Objective-To review the outcomes of transcatheter closure of atrial septal defects using the Cardio-Seal implant. Design-A prospective interventional study. Setting-Tertiary referral centre. Patients-The first 50 patients (median age 9.7 years) who underwent attempted percutaneous occlusion. Interventions-Procedures were done under general anaesthesia and transoesophageal guidance between December 1996 and July 1998. Main outcome measures-Success of deployment, complications, and assessment of right ventricular end diastolic diameter, septal wall motion, and occlusion status by echocardiography. Results-The median balloon stretched diameter was 14 mm. Multiple atrial septal defects were present in 11 patients (22%) and a deficient atrial rim (< 4 mm) in 19 (38%). In four patients (8%), a second device was implanted after removal of an initially malpositioned first implant. There were no significant immediate complications. All patients except one were discharged within 24 hours. At the latest follow up (mean 9.9 months) a small shunt was present in 23 patients (46%), although right ventricular end diastolic dimensions (mean (SD)) corrected for age decreased from 137 (29)% to 105 (17)% of normal, and septal motion abnormalities normalised in all but one patient. No predictors for a residual shunt were identified. Supporting arm fractures were detected in seven patients (14%) and protrusion of one arm through the defect in 16 (32%), the latter being more common in those with smaller anterosuperior rims. No untoward eVects resulted from arm fractures or protrusion. There were no complications during follow up, although five patients (10%) experienced transient headaches. Conclusions-The implantation of the Cardio-Seal device corrects the haemodynamic disturbances secondary to the right ventricular volume overload, with good early outcome. (Heart 2000;84:320-326)

In the patient with congenital heart disease, the phenomenon termed 'circular shunt' implies that some of the right-to-left shunted blood returns to its chamber of orgin through intracardiac channels or communications, hence bypassing the systemic capillary bed. We are reporting the angiographic appearance of a right-sided 'circular shunt' in 2 patients with pulmonary atresia, diminutive, hypertensive right ventricle, and intact ventricular septum. In these patients the intramyocardial sinusoids and diverticula form the anatomical basis for the right-sided 'circular shunt': blind, hypertensive right ventricle->intramyocardial sinusoids-1coronary artery--coronary venous system-*coronary sinus--right atrium--right ventricle. It is suggested that retrogradeflow through these intramyocardial sinusoids may impede or limit normal diastolic coronary artery perfusion and may predispose to myocardial ischaemia and dysfunction. In addition, the natural history of these intramyocardial sinusoids and diverticula is discussed.

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Anatomically corrected malpositions are uncommon cardiac anomalies in which the pulmonary artery originates above the morphological right ventricle, and the aorta above the morphological left ventricle. However, because of interposition of abnormal subaortic conal myocardium, there is absence of aortic valve-mitral valvefibrous continuity. The relation between the pulmonary artery and aorta is also abnormal because of the abnormal conal morphology.Two cases of anatomically corrected malposition of the great arteries are presented, one of which is the first reported in a patient with the congenital asplenia syndrome; in the other, there was left juxtaposition of the atrial appendages. Review of all known cases of anatomically corrected malposition reveals a significant association with juxtaposition of the atrial appendages and hence with hypoplasia of the right ventricle, subpulmonary and subaortic obstruction. Possible surgical implications of this association are discussed.Although Harris and Farber first suggested the concept of anatomically corrected transposition of the great arteries in I939, recognition and documentation of this unusual entity was first provided by Van Praagh and Van Praagh in I967. In anatomically corrected transposition of the great arteries, the aorta arises above the morphological left ventricle but with aortic-mitral discontinuity because of abnormal subaortic conus, and the pulmonary artery originates above the morphological right ventricle. Because of the abnormal conal morphology, abnormal relation between the aorta and atrioventricular valve, and abnormal relation between the great arteries, this entity was initially thought to be a form of transposition (Van Praagh and Van Praagh, I967