Ray Pryor

Right Bundle-Branch Block Associated with Left Superior or Inferior Intraventricular Block: Clinical Setting, Prognosis, and Relation to Complete Heart Block

In an 11-year period 209 cases of partial bilateral bundle-branch block were seen. These included patients with right bundle-branch block and either left superior or left inferior intraventricular block. The majority of patients had evidence of coronary artery disease or hypertension, though a significant number had no clinical evidence of heart disease. The majority of patients had follow-up ECG tracings, with an average follow-up for the whole group of about 2 years. The incidence of complete heart block was 14.4% (30 of 209). Complete heart block developed more than 10 years after the discovery of bilateral bundle-branch block in several patients. It is anticipated that with more complete and longer follow-up the incidence of complete heart block will be even higher.

Right Bundle-Branch Block Associated with Left Superior or Inferior Intraventricular Block Associated with Acute Myocardial Infarction

Over an 11-year period, 28 instances of acute myocardial infarction and bilateral bundle-branch block were encountered. Twenty-two of these patients had right bundle-branch block and left axis deviation, and six had right bundle-branch block and block of the inferior radiation of the left bundle. The overall incidence of complete heart block in these 28 cases was 21%. In-hospital mortality for the whole group was 36%, whereas it was 33% for those patients who developed complete heart block. From these results it is concluded that for the patient with bilateral bundle-branch block and acute myocardial infarction the prophylactic insertion of a temporary transvenous pacemaker is not only warranted, but is probably indicated.

The Eisenmenger syndrome. A clinical and physiologic reappraisal.

Abstract Ninety-one cases of congenital heart disease with bidirectional or reversed central shunt and high total pulmonary vascular resistance are presented. The clinical examination including history, physical examination, electrocardiogram and chest roentgenogram is of little help in determining the site of the shunt. Cardiac catheterization aids in localizing the lesion, but a second defect may be present even though 1 defect has been clearly demonstrated. Careful follow-up examinations are therefore necessary, and postoperative catheterizations mandatory. Routine use of tolazoline hydrochloride is indicated to assess reactivity of the pulmonary vascular bed, and no physiologic study is considered complete without this procedure. Management is predicated on the reactivity of the pulmonary vascular bed, and it is stressed that the term Eisenmenger syndrome does not necessarily connote inoperability. Surgery, either correction of the defect or pulmonary arterial banding, is indicated in the patient whose level of total pulmonary resistance falls to normal or near normal with tolazoline. Supportive medical management is provided for patients with fixed pulmonary vascular changes.

Angiosarcoma of the heart: Report of a case and review of the literature

Abstract The case of a patient who had a primary angiosarcoma of the right atrium is reported. Helpful points which may lead to the diagnosis of this condition are: (1) gross blood in the pericardial fluid with the patient surviving more than 2 months, (2) a shaggy, thickened pericardium, (3) no history of trauma, (4) a need for repeated pericardiocentesis, with each one revealing gross blood, and (5) increasing signs of obstruction in the superior vena cava, despite pericardiocentesis and lack of evidence of persistent tamponade.

His bundle recording in progressive external ophthalmoplegia

Summary A teen-age girl with a 5 year history of PEO was noted to have a progressive disturbance of atrioventricular conduction with LAD, RBBB, and intermittent second degree heart block of Mobitz type II. His bundle recordings revealed a prolongation of the H-V conduction time interval and the development of Mobitz type II second degree block following atropine administration. A permanent demand cardiac pacemaker was implanted and successfully paced the patient during episodes of complete heart block which subsequently developed.

Electrocardiographic observation of 493 residents living at high altitude (10,150 feet)☆

Abstract Clinical cardiovascular evaluations were performed on 508 school children living at 10,150 feet in Leadville, Colo. The electrocardiograms of 493 of these children were analyzed and the findings were compared with electrocardiographic observations on similar residents at various altitudes. Thirty per cent of the subjects had electrocardiographic findings suggestive of right ventricular enlargement. The average mean ÂQRS of the entire group was more rightward that that of children of similar age living at 5,280 feet and at sea level, and less rightward than that of teenage children living at 14,900 feet. Electrocardiographic variability is an important part of the clinical evaluation of the healthy teenage subject living at high altitude.

