William D. Towne

Chronic recurrent right and left ventricular tachycardia: Comparison of clinical, hemodynamic and angiographic findings

Abstract Twenty-seven patients with chronic recurrent ventricular tachycardia were judged to have either left or right ventricular tachycardia on the basis of electrocardiographic QRS configuration during the tachycardia. Clinical, hemodynamic and angiographic evaluation was performed. The 15 patients who had left ventricular tachycardia were older (mean age 43 years) and predominantly male ( male/female ratio 10:5), and all (100 percent) had diagnosable organic heart disease. The 12 patients who had right ventricular tachycardia were younger (mean age 32 years) and mostly female ( male female ratio, 4:8), and only three (25 percent) had diagnosable organic heart disease. Patients with left ventricular tachycardia had lower cardiac output and a much greater prevalence of abnormal left ventricular and coronary angiograms than patients with right ventricular tachycardia. Patients with left ventricular tachycardia were followed up for an average of 38 months (one patient lost to follow-up); three deaths occurred. Patients with right ventricular tachycardia were followed up for 35 months (two patients lost to follow-up); none died. Grouping of patients with chronic recurrent ventricular tachycardia into those with left or right ventricular tachycardia appears to be useful. The latter condition appears to be less serious.

Clinical assessment of external pressure circulatory assistance in acute myocardial infarction. Report of a cooperative clinical trial.

Abstract The clinical effects of early application of external pressure circulatory assistance (EPCA) in acute myocardial infarction were evaluated in a prospective, randomized trial involving 258 patients in 25 institutions. All patients had mild left ventricular failure and received circulatory assistance within the first 24 hours after the onset of symptoms. There were no significant differences between the treatment and control groups, consisting of 142 patients and 116 patients, respectively, with regard to age, sex, race, previous cardiac history, electrocardiographic location of myocardial infarction, Norris prognostic index, admission heart rate, blood pressure and chest roentgenogram, and time from onset of symptoms to hospital admission. There were also no differences between the treatment and control groups with regard to antiarrhythmic, positive inotropic, diuretic and vasodilator therapy. Hospital mortality was significantly decreased, compared with that of control patients, in the group receiving 4 or more hours of external pressure circulatory assistance within the first 24 hours after admission (mortality rate 6.5 percent [7 of 108] in treatment group versus 14.7 percent [17 of 116] in control group, p

Pulmonary Valve Vegetations Detected With Echocardiography

In a patient with pseudomonas endocarditis a pulmonary regurgitant murmur developed. Sequential echocardiography demonstrated the initial absence of vegetations, the evolution of pulmonary valve vegetations with relapse and finally the apperance of vegetations on all cardiac valves. The findings were confirmed at autopsy. Echocardiography, a useful technique for evaluating mitral, aortic and tricuspid vegetations, can also detect pulmonary valve vegetations.

Electrocardiographic changes simulating acute myocardial infarction caused by hyperkalemia: Report of a patient with normal coronary arteriograms

A patient is described with severe diabetic ketoacidosis and hyperkalemia who presented with an ECG resembling an acute anterior wall myocardial infarction. Treatment of hyperkalemia resulted in prompt return of the ECG towards normal. Subsequent work-up including exercise testing and selective coronary arteriography ruled out any significant coronary artery disease suggesting that the ECG changes were probably caused by hyperkalemia. While similar changes have rarely been described in the past, this would appear to be the first such case in whom coronary artery disease was ruled out by a negative exercise testing and coronary arteriography.

Conduction system in a patient with Prinzmetal's angina and transient atrioventricular block

His bundle recordings obtained during and between attacks of Prinzmetals variant angina and transient atrioventricular (A-V) block were followed by a comprehensive serial section study of the conduction system in a 33 year old woman. Recordings between attacks showed normal A-H and H-V intervals. During an attack there was block proximal to the His bundle recording site. Pathologic studies revealed severe narrowing of the right coronary artery. Arteriolosclerosis of the heart was diffuse. Insignificant changes were found in the approaches to the A-V node and the A-V node itself. Major changes found in the left bundle branch had no counterpart in the electrocardiogram; the discordance in these findings is discussed.

Echocardiographic diagnosis of left ventricular mural thrombi occurring in cardiomyopathy

Abstract A patient with alcoholic cardiomyopathy presented with recurrent biventricular heart failure. Echocardiography supported the clinical diagnosis and suggested the presence of multiple left ventricular mural thrombi. At postmortem large left ventricular and small right ventricular thrombi were found in association with systemic and pulmonary emboli. Echocardiography may be of value in the earlier detection of intramural left ventricular thrombi.

Infective aneurysm of the left ventricle: angiographic and echocardiographic features

A 17-year-old man with staphylococcal endocarditis of the mitral valve developed an infective aneurysm of the posterior left ventricular wall. Echocardiography revealed an echo-free space posterior to the posterior left ventricular wall. This echo-free space undoubtedly represented the aneurysmal sac, because it could be temporarily obliterated by injecting saline into it and was no longer detectable following surgical closure of the sac. Thus echocardiography may be helpful in the detection of an infective aneurysm of the left ventricle.

Systolic prolapse of the mitral valve in Noonan's syndrome

A thirty-five-year-old woman with Noonans syndrome (Turner phenotype with normal chromosome pattern) had mitral valve prolapse and mitral insufficiency associated with the auscultatory findings of a midsystolic click and late systolic murmur. Selective left-ventricular angiocardiography also showed eccentric hypertrophy of the left ventricle. To our knowledge, this is the first reported instance of mitral valve prolapse occurring in association with Noonans syndrome.

Pathologic correlations in a case of complete heart block with split his potentials resulting from a stab wound of the heart

A 23 year old previously healthy man was stabbed in the anterior chest. This resulted in a ventricular septal defect and complete atrioventricular (A-V) block. The electrocardiogram revealed complete A-V block with a QRS pattern of right bundle branch block. His bundle recordings 26 days later revealed A-V dissociation with split His potentials (P-H1 interval of 100 msec and H2-V interval of 40 msec). During the study the escape QRS shifted from right to left bundle branch block with H2 potentials still preceding each QRS interval with H2-V intervals of 40 msec. A permanent pacemaker was implanted because of persistent congestive heart failure and bradycardia due to A-V block. The patient subsequently became asymptomatic. He died suddenly 3 1/2 years later. Pathologically there were sizable openings in both the tricuspid and mitral valve substance and a ventricular septal defect involving the pars membranacea and part of the adjacent muscular septum. Serial sections of the conduction system revealed total destruction and fibrous replacement of the bifurcation and beginning of the right and left bundle branches and subtotal fibrous replacement of the branching bundle. Thus, the bifurcation of the bundle of His was totally absent at autopsy despite apparent electrophysiologic evidence of its existence 26 days after the stab wound. A possible explanation for this discrepancy is the subsequent fibrosis of the bifurcation produced by hemodynamic changes at the lower margin of the ventricular septal defect.

Pseudoatrial gallop with atrioventricular block. Demonstration of a possible mechanism by echocardiography.

Abstract A patient with marked first degree and intermittent second degree atrioventricular block was demonstrated to have an intermittent presystolic filling sound without the usual preceding atrial activity. Echocardiography disclosed late diastolic opening of the mitral valve coincident with the filling sound. When atrial contraction occurred at the onset of diastole, the mitral valve opened early and subsequently closed, thus delaying the normal rapid passive filling phase. On those cycles with presystolic filling sounds, the delayed passive filling phase terminated in presystole. We postulate that this delayed rapid filling phase of the cardiac cycle is the origin of the filling sound in presystole in the absence of the usual accompanying P wave.