The Role of Premature Ovarian Failure Awareness in Female Sexual Functions and Distress

The diagnosis of premature ovarian failure is traumatic to women, with loss of gonadal functions having been associated with distress and anxiety. The aim of this study is to evaluate the sexual function and distress of women with premature ovarian failure before the diagnosis. Women with premature ovarian failure and age-matched controls were evaluated through the Female Sexual Function Index and the Female Sexual Distress Scale-Revised, and their androgen levels were compared. The major finding of this study is the lack of difference between sexual function in women who are unaware that they have premature ovarian failure and age-matched women with normal gonadal function.

The role of oxidative stress in premalignant lesions

PURPOSE OF INVESTIGATION

The authors aimed to evaluate serum total oxidant status (TOS), total antioxidant status (TAS), and oxida- tive stress index (OSI) in women with abnormal cervical cytology, to determine the association between serum oxidant and antioxidant status of these women, and the progression of abnormal cervical cytology.

MATERIALS AND METHODS

A total of 75 women enrolled in the study: 20 women with a determination of atypical squamous cells of undetermined significance (ASCUS), 20 women with low squamous intraepithelial lesions (LSIL), 15 women with high squamous intraepithelial lesions (HSIL) and 20 healthy controls. Serum TOS and TAS were determined and OSI was calculated as the indicator of degree of oxidative stress.

RESULTS

Serum TOS levels and OSI were highest in the HSIL group and there was a trend toward increasing serum TOS levels and OSI from ASCUS to HSIL group.

CONCLUSION

The authors demonstrated that increased oxidative stress with altered antioxidant level is associated with abnormal cervical cytology. Serum oxidant and antioxidant status may provide guidance as a simple and cost-effective method for follow-up, treatment, and recommendation in all stages of lesions.

An animal model of effects of nicotine exposure on endometrial receptivity and embryo implantation in pregnancy

OBJECTIVE

This study aims at evaluating the endometrial receptivity in uterus of pregnant rats exposed to nicotine via examination of integrin expression by immunohistochemical effect.

METHODS

In this study, 16 healthy pregnant rats were divided into two groups of control and study groups each comprising eight rats. The rats randomised to study group were given a certain amount of nicotine before and during the pregnancy. Integrin expression was detected in uterus of all rats by immunohistochemical staining. The effect of nicotine exposure on embryo implantation and the endometrial receptivity were immunohistochemically and pathologically evaluated.

RESULTS

Comparison of both groups revealed no difference in living, viable foetuses. Intensity and universality of immunohistochemical staining of Integrin β3 for endometrial epithelium and endometrial stroma were detected to be identical between the groups.

CONCLUSION

No immunochemical effect was observed on integrin expression, which is a very important part of receptivity in an animal model created with pregnant rats that were transdermally exposed to nicotine. Our study demonstrated that the harmful effect of nicotine use before and pregnancy on implantation is limited at the level of integrin expression, in a dose-dependent manner and also by considering the method of administration.

Effect of IVF failure on quality of life and emotional status in infertile couples

OBJECTIVE

To investigate the effect of a previous IVF failure on the quality of life and emotional distress, in couples undergoing IVF treatment. Experiencing IVF failure might cause differences on the anxiety-depression and quality of life scores of the couples, compared to the ones who were undergoing IVF treatment for the first time.

STUDY DESIGN

This study included 64 couples who had previously experienced at least one IVF failure (Group 1) and 56 couples without history of IVF failure (Group 2) in a private Assisted Reproductive Center, Istanbul, Turkey. A sociodemographic data form, the FertiQoL International and Hospital Anxiety (HAD-A) and Depression scale (HAD-D) for evaluating the status of distress, were administered for the study.

