bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrophysiologic evaluation of sinus node dysfunction in postoperative children and young adults utilizing combined autonomic blockade–B. Marcus Et Al.: Postoperative intrinsic sinus node evaluation
Authors: Marcus B. , Gillette P. C. , Garson A.
Published: February 2009

Sinus node dysfunction is a recognized problem following surgery for congenital heart disease. Seven postoperative patients with sinus node dysfunction (5 Mustard, 1 tetralogy of Fallot, 1 Fontan) underwent electrophysiology study of sinus node function during combined autonomic blockade (CAB) utilizing propranolol 0.2 mg/kg iv and atropine 0.04 mg/kg iv to evaluate intrinsic sinus node function isolated from autonomic control. During CAB, intrinsic heart rate, intrinsic corrected sinus node recovery time, and intrinsic sinoatrial recovery time were measured. These results were compared with age‐matched normal intrinsic data from our lab [normal (n = 7, mean age 9 years) IHR 128 ± 24, intrinsic corrected sinus node recovery time 135 ± 40 ms, intrinsic sinoatrial conduction time 86 ± 19 ms]. Among postoperative Mustard patients (n = 5, mean age 13 years, mean years postoperative 11) 2 of 5 had clearly abnormal intrinsic sinus node function with nonsinus rhythm during CAB: 3 of 5 had sinus rhythm during CAB with normal or mildly abnormal intrinsic sinus node function. The postoperative case of tetralogy of Fallot (age 20 years, postoperative 14 years) had mildly abnormal intrinsic sinus node electrophysiology study. The postoperative case of Fontan (age 16 years, postoperative 1.5 years) had sinus rhythm at rest but left atrial rhythm during CAB.

Different aspects of sinus node dysfunction may be expressed during resting electrophysiology study vs. electrophysiology study utilizing CAB. The pathophysiology of sinus node dysfunction among postoperative pediatric patients is not homogeneous with regard to the contribution of intrinsic sinus node dysfunction. In those patients with normal or mildly abnormal intrinsic sinus node function, an important pathophysiologic influence of the autonomic nervous system is implicated.
Transient ischemic attack‐related syncope
Authors: Davidson E. , Rotenbeg Z. , Fuchs J. , Weinberger I. , Agmon J.
Published: February 2009

The records of 483 patients admitted to the emergency room because of syncope were reviewed. Thirty seven patients (7.7%) were found to suffer from transient ischemic attack‐ (TIA) related syncope. This group is the subject of this report. Of these patients, 28 (76%) were men (mean age 71 years). Seven patients reported previous syncopal episodes. Past history revealed a high rate of ischemic heart disease (70%) and hypertension (68%). Concurrent neurologic symptoms, which led to the diagnosis of TIA‐related syncope, included mainly vertebrobasilar symptoms: vertigo (in 55% of the patients), ataxia (46%), parasthesia (41 %). Two patients most probably were presenting bilateral carotid artery disease. Various diagnostic tests (including electroencephalography, computed tomography, sonography, and cerebral angiography) were used to exclude other causes of syncope. During follow‐up (mean 14.5 months) four patients (11%) had an additional episode of TIA and in three of them syncope reappeared. One patient had a complete stroke. We conclude that TIA is a much more frequent explanation for syncope than has been previously argued. These patients tend to be elderly males with high incidence of ischemic heart disease and hypertension. The concurrent neurologic symptoms, leading to the diagnosis, represent mainly vertebrobasilar territory ischemia.
Pulmonary artery sarcoma: Another cause of sudden death
Authors: Waller Bruce , Varriale Philip , Chryssos Basil
Published: February 2009

patient hospitalized for recurrent syncope and dyspnea died suddenly before a definite clinical diagnosis could be established. At autopsy a large sarcomatous mass (undifferentiated type) was found to arise and totally occlude the pulmonary trunk without evidence of distant metastasis.
A case of cardiac amyloidosis presenting with symptoms of exertional syncope
Authors: Fujii B. , Matsuda Y. , Ohno H. , Hamada Y. , Takashiba K. , Ebihara H. , Hyakuna E. , Tani S.
Published: February 2009

A 54‐year‐old man presented with symptoms of exertional syncope. Cardiac amyloidosis was diagnosed by endomyocardial biopsy. Exercise tolerance test revealed a failure of increased heart rate followed by sinus arrest, associated with syncope. Autopsy revealed amyloid deposits in the sinoatrial node.
The pacemaker syndrome: Old and new causes
Authors: Schüller H. , Brant J. , Camm A. J.
Published: February 2009

