Secundum Atrial Septal Defect: Surgical Closure

Secundum Atrial Septal Defect: Surgical Closure Surgical closure of secundum atrial septal defect in a patient with atrial situs solitus and interrupted inferior vena cava: report of 2 cases Key Words: Interrupted inferior vena cava, Situs solitus, Atrium septal defects, limited skin incision Abstract The occurrence of an interrupted inferior vena cava (IVC) in setting of atrial situs solitus is relatively rare. Here, we reported two cases of the surgical closure of secundum atrium septal defects (ASDs) in patients with atrial situs solitus and an interrupted IVC. The first case was a 7-year-old boy with a secundum ASD without the posterior rim whose interrupted IVC and azygos continuation had been preoperatively diagnosed by the echocardiography and cardiac catheterization. The operation was safely performed using a large-sized venous drainage cannula from the superior vena cava (SVC). The second case was a 2-year-old boy with a secundum ASD without the superior rim whose interrupted IVC was not diagnosed at the preoperative examination. The operation was performed through a median partial sternotomy via a 5.0cm limited skin incision, so direct inspection of the SVC was not clearly obtained. A cardiopulmonary bypass was established using the recommended size of venous drainage ca nnulae; however, the SVC could not be removed without elevating the SVC pressure. As a result, the ASD was closed directly under sucking the venous return from the SVC without snaring it. Post-operative computed tomography detected an interrupted IVC with azygos continuation and a persistence of both supracardinal veins, known as a double IVC. Introduction Whereas an interrupted inferior vena cava (IVC) because of the absence of its hepatic segment is mainly noted in patients with heterotaxy syndrome, the occurrence of an interrupted IVC within the atrial situs solitus is reported as ranging from 0.08 to 0.1% [1,2,3]. In these patients, cardiac malformations are frequently associated, and the main types of abnormalities include atrial septal defects (ASDs, 10.5 %) and ventricular septal defects (7.5 %) [1]. Although this systemic venous anomaly provides no symptoms by itself, it seems to be relevant in cardiac surgery, especially in procedures that require approaches through the right atrium. Here, we reported two cases of the surgical closure of secundum ASD in patients with atrial situs solitus and interrupted IVC, focusing on perioperative findings and associated issues. Case Case 1 A clinically asymptomatic 7-year-old boy (body weight, 22 kg; height, 125 cm) with an ASD secundum, which was detected at the age of 10 months, was admitted for surgical closure of the lesion. Device ASD closure by catheter intervention was contraindicated because of the absence of the posterior rim. Preoperative echocardiography revealed an atrial sinus solitus with an 18 by 21-mm ASD secundum without the posterior rim and relative valvular pulmonary stenosis. Also, interrupted IVC was suspected because drainage of the IVC into the right atrium was not detected. Cardiac catheterization to assess the indication for surgical pulmonary valvotomy showed a systemic and pulmonary blood flow ratio of 3.14 and pull-buck pressure gradient of 10 mmHg from the right ventricle to the main pulmonary artery. Furthermore, no hepatic segment of the IVC was detected; thus, an interrupted IVC with azygos continuation was confirmed (Fig. 1). Through the median full sternotomy, a cardiopulmonary bypass was established using arterial cannulation through ascending aorta perfusion with a 16-Fr cannula and venous drainage from the superior vena cava (SVC) and the hepatic vein using 28 and 20 Fr cannulae, whereas recommended cannulae sizes were 20 and 24 Fr, respectively. The ASD secundum was closed directly through the right atriotomy under moderate hypothermia and cardioplegic arrest. The operation was completed without any issues. Case 2 A clinically asymptomatic 2-year-old boy (body weight, 10 kg; height, 81 cm) had recently been