RESULT(S)

FertiQoL scores were compared between the groups, the environment scale of the quality of life in treatment section was found to be significantly higher in Group 1 compared with Group 2 (p=0.009). The HAD-A and HAD-D scores did not differ significantly between the groups. Group-variables were investigated using multilevel analysis, the infertility duration and income level were found to have an effect on the subscales of quality of life (p=0.009 and p=0.001 respectively) in Group 2. Depression scores were higher in couples with infertility duration of below five years in Group 1 and Group 2 compared to couples with infertility duration of five years or above (MANOVA analysis). The level of education was found to affect the scores of HAD-D in Group 2, but not in Group 1 (p=0.011). The score of HAD-D was significantly affected by the family type only in Group 2 (p=0.009); the depression score of the couples living with a nuclear family was found to be higher compared with the couples living in a traditional family (p=0.021).

CONCLUSION(S)

Fertility-specific quality of life scores reveals better results regarding the orientation to the treatment environment in the couples with a previous IVF failure, compared to first IVF cycle couples. Treatment failure does not elevate the level of anxiety, while the effect on depression scores changes according to duration of infertility.

The early pregnancy volume measurements in predicting pregnancy outcome

OBJECTIVE

The authors' aim was to develop a logistic regression model based on the ultrasonographic parameters on maternities which are showing a healthy improvement process during the first trimester of pregnancy.

MATERIAL AND METHODS

Using 2D transvaginal ultrasound imaging, the crown rump length (CRL), yolk sac (YS), and gestational sac (GS) diameters were recorded in 225 women with gestational age < 11 weeks. Simplified V = 0.523 x length x height x width formula was used for the volume calculations. The results which ended in abortion were not included in the study.

RESULTS

Linear regression analyses between yolk sac volume (YSV), YSV = 0.026 + 0.0018 x CRL (r²: 0.15; p < 0.001), gestational sac volume (GSV), GSV= -9.6 + 1.7 x CRL (r²: 0.52; p < 0.001), and embryo volume (EV), EV = -1.64 + 0.18 x CRL (r²: 0.4; p < 0.001), and CRL was made and a linear relationship was detected. The volume measurements showed a meaningful correlation with the week of pregnancy. The space in the GS (GS volume-embryo volume) increased as the age of pregnancy became older (r² = 0.46; p < 0.001).

DISCUSSION

The first volume value was made in the first trimester by transvaginal ultrasonography, which showed a correlation with the age of pregnancy.

Effects of altitude changes on Doppler flow parameters for uterine, umbilical, and mid-cerebral arteries in term pregnancy: A pilot study

OBJECTIVE

We hypothesized that maternal and fetal circulations may be affected by moderately high altitudes. Therefore, we compared the differences in maternal and fetal Doppler flow parameters in women with term pregnancy living at a moderately high altitude (1890 m in Erzurum) with those of women living at the sea level (31 m in İstanbul).

MATERIAL AND METHODS

Eighty women (n=40, for each group) with full-term and singleton pregnancies underwent Doppler waveform analysis, and the pulsatility and resistance index values for the uterine, umbilical, and mid-cerebral arteries were recorded. Also, sex, birth, and placental weights during delivery were obtained from the medical records.

RESULTS

Similar mean placental weight values were found at the sea level compared with the moderately high altitude (p>0.05). The mean birth weight values were found to be lower at the moderately high altitude than those at the sea level (p<0.05). The pulsatility and resistance index values for the umbilical and mid-cerebral arteries were found to be similar between the groups (p>0.05). However, the pulsatility and resistance index values for both the right and left uterine arteries were higher at the sea level than those at moderately high altitude (p<0.05, for all).

CONCLUSION

Moderately high altitude does not affect fetal vascular Doppler parameters. However, it appears to increase the uterine artery blood flow bilaterally, and these alterations in the bilateral uterine artery blood flow may be associated with a physiological adaptation to high altitude.

Gastrointestinal Stromal Tumor: May Mimic Adnexal Mass

Gastrointestinal stromal tumors (GISTs) are rare tumor of the gastrointestinal tract. GISTs occur in the entire gastrointestinal tract and may also arise from the retroperitoneum, omentum and mesenteries. They are originated from gastrointestinal pacemaker cells (Cajal’s interstitial cells) and range from benign tumors to sarcomas at all sites of occurrence. Diagnosis of GIST could be deceptive because of their similarity in appearance to gynecological neoplasms. We would like to present a case of a woman with GIST in the small intestine giving a imprint of an adnexal mass was diagnosed correctly during surgery. The diagnosis and treatment of GIST has been reformed over the past years. It is crucial to separate GISTs from possible misdiagnosis because their prognosis and treatment could be unlike clearly. The purpose of this case is to evaluate this rarely seen clinical entity, and thus, make some contribution to the literature.

