motion. In AS, the LV twist function is exaggerated, normalizes after AVR but loses its relationship with basal LV function. While the reversed septal motion results in decreased and delayed septal longitudinal displacement which is compensated for by the accentuated lateral wall displacement and the time early. These patients remain suffering from limited exercise capacity years after AVR.

INTRODUCAO: A comunicação interatrial tipo \"ostium secundum\" é um defeito cardíaco congênito caracterizado pela deficiência parcial ou total da lâmina da fossa oval, também chamada de septo primo. Corresponde a 10 a 12% do total de cardiopatias congênitas, sendo a mais frequente na idade adulta. Atualmente a oclusão percutânea é o método terapêutico de escolha em defeitos com características anatômicas favoráveis para o implante de próteses na maioria dos grandes centros mundiais. A ecocardiografia transesofágica bidimensional com mapeamento de fluxo em cores é considerada a ferramenta padrão-ouro para a avaliação anatômica e monitoração durante do procedimento, sendo crucial para a ótima seleção do dispositivo. Neste sentido, um balão medidor é introduzido e insuflado através do defeito de forma a ocluí-lo temporariamente. A medida da cintura que se visualiza no balão (diâmetro estirado) é utilizada como referência para a escolha do tamanho da prótese. Recentemente a ecocardiografia tridimensional transesofágica em tempo real tem sido utilizada neste tipo de intervenção percutânea. Neste estudo avaliamos o papel da mesma na ótima seleção do dispositivo levando-se em consideração as dimensões e a geometria do defeito e a espessura das bordas do septo interatrial. METODO: Estudo observacional, prospectivo, não randomizado, de único braço, de uma coorte de 33 pacientes adultos portadores de comunicação interatrial submetidos a fechamento percutâneo utilizando dispositivo de nitinol autocentrável (Cera ®, Lifetech Scientific, Shenzhen, China). Foram analisadas as medidas do maior e menor diâmetro do defeito, sua área e as medidas do diâmetro estirado com balão medidor obtidas por meio das duas modalidades ecocardiográficas. Os defeitos foram considerados como elípticos ou circulares segundo a sua geometria; as bordas ao redor da comunicação foram consideradas espessas (>2 mm) ou finas. O dispositivo selecionado foi igual ou ate 2 mm maior que o diâmetro estirado na ecocardiografia transesofágica bidimensional (padrão-ouro). Na tentativa de identificar uma variável que pudesse substituir o diâmetro estirado do balão para a ótima escolha do dispositivo uma série de correlações lineares foram realizadas. RESULTADOS: A idade e peso médio foram de 42,1 ± 14,9 anos e 66,0 ± 9,4kg, respectivamente; sendo 22 de sexo feminino. Não houve diferenças estatísticas entre os diâmetros maior e menor ou no diâmetro estirado dos defeitos determinados por ambas as modalidades ecocardiográficas. A correlação entre as medidas obtidas com ambos os métodos foi ótima (r > 0,90). O maior diâmetro do defeito, obtido à ecoardiografia transesofágica tridimensional, foi a variável com melhor correlação com o tamanho do dispositivo selecionado no grupo como um todo (r= 0,89) e, especialmente, nos subgrupos com geometria elíptica (r= 0,96) e com bordas espessas ao redor do defeito (r= 0,96). CONCLUSÃO: Neste estudo em adultos com comunicações interatriais tipo ostium secundum submetidos à oclusão percutânea com a prótese Cera ®, a ótima seleção do dispositivo pôde ser realizada utilizando-se apenas a maior medida do defeito obtida na ecocardiografia transesofágica tridimensional em tempo real, especialmente nos pacientes com defeitos elípticos e com bordas espessas. / INTRODUCTION: The ostium secundum atrial septal defect is a congenital heart disease characterized by partial or total deficiency of the fossa ovalis, also known as the septum primum. It corresponds to 10-12% of all congenital heart defects, being the most frequently found in adulthood. Currently, percutaneous closure is the therapeutic method of choice for defects with suitable anatomic features for device implantation in most centers in the world. Bi-dimensional transesophageal echocardiography with color flow mapping is considered the gold-standard tool for anatomic assessment and procedural monitoring, being crucial for optimal device selection. In this regard, a sizing balloon is introduced and inflated across the defect with temporary occlusion. The waist measurement seen on the balloon (stretched diameter) is used as a reference for selection of device size. Recently, real time three-dimensional transesophageal echocardiography has been utilized in this type of percutaneous intervention. In this study we assessed the role of this modality in optimal device selection taking into consideration the dimensions and the geometry of the defect and the thickness of the interatrial septum rims. METHODS: Observational, prospective, non-randomized, single-arm study of a cohort of 33 adults with atrial septal defects submitted to percutaneous closure using a self-centered nitinol device (Cera (TM), Lifetech