The pacemaker syndrome refers to symptoms and signs in the pacemaker patient caused by inadequate timing of atrial and ventricular contractions. The lack of normal atrioventricular synchrony may result in decreased cardiac output and venous “cannon A waves.” A sudden increase in atrial pressure at the onset of asynchrony may elicit a systemic hypotensive reflex response. A wide range of symptoms can be observed. The pacemaker syndrome is encountered in a significant number of patients with ventricular (VVI) pacemakers, mostly when 1:1 retrograde ventriculoatrial conduction is present. The risk of occurrence of the pacemaker syndrome is minimized if pacemaker systems are used which restore or maintain the normal atrioventricular contraction sequence. Hence, in sinus node disease, atrial stimulation with or without ventricular stimulation should be employed, while in high‐grade atrioventricular block dual‐chamber pacing is recommended. The pacemaker syndrome is not restricted to the VVI stimulation mode. It can be seen, though rarely, in atrial and dual‐chamber pacing, and an awareness of these new causes is necessary. An established pacemaker syndrome can often be counteracted by adjusting the pulse generator function.
Heparin‐releasable platelet factor 4 in patients with coronary artery disease
Authors: Sadayasu Takao , Nakashima Yasuhide , Yashiro Akjra , Kawashima Takashi , Kuroiwa Akio
Published: February 2009

Recently, platelet factor 4 (PF4) release by heparin (heparin‐releasable PF4) has been examined as a useful marker of the interaction between the substances liberated from circulating platelets and the vascular endothelium. We compared the plasma levels of PF4 and β‐thromboglobulin (β‐TG) after intravenous heparin injection in patients wtih coronary artery disease (CAD) and normal control subjects. We also studied the effects of low‐dose aspirin (81 mg/day) on the plasma level of heparin‐releasable PF4 in the CAD patients. Blood samples were obtained before and 5 min after the intravenous injection of heparin (1,000 IU) from 23 patients with CAD and 15 normal control subjects. Although the plasma β‐TG level remained unchanged after heparin injection, the plasma PF4 level markedly increased in both groups. There was a significant difference in plasma PF4 levels at 5 min after heparin injection between the CAD group (100.1±38.1) and the control group (61.0±;24.0) (p<0.01). The PF4/β‐TG ratio after heparin injection was also higher in the CAD group than in the control group (p<0.01). There was a correlation between the PF4/β‐TG ratio after heparin and the Gensini CAD score, which defines the severity of coronary atherosclerosis (r = 0.489, n = 23, p<0.01). Low‐dose aspirin was administered to 11 CAD patients for 246.0 ±;28.8 days. Blood samples for the assay of PF4 and β‐TG were obtained as stated above, and platelet aggregation, thromboxane B2 (T×B2), and 6‐keto‐prostaglandin F1α (6‐keto‐PGF1α) levels were also measured before and during aspirin administration. Aspirin significantly reduced the PF4 level and the PF4/β‐TG ratio after heparin injection (p<0.05) in accoradance with the reduction in platelet aggregation (ADP induced: p<0.01, collagen‐induced: p<0.01, epinephrine‐induced: p<0.05). Although there were no statistically significant changes in T×B2 and 6‐keto‐PGF1α levels during aspirin administration, the T×B2 level was decreased by aspirin in 7 of 11 CAD patients. The decrease in the PF4/β‐TG ratio after heparin injection was significantly correlated with the changes of ADP‐ and epinephrine‐induced platelet aggregation (r = 0.717, p<0.01 and r = 0.577, p<0.05, respectively). These results suggest that heparin‐releasable PF4 (the PF4 level and/or PF4/β‐TG ratio after heparin injection) has the potential to be used as a marker of increased platelet aggregability in CAD patients.
Elevation of factor VII activity and mass in coronary artery disease of varying severity
Authors: Suzuki Toshikazu , Yamauchi Kazunobu , Matsushita Tadashi , Furumichi Takeo , Furui Hirohiko , Tsuzuki Jitsuki , Saito Hidehiko
Published: February 2009

The present study was undertaken to determine whether the extent of Factor VII elevation correlated with the severity of coronary artery disease and whether zymogen or activated Factor VII was responsible for this elevation. A group of 69 patients with coronary artery disease with old myocardial infarction was compared with 28 control subjects. The patient groups showed elevated levels of Factor VII procoagulant activity (FVII.C) and more markedly elevated Factor VII antigen (FVII:Ag) levels than the control group; therefore they had a decreased FVII:C to FVII:Ag ratio. The increased Factor VII level in the patient groups was caused by elevated Factor VII zymogen levels, and not by activated Factor VII. Since FVII:C levels strongly correlated with the titer of thrombin‐antithrombin III complexes in all patients, the hypercoagulable state accompanying severe coronary atherosclerosis seems to underlie the increase of FVII and TAT in the stable phase of myocardial infarction.
Accelerated idioventricular rhythm detected during elective surgery in a healthy man
Authors: Lew David C. , Keim Stephen G. , Curtis Anne B.
Published: February 2009

