J. C. Demoulin

Short-term risk stratification at admission based on simple clinical data in acute myocardial infarction

Abstract Simple clinical data, available in all coronary care units, were recorded in 1,013 consecutive patients with acute myocardial infarction (AMI). In order to identify the patients at highest and lowest risk of mortality during hospital stay, a prognostic index was established from a stepwise logistic discriminant analysis of 10 clinical variables obtained at admission in a consecutive series of 477 patients hospitalized in 1 of 2 coronary care units admitting new patients on alternate days and treating them similarly. This prognostic index was applied to a comparison group of 536 consecutive patients admitted to the other coronary care unit. In the experimental group, 57 of the 477 patients (12%) died (during hospital stay; 60 of the 536 patients (11%) died in the comparison group. As individual variables, age, previous history of AMI, anterior site and left ventricular function on admission were associated witincreased mortality. Three variables were selected from the stepwise logistic discriminant analysis of the experimental group: age; site (anterior = 1, other = 0); and grade of left ventricular function (0 to 4). Prognostic index = 5.9019 − 0.8961 function −0.5708 location −0.0369 age. This index was validated in the comparison group. Patients were allocated into different classes with increasing index values associated with decreasing risk. Three subgroups of patients were identified: high risk of hospital mortality (index ≤1; mortality: 51%), intermediate risk (index 1 to 3; mortality: 18%) and low risk (index >3; mortality: 4%). The use of this simple prognostic index may improve clinical management and selection of patients for intervention trials.

Quantitative study of left bundle branch fibrosis in left anterior hemiblock: A stereologic approach

Serial sectioning of the interventricular septum was carried out in 16 hearts, 8 from elderly subjects with no conduction disturbance and 8 from patients with chronic left anterior hemiblock. The histologic slides were studied stereologically, and the relative density of fibrosis was quantitatively assessed by the point counting technique at various levels of the main subdivisions of the left bundle branch system. Statistical analysis revealed the following: (1) Although some fibrosis was found in the control hearts, the density of fibrosis was consistently and significantly greater throughout the conduction system in patients with left anterior hemiblock. (2) In the group with hemiblock, the relative density of fibrosis tended to increase significantly from the posterior ramification to the midseptal fibers and, finally, to the anterior fascicle. (3) Among the eight patients with hemiblock, fibrosis appeared to be evenly distributed throughout the conduction system in four. It was predominantly located in the anterior and midseptal fibers in one patient and showed an increasing severity from the posterior to the midseptal and anterior fibers in the remaining three patients. From this quantitative study, it is concluded that left anterior hemiblock is a reliable sign of left bundle branch disease but that the underlying lesions are more widely distributed than would be from the expected electrocardiographic terminology since they were found predominantly in the anterior ramifications in only half of the studied cases.

5-HT2-RECEPTOR BLOCKADE IN THE TREATMENT OF HEART FAILURE: A Preliminary Study

Ketanserin (R 41 468), a quinazoline derivative, has been shown to be a selective blocker of 5-HT2 receptors. The drug was administered intravenously (10 mg given over a 3 min period) to 8 patients with severe cardiac failure already treated with digitalis, diuretics, and, in 4 cases, vasodilators. R 41 468 produced a significant fall in right-atrial, pulmonary-artery, pulmonary-wedge, and systemic arterial pressures. Systemic dynamic and total pulmonary vascular resistances were also reduced. Cardiac and stroke-work indices both increased, Heart rate remained unchanged. The platelet aggregation index, assessed in 2 patients, was initially low and was nearly normal 15 min after administration of a single dose of R 41 468.

Persistent atrial standstill in familial Ebstein's anomaly.

Persistent atrial standstill occurred in a father and his youngest son with familial Ebsteins anomaly. In both cases routine electrocardiograms showed no atrial electrical activity and cross sectional echocardiograms showed inferior displacement of the septal tricuspid leaflet and tethering of the tricuspid leaflets to the right ventricle. The father had a cerebral embolism and died of a myocardial infarction. Necropsy showed attachment of the septal tricuspid leaflet below the membranous septum. On serial histological examination fibrofatty infiltration of the right atrial wall, the atrioventricular node, and the inferior part of the His bundle up to the bifurcation was present. The son had haemodynamic and electrophysiological findings consistent with mild Ebsteins anomaly and persistent atrial standstill, for which permanent cardiac pacing was necessary. The persistent atrial standstill with slow escape rhythm was most probably a consequence of the abnormalities in both the atrial wall and the His bundle which, together with the abnormal attachment of the tricuspid valve, may be features of the same congenital cardiac anomaly.

Programmable extrastimulus pacing for long-term management of supraventricular and ventricular tachycardias: clinical experience in 16 patients

Sixteen patients with recurrent, drug-resistant supraventricular (13 patients) or ventricular (3 patients) tachycardia were treated chronically by programmable extrastimulus pacing; either a fully automatic device (Telectronics PASAR 4151: eight patients with supraventricular tachycardia) or a patient--activated device (Medtronic Interactive Tachy System) was used. During a follow-up period of 5 to 30 months, five of the subjects treated with the fully automatic device showed successful results, one had recurrent tachycardia, and two had their units explanted for system-related problems. The patients treated with the externally activated device were, on the whole, very well controlled. This mode of treatment, if applied in well-selected cases, is promising; it seems safe and considerably reduces the number of hospital admissions.