Scientific, Shenzhen, China). The largest and the smallest diameter of the defect, its area and the measurements of the stretched diameter of the sizing balloon were assessed by both echocardiographic modalities. The defects were considered as elliptical or circular according to their geometry; the rims surrounding the defect were considered thick (> 2 mm) or thin. The selected device was equal to or 2 mm larger than the stretched diameter on bi-dimensional transesophageal echocardiography (gold-standard). In an attempt to identify a variable that could replace the stretched balloon diameter, a series of linear correlations were performed. RESULTS: The mean age and weight were 42.1 ± 14.9 years and 66.0 ± 9.4 kgs, respectively; being 22 of the female gender. There were no statistical differences between the largest and smallest diameters of the defects and the stretched diameters determined by both echocardiographic modalities. The correlation between the measurements obtained by both methods was excellent (r > 0.90). The largest defect diameter obtained by three-dimensional transesophageal echocardiography was the variable that showed the best correlation with the selected device size in the entire group (r= 0.89), especially in the subgroups with elliptical geometry (r= 0.96) and with thick rims surrounding the defect (r=0.96). CONCLUSIONS: In this study in adults with ostium secundum atrial septal defects submitted to percutaneous occlusion with the Cera (TM) device, optimal device selection could be performed using solely the largest diameter of the defect obtained by real time three-dimensional transesophageal echocardiography, especially in patients with elliptical defects and thick rims.

Congenital heart defects (CHDs) constitute a major proportion of clinically significant birth defects and are an important component of pediatric cardiovascular disease. Atrioventricular septal defects (AVSDs) include a range of anomalies characterized by atrial, ventricular, and atrioventricular (AV) valve defects. AVSDs commonly occur in the presence of a syndrome, most frequently Down syndrome; they also occur in isolation and are referred to as non-syndromic AVSDs (NSAVSDs). These studies were performed to evaluate for presence of an intermediate phenotype in parents and siblings of a child with a NSAVSD, risk factors associated with NSAVSDs, and prognostic risk factors for left AV valve replacement following primary repair of an AVSD. It was shown that the mean body surface area-standardized AV septal length (AVSL) was significantly shorter in the NSAVSD parents and siblings than in parents and siblings of syndromic AVSD case and control children. Using age- and gender-adjusted body surface area-standardized AVSL, it was determined that there was evidence for two component distributions in parents and siblings of NSAVSD children, suggesting the presence of an intermediate. Broadening the definition of AVSD to include those with a shortened AVSL may increase the power of genetic association and mapping studies to identify susceptibility genes. Risk factors associated with NSAVSD were examined using the 1997-2005 National Birth Defects Prevention Study database. Mothers who actively smoked or were exposed to passive smoke anytime from one month prior to pregnancy through the end of the first trimester were more likely to have an infant with a NSAVSD. There was a suggestive association between AVSDs and use of antibacterial, antifungal, and antiviral medications. Additional investigations are warranted to investigate associations with specific medications as well as to uncover possible gene-environment interaction effects that may modify these risks in order to develop improved primary prevention strategies. Using the Pediatric Cardiac Care Consortium database, factors associated with time to first reoperation and time to replacement following primary AVSD repair were evaluated. Type of AVSD repair, closure of the mitral valve cleft, moderate to severe postoperative left AV valve regurgitation, and presence of postoperative complete heart block were associated with earlier time to reoperation after adjusting for age and weight at AVSD repair. Down syndrome and presence of postoperative mitral stenosis were associated with earlier time to replacement. Prognostic risk factors following left AV valve replacement in children who had previously undergone AVSD repair were also identified. A prosthetic valve size to body weight ratio of greater than 3 and the presence of Down syndrome were identified as predictors of in-hospital death following left AV valve replacement. By adding to our knowledge of the AVSD familial and environmental risk factors from these studies, we will be able to (1) improve genetic counseling, (2) identify other family members for genetic testing, (3) begin to devise primary prevention strategies, and (4) improve treatment modalities. By recognizing prognostic factors which influence survival, optimal patient care can be devised which will not only improve treatment modalities, but also long-term survival.