Accelerated idioventricular rhythm (AIVR) is found most commonly in the presence of underlying heart disease. It is characterized by acceleration of a latent pacemaker that normally depolarizes slowly. We describe a 30‐year‐old man who was found to have episodes of accelerated idioventricular rhythm (AIVR) on cardiac monitoring during elective orthopedic surgery. Noninvasive evaluation including two‐dimensional echocardiography was unremarkable. No late potentials were detected on a signal‐averaged electrocardiogram. During an exercise tolerance test, AIVR was suppressed as heart rate increased. A 24‐h Holter monitor revealed that the AIVR rate was consistently 73‐76 beats/min, which appeared whenever the sinus rate slowed to this level. The patient has been asymptomatic, and the rhythm has persisted at least through a 5‐month follow‐up period.
Catheter balloon valvuloplasty of stenotic aortic valves Part I: Anatomic basis and mechanisms of balloon dilation
Authors: Waller Bruce F. , Vantassel James W. , Taliercio Charles , Howard Jane , Green Frank , Mckay Charles
Published: February 2009

Catheter balloon valvuloplasty of stenotic aortic valves has met with generally poor short‐ and long‐term clinical results. Part of this problem resides with the lack of recognition of various etiologies of aortic stenosis. Part I of this review discusses the various etiologies of aortic stenosis and provides an anatomic basis for successful valve dilation. Results of an in vitro study indicate stenotic aortic valves are dilated by various mechanisms (cracking, stretching) based in part upon the etiology of the aortic valve stenosis.
Signal‐averaged electrocardiography: History, techniques, and clinical applications
Authors: Jarrett Jeffrey R. , Flowers Nancy C. , John A. Camm
Published: February 2009

Signal averaging principles have been utilized since around 1875. Their application in medicine to enhance biologic signals was first made in 1947 for improved detection of electroencephalographic signals. The year 1963 marked the first application of this technique to cardiac signals. The more prevalent use in adult cardiology is in the detection of ventricular late potentials (VLPs) which correspond to areas of delayed ventricular activation as slowed conduction velocity. These VLPs have value in predicting the likelihood of malignant ventricular arrhythmias after myocardial infarction (MI). Negative predictive values on the order of 96–99% are convincing as to their ability to predict no arrhythmic event post‐MI. Positive predictive values, on the other hand, are poor (10–29%) but improve (35–62%) in combination with other parameters such as depressed left ventricular function and frequent ventricular ectopy. Additional accepted uses for the signal‐averaged electrocardiogram (SAECG) include prediction of successful ablative surgery for intractable ventricular tachycardia and facilitating evaluation of patients presenting with syncope of an unclear etiology. Potential future applications of the SAECG are (1) in following patients for rejection after cardiac transplant, (2) as a screening tool for the need for electrophysiologic study, (3) as a predictor of vessel patency after thrombolysis or percutaneous transluminal coronary angiography, and (4) as a tool to assess proarrhythmia. As the technique of signal averaging continues to evolve, its applications may become more diverse and its clinical effectiveness may improve.
Influence of exercise training soon after myocardial infarction on regional myocardial perfusion and resting left ventricular function
Authors: Beller George A. , Murray Gary C. , Erkenbrack Susan K.
Published: February 2009

There is scant information regarding the effect of exercise training begun soon after hospital discharge for myocardial infarction (MI) with respect to subsequent improvement in exercise tolerance, enhancement of regional myocardial perfusion, or left ventricular function. Accordingly, 19 post‐MI patients (mean age 53 ± 7 years) underwent treadmill exercise quantitative thallium‐201 (Tl‐201) scintigraphy and rest radionuclide angiography (RNA) prior to and after 12 weeks of thrice‐weekly exercise training which was targeted to 70–85% of maximum exercise heart rate achieved. Training was begun at 25 ± 3 days after hospital discharge. Eight Tl‐201 scan segments were each scored from 1–6 points based upon uptake and washout criteria with 6 being the most severe defect (>50% reduction in Tl‐201 events with no delayed redistribution). When matched to the pretraining peak workload on exercise testing, 12 weeks of training significantly lessened heart rate (120±4 to 97±4, p<0.001), peak systolic blood pressure (142±6 to 129±5 mmHg, p<0.01), and significantly reduced double product [17.2±10.8 to 12.7±9 (×103), p<0.001]. Training was associated with a reduction of exercise‐induced ST depression or angina (42 to 16%) which was not statistically significant. The mean resting by RNA ejection fraction was 50±3% prior to training and 51±3% after training. There was no significant change in overall Tl‐201 defect score or the number of defect regions per patient scan comparing pre‐ and post‐training scintigrams. Of the 5 patients who had elimination of exercise‐induced angina or ischemic ST depression after training, none showed an improvement in the Tl‐201 defect score between the two studies. Thus, 3 months of exercise conditioning begun soon after acute MI is associated with a significant training effect without an improvement in resting left ventricular function or myocardial perfusion at peak exercise.
The postcardiac injury syndromes
Authors: Khan Abdul Hakim
Published: February 2009