Histopathologic correlates of left posterior fascicular block

Thirteen hearts from subjects (10 male, 3 female; mean age 65 years) with left posterior fascicular block were studied. Left posterior fascicular block was associated with right bundle branch block in nine cases and alternated with left anterior fascicular block in three. In nine of the patients, the conduction disorders were observed during an episode of acute myocardial infarction. Of these nine patients, four showed interruptive lesions at the level of the posterior radiation of the left bundle or of the posterior portion of the main left bundle branch. Two were found to have severe alterations scattered throughout the left bundle branch system: One of them had alternating left anterior and left posterior fascicular block; and the other manifested complete heart block in the course of her illness. No interruptive changes of the posterior fibers were found in three cases in which the heart was obtained early after death. All 9 patients had severe coronary artery disease (six had triple vessel disease and three of the six had a left main coronary arterial stenosis or obstruction; two patients had double vessel disease). Among the four patients with chronic left posterior block, three were found to have heavy calcifications of the left side of the cardiac skeleton; the remaining one had diphtheritic myocarditis. All had major alterations of the left-sided conduction system that were consistently maximal at the level of the posterior fibers or posterior portion of the main left bundle branch. In two of these patients scattered lesions were found throughout the left bundle branch fibers; one had alternating left anterior and left posterior fascicular block and the other had complete heart block. In general, the alterations underlying left posterior fascicular block were less widely spread than in left anterior fascicular block; however, they were more severe and more proximally located.

Artificial Circus Movement Tachycardias: Incidence, Mechanisms, and Prevention

In a group of 45 patients treated with Medtronic 7000 and 7100 pulse generators for sick sinus syndrome or second or third degree atrioventricular block, an atrial synchronous mode of pacing was programmed in 34 cases and spontaneously occurring artificial circus movement tachycardios (ACMTs) were observed in nine. An analysis of conditions of occurrence, triggering mechanisms and patterns of ACMT, is presented. Various modalilies of prevention are discussed. They resulted in suppression of ACMT in five patients and decrease of incidence in a sixth; the three remaining subjects were managed by definitive reprogramming in the DVI mode. Our conclusion is that correct prevention of ACMT requires the use of dual chamber pulse generators with programmable atrial refractory periods. For patients in whom a unit has already been implanted, careful observation of the triggering mechanism and pattern of ACMT may help in determining the most suitable way to prevent and suppress the arrhythmia.

Acute diverticulitis in heart transplant recipients

Immunosuppressed patients are susceptible to complicated diverticulitis, but reports of this complication are scarce in heart graft recipients. To estimate the prevalence of acute diverticulitis in heart graft recipients, we retrospectively reviewed the cases of diverticulitis in a series of 143 patients who underwent orthotopic heart transplantation in a period of 10 years. Six (4%) of these developed acute diverticulitis and required colectomy. All of them were male patients and were older than 50 years. Four patients underwent urgent laparotomy and colon resection with end colostomy (Hartmann procedure). The two other patients suffered from diverticulitis without generalized peritonitis and underwent laparoscopic sigmoidectomy with direct transanal end-to-end anastomosis. The postoperative outcomes of these six patients were satisfactory. As are other immunosuppressed patients, heart graft recipients are susceptible to diverticulitis. Early surgical management may be safe in well-compensated patients.

Prognostic significance of electrocardiographic findings in angina at rest. Therapeutic implications.

Ninety-five patients with angina at rest were observed in the coronary care unit. Eighty-one per cent presented concomitantly or had previously presented some other manifestations of coronary artery disease. These patients were divided into two subgroups. In subgroup 1 (40 patients), episodes of non-exertional angina were associated with a pattern of hyperacute subepicardial injury and, frequently, with ventricular arrhythmias. In subgroup 2 (55 patients), the episodes of angina at rest were attended by horizontal ST depression, isolated T wave inversion, or trivial ST-T changes. Coronary angiographic findings were similar in both subgroups. Symptoms regressed in only 9% of patients in subgroup 1 while they were receiving beta-receptor antagonists, whereas amiodarone alone or amiodarone with nifedipine was successful in 58%. Of these patients, 25% developed a myocardial infarction shortly after admission. In subgroup 2 patients, beta-blockers were successful in 61%. Amiodarone isolated or associated with nifedipine was successful in 55% of the patients in whom it was tried. Only 5% of patients in this subgroup developed a myocardial infarction during their hospital stay. It is concluded that: (1) observation of the electrocardiogram during spontaneous angina in patients with known atherosclerotic coronary heart disease may be of prognostic significance and may influence therapeutic decision. (2) Amiodarone by virtue of its anginal and antiarrhythmic properties may be particularly useful in the treatment of non-exertional angina.

Aneurysm of the Ascending Aorta after Cardiac Transplantation

Abstract We report the case of a 57-year-old female cardiac transplant patient in whom an aneurysm of the recipient side of the ascending aorta developed 1 year after transplantation. Although a mycotic origin was the likely cause, histologic examination diagnosed an atherosclerotic aneurysm.