Background: The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone. Methods: PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance. Results: A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33–0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52–1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33–1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06–11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55–1.57, p = 0.78). Conclusions: The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

Introdução: As comunicações interatriais do tipo ostium secundum (CIA-OS) são tratadas por fechamento percutâneo (FP) ou intervenção cirúrgica (IC). Estudos comparando ambos métodos são escassos e avaliações de custo-efetividade inexistem na literatura nacional. Objetivos: Realizar uma avaliação da segurança e eficácia (ASE) clínica seguida de uma análise de custo-efetividade (ACE) incremental comparando o FP e IC sob a perspectiva do Sistema Único de Saúde (SUS). Materiais e métodos: ASE - Estudo observacional, não randomizado de 2 coortes de crianças e adolescentes < 14 anos com CIA-OS tratadas por FP ou IC. A coleta dos dados foi prospectiva no FP e retrospectiva no IC. ACE - Realizada revisão sistemática de estudos clínicos disponíveis no MEDLINE e a Cochrane Central. Estudos com mais de 50 pacientes e com idade média abaixo de 14 anos foram incluídos. A análise foi baseada em uma árvore de decisão computando os custos e consequências no longo prazo de ambas as opções. Foi utilizado valor da prótese de R$ 16.000 e estipulado valor de honorário médico de R$ 2.355. A efetividade foi estimada em anos de vida. A avaliação utilizou uma taxa de desconto de 5% ao ano e uma disposição a pagar de 3 vezes o PIB per capita no Brasil (63.000). Análises de limiares também foram conduzidas. Resultados: ASE - De Abr/09 a Out/11 foram alocados 75 pacientes (pts) no FP e entre Jan/06 e Jan/11 105 pts na IC. A idade e o peso foram maiores no FP e o diâmetro da CIA foi semelhante entre os grupos. Sucesso técnico foi observado em todos os procedimentos e não houve óbitos. Complicações (a maioria menores) foram encontradas em 68% na IC e em 4% do FP (p<0,001). As taxas de fluxo residual não significativo ou de oclusão total do defeito foram semelhantes nos 2 grupos. A mediana de internação foi de 1,2 dias após o FP e 8,4 dias após a IC (p< 0,001). ACE - A estratégia de busca retornou 2.957 referências, das quais 34 foram incluídas. A taxa de mortalidade foi semelhante nos 2 grupos. O FP teve discreta maior efetividade, menor taxa de complicações moderadas/graves e menor tempo de internação, mas com maior probabilidade de um segundo procedimento. A relação de custo-efetividade incremental (RCEI) do tratamento percutâneo foi de R$ 230.641 por ano de vida salvo. Considerando-se este cenário, seria necessário que o custo indireto associado à cirurgia fosse de R$ 4.960, ou que o valor pago pelo dispositivo percutâneo sofresse redução de R$ 4.960 para que o FP se tornasse aceitável do ponto de vista econômico. Conclusões: Ambos tratamentos são seguros e eficazes com ótimos desfechos, porém o FP apresenta menor morbidade e tempo de internação. Usando os valores diretos estipulados neste estudo, a RCEI foi elevada limitando a incorporação do FP pelo SUS neste momento. Estudos considerando também os custos indiretos são necessários para a adequada ACE de ambas estratégias. / Introduction: Atrial septal defects of the secundum type (ASD-OS) are treated by percutaneous closure (PC) or surgical intervention (SI). Comparative studies are scarce and there is no cost-effectiveness assessment in the Brazilian literature. Objectives: To perform a clinical safety and efficacy (ASE) assessment followed by an incremental cost-effectiveness (CEE) analysis comparing PC and SI under the Brazilian Unified Health System perspective. Materials and methods: ASE - Observational, non-randomized study of two cohorts of children and adolescents under 14 years with ASD-OS treated by PC or SI. Data was collected prospectively in PC and retrospectively in SI. CEE - A systematic review of clinical studies available in MEDLINE and Cochrane Central was performed. Studies