Leonard W. Ritzmann

Natural history of "high-risk" bundle-branch block: final report of a prospective study.

We conducted a prospective study in which 554 patients with chronic bifascicular and trifascicular conduction abnormalities were followed for an average of 42.4 +/- 8.5 months. Heart block occurred in 19 patients, and 17 were successfully treated. The actuarial five-year mortality from an event that could conceivably have been a bradyarrhythmia was 6 per cent (35 per cent from all causes). Of the 160 deaths 67 (42 per cent) were sudden; most of these were not ascribable to bradyarrhythmia but to tachyarrhythmia and myocardial infarction. Mortality was higher in patients with coronary-artery disease (P less than 0.01) and congestive heart failure (P less than 0.05). Patients in whom syncope developed before or after entry into the study had a 17 per cent incidence of heart block (2 per cent in those without syncope)(P less than 0.05); however, no single variable was predictive of which patients were at high risk of death from a bradyarrhythmia. The predictors of death were increasing age, congestive heart failure, and coronary-artery disease; the predictors of sudden death were coronary-artery disease and increasing age. The risks of heart block and of death from a bradyarrhythmia are low; in most patients, heart block can be recognized and successfully treated with a pacemaker.

A Prospective Study of Sudden Death in High-Risk Bundle-Branch Block

We prospectively followed 257 patients with bifascicular and trifascicular conduction-system disease and intact atrioventricular conduction who had undergone His-bundle studies. Forty-seven per cent had associated coronary-artery disease, and 23 per cent primary conduction-system disease. His-ventricular interval was moderately prolonged in 43 per cent and markedly prolonged in 12 per cent. During an average follow-up period of 25 months 50 patients died. However, death was sudden in only 27, and 17 of the sudden deaths were not due to bradyarrhythias. Actuarial analysis showed an overall mortality rate (mean +/- S.E.) of 19 +/- 2.6 per cent at two years, mortality from sudden death being 10 +/- 2.6 per cent. Permanent heart block occurred in 12. No clinical symptoms (including syncope), electrocardiographic findings, electrophysiologic data or their combination identified patients at high risk of sudden death. Sudden death due to bradyarrhythmia is uncommon in patients with bundle-branch block and intact atrioventricular conduction. Therefore, routine prophylactic use of permanent pacemakers in all such patients is inappropriate. Pacemaker implantation should be reserved for those with documented symptomatic bradyarrhythmias.

The pathophysiologic basis of acute coronary insufficiency. Observations favoring the hypothesis of intermittent reversible coronary obstruction

Clinical, coronary angiographic, and myocardial metabolic data were analyzed to test alternative hypotheses for the pathophysiologic basis of acute coronary insufficiency. The initial incidence of coronary collaterals was not low in relation to coexisting coronary obstructive disease; the early subsequent coronary occlusion rate was high; and in asymptomatic intervals during the acute illness, myocardial hypoxia was infrequent and coronary reserve substantial. These observations support the hypothesis that the acute coronary insufficiency syndrome is caused by reversible coronary ischemic episodes rather than by a new permanent atherosclerotic lesion.

Long-Term Anticoagulant Prophylaxis after Myocardial Infarction

Abstract In a double-blind, randomized test, long-term prophylactic anticoagulant therapy after acute myocardial infarction did not reduce mortality rate or complications. More treated patients required hospitalization than patients not receiving anticoagulant drugs. Patients continuously entered the study between 1956 and 1967. The average period at risk was about six years. All patients received six weeks of anticoagulant therapy for initial episodes of infarction, and, time and circumstances permitting, for recurrent myocardial infarctions.

Hemodynamic Studies Following Pericardiectomy for Constrictive Pericarditis

Fourteen patients underwent right heart catheterization 5 to 86 months after pericardiectomy for constrictive pericarditis. Twelve had preoperative catheterizations, all with findings typical of constrictive pericarditis.All patients showed marked hemodynamic and symptomatic improvement after operation. Three patients had persistent mild elevation of right heart and pulmonary artery pressures; one of these had a low cardiac output. Two other patients developed pulmonary hypertension with exercise, and one man showed an inadequate increase in cardiac output with exercise. Twelve patients were asymptomatic postoperatively and two had exertional dyspnea.Patients with incomplete pericardiectomy over the ventricles had abnormal hemodynamic results, while decortication of the atria and venae cavae made no difference in the postoperative findings. A left anterolateral thoracotomy incision provided adequate exposure for pericardiectomy, and continues to be the incision of choice at this hospital. Younger patients and those who progressed from recognized acute pericarditis to pericardial constriction more frequently had normal results at cardiac catheterization after operation. Certain preoperative liver-function tests correlated well with the postoperative hemodynamic findings. The role of myocardial disease in producing residual hemodynamic abnormalities remains unresolved.It is concluded that excellent clinical results and normal hemodynamic findings can be achieved by pericardiectomy in most patients with constrictive pericarditis.

Paroxysmal Atrial Tachycardia with Atrioventricular Block Its Frequent Association with Chronic Pulmonary Disease

Paroxysmal atrial tachycardia with block is a cardiac arrhythmia that is usually a manifestation of digitalis toxicity in patients with serious heart disease. The arrhythmia generally ends promptly after potassium administration and withdrawal of digitalis. Since the ventricular rates may be slow and regular, the arrhythmia may be difficult to recognize clinically. Atrial rates as slow as 115 per minute may be seen in cases which are otherwise typical of the condition. In our series associated pulmonary disease was present in 54 per cent and cor pulmonale in 27 per cent of the cases.

Rupture of the Infarcted Interventricular Septum Surgical Repair with Survival

Successful surgical closure of a ruptured interventricular septum following myocardial infarction is reported. The patient developed the loud pansystolic parasternal murmur characteristic of septal perforation, and cardiac catheterization confirmed an unusually large left-to-right shunt. The patients course was not the typical rapid deterioration with shock or intractable heart failure, but when myocardial insufficiency developed insidiously 5 weeks postinfarction, surgical closure with a Teflon patch was accomplished during cardiac bypass. Since early death ensues so frequently, surgical repair has been attempted in only a small number of instances; this patient is one of the very few with successful closure and long-term survival. The pathology, clinical course, and cardiac catheterization data of this entity are reviewed from previously reported cases.

Unusual manifestations in a case of relapsing, nodular, febrile panniculitis (Weber-Christian disease).

Abstract A case of relapsing, nodular, febrile panniculitis (Weber-Christian syndrome) is presented. Trauma was the inciting etiologic factor of the patients lesions, many of which underwent liquefaction. This case is unusual in manifesting marked bone involvement. Acute myocardial infarction, which occurred in this patient, is considered as a possible rare complication of the disease.

Serum Glycoside Concentrations in Digitalis Toxic Patients.

Excerpt The use of serum glycoside concentrations in assessing digitalis toxicity was studied. Lowensteins method for glycoside levels was adapted for clinical use by modifications giving greater ...