diagnosed with a large ASD secundum without the superior rim. Further examination revealed an atrial sinus solitus, an 18 by 18-mm ASD secundum without the superior rim, and a bicuspid aortic valve. However, an interrupted IVC was not diagnosed. Through a median partial sternotomy via a limited skin incision (50mm in length), a cardiopulmonary bypass was established using arterial cannulation through ascending aorta perfusion with a 12-Fr cannula and venous drainage from the SVC and hepatic vein, although it was thought to be an IVC at that time, using the recommended sizes of 16 and 18 Fr cannulae. During the surgery, the SVC was attempted to be snared, but it could not be because of the elevating SVC pressure. The depth of cannula and the location of snaring were repeatedly changed without resolving this issue; therefore, the SVC was left without being snared. The ASD secundum was closed directly under moderate hypothermia and cardioplegic arrest with sucking the venous return from the SVC. Weaning off from cardiopulmonary bypass was uneventful, and the operation was completed without any issues. Post-operative computed tomography showed an interrupted IVC with azygos continuation and a persistence of both supracardinal ve ins, known as double IVC (Fig. 2). On medical check-up at the outpatient clinic one year after discharge, advanced sick sinus syndrome was detected by electrocardiography. 24-Hour Holter electrocardiography monitoring showed that the total number of heartbeats was 142,036 per day, 8 beats of isolated premature atrial contractions, and had no evidence of premature ventricular contractions or more than 2.5 seconds of sinus pose. Discussion Like the first presented case, an interrupted IVC with azygos continuation can usually be diagnosed by preoperative echocardiography [1], which can be easily treated at the establishment of a cardiopulmonary bypass by selecting adequately-sized venous cannulae. If it is not preoperatively diagnosed, direct intra-operative inspection usually makes the diagnosis possible. However, the cosmetic outcome must be taken into consideration during surgical ASD repair as well as secure defect closure after the popularization of percutaneous device closure, like in the second case. Therefore, a limited skin incision with partial sternotomy was selected for this patient, which unfortunately interrupted clear observation of the SVC. Selection of large sized SVC drainage cannula should have been considered first during inadequate venous drainage, however, which was deferred because the total cardiopulmonary bypass was easily established as long as the SVC was not snared. As is our policy, the IVC is not snared during the closing of the ASD secundum in order to obtain a certain identification of the posterior rim. Therefore, the tip of the IVC drainage cannula was positioned at the IVC around the right atrial junction for sufficient drainage of both the IVC and hepatic venous blood flow. As a result, such a maneuver enabled the establishment of a total cardiopulmonary bypass with small-sized SVC drainage cannula and eventually large â€Å"hepatic vein† cannula. As shown in Case 2, an anomalous IVC is known to accompany various rhythm disorders, though only a few cases have been reported [4,5]. One of the causes of rhythm disorders is the degeneration of the atrial muscle around the sinus node, which might occur as a result of a local volume overload on the sinus node by the presence of azygos continuation. Although the total number of heart beats was well maintained and more than 2.5 seconds of a sinus pose was not observed until now, a scheduled follow-up was mandatory for early detection of further advancement of the sinus node dysfunction. In summary, two surgical experiences of secundum ASD associated with an interrupted IVC with azygos continuation were reported. Under partial sternotomy via limited skin incision, precautions should be taken to detect the presence of this venous anomaly if venous drainage from the SVC is not adequately obtained using cannula of the recommended size.

