Avraham Palant

Polymorphous ventricular tachycardia in acute myocardial infarction

Polymorphous ventricular tachycardia (VT) is thought to be uncommon in acute coronary heart disease, but its prevalence has not been determined. Seven hundred seventy-one consecutive patients admitted with acute myocardial infarction (MI) were reviewed for the occurrence of this arrhythmia. Nine patients (1.2%) had polymorphous VT. No patient had any of the predisposing factors previously associated with polymorphous VT. The arrhythmia was resistant to multiple drugs, and repeated cardioversion was effective in only 3 patients. Overdrive pacing was ineffective in the 3 patients in whom it was attempted. Verapamil was effective in 3 of 4 patients in whom it was tried. Six patients with polymorphous VT died during hospitalization; the remaining 3 died within 6 months of discharge. It is concluded that, when compared with regular VT, polymorphous VT in MI carries a poor prognosis. When the arrhythmia occurs in the context of acute ischemia, it appears to be more difficult to treat compared with its occurrence due to other predisposing factors. Verapamil, not usually indicated for ventricular arrhythmias, should be tested in a therapeutic trial.

ENDOGENOUS CORTISOL AND THYROID HORMONE LEVELS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Thyroid hormones and cortisol levels were serially measured over seven mornings and evenings in 23 consecutive patients with acute myocardial infarction (AMI) or acute coronary insufficiency (ACI). The patients were divided into two groups, high level cortisol (HLC) and low level cortisol (LLC) groups, according to mean morning and evening cortisol levels. The transient increase in plasma rT3, decrease in T3 and TSH was significantly greater in the HLC group. A diurnal variation in cortisol levels was observed in the LLC group 48 h and in the HLC group 72 h after admission. Taking the 23 patients together, no significant correlation was observed between infarct size (peak CPK levels) and the altered rT3, T4 or TSH levels. However, a significant correlation was obtained between the maximal change in T3, rT3 or TSH and the mean cortisol levels preceding these alterations, as well as between cortisol levels and infarct size. It is suggested that cortisol rather than infarct size may be the dominant factor involved in the alteration of thyroidal levels in AMI patients.

The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome

Echocardiographic studies were performed on 134 consecutive patients with idiopathic mitral valve prolapse syndrome. Fifteen patients (11.2%) were noted to have ruptured chordae tendineae on M-mode examination and in 12 of them the diagnosis was confirmed by bidimensional studies. Only four patients were referred for surgery as a result of severe mitral regurgitation. At operation one patient was found to have rupture of the anterior mitral chorda and the other three had posterior mitral chordal rupture. Eleven patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome does not always result in severe hemodynamic deterioration and may go undetected unless a high index of suspicion is maintained. Serial echocardiographic studies may reveal the natural history of this condition in asymptomatic patients.

The Efficacy of Ajmaline in Ventricular Arrhythmias after Failure of Lidocaine Therapy in the Acute Phase of Myocardial Infarction

Forty-three patients in the acute phase of myocardial infarction who were resistant to conventional doses of lidocaine received Ajmaline intravenously (50 mg bolus followed by constant infusion rate of 1-1.5 mg/min). Dangerous ventricular arrhythmias were abolished in 72% of this group of patients (group A). In the remaining patients (28%), Ajmaline was found to be ineffective (group B). There was no reduction of systolic or diastolic blood pressure and there was an insignificant increase in heart rate. Atrio-ventricular or intraventricular conduction defects appeared in 46% of the patients described. There was a statistically significant increase in occur rence of heart blocks in group B patients and among these complete left bundle branch block (CLBBB) was the most prevalent. Atrio-ventricular or intraventricular conduction defects were transient, appearing between 8-36 h (mean 23 h), and were not accompanied by reduction of ventricular rate. Conduction defects disappeared within several hours (up to 24 hours) after Ajmaline was discontinued. It is concluded that Ajmaline administered by this regimen is an effective alternative agent for patients with ventricular arrhythmia not controlled by lidocaine in the acute phase of myocardial infarction.

Detection of round floating left atrial thrombus simulating left atrial myxoma by two-dimensional echocardiography.