with more than 50 patients and mean age under 14 years were included. Analysis was based on a decision tree that took into account costs and consequences during long-term follow-up for both options. The cost of the device and medical honorarium were estimated at R$ 16.000 and R$ 2.355, respectively. Effectiveness was estimated in years of life. Assessment was performed using a discount tax of 5% and a willingness to pay of 3 times the GID in Brazil (63.000). Threshold analyses were also conducted. Results: ASE - From Apr/09 to Oct/11 75 patients (pts) were enrolled in PC and from Jan/06 to Jan/11 105 pts in SI. Age and weight were greater in PC and the ASD diameter was similar. Technical success was achieved in all procedures and there were no deaths. Complications (most minor) occurred in 68% of SI and 4% of PC (p<0,001). The rate of total occlusion or non-significant residual shunts was similar in both groups. Median hospitalization time was 1.2 days in PC and 8.4 days in SI (p<0,001). CEE - Search strategy returned 2957 references and 35 were included. Mortality was similar in both groups. PC was associated with slightly better effectiveness, lower rates of moderate/severe complications and reduced hospital stay despite a higher probability of a second procedure. Incremental cost-effectiveness ratio (ICER) was R$ 230.641 for life-year gained. In this scenario, PC would be acceptable from the economic point of view if the indirect costs of the SI was R$ 4.960 or the cost of the device was reduced by R$ 4.960. Conclusions: Both methods are safe and effective with excellent outcomes, however PC is associated with less morbidity and in-hospital time. Using the direct costs stipulated in this study, the ICER was high limiting the incorporation of PC by the Brazilian Unified Health System (SUS) at this moment. Studies also considering the indirect costs should be performed for better CEE assessment of both strategies.

La fermeture percutanée est le traitement de référence des communications interatriales (CIA). Après son implantation, une cicatrisation du dispositif est classiquement attendue après quelques mois ; il semble cependant qu’un recouvrement incomplet ou partiel puisse être observé dans de rares cas, sans que l’on en connaisse les mécanismes impliqués. Cette cicatrisation imparfaite du dispositif est associée à la survenue de complications retardées. Dans le cadre de cette thèse nous avons étudié la cicatrisation de ces prothèses de CIA, en nous focalisant sur les processus de recouvrement et d’endothélialisation des dispositifs, à travers une approche translationnelle incluant expérimentations in vitro, modèle animal chronique et étude clinique. A la fin de ce travail, il est possible de conclure que : 1) il existe des cas de complications au long cours après fermeture de CIA, liées à un défaut de recouvrement du dispositif, 2) sur une large cohorte pédiatrique avec un suivi allant jusqu’à 18 ans après l’implantation, l’incidence de ces complications est faible 3) les modèles animaux, utilisés seuls, ne peuvent suffire à expliquer ni à avancer dans la compréhension de ce phénomène, 4) il n’existe pas de différences significatives concernant le processus de recouvrement entre les 3 prothèses analysées au cours de ce travail, 5) une évaluation non invasive et individualisée du recouvrement prothétique , grâce aux techniques d’imagerie, est une perspective prometteuse. Ces données montrent qu’une meilleure compréhension du processus de recouvrement prothétique passe par la réalisation conjointe d’études fondamentales et cliniques. Cependant, le développement d’outils permettant une évaluation individualisée du recouvrement doit être poursuivi, du fait de leur fort potentiel de translation clinique et de leur capacité à optimiser la prise en charge du patient. / The percutaneous device closure is the gold treatment of atrial septal defect (ASD). After implantation, device healing is classically expected following several months; however, an incomplete or partial covering of the device may be observed without a full knowledge of the underlying mechanisms. In this thesis we studied the healing of these intracardiac