Late pericarditis following myocardial infarction, cardiac surgery, or trauma is referred to as postmyocardial infarction syndrome (PMIS) or postcardiotomy syndrome (PCS), respectively. The term postcardiac injury syndrome (PCIS) is used to encompass both these entities. PCIS is characterized by fever, pleuropericardial pain, pericarditis, and pulmonary involvement. Abnormal laboratory findings include leukocytosis, high sedimentation rate, and chest x‐ray abnormalities of pleural effusion with or without pulmonary infiltrates. Evidence supports an immunopathic etiology; viruses may play a contributing role. The course is benign but rare complications include tamponade, constriction, anemia, and coronary bypass graft occlusion. Anti‐inflammatory agents are helpful; indo‐methacin and steroids are preferably avoided. Rarely, PMIS‐like syndrome may occur following pulmonary embolism. Anticoagulation and steroids have been used successfully in the latter situation.
Coronary hemodynamic effects of systemic thrombolysis in patients with unstable angina
Authors: Pozzati Andrea , Bugiardini Raffaele , Ottani Filippo , Morgagni Gian Luigi , Puddu Paolo
Published: February 2009

Intracoronary (i.c.) thrombus is a frequent finding in patients with unstable angina (UA). Accordingly, thrombolytic treatment could be beneficial, as resolution of thrombus might result in increased delivery of blood flow to the ischemic regions. To test this hypothesis, we studied 13 patients with active UA and ST‐segment shift in the anterior leads. Coronary angiography was performed and great cardiac vein blood flow (GCVF; thermodilution) was measured in all patients 25 ± 14 h after the last chest pain episode. Following angiography, patients received i.v. urokinase (UK: 1,000,000 IU/30 min); aortic pressure and GCVF were measured before and every 10 min following drug infusion, for a total time of 90 min. At baseline angiography, 5 of 13 patients (Group 1) had evidence of i.c. thrombus (intraluminal filling defect or thrombotic subocclusion) in the ischemia‐related left coronary artery, whereas 8 patients (Group 2) did not. Group analysis showed that UK increased GCVF and decreased anterior coronary resistance in Group 1 (respectively, from 86±33 to 114±41 ml/min: p<0.005; and from 1.37±0.68 to 1.01±0.44 mmHg/ml/min: p<0.05) but not in Group 2 (both: p=NS). In conclusion, UK has been shown to increase regional coronary blood flow in selected patients presenting with active UA, as well as evidence of i.c. thrombus at early angiography. Heterogeneity of angiographic findings could explain controversies in trials dealing with thrombolysis in UA.
Effect of diuretic therapy on the electrocardiographic response to exercise
Authors: Pascual Eduardo E. , Cintron Guillermo B. , Valdez Michael G. , Clark Pamela I.
Published: February 2009

For nearly 30 years clinicians have assumed that diuretic therapy, per se, even in the absence of clinical hypokalemia, can cause false‐positive exercise ST‐segment responses. The precept has stubbornly persisted in the literature and in the day‐to‐day interpretation of exercise tests in clinical settings. The assumption probably originated with very early studies of patients on diuretics, in which other causes of false‐positive tests were not excluded. This study was undertaken to show that diuretic therapy alone is not sufficient to cause ST depression. Twenty healthy male volunteers, aged 18 to 35, with normal history and physical examinations, echocardiograms, electrocardiograms, serum electrolytes, renal function tests and exercise tests, took 50 mg of hydrochlorothiazide daily for four weeks. Exercise tests, serum electrolytes, and renal function tests were repeated at Weeks 2 and 4. The administration of the diuretic resulted in a statistically significant reduction in serum potassium (from 4.37±0.37 to 3.96±0.28, and 3.94 ±0.31 mEq/1 at 2 and 4 weeks, respectively). There were no abnormal ST‐segment shifts on any of the exercise tests. It is concluded that exercise‐induced ST‐segment shifts in otherwise healthy young male normokalemic subjects who are taking diuretics should not be ascribed to a false‐positive response to diuretics.
Combination Therapy with Nicardipine and Beta‐Adrenergic Blockade for Angina Pectoris
Authors: Lambert Charles R.
Published: February 2009

