Viagra Vigour

Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes order viagra vigour 800mg mastercard erectile dysfunction doctor in kolkata. Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance buy generic viagra vigour 800mg online erectile dysfunction diagnosis. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program purchase viagra vigour overnight erectile dysfunction treatment new orleans. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. Does sports activity enhance the risk of sudden death in adolescents and young adults? Incidence of sudden cardiac death in National Collegiate Athletic Association Athletes. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Task force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, et al. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study. Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. An electrocardiogram should not be included in routine preparticipation screening of young athletes. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death: proven fact or wishful thinking? Sudden cardiac death and preparticipation screening: the debate continues—in support of electrocardiogram-inclusive preparticipation screening. Evidence for efficacy of the Italian national pre-participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. A Scientific Statement from the American Heart Association and the American College of Cardiology. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Outcome of patients with hypertrophic cardiomyopathy and a normal electrocardiogram. Recommendations for interpretation of the 12-lead electrocardiogram in the athlete. Normal electrocardiographic findings: recognizing physiologic adaptations in athletes. Abnormal electrocardiographic findings in athletes: recognizing changes suggestive of cardiomyopathy. Abnormal electrocardiographic findings in athletes: recognizing changes suggestive of primatery electrical disease. Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes. Relation of race to electrocardiographic patterns in elite American football players. Ethnic differences in left ventricular remodeling in highly trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. Comparison of electrocardiographic criteria for detection of cardiac abnormalities in elite black and white athletes. Is there evidence for recommending electrocardiogram as part of the pre- participation examination? Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Preparticipation screening of young competitive athletes for cardiovascular disorders. Ventilatory anaerobic threshold for evaluating exercise performance in children with congenital left-to-right intracardiac Shunt. Serial cardiorespiratory exercise testing in patients with congenital heart disease. Lower exercise capacity in children with asymptomatic atrial septal defect associated with circulatory impairment. Is it worth closing the atrial septal defect in patients with insignificant shunt? Recommendations for participation in competitive and leisure sports in patients with congenital heart disease: a consensus document. Effect of physical training on exercise performance of children following surgical repair of congenital heart disease. Atlantoaxial instability in individuals with Down syndrome: epidemiologic, radiographic, and clinical studies. Longitudinal evaluation and assessment of cardiovascular disease in patients with homozygous familial hypercholesterolemia. Left ventricular outflow obstruction: subaortic stenosis, bicuspid aortic valve, supravalvar aortic stenosis, and coarctation of the aorta. The value of cardiopulmonary exercise testing in individuals with apparently asymptomatic severe aortic stenosis: A pilot study. Effects of exercise training on aerobic fitness in children after open heart surgery. Postoperative exercise training develops normal levels of physical activity in a group of children following cardiac surgery. Exercise training in adults with congenital heart disease: feasibility and benefits.

purchase discount viagra vigour on line

Myocardial ischemia in patients with pulmonary atresia and intact ventricular septum discount viagra vigour 800 mg without a prescription erectile dysfunction causes infertility. Effects of persisting myocardial sinusoids on left ventricular performance in pulmonary atresia with intact ventricular septum discount 800 mg viagra vigour otc zma impotence. Right ventricular infarction with cardiac rupture in an infant with pulmonary valve atresia with intact ventricular septum discount viagra vigour online american express impotence natural supplements. Capillary distribution in the ventricles of hearts with pulmonary atresia and intact ventricular septum. Coronary arterial abnormalities in pulmonary atresia with intact ventricular septum. Development of the coronary vasculature and its implications for coronary abnormalities in general and specifically in pulmonary atresia without ventricular septal defect. Competition of coronary arteries and ventriculo-coronary arterial communications in pulmonary atresia with intact ventricular septum. Abnormalities of the coronary circulation in pulmonary atresia and intact ventricular septum. Echocardiographic predictors of coronary artery pathology