The Effect of Controlled Reperfusion in the Prevention of Infertility Caused by Ischemia Induced in the Contralateral Ovary in Rats with Unilateral Ovariectomy

BACKGROUND/AIMS

To investigate the effectiveness of controlled reperfusion (CR) on ovarian tissue malondialdehyde, total glutathione and 8-hydroxyguanine levels and infertility rates in a rat model of induced ischemia-reperfusion (I/R) injury with unilateral oophorectomy.

METHODS

A total of 135 adult female albino Wistar rats were divided into 9 groups (n = 15 for each group): unilateral ovariectomy + ovarian I/R (OIR), unilateral ovariectomy alone (OEG), a sham operation group (SG), and unilateral ovariectomy + CR performed at different intervals (the clips were released 10 times for 10, 8, 6, 4, 2 or 1 s and closed again 10 times for 10, 8, 6, 4, 2 or 1 s; OCR-1-6, respectively). Five rats from each group were sacrificed, and their ovaries were removed.

RESULTS

Higher ovarian tissue malondialdehyde and 8-hydroxyguanine levels and lower ovarian tissue total glutathione levels were found in the OIR group compared with the SG, OEG and OCR-4-6 groups. The number of rats giving birth during the study period was found to be similar among the SG (n = 8), OEG (n = 8) and OCR-6 (n = 7) groups.

CONCLUSION

These results suggest that sterility and ovarian oxidative stress caused by I/R injury decreases in parallel to the shortening of CR duration.

Relation of metabolic syndrome with endometrial pathologies in patients with abnormal uterine bleeding

PURPOSE

We aimed to investigate the association of metabolic syndrome and metabolic risk factors with endometrial hyperplasia and carcinoma among women with abnormal uterine bleeding (AUB).

METHODS

This study included 199 patients who had undergone endometrial curettage due to abnormal uterine bleeding. We divided the patients into two groups according to whether they had an abnormal (n = 53) or normal endometrium (n = 146). Waist circumference, blood pressure, fasting glucose and serum lipid levels were measured and statistically analyzed. The women in each group were matched with regard to mean age, gravidity, parity and menopausal status.

RESULTS

We found increased prevalence of metabolic syndrome, diabetes, general and abdominal obesity, hypertension, elevated levels of glucose, total cholesterol and LDL-cholesterol and reduced levels of HDL-cholesterol among women with endometrial carcinoma and hyperplasia. These results were detected particularly in postmenopausal (>50 years) women compared to pre-menopausal cases (<50 years). All metabolic parameters were similar between hyperplasia and cancer groups.

CONCLUSION

Metabolic syndrome and its components have been shown to have profound impacts on initiation and progession of endometrial pathology, particularly during post-menopausal period.

Can we predict postpartum depression in pregnant women?

OBJECTIVE

The authors aimed to determine risk factors for postpartum depression (PPD) in this prospective study.

MATERIALS AND METHODS

The study included 285 pregnant women. The first assessment was conducted during pregnancy and a second time at 24 weeks after delivery. The participants were asked to fill out a series of questionnaires, which included psychosocial variables and socio- demographic characteristics, the Beck Depression Inventory (BDI), and Edinburgh Postnatal Depression Scale (EPDS). After delivery, 276 mothers participated again in the study and filled out a similar series of questionnaires.

RESULTS

A significant difference was not found between the socio-demographic and obstetric factors of mothers. A significant relation was found between the BDI score, which is used in antepartum depression evaluation, and EPDS score, which is used on postpartum depression evaluation (rho: 0.433 to 0.645, p < 0.0001). In cases in which BDI score was more than 6 were selected, phenomena in which could develop PPD had 90.3% sensitivity and 45.3% specificity.