Nicardipine a second‐generation dihidropyridine calcium antagonist, has been approved in oral formulation for use in the United States, and is under review for parenteral use. Nicardipine is the most vascular‐selective a‐gent of this class currently approved and should, on theoretical grounds, be ideal for combination therapy with beta‐adrenergic blocking agents. Studies have shown that the combination of nicardipine and beta‐blocking agents offers additional efficacy over monotherapy with either agent alone. The hemodynamic profile of combination therapy appears to be especially favorable in patients with diminished left ventricular function needing therapy with agents of both classes. Adverse effects are few and may be improved compared with other agents of the dihidropyridine class.
Effects of diltiazem, propranolol, and their combination in the control of atrial fibrillation
Authors: Dahlström C.G. , Bertil Olsson S. , Edvardsson Nils , Nasheng Cai
Published: February 2009

The effect of the combined treatment with propranolol 20 mg tid and diltiazem 60 mg tid in patients with chronic atrial fibrillation treated with digoxin was evaluated. Thirteen patients entered a double‐blind, three‐phase crossover study. Heart rate was significantly reduced during rest and at maximal exercise (p < 0.05) during combined treatment compared with treatment with any single drug. No significant changes in maximal work load, exercise time, systolic blood pressure at maximal work load, or subjective sensation of well‐being could be demonstrated during combined drug treatment. The RR distribution pattern was unaffected by the addition of propranolol, diltiazem, or their combination to the chronic digoxin treatment. It is concluded that the combination of diltiazem and propranolol has no advantages over any of these drugs singly, in the moderation of heart rate in patients with atrial fibrillation even combined with basic digitalis treatment, and that the intrinsic AV nodal function is unaffected by these drugs or their combination.
Does juxtamesenteric placement of intra‐aortic balloon interrupt superior mesenteric flow?
Authors: Shimamoto Hiroyuki , Kawazoe Kohei , Kito Hiroyuki , Fujita Tsuyoshi , Shimamoto Yoriko
Published: February 2009

To assess influences of intra‐aortic balloon pumping (IABP) on superior mesenteric flow, 15 postoperative patients were examined, in whom distal aspects of balloons were distal to the superior mesenteric artery. Superior mesenteric flow velocity‐time integral in systole (IntS), that in diastole (IntD), and the sum of IntS and IntD (IntS+IntD) were determined on and off IABP (IABP ON‐OFF test). The same parameters were obtained with balloon inflating on every other beat (IABP 1:2 test). The cardiac cycle with balloon inflation during diastole was defined as “1:2 ON,” and the cardiac cycle without balloon inflation during diastole was defined as “1:2 OFF.” (1) IABP ON‐OFF test. IABP increased IntS (p<0.01), IntD (p<0.01), IntS+IntD (p<0.01), and cardiac output (p<0.05). The increments in IntS, IntD and IntS+IntD on IABP are attributed largely to an increase in cardiac output. (2) IABP 1:2 test. IntS during 1:2 OFF was greater than IntS during 1:2 ON (p<0.01), whereas IntD during 1:2 OFF was smaller than IntD during 1:2 ON (p<0.01). There was no significant difference in IntS+IntD between 1:2 ON and 1:2 OFF. These data suggest that juxtamesenteric balloon placement did not interrupt the arterial inflow of a superior mesenteric artery.
24‐hour efficacy of once‐daily diltiazem in essential hypertension
Authors: Massie Barry M. , Der Elaine , Herman Theodore S. , Topolski Pat , Park Glen D. , Stewart William H.
Published: February 2009

The safety and effectiveness of a once daily formulation of diltiazem hydrochloride (diltiazem CD) in the treatment of essential hypertension was assessed in a total of 127 patients with supine diastolic blood pressures (DBP) of 95 to 110 mmHg randomized to diltiazem CD (n=61) or placebo (n= 66). Patients were titrated to doses of 120, 240, or 360 mg to achieve DBP reduction to less than 90 mmHg. At end study diltiazem CD changed trough supine SBP and DBP by −8.4± 1.7 (p=0.0009) and −8.6± 1.1 mmHg (p=0.0075), respectively. Heart rate was not significantly changed (−1.3 ±1.1 beats/min, p=0.4362). The average dose of diltiazem CD was 268 mg with 69% achieving a clinical response. A subset of 47 patients underwent ambulatory blood pressure monitoring to assess the consistency of the effect over the full 24‐h dosing interval. Diltiazem CD lowered DBP and SBP throughout the dosing interval. The overall side effect profile was similar to placebo. This study provides evidence of 24‐h efficacy of this new, once daily formulation of diltiazem.
Diagnostic value of technetium‐99m‐MIBI as a myocardial perfusion imaging agent: Comparison of long and short intervals between rest and stress injections
Authors: Magriñà Jordi , Bosch Xavier , Roig Eulàlia , Lopez Francisco Navarro , Garcia Alicia , Pons Francesca , Moragas Mercè , Setoain Jordi
Published: February 2009