prostheses, focusing on the covering and endothelialization processes of devices, approach through a translational approach including in vitro experiments, chronic animal model and clinical study. At the end of this work, it is possible to conclude that 1) there are cases of long-term complications after closure of CIA, related to a lack of recovery of the device, 2) in a large cohort of pediatric with a follow up of up to at 18 years after implantation, the incidence of these complications is low 3) animal models, used alone, can not suffice to explain or improve the understanding of this complex process, 4) there is no significant differences in the covering process between the 3 prostheses analyzed during this work, 5) a non-invasive and individualized assessment of prosthetic recovery, using imaging techniques, is a promising perspective with significant potential for clinical translation . These data show that a better understanding of device healing process needs the joint undertake of basic and clinical studies. Moreover, the development of tools for individualized assessment of device covering should be pursued in parallel, due to their high translational potential, in order to optimize patient management.

Introdução: A comunicação interatrial tipo ostium secundum(CIA) é uma cardiopatia congênita frequente, sendo a mais comumente encontrada na população adulta. Seu tratamento está indicado quando há repercussão hemodinâmica caracterizada pelo aumento das dimensões das câmaras direitas à ecocardiografia, independente da presença de sintomas. Nas últimas 2 décadas o fechamento percutâneo da CIA emergiu como a modalidade terapêutica preferencial devido sua alta eficácia e menor morbidade que a correção cirúrgica.Tanto o tratamento cirúrgico como o percutâneo da CIA resultam em remodelamento cardíaco com redução progressiva do tamanho das câmaras direitas e aumento das esquerdas. Recentemente, novas técnicas ecocardiográficas vem sendo empregadas para avaliação das dimensões, geometria e função das câmaras cardíacas incluindo o ecocardiograma tridimensional e o rastreamento de marcadores acústicos. Hipótese e objetivos: Partiu-se da hipótese que o fechamento percutâneo da CIA, por ser um método não invasivo, levaria a rápido remodelamento cardíaco mesmo em adultos com sobrecarga volumétrica crônica das câmaras direitas. Tivemos como objetivo avaliar o comportamento temporal do remodelamento cardíaco e analisar possíveis diferenças existentes entre pacientes de diferentes faixas etárias e com tamanhos diversos de CIA. Material e métodos: Estudo observacional, prospectivo, não randomizado de um braço único de uma coorte de adultos submetidos ao fechamento percutâneo da CIA com a prótese Cera (Lifetech, Shenzheng, China) e acompanhados por um ano. Foram selecionados 29 adultos com CIA com repercussão hemodinâmica com anatomia favorável para a oclusão percutânea e sem contra-indicações para tal. O remodelamento cardíaco foi estudado por meio de várias técnicas ecocardiográficas incluindo as clássicas e outras de introdução recente. A ecocardiografia bidimensional foi usada para a medição das dimensões do átrio direito (AD), ventrículo direito (VD) e ventrículo esquerdo (VE), para determinação da área fracionada do VD (FAC) e da excursão anterior da valva tricúspide (TAPSE) e para análise volumétrica das câmaras cardíacas. A ecocardiografia tridimensional foi empregada para análise volumétrica e funcional do VD. O rastreamento de marcadores acústico foi utilizado para avaliação da função do AD, VD e VE. O teste ANOVA foi usado para avaliação das mudanças observadas nas variáveis repetidas ao longo do tempo com comparações múltiplas de Bonferroni quando aplicável. Uma análise intra e interobservador das medidas foi realizada utilizando coeficientes de concordância. Resultados: A média de idade e peso dos pacientes foi de 45,2 ± 17,0 anos e 68,8 ± 14,0 kgs, respectivamente. Nenhum paciente apresentada hipertensão pulmonar significativa. A média do tamanho da CIA foi de 20,2 ± 5,0 mm e a média do tamanho da prótese implantada foi de 22,9 ± 6,2 mm. Em todos os pacientes houve sucesso no implante. Não houve complicações relacionadas