CONCLUSIONS

The authors found that there was a correlation between EPDS score and BDI. The rate of PPD was found to be significantly higher in women, who had a depression history. Patients who have a potential risk of PPD should be evaluated during the postpartum period in terms of depression.

Effect of vaginal electrical stimulation on female sexual functions: a randomized study

INTRODUCTION

Female sexual dysfunction (FSD) is a common problem that may be encountered in the interruption of normal sexual functioning in the sexual response cycle. Women with a pelvic floor disorder who scored low on the Female Sexual Function Index (FSFI) showed an improvement in their sexual life following treatment by vaginal electrical stimulation (VES).

AIM

The aim of this trial was to evaluate the effectiveness of VES in women with FSD without a predominant pelvic floor disorder or urinary incontinence.

METHODS

Forty-two women with FSD were randomly allocated to VES and placebo groups. Pelvic floor muscle (PFM) assessment and the FSFI questionnaire were performed at baseline and after the completion of sessions. VES treatment was administered using a vaginal probe. The probe was inserted, and a medium-frequency (50 Hz) alternating current was administered for a duty cycle of 5 seconds on followed by a 5-second rest.

MAIN OUTCOMES MEASURES

Primary outcome measure was the improvement in FSFI score. PFM assessments were performed according to the PERFECT scheme.

RESULTS

Total FSFI scores improved significantly in both the VES group and the control group. Results show that in the VES group, there was an improvement in total score and FSFI domains that improved including arousal, desire, orgasm, and satisfaction. Similarly, control group domains that improved were desire, arousal, and orgasm. But there was no significant increase in satisfaction scores in the placebo group. No significant changes in pain or lubrication domains were seen in either group. Power, endurance, fast contractions, and repetitions were significantly improved in the VES group.

CONCLUSIONS

The lack of significant differences between the placebo and VES groups, except the satisfaction domain, puts into question the effectiveness of electrical stimulation as a monotherapy in treating primary FSD without pelvic floor disorder.

Is three-dimensional prenatal ultrasound necessary: pregnant women's point of view

OBJECTIVES

The role and applicability of three-dimensional ultrasound (3D-US) in perinatology has been repeatedly discussed in the literature. Regardless, our knowledge about patient expectations remains limited. We aimed at determining the expectations, perception and knowledge of pregnant women about 3D-US.

MATERIAL AND METHODS

Upon admission to the labor unit, the women filled out a questionnaire, with the help of a doctor investigating sociodemographic data, pregnancy and delivery history previous experiences and expectations for US imaging.

RESULTS

A total of 644 pregnant women were included in the study Respondents declared that approximately 70% of all kinds of structural abnormalities could be detected by 3D-US and estimated its reliability at nearly 70%. While 60% of the participants underwent 3D-US, 70% of them believed that every pregnant woman should undergo such test. Also, 457 (70.9%) of the participants were of the opinion that every pregnant woman must undergo 3D-US imaging, whereas 173 (26.8%) did not think 3D-US imaging was necessary

CONCLUSIONS

To the best of our knowledge, this has been the first study on patient opinions regarding the need for 3D-US imaging during pregnancy Although the participants were not certain about the harmful effects of 3D-US, the majority believed that it was necessary for every pregnant woman to undergo such testing. Obviously patients must be instructed on the limitations of US imaging before the examination to clarify any misunderstandings about the possibilities such a technique may offer

Polycystic ovary syndrome is associated with P-wave prolongation and increased P-wave dispersion

BACKGROUND

The polycystic ovary syndrome (PCOS) is associated with various cardiac manifestations including cardiac arrhythmias. P-wave dispersion (Pdis) is an appealing marker for predicting the risk of developing atrial arrhythmias. The purpose of this study was to evaluate P-wave durations and Pdis in patients with PCOS.

METHODS

Forty adult patients with PCOS and 46 age- and sex-matched healthy individuals were included in this study. P-wave maximum duration (Pmax) and P-wave minimum duration (Pmin) were calculated on the 12-lead electrocardiogram, and the difference between the Pmax and the Pmin was defined as Pdis. All individuals also underwent transthoracic echocardiographic evaluation.