in pulmonary atresia with intact ventricular septum. Pulmonary atresia with intact ventricular septum and hypoplastic right heart in sibs: a single gene disorder? Usefulness of Doppler echocardiography in diagnosing right ventricular coronary arterial communications in patients with pulmonary atresia and intact ventricular septum and comparison with angiography. Complete atresia of coronary ostia in pulmonary atresia and intact ventricular septum. Importance of right ventricular outflow tract angiography in distinguishing critical pulmonary stenosis from pulmonary atresia. Survival after systemic to pulmonary arterial shunts in infants less than 30 days old with obstructive lesions of the right heart chambers. Right ventricular growth after transventricular pulmonary valvotomy and central aortopulmonary shunt for pulmonary atresia and intact ventricular septum. Thromboexclusion of the right ventricle in children with pulmonary atresia and intact ventricular septum. Echocardiographic determinants of successful balloon dilation in pulmonary atresia with intact ventricular septum. The prevalence of coronary arterial abnormalities in pulmonary atresia with intact ventricular septum and their influence on surgical results. Predictors for biventricular repair in pulmonary atresia with intact ventricular septum. Changing trends in the management of pulmonary atresia with intact ventricular septum: the Melbourne experience. Restrictive right ventricular physiology and right ventricular fibrosis as assessed by cardiac magnetic resonance and exercise capacity after biventricular repair of pulmonary atresia and intact ventricular septum. Long-term functional health status and exercise test variables for patients with pulmonary atresia with intact ventricular septum: a Congenital Heart Surgeons Society study. Outcomes and predictors of reintervention in patients with pulmonary atresia and intact ventricular septum treated with radiofrequency perforation and balloon pulmonary valvuloplasty. Pulmonary atresia with intact ventricular septum: long-term results of “one and a half ventricular repair”. Superior vena cava to pulmonary artery anastomosis: an adjunct to biventricular repair. Determinants of mortality and type of repair in neonates with pulmonary atresia and intact ventricular septum. Pulmonary atresia with intact ventricular septum: management of, and outcomes for, a cohort of 210 consecutive patients. The Fontan procedure for pulmonary atresia with intact ventricular septum: operative and late results. Pulmonary atresia with intact ventricular septum: results of the Fontan procedure. Transcatheter laser-assisted balloon pulmonary valve dilation in pulmonic valve atresia. Pulmonary atresia with intact ventricular septum percutaneous radiofrequency-assisted valvotomy and balloon dilation versus surgical valvotomy and Blalock Taussig shunt. Successful transcatheter perforation of the atretic pulmonary valve membrane in a newborn using the new Coe radiofrequency end hole catheter. Determinants of successful balloon valvotomy in infants with critical pulmonary stenosis or membranous pulmonary atresia with intact ventricular septum. Radiofrequency-assisted “reconstruction” of the right ventricular outflow tract in muscular pulmonary atresia with ventricular septal defect. Transcatheter perforation of the right ventricular outflow tract as initial therapy for pulmonary valve atresia and intact ventricular septum in the newborn. Nonsurgical treatment of a neonate with pulmonary atresia and intact ventricular septum by transcatheter puncture and balloon dilation of the atretic valve membrane. Balloon valvuloplasty after pulmonary valvotomy for babies with pulmonary atresia and intact ventricular septum. Percutaneous laser valvotomy with balloon dilatation of the pulmonary valve as primary treatment for pulmonary atresia. Radiofrequency-assisted balloon dilatation in patients with pulmonary valve atresia and an intact ventricular septum. Technique of percutaneous laser-assisted valve dilatation for valvar atresia in congenital heart disease. Transcatheter radiofrequency perforation and stent implantation for palliation of pulmonary atresia in a 3060-g infant. Transcatheter management of neonates with pulmonary atresia and intact ventricular septum. Outcomes of transcatheter valvotomy in patients with pulmonary atresia and intact ventricular septum. Initial and late results after catheter intervention for neonatal critical pulmonary valve stenosis and atresia with intact ventricular septum: a technique in continual evolution. Percutaneous radiofrequency valvotomy using a standard 5Fr electrode catheter for pulmonary atresia in neonates. Long-term results of catheter-based treatment of pulmonary atresia and intact ventricular septum. Long-term outcome following catheter valvotomy for pulmonary atresia with intact ventricular septum. Concomitant stenting of the patent ductus arteriosus and radiofrequency valvotomy in pulmonary atresia with intact ventricular septum and intermediate right ventricle: early in-hospital and medium-term outcomes. Growth of the right ventricle after successful transcatheter pulmonary valvotomy in neonates and infants with pulmonary atresia and intact ventricular septum.