ao procedimento e em todos os pacientes foi observada oclusão do defeito. Após o procedimento, houve redução precoce (< 3 meses) das dimensões do AD (p<0,001) e do VD (p<0,001) e aumento das dimensões do VE (p<0,014). Não houve mudanças significativas na função de deformação longitudinal do AD para onda P (p=0,227) e para onda T (p=0,124). Houve redução abrupta da função do VD pelo TAPSE (p=0,032), pela deformação longitudinal (p=0,002) e pela ecocardiografia tridimensional (p=0,084). Não houve mudanças significativas da onda S\' (p=0,55) e da FAC (p=0789) do VD. Houve redução precoce do volume de ejeção do VD (p< 0,001) e aumento do volume de ejeção do VE (p=0,027). Houve redução da deformação longitudinal do VE (p=0,049) e não houve mudanças na função do VE pelo método de Simpson (p=0,462). Pacientes maiores que 60 anos (n=8) apresentaram valores iniciais maiores nas dimensões do AD e redução mais prolongada (p=0,0497). Pacientes com CIAs maiores que 20 mm (n=12) apresentavam valores iniciais maiores de TAPSE com redução mais retardada (p=0,013). Todas as mudanças observadas inicialmente nos primeiros 3 meses se sustentaram ao final do seguimento. Houve excelente concordância na análise intraobservador para todas as medidas repetidas (CCI> 0,9) com exceção da deformação do VE (CCI< 0,7). A concordância entre as medidas realizadas por diferentes observadores não foi tão boa, com apenas as variáveis TAPSE, deformação do VE e dimensões do AD possuindo CCI > 0,7. Conclusões: O fechamento percutâneo da CIA em adultos de meia idade leva a rápido remodelamento cardíaco tanto do ponto de vista anatômico como funcional com resultados sustentados dentro do primeiro ano de seguimento. Tais mudanças temporais são observadas independente do tamanho da CIA e da idade dos pacientes, denotando o efeito benéfico do procedimento sobre a geometria e o funcionamento cardíaco global em todos adultos portadores desta frequente cardiopatia congênita. / Introduction: The atrial septal defect of the secundum type (ASD) is a frequent congenital heart disease, being the most commonly encountered in the adult population. Treatment is indicated when there is hemodynamic burden characterized by increased dimensions of the right chambers on echocardiography, regardless of the presence of symptoms. In the last two decades, percutaneous closure of the ASD has emerged as the preferred therapeutic modality due to its high efficacy and lower morbidity when compared to surgical correction. Both surgical and percutaneous treatment of the ASD result in cardiac remodeling with progressive reduction in the size of the right chambers and increase in the left chambers. Recently, new echocardiographic techniques have been employed to assess the dimensions, geometry and function of the cardiac chambers including three-dimensional echocardiography (3D echo) and acoustic speckle tracking. Hypothesis and objectives: Hypothesizing that percutaneous closure, being a non-ivasive method, results in a fast cardiac remodeling even in adults with chronic volume overload of the right chambers, our aim was to assess the temporal pattern of cardiac remodeling and analyse possible differences between patients of different age groups and different ASD sizes. Material and methods: This was an observational, prospective, non randomized, single arm study of a cohort of adults submitted to percutaneous closure of the ASD with the Cera device (Lifetech, Shenzheng, China) followed along a year. Twenty nine adults with hemodynamicaly significant ASDs with suitable anatomy for percutaneous closure and no contra-indications for the procerdure were selected. Cardiac remodeling was assessed by various echocardiographic techniques including standard and new ones. Bidimensional echocardiography was used to measure the dimensions of the right atrium (RA), right ventricle (RV) and left ventricle (LV), to determine the fractional area of the RV (FAC) and the systolic anterior excursion of the tricuspid valve (TAPSE), and to analyse the volumes of the cardiac chambers. Three-D echo was employed for volumetric and functional analysis of the RV. Acoustic speckle tracking was utilized to assess the