A case of round left atria1 (LA) thrombus, simulating LA myxoma, is demonstrated by echocardiography, followed by dislodgement of the thrombus 22 hours later to the right leg. After a Fogarty catheter procedure, no traces of atria1 mass could be seen on repeated echocardiograms. Histologic examination confirmed the diagnosis of thrombus. To the best of our knowledge, this is the first case report of a left atria1 thrombus detected by echocardiogram, and dislodged completely. A 73-year-old woman was admitted to the hospital because of palpitations and weakness, which started 3 days preceding admission. Her past medical history was noncontributory. The physical examination was normal, apart from an irregular pulse. Her blood pressure was 110/75 mm Hg. Cardiac examination was normal; no murmurs or clicks were heard. No neurologic deficit was noticed. An ECG demonstrated slow atria1 fibrillation with ventricular response of 80 to 90 bpm and minor anterior wall ST-T changes. Chest roentgenogram was normal, as were routine blood laboratory examinations, including thyroid function tests. Routine echocardiographic examination was normal, except for a floating mass 1 x 2 cm in the normal left atrium, that was attached to the intra-atria1 septum by a short pedicle (Fig. 1). The diagnosis of a left atria1 mass (thrombus or tumor) was made, and the patient was therefore prepared for surgery. Twenty-two hours later, the patient complained of sudden, severe pain in her right leg. The color was white below the knee, and the leg was cold and pulseless. Doppler examination confirmed the disappearance of pulses below the femoral artery. A Fogarty catheter was inserted through an incision in the upper thigh, and a thrombus, measuring 2 X 2 cm, was removed from the popliteal artery. On repeated echocardiograms, no mass could be visualized in the left atrium (Fig. 2). Histologic examination confirmed the diagnosis of a thrombus. The patient was treated with heparin and warfarin sodium, and was discharged in a good, clinical condition 2 weeks later, LA thrombus is found especially in patients with mitral stenosis with enlarged left atrium, in patients after mitral valve replacement, in low cardiac output states, and in patients with atria1 arrhythmias.‘~” Systemic embolization

Autosomal dominant inheritance of sinus node disease

A family with sinus node disease is presented. The mother was severely affected by sinus bradycardia and required a permanent atrial pacing system. The father is asymptomatic and has no evidence of conduction disturbances. All their offspring (one son and two daughters) are affected with variable degrees of severity. The occurrence of the disease in this family is suggestive of autosomal dominant inheritance with variable penetrance.

Transient electromechanical dissociation in hypertrophic cardiomyopathy

We describe a patient with hypertrophic cardiomyopathy who experienced several episodes of syncopal attacks, in whom the mechanism was transient electromechanical dissociation.

Discrete Membranous Sub-Aortic Stenosis in Adult Patient Obtained by Echocardiography and Not Proved by Catheterization

A case of a 60-year-old patient with discrete membranous sub-aortic stenosis is described. The diagnosis was established based on echocardiog raphic evaluation by demonstration of a premature aortic valve closure and a sub-aortic membrane. No evidence of the sub-aortic membrane was noticed on cardiac catheterization. At operation, a discrete sub-aortic membrane was found 9 mm below the aortic valve, leaving an aperture of 1 cm diameter and a mildly deformed stenotic aortic valve. We stress the importance of careful pre-operative echocardiographic evaluation of every patient suspected of hav ing any kind of left ventricular outflow tract obstruction, even if catheterization data are not contributory.

The value of electrocardiography in patients with right ventricular endocardial pacemakers in the diagnosis of left ventricular hypertrophy: a correlative study of pace electrocardiography and left ventricular mass derived from M-mode echocardiography

This study evaluated 51 patients with permanent apical right ventricular endocardial pacemakers. The assessment of the diagnostic value of pace electrocardiograms for the determination of left ventricular hypertrophy revealed specificity of 94% and sensitivity of 66%, applying a new parameter: RL1 + SV3 greater than or equal to 30 mm. The application of this criterion in the interpretation of pace electrocardiograms correlated well with values for the left ventricular mass derived from M-mode echocardiograms (r = 0.644, P less than 0.0001).

Heart Block in Marfan's Syndrome

Marfans syndrome is classified as a heritable disorder of connective tissue in which the supporting structure is involved in clinical and pathologic alterations. In its classic form the syndrome is associated with abnormalities of the eye, aorta, and the skeleton. Conduction disturbances and ventricular arrhythmias have rarely been described in this syndrome. In this brief case report a patient with symptomatic heart block, prolonged atrial-His interval and ventricular arrhythmia in whom a permanent ventricular pacemaker has been implanted, is described.