buy viagra vigour visa

This is a clustering of risk factors for diabetes and cardiovascular disease that is frequently observed in patients who are overweight generic 800 mg viagra vigour overnight delivery erectile dysfunction doctors phoenix, particularly with an increased central distribution of fat (75) viagra vigour 800mg visa erectile dysfunction medications comparison. Most investigators have chosen to adopt a schema similar to that used in adults but have used age- and sex- specific percentiles to define clinical cutpoints (76 order viagra vigour 800mg otc prostate cancer erectile dysfunction statistics,77,78). This often results in a discontinuity between the child/adolescent definition and the adult definition. As might be expected, the choice of different risk factors and different cutpoints results in very different estimates of the prevalence of metabolic syndrome. One approach has been to use the variables in the metabolic syndrome complex as continuous variables rather than defining cutpoints (79). A particular concern about the metabolic syndrome is that it appears not to be a stable diagnosis throughout adolescence with some individuals gaining the diagnosis and others losing it over time (80). Further research is necessary to determine the optimum definition of the metabolic syndrome (81). Nevertheless, clinicians should be well aware of the clustering of cardiovascular risk factors that occurs with obesity. These factors should be evaluated in the child with obesity, and the risk factors should be treated when abnormalities are found. An important issue is whether resolution of obesity, once it has occurred in a child or adolescent, will lower risk of cardiovascular disease. First, a group that remained at a normal body mass index from childhood to adulthood. These results are quite encouraging and emphasize that treatment for overweight and obese children and adolescents is quite important. They identified a number of cardiovascular health issues that are related to diminished physical activity. Cardiovascular fitness has been identified as a risk factor for cardiovascular disease in adults (84). Experimental studies showed that exercise training can improve cardiovascular fitness in children 8 years of age and older. Generally, the successful programs included continuous vigorous exercise for >30 minutes per session at a minimum of 3 days per week. Epidemiologic studies in children have generally shown a weak association between the level of physical activity and lipids and lipoproteins. The results of studies evaluating the relationship of cardiovascular fitness to lipids and lipoproteins mostly do not show a significant correlation. One of the reasons for inconsistent results is the fact that different studies used different levels of intensity of physical activity with different frequencies of exercise episodes and different durations of treatment. There is no clear association between exercise and lower blood pressure in children with normal blood pressure (86). Strength training appears to have little effect on blood pressure in children with hypertension. These results suggest that children and adolescents with essential hypertension should be encouraged to engage in aerobic activity on a regular basis. It is necessary to continue the physical activity to maintain the beneficial effect. An important aspect of the impact of physical activity is that it is also useful in management of overweight. It has been shown that programs of moderate intensity lasting 30 to 60 minutes per episode with three to seven episodes per week can lead to a reduction in both total body and visceral adiposity in children and adolescents (87). Thus, it is clear that there are numerous beneficial effects to increasing the level of physical activity in children. Summary There has been increasing interest in the improvement of cardiovascular health (88). There is evidence that individuals who are able to maintain low-risk status with optimum levels of cardiovascular disease risk factors through childhood, adolescence, and adulthood to age 50 have a very low lifetime risk of cardiovascular disease (87). This puts the focus on primordial prevention, which is the prevention of development of risk factors in the first place. Unfortunately, currently the prevalence of ideal cardiovascular health is quite low. Thus, the prevalence of ideal cardiovascular health is currently quite low in a community-based sample of middle-aged adults. While there are genetic factors involved, there are clearly behavioral and lifestyle factors that are quite important. It is increasingly clear that pediatricians, family physicians, and pediatric cardiologists must play a critical role in developing and maintaining cardiovascular health. Atherosclerosis is a slow but progressive process that begins in childhood and progresses throughout adolescence and into adulthood. There are numerous risk factors for atherosclerosis in children, which generally parallel the risk factors in adults. Pediatricians and pediatric cardiologists should take an integrated approach to the prevention of cardiovascular disease and atherosclerosis (89,90). This type of approach will be necessary for reducing death and disability from cardiovascular disease, which is the major cause of death in the United States. Lipids and Lipoproteins Lipids are organic compounds that are not soluble in water but are soluble in organic solvents. This combination of lipids (including cholesterol triglycerides and phospholipids) and protein (called apolipoproteins) allows the lipid component to become soluble in water and blood. They also are cofactors for enzymes involved in lipid metabolism such as lecithin cholesterol acyltransferase and lipoprotein lipase. Third, they function as structural protein for the biosynthesis and secretion of plasma lipoproteins. Their primary function is to transport cholesterol and triglycerides from the diet to sites for metabolism or storage (91). Chylomicrons are usually not present during fasting and normally are rapidly cleared after a meal. The clearance occurs as a result of lipoprotein lipase, which creates remnants of chylomicrons. Normal Levels of Lipids and Lipoproteins Normal values and distribution for plasma lipids and lipoproteins in American children have been published (95). These values have generally been used in subsequent guidelines to characterize children from a clinical perspective. The changes in concentration of lipids and lipoproteins during puberty can be important from a clinical perspective (96). This means that some adolescents may experience a decline from an abnormal value to normal for a period of time.

