Lotfy L. Basta

Effect of intermittent left bundle branch block on left ventricular performance

Abstract In a patient with intermittent left bundle branch block (LBBB), left ventricular (LV) performance was compared during normal and delayed left ventricular activation. LBBB was associated with delay in onset of left ventricular systole by 0.02 second, prolongation of isovolumic contraction time by 0.038 second, fall in mean systemic arterial blood pressure by 27 mm Hg, and marked reduction in the rate of left ventricular isovolumic pressure rise (dp/dt) at the peak common isovolumic pressure. LBBB depressed left ventricular performance, probably by causing a less synchronous ventricular contraction.

Eisenmenger's syndrome in pregnancy: Does heparin prophylaxis improve the maternal mortality rate?

Seven consecutive patients with Eisenmenbers syndrome, cared for by the obstetric team in conjunction with the cardiology service, were reviewed to assess the possible role of prophylactic heparin therapy and intensive care on the outcome of these patients. In each patient, the diagnosis of Eisenmengers syndrome was established by the demonstration of equal pulmonary arterial and aortic pressures with a predominantly right-to-left shunt at cardiac catheterization. Five of the seven patients died as follows: Three patients died between the fifth and eighth post-partum days, one patient died during the twenty-sixth week of pregnancy, and one patient died on the fifth postoperative day following tubal ligation. All of these five patients received prophylactic heparin therapy. In three patients, heparin therapy was complicated by excessive bleeding during the postoperative or postpartum period. Autopsy examination in two patients revealed no evidence of thrombosis in the main pulmonary arteries and no pulmonary infarction, contrary to the antemortem clinical suspicion. The two survivors did not receive prophylactic heparin. They comprised one patient who had normal delivery and one patient who underwent tubal ligation and induction of abortion. We conclude that the prohibitive mortality rate of Eisenmengers syndrome during pregnancy, puerpurium, or surgical procedures probably cannot be modified with prophylactic heparin therapy. Anticoagulant treatment does not prevent deterioration of patients and probably compounds the problem by causing significant bleeding.

Regression of atherosclerotic stenosing lesions of the renal arteries and spontaneous cure of systemic hypertension through control of hyperlipidemia

We describe a 49 year old woman with impressive regression of renal artery stenosing atherosclerotic lesions in response to sustained excellent control of hyperlipidemia. Initially, she had high blood pressure necessitating combined drug therapy with chlorothiazide, methyldopa and propranolol, with only moderately satisfactory control. Renal arteriography revealed a 90 per cent stenosing lesion of the right renal artery and 75 per cent narrowing of the left renal artery. Peripheral vein plasma renin was markedly increased at 32 ng/ml. With a combination of cholestyramine and clofibrate, serum lipids were maintained at normal values for several years. Increased blood pressure diminished spontaneously, and the patient has maintained normal blood pressures after discontinuation of antihypertensive therapy. Repeat renal arteriograms showed almost complete regression of the right renal artery lesion and a possible decrease in left renal artery disease. Peripheral vein plasma renin became normal at 3 ng/ml. This case illustrates that sustained control of hyperlipidemia could lead to regression of atherosclerotic nodules and impressive clinical improvement in certain patients.

Aneurysmectomy in treatment of ventricular and supraventricular tachyarrhythmias in patients with postinfarction and traumatic ventricular aneurysms

Serious, refractory or recurrent, or both, paroxysmal tachyarrhythmia occurred in 8 of 33 consecutive patients with a diagnosis of left ventricular aneurysm established by angiocardiography. The arrhythmia was ventricular in origin in five patients and supraventricular in three. Six of the eight patients were operated upon and the aneurysms resected. Four patients survived the operation and had no recurrence of the arrhythmias during a follow-up period of 7 to 25 months. One of these patients had a traumatic myocardial aneurysm associated with ventricular tachyarrhythmia. The other three patients had postinfarction aneurysms; ventricular tachycardia had been present in two and recurrent atrial flutter in the third. Two patients died after operation. They differed from the surviving patients in that they both had three-vessel coronary artery disease and severe impairment of myocardial contractility. Two patients responded satisfactorily to medical treatment so that surgery was not considered necessary. One of these had a postinfarction aneurysm and ventricular tachycardia that recurred less frequently with antiarrhythmic therapy. The other had a traumatic myocardial aneurysm and supraventricular tachycardia that was adequately controlled with drugs. Aneurysmectomy should be considered in the management of patients with postinfarction or traumatic ventricular aneurysms who present with refractory ventricular or supraventricular tachycardia.

Spontaneous return of sinus rhythm in older patients with chronic atrial fibrillation and rheumatic mitral valve disease: Description of three patients

Abstract Three patients with rheumatic mitral stenosis had had atrial fibrillation for over ten years before spontaneously restoring normal sinus rhythm. Each had undergone a closed mitral commissurotomy ten to twelve years before the conversion. Their ages at the time of resuming normal rhythm were 47, 59, and 71 years. This unusual phenomenon has no satisfactory explanation by our present knowledge of the natural history of mitral valve disease and the pathogenesis of atrial fibrillation.

The Value of Left Parasternal Impulse Recordings in the Assessment of Mitral Regurgitation

Left parasternal cardiograms were recorded at the fifth intercostal space in 30 patients with mitral regurgitation. Early systolic outward movements (E), late systolic outward movements (LOM), and the ratio of the LOM area to the total area occupied by the left parasternal cardiogram (LPC area) were examined. Thirteen patients had pure mitral regurgitation due to ruptured chordae tendineae (ten patients) or “floppy mitral valve’ (three patients). In these patients LOM/E correlated significantly with the regurgitation volume determined by the difference between angiographic and Fick stroke volumes, (r = 0.93, P < 0.01), and with the height of the “v’ wave in the pulmonary artery wedge pressure tracings (r = 0.79; P < 0.01). Simultaneous recordings of left parasternal movements and pulmonary wedge pressures in eight patients in this group showed a close relationship between LOM and “v’ waves.Fourteen patients had rheumatic heart disease and mitral regurgitation associated with mitral stenosis of varying degrees of severity. In this group there was no significant correlation between LOM/E or LOM area/LPC area and the regurgitation volume or the height of the “v’ wave. Of three patients who had congenital atrial septal defect in addition to mitral regurgitation, none had prominent LOM in the left parasternal cardiogram.This study suggests that if mitral stenosis and atrial septal defect can be excluded on clinical evidence, the left parasternal cardiogram may be used to obtain a noninvasive assessment of the severity of mitral regurgitation, particularly in patients with recent onset of the disease.

Aneurysmectomy for Control of Ventricular and SupraventricularTachyarrhythmias in Patients with Post-infarction or Traumatic Myocardial Aneurysms.

Excerpt Few patients have been described in whom refractory ventricular tachycardia was controlled by removal of myocardial aneurysms; most of these were postinfarction aneurysms. Of 33 consecutive...