Early rapid and long-lasting reperfusion is the most important factor in reducing mortality and morbidity in AMI. Both intravenous thrombolytic therapy and primary PTCA are effective treatment modalities in this respect. Although the debate over relative merits of each of these treatment possibilities is likely to continue, existing evidence shows that primary PTCA with stenting is currently the most effective method of acute reperfusion therapy for patients who present to institutions and operators with the requisite expertise. If mechanical reperfusion can be offered to a patient with AMI within 60 to 90 minutes by a team with a 90% success rate, it should be the treatment of choice. The decision should be based on a rigorous scrutiny of local experience and results and if these targets cannot be met, thrombolysis is probably the better option. For the majority of patients, however, the logistics of providing primary angioplasty is, at the present time, prohibitive and they will have to rely on improvements in thrombolytic therapy as well as on strategies to deliver it as quickly as possible to all eligible patients. The future of reperfusion therapy may be a combination of both approaches, which would eliminate the inherent disadvantages of each modality. Progress in this fast developing field will bring further improvement in the prognosis and outcomes of acute myocardial infarction patients.

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Diagnostic procedures make up a major portion of the practice of pediatric cardiology. Patient cooperation, often for extended periods, is of utmost importance for successful completion of many pediatric cardiac diagnostic procedures particularly those involving infants and preschool-age children. This requires the use of sedation. Invasive procedures such as cardiac catheterization and transesophageal echocardiography may cause significant discomfort, necessitating the use of additional analgesic and amnesic agents. Multiple drugs or repeated doses may be required during lengthy procedures. Ensuring patient safety by appropriate cardiorespiratory monitoring is mandatory. This review focuses of the pharmacologic agents used in pediatric cardiac catheterization. The pharmacology, indications for usage, and the risks and benefits of commonly used agents are addressed.

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An extensive body of research conducted in the past 25 years has helped foster understanding of the mechanisms and pathogenesis of the acute coronary syndromes and occlusive disease. The role of platelet and the endothelium in the pathogenesis of atherosclerosis and subsequent ischemic events is well established. The field of antiplatelet therapy is rapidly expanding with the availability of newer antiplatelet agents. However, at the present time, there is no convincing data available that other antiplatelet drugs are superior to aspirin. Aspirin remains the cornerstone of therapy for various ischemic disorders and the foundation on which other therapies are added, both in the short and long term.

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Percutaneous Amplatzer device closure of atrial septal defects has been gaining popularity in recent years, mainly in children. Its use in adults began in October 1996. In May 1997, the first Australian adult was treated with the device. As of July 1, 1999, 160 devices have been implanted in Australia, one-third of these in adults. Data was collected on 63 adult patients aged 16 – 78 years. Of the 63 patients, 52 underwent successful implantation. 5 patients were brought back for a second procedure because the first device implanted was smaller in size than the size of the defect. The device is now available in sizes ranging from 10 to 38mm. 23 patients have had the device implanted in Perth and 3 patients underwent a second procedure when a larger device became available. Not all patients were symptomatic before the procedure, but of those who were, 18 of 34 were symptomatically improved. 21 of 36 patients with right-sided dilatation showed reduction in size of the right atrium and right ventricle at 2 – 19 months of follow-up. Potential problems include difficulty in sizing the device correctly, embolization (1 patient), and transient ST segment elevation (2 patients). Our experience shows that the Amplatzer ASD closure device can be used successfully in adult patients.

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Over the last decades, the Bland-White-Garland syndrome has been treated with various surgical approaches, ranging from simple ligation to anatomic revascularization, usually creating a two coronary artery system. In Vienna, between 1965 and 1999, 20 patients underwent an operation (ligation in 3, revascularization techniques in 17). Total mortality was 67 % in the group with ligation and 24 % following revascularization. Out of 14 survivors with a mean follow-up of 11 years, 12 have an excellent functional result; only one required reoperation with mitral valve repair and bypass grafting. The state of the art in surgical treatment is discussed, including mitral valve sequelae, presentation in adults and the option of transplantation. So far, in the literature the incidence of the syndrome seems to be underestimated. According to the Vienna experience, the Bland-White-Garland syndrome may be expected in one of every 25,000 live births.

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