cheap 800mg viagra vigour

Outcomes of prenatally diagnosed tetralogy of Fallot: Implications for valve-sparing repair versus transannular patch buy viagra vigour 800 mg fast delivery erectile dysfunction doctor washington dc. Management and outcomes of heterotaxy syndrome associated with pulmonary atresia or pulmonary stenosis best 800 mg viagra vigour erectile dysfunction treatment san antonio. Common arterial trunk in the fetus: Characteristics purchase 800mg viagra vigour with amex impotence marijuana facts, associations, and outcome in a multicentre series of 23 cases. Truncus arteriosus: Diagnostic accuracy, outcomes, and impact of prenatal diagnosis. Anatomy, echocardiography, and surgical approach to double outlet right ventricle. The epidemiology of cardiovascular defects, part I: A study based on data from three large registries of congenital malformations. Impact of prenatal diagnosis and anatomical subtype on outcome in double outlet right ventricle. Prenatal diagnosis of aortopulmonary window with interrupted aortic arch by fetal echocardiography. Pulmonary atresia with intact ventricular septum: From fetus to adult: Congenital heart disease. Fetal tricuspid valve size and growth as predictors of outcome in pulmonary atresia with intact ventricular septum. Coronary arterial abnormalities in pulmonary atresia with intact ventricular septum diagnosed during fetal life. Pulmonary atresia/critical stenosis with intact ventricular septum: Prediction of outcome in the second trimester of pregnancy. Morphologic and functional predictors of eventual circulation in the fetus with pulmonary atresia or critical pulmonary stenosis with intact septum. Fetal pulmonary valvuloplasty for critical pulmonary stenosis or atresia with intact septum. Invasive intrauterine treatment of pulmonary atresia/intact ventricular septum with heart failure. Congenital heart surgery nomenclature and database project: Hypoplastic left heart syndrome. Hypoplastic left heart syndrome diagnosed in fetal life: Associated findings, pregnancy outcome and results of palliative surgery. Borderline left ventricles in prenatally diagnosed atrioventricular septal defect or double outlet right ventricle: Echocardiographic predictors of biventricular repair. The developmental complex of “parachute mitral valve,” supravalvular ring of left atrium, subaortic stenosis, and coarctation of aorta. Foramen ovale size in the normal and abnormal human fetal heart: An indicator of transatrial flow physiology. Subcostal two-dimensional echocardiographic identification of anomalous attachment of septum primum in patients with left atrioventricular valve underdevelopment. Fetal aortic valve stenosis and the evolution of hypoplastic left heart syndrome: Patient selection for fetal intervention. Development of hypoplastic left heart syndrome after diagnosis of aortic stenosis in the first trimester by early echocardiography. Hypoplastic left heart syndrome: Progression of left ventricular dilation and dysfunction to left ventricular hypoplasia in utero. Low rate of prenatal diagnosis among neonates with critical aortic stenosis: Insight into the natural history in utero. Hypoplastic left heart syndrome with intact atrial septum: Utilization of a hybrid catheterization facility for cesarean section delivery and prompt neonatal intervention. Hypoplastic left heart syndrome with intact or highly restrictive atrial septum: Surgical experience from a single center. Optimization of preoperative status in hypoplastic left heart syndrome with intact atrial septum by left atrial decompression and bilateral pulmonary artery bands. Results of in utero atrial septoplasty in fetuses with hypoplastic left heart syndrome. Hypoplastic left heart syndrome with atrial level restriction in the era of prenatal diagnosis. Intrauterine pulmonary venous flow and restrictive foramen ovale in fetal hypoplastic left heart syndrome. Prediction and perinatal management of severely restrictive atrial septum in fetuses with critical left heart obstruction: Clinical experience using pulmonary venous Doppler analysis. Vasoreactive response to maternal hyperoxygenation in the fetus with hypoplastic left heart syndrome. Aortic stenosis and severe mitral regurgitation in the fetus resulting in giant left atrium and hydrops: Pathophysiology, outcomes, and preliminary experience with pre-natal cardiac intervention. Prenatal diagnosis and risk factors for preoperative death in neonates with single right ventricle and systemic outflow obstruction: Screening data from the Pediatric Heart Network Single Ventricle Reconstruction Trial. Outcome after prenatal diagnosis of hypoplastic left-heart syndrome: A case series. Fetal diagnosis of hypoplastic left heart, associations and outcomes in the current era. Tricuspid valve disease with significant tricuspid insufficiency in the fetus: Diagnosis and outcome. Outcomes and Predictors of Perinatal Mortality in Fetuses With Ebstein Anomaly or Tricuspid Valve Dysplasia in the Current Era: A Multicenter Study. Left ventricular function and geometry in fetuses with severe tricuspid regurgitation. Prenatal findings in total anomalous pulmonary venous return: A diagnostic road map starts with obstetric screening views. Spectrum of cardiovascular disease, accuracy of diagnosis, and outcome in fetal heterotaxy syndrome. Echocardiographic diagnosis and prognosis of fetal left ventricular noncompaction. Outcome of antenatally diagnosed cardiac rhabdomyoma: Case series and a meta-analysis. Diagnosis and management of fetal cardiac tumors: A multicenter experience and review of published reports. Association between cardiac tumors and tuberous sclerosis in the fetus and neonate. The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: A prospective cohort study. Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome.