Pseudo A-V block associated with A-H and H-V conduction defects

Abstract His bundle electrograms were recorded in a patient with tertiary syphilis whose ECGs showed right bundle branch block, junctional premature systoles, and episodes suggesting both Mobitz Type I and II second degree A-V block. Junctional premature depolarizations were found to cause: (1) ventricular systole, (2) retrograde atrial depolarizations with atrial fusion, and (3) nonconducted P waves of normal contour (pseudo A-V block). Nonconducted nonpremature P waves were also noted to occur secondary to both A-H and H-V forms of second degree A-V block in the absence of junctional premature activity. The presence of an H-V conduction defect may cause antegrade block of junctional premature depolarizations and enhance their expression as pseudo A-V block. This term should, therefore, not be meant to imply A-H and H-V conduction.

Isolated right ventricular hypoplasia

Abstract A 3 month old girl with cyanosis was found to have isolated right ventricular hypoplasia by cardiac catheterization and angiography. On physical examination, no murmur was heard and a single second heart sound was noted. The electrocardiogram revealed a frontal plane ÂQRS of 40 °, left atrial enlargement and left ventricular preponderance for age. Chest x-ray examination was not remarkable and probably normal. At cardiac catheterization, a large right to left shunt at the atrial level was demonstrated in spite of normal right-sided pressures. Angiograms revealed a diminutive right ventricular chamber which emptied into normal-sized pulmonary arteries. Intramyocardial contrast material was present after the injection, but no morbidity resulted; however, right ventricular injection of contrast material may be more hazardous in patients with isolated right ventricular hypoplasia. The clinical findings in reported cases so vary that, at present, cardiac catheterization is necessary for definitive diagnosis of this rare entity. The clinical findings in isolated right ventricular hypoplasia may mimic those of tricuspid atresia or type I pulmonary atresia and should be included in the differential diagnosis of any patient with cyanosis and left ventricular enlargement or preponderance.

The cardiovascular systemin children from high altitude

The cardiovascular system in the normal child from high altitude may differstrikingly from that of the child at sea level or lower altitudes. Physical signs of pulmonary hypertension, right ventricular preponderance in the electrocardiogram, and prominence of the pulmonary artery, right ventricle, and right atrium in the chest x-ray may be present. Cardiac catheterization studies have substantiated the presence of higher pulmonary arterial pressures in the normal resident of high altitude than those found at low altitude. Findings suggest that altitudes over 10,000 feet represent critical altitudes so far as the pulmonary circulation is concerned.

Fascicular blocks and the bilateral bundle branch block syndrome

Abstract Anterior fascicular block (AFB) and posterior fascicular block (PFB) are monoor unifascicular blocks —electrocardiographic entities which should be recognized and labeled appropriately; they are usually associated with heart disease but their clinical significance in an individual patient is a final decision that must be made by the clinician. When right bundle branch block (RBBB) is associated with either AFB or PFB, then bifascicular block (partial or incomplete bilateral bundle branch block) is present and these patients are at risk of developing the bilateral bundle branch block syndrome (at least a trifascicular block) , i.e., complete heart block, Stokes-Adams episodes, heart failure, or sudden death. The additional presence of Mobitz II block is even more worrisome and RBBB with Mobitz II block or left bundle branch block with Mobitz II block may also be forms of bifascicular block and potential precursors of bilateral bundle branch block. Patients with bifascicular block who are asymptomatic and clinically stable may be followed closely but borderline patients with bother-some problems may be individualized and some selected for ECG monitoring. If complete heart block is ever documented or Stokes-Adams episodes occur, cardiac pacing is indicated. With increasing awareness of and experience with bifascicular blocks, it is believed that the bilateral bundle branch block syndrome will probably prove to be more common than we now know, especially with RBBB and PFB. Although isolated AFB and PFB are most commonly seen in patients with coronary artery disease, hypertension, diabetes, obesity, or aortic valve disease, it must be emphasized that the single most common lesion that is found at autopsy in patients with the bilateral bundle branch block syndrome is fibrocalcific degenerative involvement of the ventricular conduction system.