Alden S. Gooch

Arrhythmias and left ventricular asynergy in the prolapsing mitral leaflet syndrome

Abstract Twenty-four subjects with the prolapsed mitral leaflet syndrome were studied in detail, with emphasis on (1) arrhythmias and the use of exercise testing for their detection and evaluation, and (2) the sequential motions of the left ventricle during the cardiac cycle. Twelve subjects (50 percent) had arrhythmias, usually isolated atrial or ventricular premature beats, on the resting electrocardiogram. With treadmill exercise testing, 16 subjects (75 percent) had arrhythmias. Moreover, in 5 cases exercise testing induced more advanced types of cardiac irritability: bigeminy, trigeminy or transient bouts of atrial and ventricular tachycardia. Arrhythmias tended to diminish during treadmill walking and to reappear in greater profusion immediately after exercise. Left ventriculography showed that 17 subjects (70.8 percent) had asynergistic contractions or relaxations. Sixteen had an anterior convex bulging during late systole or early diastole; 8 of these also had systolic bulging of the inferoposterior wall into the ventricular cavity. One patient had apical akinesia. Selective coronary arteriography, performed in 10 subjects, was noncontributory. The most important clinical problem in patients with prolapsing mitral leaflets is the management of arrhythmias. Deformities of the left ventricular myocardium may be seen during systole and diastole. The relation of this functional myocardiopathy to leaflet prolapse and arrhythmia is obscure.

Prolapse of Both Mitral and Tricuspid Leaflets in Systolic Murmur-Click Syndrome

Abstract Thirteen patients with proved prolapsed mitral leaflets were selected for right ventriculography to visualize their tricuspid valves. Twleve patients without prolapse were studied as controls. Six had late systolic prolapse of the tricuspid leaflets, most evident with the inferior leaflet. In one patient a clinical clue to the presence of tricuspid pathology was the appearance of a mid-late systolic murmur at the lower left sternal border after inspiration. Whether due to a primary derangement of valve anatomy or to vigorous or asynergistic ventricular contraction, the syndrome of prolapsed leaflets with myocardopathy can involve both atrioventricular valves.

Exercise testing for detecting changes in cardiac rhythm and conduction

Abstract In addition to other well known applications, treadmill exercise testing can be utilized for provoking transient changes in cardiac rhythm and conduction. When started at low stress levels and limited to easily tolerated levels, the procedure is safe and productive. In ambulatory patients with regular sinus rhythm and heart disease, arrhythmias often develop during or after exercise. When abnormalities of rhythm or conduction are present before exercise, the response is unpredictable. Exercise testing for arrhythmias can add significant diagnostic information. Serial treadmill testing is feasible and provides additional information on the natural history of arrhythmias.

Phentolamine for Primary Pulmonary Hypertension

Excerpt To the editor: In the May issue, Ruskin and Hutter (1) reported a case of primary pulmonary hypertension in a patient who showed impressive symptomatic and hemodynamic improvement after a t...

The influence of exercise on atrial flutter

To study the effect of exercise on atrial flutter the electrocardiogram was recorded continuously before, during and after low level treadmill walking in twenty-two ambulatory patients. Atrial flutter rates increased during exercise testing in four patients. Improved A-V conduction with consequent higher ventricular rates occurred during exercise in thirteen subjects. One patient, with 4:1 conduction at rest, continued with 4:1 block throughout exercise testing, was believed to be over-digitalized. During the recovery period after exercise, ten patients transiently developed periods of Wenckebach A-V block. Walking exercise induced 1:1 conduction in six patients and was promoted by the following circumstances: 1) atrial rates of 250/min or less; 2) inadequate dosage of digitalis; and 3) the administration of quinidine. For the patient with chronic atrial flutter, treadmill testing provides a simple method for demonstrating the range of changes of A-V conduction and for deriving implications for appropriate drug therapy.

The vectorcardiogram in prolapsed mitral leaflet myocardopathy

Summary The vectorcardiograms (VCG) of 87 cases of prolapsed mitral leaflets syndrome were analyzed with reference to clinical, electrocardiographic and catheterization data. A total of 36.8% of electrocardiograms and 72.4% of vectorcardiograms displayed abnormal T changes. T loop changes included abnormal T vector directions, wide QRS-T angles and increased T vector magnitudes. Abnormal QRS loops were seen in 30 (34.5%) VCG. All thirty-two patients with chest pain had normal selective coronary arteriograms. It is believed, therefore, that these primary T vector abnormalities are not ischemic and that they are related to some myocardial changes of unknown etiology.

Exercise-Induced Pseudoarrhythmia

Abstract During treadmill exercise of a 43-year-old man an electrocardiographic change was noted that simulated a severe ventricular arrhythmia. This was a harmless effect of sinus tachycardia in a...

Cyanotic Congenital Heart Disease: Clues and Approach To Diagnosis

* From the Department of Cardiology, Deborah Hospital, Browns Mills, N. J., and the LMR Cardio-Pulmonary-Renal Laboratories of Albert Einstein Medical Center, Northern Division, Philadelphia, Pa. The differential diagnosis of cyanosis in an infant is of paramount importance, because the therapeutic approach is dependent on the nature of the lesion. When approached methodically, with the use of known information regarding clinical features and pathology of right-to-left shunts, the challenge of diagnosis in this area may be met with a high degree of accuracy. The goal of this review is to present salient clues to diagnoses encountered in clinical situations. These important clues may be found in the history, physical examination, roentgenogram, phonogram and electrocardiogram, as well as in well-planned and well-executed hemodynamic and angiocardiographic studies. They will enable a physician to reach, in the majority of the