purchase viagra vigour 800 mg on-line

In transposition of the great arteries specifically order cheap viagra vigour on line impotence at age 70, the terms “left-to-right shunt” or “right-to-left shunt” can be confusing 800mg viagra vigour otc erectile dysfunction family doctor, and some authors have attempted to avoid confusion by distinguishing the terms “physiologic left-to- right shunt” from “anatomic left-to-right shunt discount viagra vigour 800 mg fast delivery erectile dysfunction vs impotence. This will become clear as we discuss what precisely constitutes the “shunted” blood in transposition of the great arteries. It is therefore inaccurate in the setting of transposition of the great arteries to describe flow occurring from the left atrium to the right atrium across a foramen ovale as a left-to-right shunt, although some authors might use the term “anatomic left-to-right shunt” because it is occurring from a left-sided anatomical structure to a right-sided anatomical structure (certainly, all would agree that this does not constitute a physiologic left-to-right shunt). In addition, it can be seen that the terminology “anatomic shunt” breaks down when describing a shunt between the aorta and the pulmonary artery: Normally the aorta is considered a left-heart structure and the pulmonary artery a right-heart structure, but in transposition of the great arteries, the aorta is connected to the right ventricle and the remainder of the right heart. Does that make the aorta an anatomic right-heart structure, while the pulmonary artery becomes a left-heart structure? This becomes confusing, and it is therefore best to avoid the terms “anatomic left-to-right shunt” and “anatomic right-to-left shunt,” in favor of describing the actual chambers or vessels that allow communication between them and the manner in which the flow occurs between these structures (e. Similarly when interpreting hemodynamic cardiac catheterization data in these patients, it is important to understand the limitations in this situation and to interpret the data in the context of “transposition physiology” discussed in this section. When considering a newborn baby with transposition of the great arteries, the foramen ovale is expected to be available for shunting, as is the ductus arteriosus in the first few minutes or hours of life. Hence, the two parallel circuits consisting of the pulmonary and systemic circulations are expected to have two possible areas of communication between them in almost every newborn with transposition of the great arteries. Hence, immediately after birth the pulmonary vascular resistance is elevated, and accordingly it is possible for the ductus arteriosus to have flow occur bidirectionally, typically from pulmonary artery to aorta in systole, and from aorta to pulmonary artery in diastole. This phenomenon is responsible for the classic “reversed differential cyanosis” seen in newborns with transposition of the great arteries (i. It is important to note that this phenomenon is a fleeting one, typically lasting only the first few hours of life. The two conditions necessary for the presence of this phenomenon are patency of the ductus arteriosus, and elevation of the pulmonary vascular resistance. The systolic flow of blood from pulmonary artery to aorta brings highly oxygenated blood from the pulmonary artery to the descending aorta to result in relatively higher saturations in the lower extremities compared to the upper extremities. However, within the first few hours of life as the pulmonary vascular resistance drops precipitously, there will cease to be systolic flow from pulmonary artery to aorta across the ductus, and eventually the flow across the ductus will entirely be from aorta to pulmonary artery throughout the cardiac cycle. When this occurs, differential cyanosis disappears, and with it an important bedside clinical clue to the presence of transposition physiology. The increased flow across the ductus arteriosus from aorta to pulmonary artery caused by the drop in pulmonary vascular resistance also results in increased pulmonary venous return to the left atrium. The relative increase in left atrial pressure causes the foramen ovale to flow from the left atrium to right atrium. This physiologic set up is the justification of two of the most important strategies for treatment of newborns with transposition of the great arteries: the institution of a prostaglandin infusion to maintain patency of the ductus, and the performance of a balloon atrial septostomy to enlarge the foramen ovale. It is a common misconception that the ductus and foramen are necessary to improve “mixing” in transposition of the great arteries. In fact, it is not mixing back-and- forth across these structures, but rather net flow across these structures (from aortic to pulmonary artery, and from left atrium to right atrium) that is occurring during this physiologic state in