Secundum atrial septal defect in the adult. Clinical, haemodynamic and electrophysiological aspects.

Atrial septal defect (ASD) is the most common congenital heart malformation diagnosed in adult life. In this thesis important clinical, haemodynamic and electrophysiological aspects of ASD in the adult are explored. The diagnostic accuracy of magnetic resonance velocity mapping (MRvm)in calculating the pulmonary/systemic flow ratio (QP/QS)was assessed (I). The mean and maximal error by MRvm was 1±1% and ≤4% respectively in the whole range of different QP/QS and repeatability showed a difference of 1±5%. Interobserver variability was four times higher for radionuclide angiography than MRvm, 16% vs. 4%, demonstrating the superiority of MRvm. Atrial electrophysiological properties before and 8±6 months after ASD closure were examined by means of high-resolution orthogonal P-wave signal-averaged ECG (II and III). P-wave duration was significantly longer in ASD patients than in controls and overall, it was not significantly affected by ASD closure. P-wave duration did not relate to echocardiographic atrial sizes, suggesting atrial conduction delay which seems more or less irreversible in middle-aged ASD patients. The remodelling potential and its speed were investigated by repeated echocardiograms before and during the 1st year after ASD closure (IV). Right ventricular and right atrial sizes as well as the pulmonary pressure levels were markedly reduced after ASD closure and became normal in a majority of the patients. In contrast, the left atrial size did not change and remained abnormal in 44%. When changes occurred they came early. Outcome of ASD closure was compared to medical management 6 and 30 years after the initial assessment (V). Closure of the defect was superior to medical management in terms of functional class, heart size and pulmonary pressure in the intermediate term. Early ASD closure also seemed beneficial in terms of late cardiovascular morbidity and mortality, in spite of a high frequency of late ASD closure, after the intermediate exam, in the medically managed group. In summary, the findings favour timely closure of the ASD if to reduce the risk of late mortality and morbidity

Samernas situation i Sverige: De internationella organisationernas betydelse för samernas relation till den svenska staten

Ursprungsfolk är idag en av de mest utsatta folkgrupperna i världen men den problematik de möter förknippas främst med förhållandena i u-länder och inte med förhållandena i ett i-land som Sverige. Samerna i Sverige har genom historien och i nutid utsatts för grov diskriminering och gör idag anspråk på självbestämmande och förbättrade förhållanden enligt internationell rätt. Denna uppsats ska därför utreda ursprungsfolks situation i Sverige genom en fallstudie av samerna som undersöker vilken betydelse de internationella organisationerna FN, ILO, EU och ursprungsfolks NGO:er har haft för utvecklingen av ursprungsfolksrättigheter och dess implementering i Sverige. Genom Ted Robert Gurrs teori om minoritetsgruppers konflikter med staten ska jag visa på allvaret i samernas utsatthet och konfliktfyllda relation till svenska staten och hur internationella organisationer haft avgörande betydelse för utvecklingen av ursprungsfolksrättigheter och implementeringen av dem i Sverige samt för samernas möjlighet att genom fredliga politiska strategier verka för sina rättigheter

The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period: The Euro Heart Survey on adult congenital heart disease

Aims To describe clinical and demographic characteristics at baseline of a European cohort of adults with congenital heart disease (CHD) and to assess mortality and morbidity in a 5 year follow-up period. Methods and results Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions (‘defects'), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common. Conclusion The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year perio

Adherence to guidelines in the clinical care for adults with congenital heart disease: The Euro Heart Survey on Adult Congenital Heart Disease

Aims To investigate the role of guidelines in structuring the clinical care for adult patients with congenital heart disease (CHD), and to assess adherence to the guidelines in Europe. Methods and results A selected number of current guidelines were chosen pertaining to operative procedures, investigations, and the use of medication (‘interventions'). The source for this analysis was the database of the Euro Heart Survey on adult CHD, which contains retrospectively collected data on 4110 patients followed-up for a median of 5.1 years. For each guideline investigated, patients were selected from the database for whom the particular guideline was relevant. The selected cases were classified according to two criteria: was there an indication for the particular intervention and did the intervention take place? In this manner, cases of ‘undue treatment' and ‘insufficient treatment' were identified. Adherence to guidelines was found to be good in the case of operative procedures and prophylactic drug treatment. However, regarding diagnostic procedures there had been adherence to guidelines in only slightly more than half of the cases. Conclusion Guidelines have an important role in the actual clinical care of adults with CHD. However, large outcome studies are needed to develop more precise guideline

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease

OBJECTIVE: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.  METHODS: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country).  RESULTS: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.  CONCLUSION: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome

Closure of atrial septal defect in the adult. Cardiac remodeling is an early event.

Background: Study aimed to describe the extent and the temporal profile of cardiac remodeling after atrial septal defect closure in the adult. Methods: Prospective and longitudinal echocardiographic assessment of right and left heart size before and after (1 day-1 week/1/4/12 months) surgical or catheter-based atrial septal closure in 39 adults (age 54 15 years). Results: Right ventricular and atrial sizes were markedly reduced, left ventricular size increased and left atrial size remained unchanged after closure. Older age and a history of atrial fibrillation reduced the potential to normalize right and left atrial size after closure. The greater part of the changes occurred very early, in the 1st day/1st week, From then on the speed of change gradually diminished and after 4 months no important changes were observed. The mode of closure did not influence the degree or the pace of the remodeling. Conclusion: Cardiac remodeling after atrial septal closure in the adult is a common and early event that seems by and large completed within the first half year after closure. The ventricles seem to have a higher capacity of remodeling than the atria in this setting. The mode of closure does not seem to significantly impact remodeling. (c) 2005 Elsevier Ireland Ltd. All rights reserved