Barry M. Beller

Pitressin-induced myocardial injury and depression in a young woman

Abstract In a thirty-five year old woman given Pitressin intravenously for control of esophageal hemorrhage, electrocardiographic evidence of severe myocardial injury and clinical evidence of hemodynamic deterioration were found. Although these effects were prolonged over several hours, they were completely reversible. We review the cardiac and systemic effects of Pitressin, emphasizing its potency as a coronary vasoconstrictor. We also stress the need for cautious administration of Pitressin and recommend electrocardiographic monitoring of all patients to whom it is given.

Hyperdynamic circulatory state due to intrahepatic fistula in Osler-Weber-Rendu disease

Abstract A case of Osler-Weber-Rendu disease with extensive hepatic arteriovenous fistulation is described in detail. The patient suffers from a hyperkinetic circulation characterized by high cardiac output and diminished reserve. The availability of an open liver biopsy specimen showing arteriovenous communications performed three years ago allows anatomic correlation with recent hemodynamic and angiographic data indicating hepatic artery to hepatic vein shunting. The progressive nature of this rare disorder is emphasized.

The use of ventricular pacing for suppression of ectopic ventricular activity

Abstract In 13 patients with acute myocardial infarction, digitalis toxicity or recent cardiac surgery, ventricular pacing was found to be of value for control of ectopic ventricular beats. In 12 of the 13 pacing alone was found to produce complete suppression, whereas the thirteenth required both pacing and beta adrenergic blockade with propranolol to prevent ventricular tachycardia resistant to either alone. The indications for pacing in these patients were found to be lack of response to standard drugs, underlying bradyarrhythmias or heart block, presumed allergy to suppressive agents or fear of myocardial depression by drugs. The advantages of pacing for suppression of ectopic ventricular beats are discussed, and possible electrophysiologic mechanisms by which ventricular pacing is effective in control of the irritable heart are reviewed.

Conduction disturbances of the left bundle branch system and their relationship to complete heart block: II. A review of differential diagnosis, pathology and clinical significance

Abstract The differential electrocardiographic diagnosis between left anterior and posterior fascicular block and other conditions causing abnormally directed mean and terminal QRS forces in the electrocardiogram is aided significantly by clinical evaluation of the patient. Recognition of these two electrocardiographic patterns and their more complex combinations with right bundle branch block is important because of their relationship to complete heart block and the Stokes-Adams syndrome. This is particularly true when a pattern of partial bilateral bundle branch block develops during the course of acute anterior myocardial infarction, since this lesion may produce destruction of both bundle branches and cause complete heart block. Review of clinical and pathologic data associated with the patterns of partial bilateral bundle branch block and complete atrioventricular (A-V) block gives support to the concept that most cases of chronic complete heart block are not caused by coronary atherosclerosis or myocardial infarction, but rather by a primary process of unknown nature affecting the bundle branches. This process is characterized by slowly progressive loss of conducting fibers and their replacement by fibrosis. The evidence which suggests that insufficiency of the microcirculation of the subendocardium may play an important role in the development of this process is summarized. The clinical aspects of this disease of the conduction system are reviewed. The association of unexplained neurologic symptoms in patients with these electrocardiographic syndromes should raise the suspicion of transient complete heart block secondary to bilateral bundle branch disease involving the three conducting fascicles.

Conduction disturbances of the left bundle branch system and their relationship to complete heart block: I. A review of experimental, electrophysiologic and electrocardiographic aspects

Abstract Interruption of the normal ventricular excitation process occurring in one or more of the three main divisions of the conduction system may determine specific electrocardiographic patterns. Patterns as well as initial, mean and terminal QRS vectors are presented for diagnosis of an isolated block in each of the three divisions. The experimental and clinical basis for each diagnosis is reviewed. The electrocardiographic diagnosis of block in each of the two divisions of the left bundle in the presence of right bundle branch block is reviewed, and the association of these conduction defects with myocardial infarction is illustrated. Also, the electrocardiographic basis for identification of divisional left bundle branch as opposed to conventional (predivisional) left bundle branch block is discussed. Because of the confusing terminology previously utilized and the lack of pathologic specificity of conduction disturbances affecting the divisions of the left bundle, it is recommended that the terms superior and inferior peri-infarction block be abandoned and the terms left anterior and posterior fascicular block be considered. These terms are anatomically and electrophysiologically correct and do not imply etiologic diagnoses.

Chest-wall stimulation: A method of demand QRS-blocking pacemaker suppression in the study of arrhythmias

Abstract Low amplitude electrical stimuli delivered to the chest wall from a portable pacemaker may be used to suppress the implanted QRS-blocking, demand-type pacemaker. This technique allows analysis of the underlying electrocardiogram. The value of this method in the study of the natural history of conduction system disease, pacemaker-conduction system interaction, and in management of patients wearing these devices is illustrated.