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mum defect, there are mitral or tricuspid valve clefts as part of the atrioventricular (AV) canal defect A third form of ASD is the sinus venosus defect, a hole usually at of the upper part of the atrial septum due to failure of the embryonic superior vena cava (SVC) to merge with the atria properly This latter lesion is often associated with anomalous drainage of the right upper pulmonary vein into the SVC Rarer forms of ASD include a sinus venosus defect associated with failure of formation of the wall between the inferior vena cava (IVC) and the left atrium (LA) A coronary sinus ASD is basically an unroofed coronary sinus In all cases, normally oxygenated blood from the higher-pressure LA passes into the RA, increasing RV output and pulmonary blood flow In children, the degree of shunting across these defects may be quite large (3:1 or so) As the RV diastolic pressure rises from the chronic volume overload, the RA pressure may rise and the degree of left-to-right shunting may decrease Eventually, the shunt may even be right-to-left and cyanosis appears The pulmonary pressures are modestly elevated in most patients with an ASD due to the high pulmonary blood flow, but severe pulmonary hypertension with cyanosis (Eisenmenger s physiology) is actually rare, occurring in only about 15% of the patients Eventual RV failure may occur, and most shunts should be corrected unless they are quite small (< 15:1 right-to-left shunt) In adults, a large right-to-left shunt may have begun to reverse, so the absolute size at the time the patient is studied may underestimate what it was some years ago In addition, in most patients the LV compliance normally declines more over time than the RV, and the natural history of small atrial septal shunts is to increase as the patient ages (unless RV failure ensues) ASDs also predispose to atrial fibrillation due to RA enlargement, and paradoxic right-to-left emboli do occur Interestingly, paradoxic emboli may be more common in patients with a patent foramen ovale (PFO) than a true ASD, as the eustachian valve in the RA directs flow from the IVC toward the septum, and the usual significant left-to-right flow from an ASD is often not present with a simple PFO.



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1 May 2015 ... I'm not able to dynamically create and populate pages in a for loop. Is this possible? A simplified version to get four populated pages might look ...

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well With sinus venosus defects, the P axis is leftward of +15 due to abnormal atrial activation with loss of the upper RA tissue from around the sinus node The chest radiograph shows large pulmonary arteries, increased pulmonary vascularity, an enlarged RA and RV, and a small aortic knob with all pre-tricuspid valve cardiac left-to-right shunts

The subtransient, transient, and steady-state fault currents are given in per-unit above The actual fault currents are found by multiplying by the base current in Region 2:





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Echocardiography demonstrates evidence of RA and RV volume overload The atrial defect is usually observed, though sinus venosus defects may be elusive Many patients with a PFO also have an atrial septal aneurysm Echocardiography with agitated saline bubble contrast can demonstrate a rightto-left shunt and both pulsed and color flow Doppler flow studies can demonstrate shunting in either direction A transesophageal echocardiogram (TEE) is helpful when transthoracic echocardiography quality is not optimal, and it improves the sensitivity for small shunts and provides a better assessment of PFO anatomy Radionuclide flow studies quantify left-to-right shunting by observing the bolus of contrast within the lung fields and demonstrating early recirculation Both CT and MRI can elucidate the atrial septal anatomy and demonstrate associated lesions Cardiac catheterization is often helpful, especially if there are associated anomalous pulmonary veins The size and location of the shunt can be determined and the pulmonary pressure and pulmonary vascular resistance (PVR) measured Cardiac catheterization is required if percutaneous closure is to be contemplated

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Command-prompt Telnet clients lack a number of handy features They can t, for example, remember the IP addresses, user names, or passwords for Telnet servers, so every time you use Telnet, you have to enter all that information again Third-party Telnet clients, such as the very popular PuTTY you saw in 8, store all this information and much more (Figure 9-23)

Patients with small atrial shunts may live a normal life span Large shunts usually cause disability by age 40 years Because left-to-right shunts tend to increase with age-related changes in LV compliance, most clinicians believe that closure of all shunts over 15:1 should be accomplished Increased PVR and hypertension secondary to pulmonary vascular disease rarely occur in childhood or young adult life in secundum defects but are more common in primum defects After age 40 years, cardiac arrhythmias (especially atrial fibrillation) and heart failure may occur due to the chronic right heart volume overload Paradoxical systemic arterial embolization becomes more of a concern as RV compliance is lost and the left-to-right shunt begins to reverse PFOs are not associated with significant shunting, and therefore the patients are asymptomatic and the heart size is normal However, PFOs are responsible for most paradoxical emboli and are one of the most frequent causes of cryptogenic strokes in patients under age 55 years Small ASDs do not require intervention if echocardiography shows that the shunt is not creating an RV volume overload For larger deficits (those with an RV volume overload), surgery can be done at very low risk Surgery involves anything from simple stitching of the foramen closed to patching of the hole with Dacron or a pericardial patch Anomalous pulmonary venous connections are baffled to the LA through the sinus venosus defect when such anomalous veins are present For ostium secundum ASDs, percutaneous closure by use of a variety of devices is now

Patients with small or moderate ASDs and with a PFO are asymptomatic unless a complication occurs With large shunts, exertional dyspnea or cardiac failure may develop, most commonly in the fourth decade of life or later Prominent RV and PA pulsations are readily visible and palpable A moderately loud systolic ejection murmur can be heard in the second and third interspaces parasternally as a result of increased PA flow S2 is widely split and does not vary with breathing due to the fact that the left-to-right shunt decreases as the RA pressure increases with inspiration

Right axis deviation or RVH may be present depending on the size of the RV volume overload Incomplete or complete right bundle branch block is present in nearly all cases of ASD, and superior axis deviation is noted in the AV canal defect, where complete heart block is often seen as

vascular disease and severe pulmonary hypertension (Eisenmenger physiology)

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