RESULTS

Pmax and Pdis were significantly higher in patients with PCOS compared with controls (p = 0.007, p < 0.001, respectively). There was no difference in Pmin duration between both the groups (p = 0.2). Waist-to-hip ratio, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were higher in the PCOS group. Early mitral inflow deceleration time (DT) (p < 0.001) and isovolumetric relaxation time (p = 0.003) were longer in PCOS group. Waist-to-hip ratio, DT, E/A ratio and diastolic blood pressure correlated with Pdis.

CONCLUSIONS

Patients with PCOS have prolonged Pmax and Pdis. The increase in those parameters may be an indicator for identification of patients at increased risk of atrial fibrillation.

Subclinical left ventricular dysfunction in women with polycystic ovary syndrome: an observational study

OBJECTIVE

Cardiac involvement has been increasingly recognized in patients with polycystic ovary syndrome (PCOS). Identification of the earliest asymptomatic impairment of left ventricular (LV) performance may be important in preventing progression to overt heart failure. Our aim was to investigate LV function with different echocardiographic techniques in patients with PCOS.

METHODS

Thirty patients with PCOS and 30 age and body mass index matched healthy subjects were enrolled to this cross-sectional observational study. All subjects underwent echocardiography for assessment of resting LV function as well as two-dimensional speckle tracking echocardiography (2D-STE) and real-time three-dimensional echocardiography (3D-Echo). Global longitudinal strain (GLS) was calculated from 3 standard apical views using 2D-STE. Student t-test, chi-square test, Pearson's, and Spearman's correlation analysis were used for statistical analysis.

RESULTS

The early mitral inflow deceleration time (DT), isovolumetric relaxation time (IVRT) and E/Em ratio were increased in the PCOS group (p<0.05 for all). Waist-to-hip ratio, fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR) and low-density lipoprotein (LDL) levels were higher in PCOS group (p<0.05 for all). Significant correlation was observed between DT, IVRT and insulin value, HOMA-IR (p<0.05 for all). On 3D-Echo evaluation, none of the patients in both groups had LV systolic dysfunction with comparable LV ejection fraction and LV volumes. 2D-STE showed that GLS was significantly reduced in the PCOS group compared to control group (-16.78 ± 0.56% vs. -18.36 ± 1.04%, p<0.001). The GLS was found to be negatively correlated with waist-to-hip ratio and LDL values (p<0.05 for all).

CONCLUSION

These results indicate that PCOS may be related to impaired LV systolic function detected by 2D-STE. In addition, PCOS may lead to diastolic dysfunction. Reduced GLS might be an early indicator of cardiac involvement in this patient population.

First trimester maternal serum pregnancy-associated plasma protein-A is a predictive factor for early preterm delivery in normotensive pregnancies

In this study, we investigated whether the concentrations of pregnancy-associated plasma protein-A (PAPP-A) or free β-hCG (fβhCG) in the first trimester can identify women at increased risk of subsequent preterm delivery in the absence of hypertensive disorders. Preterm and early preterm deliveries are defined as those deliveries before completing 37 and 34 weeks, respectively. A total of 868 women were enrolled into this study. According to the level of the markers, the patients were evaluated in three groups: 1 - maternal serum level ≤ 5 th percentile, 2 - between 5th and 95th percentiles, 3 - ≥ 95 th percentile. In the group of patients with a PAPP-A level ≤ 5 th percentile [≤ 0.35 multiples of the median (MoM)], mean gestational age (GA) at delivery, mean birth weight and the number of the cases with early preterm delivery were significantly lower than the others. Mean level of PAPP-A was significantly lower in cases with early preterm than term deliveries (0.58 ± 0.32 versus 1.09 ± 0.69; p = 0.01). Maternal serum level of fβhCG did not show significant difference between these groups (0.84 ± 0.45 versus 1.17 ± 0.77; p = 0.15). Low levels of maternal serum PAPP-A (≤ 0.35 MoM) (Odds ratio = 7; 95% confidence interval 1.8-27.7; p = 0.0048) significantly predicted early preterm delivery in normotensive pregnancies. Women with low levels of PAPP-A at first trimester have a higher risk of early preterm delivery even in the absence of hypertensive disorders.

Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection

PURPOSE

The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection.

METHOD

Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems.

RESULTS

In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001).

CONCLUSION

Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone.

LEVEL OF EVIDENCE

Randomized, controlled trial, Level I.

[Therapy and prognosis of infectious complete atrioventricular block in children]

From 1983 to 1997, we have studied ten children with complete atrioventricular block likely due to myocarditis in order to assess its prognosis and to define a therapeutic strategy. Their age ranged from 6 days to 16 years (median: 4.1 years). All were admitted for sudden complete block, with symptoms in seven: syncope or fainting, seizures, collapse. Three had an asymptomatic bradycardia which was detected on routine auscultation in children with fever or already hospitalized; fever was present in 5. The disease was related to infection on biological data in 4 cases (1 listeriosis and 3 seroconversions for Epstein Barr or cytomegalic or Coxsackie B viruses), on a myocardial biposy in 1 case and on scintigraphic data in 1 case. In the remaining 4, indirect arguments were considered such as infectious context, normal recent ECG, favourable outcome. Five children were given intravenous isoprenalin with ventricular tachycardia in 3. Five were treated with steroids and 3 with specific antiviral agents. Seven patients were paced temporarily. One child died, 6 recovered totally and 3 have a permanent block with a definitive pacemaker implanted in 2. In conclusion, sudden acquired complete atrioventricular blocks are often ill-tolerated in children and have to be treated with transient pacing. Recovery occurs as a rule but some of these blocks may be definitive. Infective myocarditis is likely to be the cause of the disease even if the pathogen agent cannot always be identified.

Regression of right ventricular pressure in ventricular septal defect in infancy: a longitudinal color-flow Doppler echocardiographic study

To determine the course of right ventricular pressure (RVP) in patients with isolated ventricular septal defect (VSD) and factors influencing it, unselected 148 infants were followed-up longitudinally with color-Doppler echocardiography from a median age of 1 month for 201 patient-years. The patients were divided into three groups by absolute echographic size of VSD: group I, </=4.0 mm; group II, >4 to </=7 mm; group III, >7 mm. Sixty percent belonged to group I. Muscular defects dominated in group I, perimembranous defects dominated in group II, and those with outlet extensions dominated in group III. Peak systolic RVP was obtained by Doppler-estimated difference between systolic brachial artery and peak gradient across the VSD. Initial RVP ranged between 15 and 95 mmHg and increased in parallel to the size of defect. According to the regression equations RVP decreased in general by 0.17 mmHg per month. This correlated significantly with the size of the defect. In group I, the rate of decrease was very fast and is best expressed by a log function of time (r = -0.67, r(2) = 0.45). In groups II and III the rate of decrease was less steep and had a greater variability. RVP normalized in 100% in those of group I and in 90% of group II, at median ages of 0.17 and 0.33 years, respectively. Median Q(p):Q(s) values were 1.5, 2.2, and 3.0 in groups I-III, respectively. The outcome depended on the size of VSD. Spontaneous closure was observed in 51% of group I, 10% of group II, and none of group III. The rate was higher in muscular defects. Congestive heart failure was present in 53% and 100% in groups II and III, respectively. Death rate was 2.03%, all in patients with large defects. It is concluded that the temporal course of RVP with time can be estimated fairly well by the regression equation presented in relation to the initial size of the VSD.

