Tiberio Rosenfeld

Short‐Term Thrombosis after Transvenous Permanent Pacemaker Insertion

In order to assess prospectively the incidence and significance of venous thrombosis early after permanent transvenous pacemaker implantation venographic studies were carried out in 40 consecutive patients. The venograms performed between 1 and 6 months (mean 4 months) after the implantation were normal in 31 patients (77%), in six patients (15%) they showed partial venous obstruction and in three patients (8%) total obstruction. Between 6 and 12 months (mean 9 months) the venograms of five patients, that were previously normal, showed partial venous thrombosis. No changes were found in (he venograms performed later. Only two of 14 patients with thrombosis of the great veins was clinically symptomatic and developed arm edema, that resolved spontaneously within about a month. No difference in incidence of abnormal venograms was found according to the type of insulation, the polarity of the electrode and the route of entry.

Calcium antagonists and mortality in patients with coronary artery disease: A Cohort study of 11,575 patients☆

OBJECTIVESnThis study sought to establish the risk ratio for mortality associated with calcium antagonists in a large population of patients with chronic coronary artery disease.nnnBACKGROUNDnRecent reports have suggested that the use of short-acting nifedipine may cause an increase in overall mortality in patients with coronary artery disease and that a similar effect may be produced by other calcium antagonists, in particular those of the dihydropyridine type.nnnMETHODSnMortality data were obtained for 11,575 patients screened for the Bezafibrate Infarction Prevention study (5,843 with and 5,732 without calcium antagonists) after a mean follow-up period of 3.2 years.nnnRESULTSnThere were 495 deaths (8.5%) in the calcium antagonist group compared with 410 in the control group (7.2%). The age-adjusted risk ratio for mortality was 1.08 (95% confidence interval [CI] 0.95 to 1.24). After adjustment for the differences between the groups in age and gender and the prevalence of previous myocardial infarction, angina pectoris, hypertension, New York Heart Association functional class, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and current smoking, the adjusted risk ratio declined to 0.97 (95% CI 0.84 to 1.11). After further adjustment for concomitant medication, the risk ratio was estimated at 0.94 (95% CI 0.82 to 1.08).nnnCONCLUSIONSnThe current analysis does not support the claim that calcium antagonist therapy in patients with chronic coronary artery disease, whether myocardial infarction survivors or others harbors an increased risk of mortality.

Implantation of Permanent Dual Chamber Pacemaker in a Pregnant Woman by Transesophageal Echocardiographic Guidance

A 37‐year‐old woman complained of fatigue and dizziness because of intermittent sinus arrest and asystole up to 5.2 seconds. She was 3 months into her pregnancy and a dual chamber permanent pacemaker was implanted by transesophageal echocardiographic guidance.

Transiliac vein approach to a rate responsive permanent pacemaker implantation

A 60‐year‐oId patient was admitted for elective replacement of a depleted pulse generator. The pacemaker was implanted 5 years before because of sick sinus syndrome and it was connected to an epicardial lead due to total occlusion of the superior vena cava. The pacing threshold of the epicardial electrode was unacceptabiy high, so an endocardial lead was inserted through the iliac vein. The lead was connected to a VVIR pacemaker, ivhich was located in the abdomen just lateral to the umbilicus. During a 1‐year follow‐up period, the patient felt well and pacemaker performance was satisfactory.

Effect of isosorbide-5-mononitrate on exercise performance and clinical status in patients with congestive heart failure: Results of the nitrates in congestive heart failure (NICE) study

Background and Aims: Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied. Methods: Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2–3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy. Results: Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI –5, +90 s at 12 weeks and +21 s, 95% CI –25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31–40% (+55 s, 95% CI –11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001). Conclusions: ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.

An unusual case of mitral valve aneurysm: Two dimensional echocardiographic and cineangiocardiographic features☆

A patient is described in whom an aneurysm of the posterior mitral leaflet caused severe mitral incompetence and cardiac failure. The aneurysm was seen as an additional echo-free space within the left atrium in the real time two dimensional echocardiogram. Both echocardiographic and cineangiocardiographic appearances were misinterpreted initially because the aneurysmal leaflet did not more into the left ventricle during diastole. This feature was explained during the successful surgical repair of the valve by the observation that the aneurysm was adherent to the left atrial wall.

Noonan's syndrome associated with hypoplastic left heart

A case of a week old female baby, admitted because of apathy, hypothermia, dyspnea, jaundice and cyanosis is described. She had the characteristic phenotype of Turners syndrome with normal karyotype. Signs of severe heart failure were present. Therapy with diuretics, digoxin, dopamine and mechanical ventilation were unsuccessful, and the patient died several hours after her admission. The anatomopathological examination revealed the presence of hypoplastic left heart syndrome with mitral atresia and aortic atresia, atrial septal defect, double outlet right ventricle, and a patent ductus arteriosus.

Intermittent to-and-fro murmur in cardiac pseudoaneurysm: Doppler echocardiographic findings

A case is presented in which a to-and-fro murmur was heard at auscultation. Cross-sectional echocardiography, combined with Doppler examination, showed that the murmur was produced by flow across the neck of a left ventricular pseudoaneurysm.

Failure of Left‐Sided Implantable Cardioverter Defibrillator Implantation Due to Absence of Left Brachiocephalic Vein

Implantation of an implantable cardioverter defibrillator by the transvenous approach was impossible from the left side in a patient with an absence of the left brachiocephalic vein; the left subclavian vein was connected by a large left superior intercostal vein to the accessory hemiazygos vein that joined the azygos vein; then the blood flowed into the superior vena cava. Implantation was successfully attempted using the right‐sided venous access.

Deglutition syncope associated with carotid sinus hypersensitivity.

A 78‐year‐old patient complained of syncope, near syncope, and dizziness when eating; complete atrioventricular block, with ventricular asystole for 3.6 seconds, was recorded on continuous electrocardiographic monitoring. Left and right carotid sinus masssage produces sinus arrest and ventricular asystole lasting 6.4 and 4.8 seconds, respectively. These phenomena were prevented by atropine administration. The symptoms were completely relieved by permanent pacing, but the patient died 6 months later because of large cell undifferentiated carcinoma of the lower third of the esophagus.