To assess the diagnostic value of technetium‐99m‐MIBI (99mTc‐MIBI) as a myocardial perfusion imaging agent, and if rest and exercise scans could be performed on the same day, 21 patients with coronary artery disease were studied. Qualitative planar 201‐thallium (201T1) scans, coronary angiography, or both were also performed (median between studies 11 days). In 10 patients an injection of 740 mBq of 99mTc‐MIBI at stress was followed by a second injection of 740 mBq at rest 24 h later (long interval) (LI). In 11 patients injection of 370 mBq at rest was followed 3 h later by an injection of 740 mBq at stress (short interval) (SI). Exercise scans were performed to similar maximal work load (LI = 6.6±1.8 METs; SI = 6.3±1.7 METs; 201T1 = 6.8±1.2 METs; p = NS) and double product (LI = 19551±7370; SI = 19900±6797; 201T1 = 19965 ±5282; p = NS). Overall, 99mTc‐MIBI and 201T1 agreed in 92% of the patients tested and in 165 of 180 (92%) left ventricular segments in both 99mTc‐MIBI protocols using short and long intervals between injections. In 15 patients with significant stenosis, 99mTc‐MIBI correctly identified 13 patients (sensitivity of 87%). Thus, 99mTc‐MIBI is a useful imaging agent with similar diagnostic value as 201T1. In spite of its lack of myocardial redistribution, 99mTc‐MIBI rest and exercise scans performed on the same day seem to have a similar concordance rate with 201T1 as when performed on separate days.
Acoustic appearance of atrial septal aneurysm
Authors: Kautzner Josef , Bëlohlávek Marek , Holm Františ Ek V. , Munclinger Miroslav J.
Published: February 2009

Atrial septal aneurysm in the otherwise normal heart is a very rare and usually asymptomatic condition. A midsystolic click was described as the only clinical manifestation so far. A low‐pitched early‐to‐midsystolic acoustic phenomenon in a 39‐year‐old woman corresponding with maximal leftward motion of the aneurysmatic interatrial septum during early systole is the subject of this case report. Our experience, plus review of the literature, supports the suggestion that atrial septal aneurysm should be considered in the interpretation of added systolic sounds.
Electrophysiologic studies in atrial flutter
Authors: Cosio Francisco G. , Löapezgil Maria , Goicolea Antonio , Arribas Fernando , John Camm A.
Published: February 2009

The clinical electrophysiologic approaches to atrial flutter (F) have been activation mapping and the observation of changes induced by programmed stimulation. Sequential endocardial activation mapping has recently yielded information indicating that common F is produced by a large right atrial (RA) reentry circuit, with counterclockwise rotation in the frontal plane, including the inferior vena cava in its center. Functional block in the crista terminalis and conduction slowing in the approaches to the atrioventricular node seem to be important to support reentry. F inscribing positive deflections in the inferior leads usually follows the same path, but in a clockwise direction. Atypical F may be produced by left atrial circuits. Atrial stimulation during F entrains the circuit, resetting it with each stimulus. Collision between antidromic and orthodromic activation during entrainment produces fusion that can be identified in the surface electrocardiogram. The last paced activation restarts F, unless circuit penetration has been enough to modify it by block or disorganization. Entrainment may result in F acceleration, with changes in activation sequence, suggesting a different type of reentry, possibly based on functional factors.
The usefulness of echocardiography in the surgical management of infants with congenital heart disease
Authors: Sharma Shiva , Anand Rajani , Kanter Kirk R. , Williams Willis H. , Dooley Kenneth J. , Jones David W. , Vincent Robert N.
Published: February 2009