function of the RA, RV and LV. ANOVA tests were used to assess the observed changes in the repeated variables over time with multiple Boferoni comparison as applicable. An intra and interobserver analysis of the measurements was performed using concordance coefficients. Results: Mean age and weight was 45,2 ± 17,0 years and 68,8 ± 14,0 kgs, respectively. No patient had significant pulmonar arterial hypertension. The ASD dimension and the size of the device was a mean of 20,2 ± 5,0 mm and 22,9 ± 6,2 mm, respectively. In all patients the device was implanted successfully. There were no complications related to the procedure and in all patients the ASDs were successfully closed. After the procedure, there was an early (< 3 months) reduction of the RA (< 0.001) and RV (< 0.001) sizes and an increase of the LV dimensions (p< 0.014). There were no significant changes in the function of the RA as assessed by longitudinal strain (p=0.227 for the P wave and p=0.124 for the T wave). There was an abrupt reduction of the RV function assessed by TAPSE (p=0.032), longitudinal strain (p=0.002) and 3D echo (p=0.084). There were no changes in the S\' wave (p=0.55) and FAC (p=0.789) of the RV. There was an immediate decrease in the RV stroke volume (p< 0.001) and an increase in the LV srtroke volume (p=0.027). There was a reduction in LV longitudinal strain (p=0.049) and no change in LV function as assessed by the Simpson method (p=0.462). Patients older than 60 years of age (n=8) presented with larger RA dimensions, which decreased in a slower fashion (p=0.0497). Patients with ASDs larger than 20 mm (n=12) had initial higher TAPSE values, which decreased in a slower fashion (p=0.013). All changes observed earlier on endured after a year. There was excellent concordance in the intra observer analysis for all the repeated measures (CCI > 0.9) with the exception of LV strain (CCI < 0.7). The concordance between different observers was not as good with only TAPSE, LV strain, and RA dimensions variables having a CCI > 0.7. Conclusions: Percutaneous closure of the ASD in middle aged adults results in fast cardiac remodeling from both the anatomic and functional point of view with sustained results over the first year of follow up. These temporal changes are observed regardless of the ASD size and the age of the patients, which demonstrates the beneficial effect of the procedure over the cardiac geometry and global function in all adults who have this frequent congenital heart disease.

<p>To assess the impact of congenital malformations in Down syndrome (DS) on morbidity, mortality and outcome at birth, information on all children with DS born in the northern part of Sweden in 1973-80 (n=211) and 1995-98 (n=88) was collected. Most common were congenital heart defects (CHD), dominated by atrioventricular septal defects (AVSD). Up to age 10 years, morbidity and mortality were more than 10 times higher in DS children with CHD than in healthy DS children. The DS children seemed more vulnerable at birth than Swedish children in general: they had increased frequencies of Cesarean sections, premature birth, asphyxia, and low birthweight, and higher proportions of children small for gestational age, regardless of the presence of CHD. Infant mortality decreased from 14.2% to 2.3% between the two periods.</p><p>All children with AVSD with and without DS born in Sweden 1973-1997 (n=801) were followed up retrospectively to 2001. Children with isolated AVSD without complex additional CHDs were studied more closely (n=502). A reduction in age at operation and postoperative mortality (from 28 to 1%) was observed. No significant difference in 5-year postoperative mortality between genders or between DS and non-DS children was found. The 5-year postoperative mortality in DS decreased from 35% in 1973-77 to about 10% in 1993-97. </p><p>CHD had a major influence on morbidity, infectionrate and mortality in DS, but not on DS birth variables. The formerly high mortality in CHD is now reduced. In isolated AVSD measures seem equally successful in DS and non-DS children. Mortality is still 3 times higher in DS children with isolated AVSD than in healthy DS children. </p>