Balloon atrial septostomy under echocardiographic guidance. Case report

A seven-days-old male neonate was transferred to our institution in critically ill condition. Echocardiographic (ECHO) examination revealed the transposition of the great arteries (TGA) with a small ventricular septal defect. In the laboratory examination, arterial oxygen saturation was 29 percent and pH was 7.16. The poor condition of the neonate led us to decide to perform an immediate bedside balloon atrial septostomy (BAS) in the intensive care unit (ICU) with ECHO guidance. The umbilical vein was cannulated with a 5 Fr. Miller BAS catheter. Four balloon passes were performed resulting in large atrial septal defect. After the procedure, arterial oxygen saturation was measured at 40 percent. In TGA, the baby may present with severe hypoxia and may need management in the ICU. Emergency BAS may improve the clinical condition of the patient. Transferring the baby, who is mechanically ventilated (and is in openbed), to the catheterization laboratory takes time and can be harmful for him, and carries risk of extubation and heat loss. The limitations of transthoracic ECHO guidance of BAS include the possibility of a poor ECHO window in an ill neonate on assisted ventilation and possible interference with maneuverability for both echocardiographer and catheter operator. It also carries the risk of contamination of the sterile field. When the advantages and disadvantages of transthoracic ECHO guidance are considered, transferring the baby to the catheterization laboratory can cause problems and time loss. Thus, ECHO-guided BAS at bedside is an efficient and good alternative. The transumbilical approach may be easier in the first few days of life.

The natural course of isolated ventricular septal defect during adolescence

Serial changes in patients with isolated VSD during adolescence have not previously been investigated. Hemodynamic status, diameter of the defect, and growth were studied yearly in 106 children with VSD. The mean duration of the follow-up was 13.16 years and ranged in 80% of subjects from 7 to 19 years (1395 patients years). The mean ages at pre- and postpuberty were 8.62 and 16.67, respectively. The presented longitudinal study, in which losses due to death and operation were minimal (4%), ideally reflected the natural history of VSD. Although weight showed retardation during prepuberty, this lag was caught up by the end of adolescence. Stature showed no retardation in pre- and postpuberty. Cardiothoracic ratio decreased significantly from a mean of 0.48 to 0.44 and showed normal variation. Although the mean defect diameter at prepuberty was 5.33 mm, this decreased to 2.7 postpubertally. The individual decrease (1.7 +/- 2.34 mm) was significant (t = 5.349, p < 1/10(5)). The defect closed spontaneously in 24 (22.6%). In the 75 patients without pulmonary hypertension and with mild left-to-right shunting, 52 remained in the same class and spontaneous closure was observed in 23. In the 24 patients with moderate to severe left-to-right shunt, this decreased in 23 and only one remained stable. The 2 patients (1.9%) with Eisenmenger syndrome remained stable and 1 died. Aortic regurgitation developed in 10 patients (9.4%); however, this was of mild degree in most of them. No infective endocarditis was observed. It is concluded that patients with VSD should be followed closely through adolescence, because the diameter of the defect, as well as left-to-right shunting, can decrease, and it is concluded that the spontaneous closure of the defect is to be expected in a considerable 23%, and aortic prolapse or mild regurgitation may develop in approximately 10%.

Anomalous origin of the left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCA-PA) is a rare form of congenital heart disease. In this report, three cases with this anomaly are described; two patients presented in infancy with heart failure from myocardial ischemia and infarction, while the third was asymptomatic and ALCA-PA was diagnosed during evaluation of a residual murmur after surgery for associated cardiac defects (ventricular septal defect and patent arterial duct). All three cases underwent aorto-pulmonary tunnel repair (Tukeuchi procedure), and to our knowledge two of them are the first infantile cases reported in Turkey.

Balloon dilatation angioplasty of a stenotic Blalock-Taussig anastomosis. A case report

A 12-year-old boy with tetralogy of Fallot was evaluated for increasing cyanosis and exercise intolerance. The patient had a right Blalock-Taussig shunt operation 11 years previously and a left modified Blalock-Taussig shunt operation one year previously. After demonstration of hypoplastic pulmonary arteries, the stenosed right Blalock-Taussig shunt and the totally occluded, left modified Blalock-Taussig shunt were successfully dilated with a 7-mm-diameter angioplasty balloon resulting in a 5-mm-diameter patent shunt. We believe that, when possible, balloon dilatation angioplasty of stenosed Blalock-Taussig shunts is a reasonable and safe alternative to surgery.