Between January 1988 and August 1991, at The Children's Heart Center, Atlanta, 83 infants with congenital heart defects were diagnosed by echocardiography and underwent surgery without cardiac catheterization. The diagnostic categories included 46 infants with left heart obstructive lesions, 19 infants with cyanotic heart lesions, and 18 infants with miscellaneous lesions. Forty‐five infants (55%) underwent surgery under cardiopulmonary bypass. There were three errors in diagnosis, yielding a diagnostic accuracy of 95%. Many infants with congenital heart disease can be accurately and completely diagnosed by echocardiography and can safely undergo surgery without cardiac catheterization.
Acute ischemic exacerbation of rheumatic mitral regurgitation
Authors: Simpson Iain A. , Sneddon James , Millane Teri , Pepper John R. , Ward David E.
Published: February 2009

This report describes a patient who developed acute severe exacerbation of mild rheumatic mitral regurgitation caused by ischemia in the territory of a small, non‐dominant circumflex coronary artery without myocardial infarction.
New directions in myocardial perfusion imaging
Authors: Beller George A.
Published: February 2009

In recent years, substantial progress has been made in the field of nuclear cardiology. Pharmacologic stress perfusion imaging with intravenous administration of dipyridamole or adenosine provides comparable sensitivity and specificity values for detection of coronary artery disease (CAD) as exercise imaging and has been employed successfully for risk stratification prior to peripheral vascular or aortic surgery and after myocardial infarction. Detection of myocardial viability can be enhanced utilizing reinjection of a second dose of thallium‐201 (T1‐201) at rest after acquisition of redistribution images with the single photon emission computerized tomography (SPECT) technique. Imaging solely in the resting state with T1‐201 can also provide information concerning presence of viable myocardium in asynergic regions that are stunned or hibernating. New technetium‐99m (Tc‐99m) perfusion agents have emerged in the clinical setting and have provided excellent predictive value for detection of CAD in patients with chest pain and permit simultaneous assessment of function and regional blood flow. Tc‐99m Sestamibi, one of these agents, is also a valid marker of viability when assessing myocardial salvage after coronary reperfusion in acute myocardial infarction.
Late thrombotic obstruction of an aortic bioprosthetic valve: Successful treatment by oral anticoagulation
Authors: Juliard Jean‐Michel , Paillole Catherine , Dahan Michel , Gabriel Steg P. , Himbert Dominique , Aumont Marie‐Claude
Published: February 2009

Thrombotic obstruction of aortic bioprostheses is rare. Few cases have been reported involving the use of the Carpentier‐Edwards (CE) prosthesis, the Hancock bioprosthesis, or the Medtronic Intact porcine valve.1, 4 Thrombolytic therapy for mechanical valve thrombosis has been used frequently even though it is known to carry a high risk of embolism and recurrence.5 However, the use of this therapy was reported for the first time only recently,1 in a case of acute aortic thrombosis which occurred 3 1/2 months after bioprosthesis insertion. We report a case of late progressive thrombotic obstruction of a CE aortic valve 3 years after insertion. The case was successfully treated with Coumadin therapy, as confirmed by serial Doppler echocardiographic examinations and a 3‐year follow‐up.
Effects of intracoronary administration of nitroglycerin on contralateral intracoronary acetylcholine test results
Authors: Miwa Kunmisa , Fujita Masatoshi , Yamanishi Kazuto , Igawa Akihiko , Sasayama Shigetake
Published: February 2009

This study examined the question of whether intracoronary administration of nitroglycerin modifies contralateral intracoronary acetylcholine test results. Acetylcholine was injected separately into both left and right coronary arteries in 63 patients with coronary spastic angina. Acetylcholine (20 and 50 μg) was injected first into the coronary artery responsible for the documented regional ischemia during spontaneous or induced attacks, and then into the other coronary artery. Coronary spasm was defined as severe transient coronary artery vasoconstriction with chest pain and/or electrocardiographic ischemic ST‐segment deviation. Spasm was induced in either coronary artery in 60 patients (95%) and in both coronary arteries in 23 patients (37%). The frequency of induced spasm was 67% (42 of 63) in the coronary artery first challenged by acetylcholine. The coronary artery spasm subsided with the intracoronary injection of nitroglycerin (250‐750 μg) in 19 patients. In the second challenge of intracoronary acetylcholine injection into the contralateral coronary artery, coronary spasm was induced in 29 (66%) of 44 patients. This was done without intracoronary administration of nitroglycerin in the first challenge and in 12 (63%) of 19 patients who had been given intracoronary nitroglycerin. The sensitivity for spasm induced by intracoronary acetylcholine appeared to be unaffected by nitro‐glycerin. Coronary spasm with ST‐segment elevation by intracoronary acetylcholine in the second challenge was significantly less frequent in the patients receiving intracoronary acetylcholine in the second challenge was significantly less frequent in the patients receiving intracoronary nitroglycerin (first: 89%, second: 26%, p > 0.05) as well as in those not receiving intracoronary nitroglycerin for the spasm in the first challenge (first: 52%, second: 13%, p > 0.05). Our results suggest that intracoronary nitroglycerin administered for prompt relief of coronary spasm exerts no significant influence on the results of the contralateral intracoronary acetylcholine test.
New and combined sensors for adaptive‐rate pacing
Authors: Katritsis Demosthenes , F. Shakespeare Carl , Camm A. John
Published: February 2009