The 19th Century Aesthetic Movement Essay example -- Art History Essay

The 19th Century Aesthetic Movement The Arts and Crafts Movement is the main line of reform design in the 19th century that defines the period of its greatest development, roughly between 1875-1920. The Aesthetic Movement and Art Nouveau, whose roots were in the reaction to the Industrial Revolution in England in the middle of the 19th century, are the two major stylistic developments of this Movement’s philosophy (A Thing of Beauty 9). The term "Aesthetic Movement" refers to the introduction of principles that emphasized art in the production of furniture, metalwork, ceramics, stained glass, textiles, wallpapers, and books. The catalyst for its widespread popularity was the Philadelphia Centennial Exposition of 1876. There, in numerous displays, many Americans, artists and craftsmen as well as the general public, were exposed to art objects from a great variety of nations and periods (Bolger Burke et al. 19). Most writers on the Aesthetic Movement agree that its roots lie in the reaction to Industrialization in mid-19th century England The movement incorporated both exotic and historical sources of design generally, the Japanese influence became the strongest and best known. However, not all Aesthetic Movement design is in a Japanese style and vice versa. Today relatively little remains of the highest expressions of Aesthetic Movement design. Never inexpensive and therefore never plentiful, few objects and very few intact interiors, particularly the domestic interior, survive to suggest their richness and beauty (A Thing of Beauty 11-12). The Aesthetic movement in Britain began as a reform impulse. It was a part of a larger critique of the Industrial Revolution, which had radically altered Britain following the Napoleon... ... oriented away from ritual and visual symbols and more towards social and community ideals, it reinforced the social nature of the movement (A Thing of Beauty 9). Thus, although the Movement definitely had its stylistic expressions, it was not simply an art movement but had a rather complex structure of social, political and moral ideas of the British life in during that period. Works Cited A Thing of Beauty (Catalog of an exhibition at the High Museum of Art in Atlanta, Georgia, February 1-April 6, 1980). Atlanta: The High Museum of Art. 1980. Bolger Burke, et al. In Pursuit of Beauty. New York: Metropolitan Museum of Art. 1986. Kaplan, Wendy. The Art That Is Life: The Arts & Crafts Movement in America, 1875- 1920. New York: Little, Brown and Company. 1987. Klein, Dan. Aspects of the Aesthetic Movement. London: Gordon House/Hillingdon Press. 1978.

Harry Potter and Traditional Spiritual Values

This becomes a somewhat silly argument because there is not evidence of the Harry Potter series undermining traditional values. That is to say, while the books have become incredibly popular and sold millions of copies (to say nothing of the millions of tickets sold to the cinematic adaptations of the novels), American society has not changed. In other words, the books and the films have not set in motion a radical change in American civilization nor have they led to any conversions to witchcraft.Furthermore, the Harry Potter series are very traditional in their approach to ‘good and evil. ’ Harry Potter is not an anti-hero. He is an adolescent trying to find his place in the world while struggling with the fact that he is a warlock and this sets him apart from much of society. However, underlying Harry Potter’s actions are a desire to do good deeds in the world and, in the primary theme of Harry Potter and the Sorcerer’s Stone, develop solid relationships with peers and avoid capitalizing on his warlock skills in an unfair way.Unfortunately, there will be those who will get ‘hung up’ on the magic and witchcraft angle of the series, but to do so is to take life just a little too serious. It is, after all, a harmless children’s book series that contains solid moral messages and not an attempt at undermining values and indoctrinating the youth. To a great extent, many of the negative feelings towards the series will be developed by individuals who have not actually read the series or have developed a pre-existing opinion that has already drawn a negative conclusion.