transposition of the great arteries (41). After a septostomy has been performed, the systemic arterial saturation typically increases tremendously, such that prostaglandin can frequently be discontinued. In the setting of a closed ductus, the patient then relies essentially on the atrial defect that has been created via balloon atrial septostomy to maintain adequate oxygen saturation. In this physiologic state, the flow of blood across the atrial septal defect occurs bidirectionally, thus it is perfectly accurate to describe the atrial septal defect as being responsible for improving “mixing. Associated lesions such as ventricular septal defects, pulmonary stenosis, or both, add additional complexity to the physiology of transposition of the great arteries. Accordingly, the saturations will generally be higher in patients with transposition of the great arteries with ventricular septal defect. In patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis, the pulmonary stenosis, especially if severe, will significantly limit pulmonary blood flow and contribute to lower oxygen saturation. Clinical Features and Investigation Presentation and Symptoms The clinical features of children with transposition of the great arteries depends on the anatomic details of the lesion (e. In addition, the clinical features depend on the age of presentation, which in most cases is the newborn period, but in developing countries, late presentation can occur. Newborns with transposition of the great arteries and intact ventricular septum present with cyanosis. Inadequate atrial and ductal communications result in profound cyanosis and lethargy. Patients with left ventricular outflow tract obstruction and a ventricular septal defect may present with profound cyanosis and lethargy if severe left ventricular outflow tract obstruction is present, or heart failure symptoms if little obstruction is present. Mild cyanosis with no symptoms may be present in infants with a “well-balanced” degree of left ventricular outflow tract obstruction. However, “reverse” differential cyanosis, for example, oxygen saturation higher in the lower extremities than upper extremities, may be present in newborns with transposition of the great arteries and a patent ductus arteriosus with pulmonary hypertension or coarctation of the aorta/interrupted aortic arch. Compromise in systemic perfusion, manifested by cool extremities and hypotension may be present if little mixing is present. A harsh holosystolic murmur is heard at the left lower sternal border and is more evident as the pulmonary vascular resistance drops, along with a diastolic rumble at the apex. In the presence of left ventricular outflow tract obstruction, a harsh systolic ejection murmur of varying intensity depending on the degree of obstruction is heard at the left sternal border. Biventricular hypertrophy may be seen particularly in cases of left ventricular outflow tract obstruction or significant left ventricular volume overload. Note the narrow mediastinum due to the direct anterior–posterior relationship of the aorta and pulmonary artery. In cases where the aorta and pulmonary trunk exhibit a direct (or somewhat direct) anterior–posterior relationship, the mediastinal shadow is narrow and not as prominent as usual, leading to the classic “egg on a string appearance” of the cardiac silhouette (Fig. Pulmonary vascular markings correlate inversely to the severity of left ventricular outflow tract narrowing in patients with transposition of the great arteries, ventricular septal defect and left ventricular outflow tract obstruction. Echocardiography In the current era, the diagnosis is confirmed by transthoracic echocardiography. Two-dimensional (2-D) echocardiography in the parasternal long-axis view demonstrates the pulmonary artery originating from the left ventricle coursing posteriorly (and bifurcating into branch pulmonary arteries) and the aorta originating from the right ventricle in the same plane coursing anteriorly (Fig. Doppler interrogation shows flow into the posterior vessel (pulmonary artery) via the arterial duct. The origin of the pulmonary trunk from the left ventricle and the aorta from the right ventricle is also seen in other views, for example, in sweeps in the subcostal and parasternal apical chamber views. The parasternal short-axis view is helpful in determining the exact relationships of the aorta (identified as the great vessel from which the coronary arteries are seen originating) and pulmonary artery (identified as the great vessel that bifurcates) (Fig. A number of pertinent anatomic details should be obtained from transthoracic echocardiography that are relevant to the medical, interventional catheterization and surgical management of these patients. The size of the patent ductus arteriosus and direction of flow is important for medical management, prior to and while the patient is receiving prostaglandin infusion.