Haim Bartall

Accelerated Ventricular Rhythm and Cocaine Abuse

Excerpt Cocaine has the peculiar quality of being both a local anesthetic and a sympathomimetic agent with powerful central nervous-system stimulant effects. In small doses cocaine can slow the hea...

Echocardiographic Left Atrial Enlargement. Comparison of Vectorcardiogram and Electrocardiogram for Detection.

Standard electrocardiograms (ECG) and Frank vectorcardiograms (VCG) were obtained in 43 consecutive patients in sinus rhythm who had echocardiographic evidence of left atrial enlargement (left atrial internal dimension greater than 4.0 cm; x +/- 1SD = 4.7 +/- 0.5 cm). High gain VCG P loop measurements for the study group were: maximal posterior magnitude, 0.11 +/- 0.03 mv; duration, 106 +/- 14 msec and ratio of maximal posterior to maximal anterior P vector magnitudes, 3.2 +/- 1.4. Thirty of 43 (70%) patients with echocardiographic determined left atrial enlargement had VCGs diagnostic of that condition. Utilizing New York Heart Association criteria for left atrial enlargement, 17 of 43 patients (40%) had ECGs which were diagnostic. Fifteen of 43 (35%) subjects manifested both ECG and VCG criteria for left atrial enlargement and only two patients had diagnostic ECGs and normal VCGs. It is concluded that analysis of high gain VCG P loops provides a 30% higher yield for the diagnosis of echocardiographically determined left atrial enlargement when compared with P wave examination on the standard ECG.

Push-up palpitations: unusual presentation of ruptured chordae tendineae: a case report.

A 47-year-old man experienced palpitations and shortness of breath following push-up exercises. Because of paroxysmal atrial fibrillation and fatigue, the patient underwent investigation. Echocardiography and cardiac catheterization indicated the diagnoses of mitral valve prolapse and rupture of the chordae tendineae. This report represents the first description of such a sequence of events.

Vectorcardiographic study of initial QRS forces in left bundle branch block associated with myocardial infarction, primary myocardial disease and valvular heart disease.

Summary Distribution of the initial 10–30 msec QRS forces was determined on the Frank vectorcardiograms (VCGs) of 31 patients with complete left bundle branch block (LBBB). Of nine patients with coronary artery disease, three had all 10–30 msec vectors directed posteriorly in the horizontal plane (HP) and associated inferior or apical left ventricular asynergy. Frontal plane initial 30 msec QRS forces were oriented superiorly in two of these three subjects. In five patients with isolated anterior wall myocardial infarction, the HP 10 msec QRS vectors were anterior, followed by posteriorly directed 20–30 msec QRS vectors. Twelve patients with primary cardiomyopathy had initial QRS vectors distributed as follows: 10–30 msec posterior and left in two; 10–20 msec anterior and left in five; 10 msec anterior and left with the 20–30 msec posterior and left in four. In one patient the 10 msec was posterior and right, and 20–30 msec posterior and left. Of 10 patients with valvular heart disease three manifested posterior 10–30 msec QRS vectors. In four the 10 msec vector was anterior and left and 20–30 msec posterior and left. The 10–20 msec were anterior and left and 30 msec posterior and left in two subjects. There was no correlation between posteriorly directed initial QRS forces and left ventricular hypertrophy in the latter group. We conclude that: 1) posterior orientation of the initial 10 msec QRS vectors in the presence of LBBB is not specific for myocardial infarction; 2) when present in patients with obstructive coronary artery disease such abnormal posterior forces correlate with anterior and probable co-existing infero-apical infarction and, 3) factors aside from left ventricular hypertrophy can produce abnormally directed initial 10–30 msec QRS vectors in subjects with valvular heart disease.

Noninvasive Estimation of Left Ventricular Function After Mitral and Aortic Valve Replacement With the Hancock Porcine Prosthesis

Left ventricular function was noninvasively assessed by echocardiography, and left ventricular ejection time index (LVETI) was derived from external carotid pulse tracings in 25 patients before (B) and an average of 17 days after (A) Hancock porcine valve implantation. Fifteen patients had aortic valve replacement and 10 had mitral valve replacement; 4 had a combined procedure. In the aortic and combined group, (n = 15) there were significant (P < 0.0025) changes of mean (± 1 SD) left ventricular end-systolic dimension (ESD), B = 5.1 ± 0.9, A = 4.3 ± 0.9 cm; end-diastolic dimension (EDD), B = 5.7 ± 1, A = 4.9 ± 0.9 cm; mean rate of circumferential fiber shortening (VCF), B = 0.37 ± 0.05, A = 0.75 ± 0.04 circumf/sec and LVETI, B = 0.45 ± 0.05, A = 0.39 ± 0.02 sec. In subgroups with preoperative aortic stenosis (n = 8), combined aortic stenosis and insufficiency (n = 3), and coexisting aortic and mitral disease (n = 4), there was a uniform reduction of ESD, EDD, and LVETI with an increase of VCF. In the isolated mitral valve replacement group (n = 10), the values were ESD (B = 4.6 ± 0.7, A = 4.4 ± 0.8 cm, P = not significant); EDD (B = 5.2 ± 0.6, A = 4.7 ± 0.8 cm, P < 0.0025); VCF (B = 0.36 ± 0.08, A = 0.7 ± 0.04 circumf/sec, P < 0.0025); and LVETI (B = 0.40 ± 0.03, A = 0.37 ± 0.03 sec P < 0.05). Patients with mitral stenosis (n = 2), mitral insufficiency (n = 3), and combined mitral stenosis and insufficiency (n = 5) all had a postoperative decrease in ESD, EDD, and LVETI with augmentation of VCF. We concluded that (1) early noninvasive assessment of left ventricular function after Hancock valve implantation indicates a significant hemody namic improvement, and (2) echocardiography combined with external ca rotid arterial pulse tracing analysis is useful for the follow-up of patients who receive Hancock valves.

Coexisting left anterior descending coronary-pulmonary artery fistula and mitral valve prolapse.

area. A n electrocardiogram showed nonspecific ST-T segment and T-wave changes. A Frank vectorcardiogram disclosed initial QRS forces which were directed from right to left. Echocardiography demonstrated mitral valve prolapse. Left ventriculography indicated prolapse of the posteromedial and anterolateral mitral valve commissural scallops. Coronary arteriography indicated a fistula between the left ante-