A class trip to remember Essay Example

A class trip to remember Essay Example A class trip to remember Essay A class trip to remember Essay Lending nice exposure from our category trip would be the great challenge to finish an album, which is the photomontage and portion of package of our portfolio assignment. We planned beforehand the journey to Damai Puri Resort and came out with a list of interesting activities and equipment that we will hold to convey along. Out of outlook, it was merely the start of the catastrophe that we could neer conceive of. The category trip was merriment, memorable, and gratifying. The twenty-four hours of the trip began as usual but it was fun plenty for us. The cardinal issue of the trip was the transit to the location. We have deficient budget and could merely lease a mini new wave. Then, some of us had no pick and were forced to carpool in Bryan’s auto. We had a merriment siting trip with some card games and singing some swerving vocals in the auto. Then, Yasmin brought up a hot treatment subject and all of us had a truly fun clip debating over each other’s statement. Not long after that, the entryway of Damai Puri Resort is merely right in forepart of us. Once we arrived at the finish, we instantly settle down in the hotel room. The coach siting brought us an unforgettable memories and we had enjoyed the greatest minute, chew the fating, singing dad vocals and express joying together. I noticed that we were already bonded and literally grouped. We so took our first group exposure on the beach. By so, we were divided into groups to play around. Damai is so a merriment topographic point for out-of-door activities and the position is superb, one that we could neer bury. Nevertheless, the conditions was highly hot and was unsuitable for activities on the beach. So some of us have decided to soak into the pool and merely chilling around. Some other misss who were non interested to swim decided to hold their misss talk under the coconut trees. The scenes were memorable. After that, it was about flushing. We have decided to watch the sundown on the beac h, it was so beautiful. Likewise, we enjoyed the strong air current blows, the coconut torso up, I closed my eyes and listened to the loosen uping sound of sea moving ridges. It was such an gratifying minute. By six o’clock, all of us were exhausted. We were already hungering but it is still long to our barbecue dinner. Some of us insisted to take the early dinner at the cardinal nutrient tribunal. Those who struggled famishment went at that place for their early dinner while the commission were busy fixing the barbeque dark for the others. During the readying of the dinner, Celine, one of the commission, shouted. Apparently, she forgot to convey the necessary equipment and we could non lodge to our program without it. The misss were kicking and struggle arose. The commissions were faulting each other excessively. Meanwhile, another category were besides holding the barbeque dinner nearby. At that minute, the smartest cats in our category, Julius came out with an thought, which was to borrow the equipment from them after their dining. Fortunately, the thought worked truly good. Although the barbeque became our supper but we still bask of it. To sum up the trip experiences, I would utilize the words: memorable, unforgettable and merriment! However, our group leader was reasonably upset about the struggles. There are ever ups and downs in our life and I hope she is no longer sorrowing, I besides hope that we will hold another trip together and I will decidedly volunteer to be the leader to convey up the joy to everyone.

Priestly and Yahwist Views of Creation Essays

Priestly and Yahwist Views of Creation Essays Priestly and Yahwist Views of Creation Essay Priestly and Yahwist Views of Creation Essay How many people have ever noticed that there are two stories of creation in the Bible? The sources of the Genesis story, which I will analyze below, is that of the Priestly (P) source and of the Yahwist (J) source. Upon hearing there are multiple accounts, various sources, etc. it is tempting to automatically assume there are contradictions and discrepancies. This does not have to be the case. As such, I will describe differences between the two sources below and how one can read these accounts through theological and pastoral eyes. The two creation stories give different kinds of information, without a doubt, but this can be quite complimentary to one another. The P source is concerned with reflecting the order and structure of Gods plan for the world – an almighty God full of power and authority. In the P source of Genesis 1, we read Gods name as Elohim, which is the generic name of God giving off a connotation of a powerful being. This source of the creation story, reveals God as majestic and transcendent, where all events occur according to His will. The differences between the P and the J source is that in the former, God creates the Heavens and earth and humanity by mere words where as in the former, God is like a potter molding and shaping humanity using the dust from the ground. Humanity is favored in that it has been created in the image, the likeness of Elohim. Furthermore, the P source only mentions humanity at the end as the final creation in the likeness of God. When we review the J source of the creation story, no longer is God called Elohim but now, the Lord is called Yahweh meaning â€Å"He is†. Between the P and J source, we can recognize the ladder as giving a more personal account related to human beings – a God seriously invested in the affair of mankind, His creation. How do we conclude such a thing? The J gives name much more personal detail in that we learn of the names of Adam and Eve, we are given a mor

Free Essays on Washington D.C. - A First Hand Experience

Washington D.C. – One Student’s First Hand Experience Nothing can compare with the experience I had in Washington D.C. Within the first week of my arrival I learned more than any number of years behind a school desk could teach me. There are invaluable lessons learned through experience that simply cannot be replicated in the classroom. For instance, speaking to people who have actually â€Å"been there†. Not only did I read about refugees in my texts, I spoke with one as well. Not only did I read about Corporate Social Responsibility, I spoke with an expert in USAID on the topic. Where learning in the classroom gives concepts, experience provides students with the opportunity to apply these concepts. My experience in Washington D.C. provided me with a concrete foundation for the knowledge I have learned at college. I will attempt to explain the value of my experience in D.C. by writing about a few of the first-hand experiences I had in our nation’s capital. The Protest As part of my experience in Washington D.C. with the Lutheran College Washington Consortium, I was required to attend a protest. Thousands of people showed up September 29th in Freedom Plaza across from where I worked at the Ronald Reagan building. The streets were filled with all sorts of people from all different kinds of backgrounds to join in together to protest racism and the war in Afghanistan. At this point after September 11th, popular sentiment in the nation was leaning toward bombing the country of Afghanistan off the face of the earth. President Bush spoke of the â€Å"evil† enemy. The press portrayed pictures of Arabic people burning the United States’ flag. When combined together with the emotional loss felt after September 11th, this created a need for vengeance amongst the collective conscience, and the need for a viable scapegoat. It seemed at the time that Arabic people were taking the role as the scapegoat for all the ... Free Essays on Washington D.C. - A First Hand Experience Free Essays on Washington D.C. - A First Hand Experience Washington D.C. – One Student’s First Hand Experience Nothing can compare with the experience I had in Washington D.C. Within the first week of my arrival I learned more than any number of years behind a school desk could teach me. There are invaluable lessons learned through experience that simply cannot be replicated in the classroom. For instance, speaking to people who have actually â€Å"been there†. Not only did I read about refugees in my texts, I spoke with one as well. Not only did I read about Corporate Social Responsibility, I spoke with an expert in USAID on the topic. Where learning in the classroom gives concepts, experience provides students with the opportunity to apply these concepts. My experience in Washington D.C. provided me with a concrete foundation for the knowledge I have learned at college. I will attempt to explain the value of my experience in D.C. by writing about a few of the first-hand experiences I had in our nation’s capital. The Protest As part of my experience in Washington D.C. with the Lutheran College Washington Consortium, I was required to attend a protest. Thousands of people showed up September 29th in Freedom Plaza across from where I worked at the Ronald Reagan building. The streets were filled with all sorts of people from all different kinds of backgrounds to join in together to protest racism and the war in Afghanistan. At this point after September 11th, popular sentiment in the nation was leaning toward bombing the country of Afghanistan off the face of the earth. President Bush spoke of the â€Å"evil† enemy. The press portrayed pictures of Arabic people burning the United States’ flag. When combined together with the emotional loss felt after September 11th, this created a need for vengeance amongst the collective conscience, and the need for a viable scapegoat. It seemed at the time that Arabic people were taking the role as the scapegoat for all the ...

Philosophy 3330 interpretive essay final Example | Topics and Well Written Essays - 1250 words

Philosophy 3330 interpretive final - Essay Example rgument — often called the cogito argument in reference to Descartes’ most-quoted catchphrase the Latin cogito; ergo sum, or â€Å"I think; therefore I am† — to explain the rise of capitalism in Protestant society is perhaps one of the more interesting takes on Cartesian theory. Weber argues that instead of using Descartes’ notion of self simply as a philosophical proof of individual being, Protestants transformed the concept into â€Å"an ethical reinterpretation† (Weber 80), using it as the basis for a life of contemplation: In other words, Weber argues that Protestants seized on the idea of self-knowledge as a sort of manifesto, not a proof existence but a responsibility of existence. So far, so good, but where does the connection to capitalism come in? How does it relate to the notion of an inner life? What does it have to do with the notion of intellectual responsibility? â€Å"The name of Weber makes it clear that we cannot begin to sense the real ideological function of religious aestheticism unless we place it within that larger intellectual and ideological preoccupation which is the study and interrogation of value,† wrote Frederic Jameson (124). Or, more simply put, the religious contemplation of the Protestants was both a factor in and a result of their historio-economic status. For Weber, this status follows a predictable trajectory, journeying from the traditional to the rational with a brief, joyous moment of transformation Weber calls â€Å"charisma.† (Weber 96) The Protestant Reformation is an example of a charismatic period in the evolution of Western society, a time in which society was moving from traditional values and ethics toward restructured, rationalized ethics. And economic success was an important part of these metamorphosing ethics. Part of this emerges from what Weber sees as the Protestant notion of â€Å"craft ,† or pride in workmanship. The idea of a â€Å"calling† for a career path was no longer restricted to men and women of