A new potential indication for cardiac pacing is chronotropic incompetence, that is, an inadequate cardiac rate response to exercise and other metabolic demands. Many patients who have been paced for indications such as complete heart block or sick sinus syndrome also have chronotropic incompetence. Such patients are not adequately treated when fitted with a constant rate pacemaker. Adaptive‐rate pacemakers increase the pacing rate in proportion to signals derived from a biosensor which is sensitive to exertion and possibly to other metabolic requirements. These pacemakers have proven valuable for patients with overt chronotropic incompetence. However, no single sensor/algorithm is ideal and improvement has been sought by introducing new sensors, adjusting the algorithms by which biosensor signals are converted to the most appropriate pacing rate, or by combining sensors in such a way that a composite biosensor signal is derived which bears a close linear relationship with the appropriate heart rate. An example of a new sensor is the accelerometer, which is sensitive to a fuller range of movements than the piezo crystal. A successful new algorithm is the rate augmentation algorithm for use with minute ventilation, which provides a better initial pacing rate response. A combination of minute ventilation sensed by impedance changes and movement sensed with piezo crystals maintains the rapid response from the piezo crystal and overcomes its lack of proportionality. Another successful new combination of sensors is QT sensing from the evoked ventricular potential and motion sensing with a piezo crystal. As yet, these innovations have not been exhaustively tested and shown to confer clinical benefit but the improvements are such that an advantage can be expected.
Spontaneous secure reimplantation of a dislodged pacemaker electrode onto the right ventricular outflow tract, reestablishing a sufficient pacing condition
Authors: Nawa Sugato , Shimizu Nobuyoshi , Kino Khichi , Hayashi Kenji
Published: February 2009

A 62‐year‐old woman underwent cardiac pacemaker implantation for sick sinus syndrome with bradycardia, and the tip of an endocardial tined lead was positioned to the right ventricular apex. On the fifth postoperative day, an incomplete pacing failure, lasting about 10 min, was observed transiently on 24‐h monitoring. This event, however, was not considered to be a clinical manifestation of the ensuing complication until the patient visited our pacemaker clinic 2 months postoperatively. At that time, a chest x‐ray demonstrated that the electrode tip had migrated markedly to the right ventricular outflow tract (RVOT), but presented a sufficient pacing condition. The reimplantation site appeared to be very insecure for pacing, raising the potential risk of repeat dislodgment since the lead was not provided with a helix. At the second operation, performed to assess the problem, the ventricular excitation threshold measured at 1.3 V with a 0.5 ms pulse width. Furthermore, it was unexpectedly disclosed that the electrode tip was so tightly anchored at the site that it could not be withdrawn, eliminating the possibility of repeat dislodgment. Consequendy, the entire original pacing system could be used as before and no further complications were observed. Although the situation encountered was very rare and seemed to be problematic, careful observation might be an alternative to surgical intervention even when a tined tip without helix has been used.
Anomalous inferior vena cava mimicking aortic dissection on transesophageal echocardiography
Authors: Torbicki Adam , Jakubowska‐Najniger Maria , Stanislawska Jolanta , Gorecki Aleksander , Kalinowski Roman , Sakai Kichiro , Hosoda Saichi , Shimamoto Ken
Published: February 2009

Transesophageal echocardiography (TEE) is considered an excellent method for the diagnosis of aortic dissection, especially that involving the descending aorta. It has also proved useful in the evaluation of conditions mimicking aortic dissection, usually disclosing in these situations other types of severe aortic disease. We are not aware of any report dealing with venous abnormalities which presented diagnostic problems in a patient evaluated with TEE because of a suspected aortic dissection.

Left ventricular (LV) free wall rupture complicated with acute myocardial infarction (AMI) usually occurs in the early phase of AMI. True aneurysm of the LV is sometimes a complication of AMI but rarely ruptures. In our patient, a 72‐year‐old woman, the LV free wall ruptured on Day 49 after the onset of AMI and the ruptured site was the thinnest wall of large true aneurysm of the LV. The large aneurysmal formation probably was due to corticosteroids used for pericarditis. More attention should be paid to late cardiac rupture and the use of corticosteroids.
The effect of extracorporeal high blood flow rate on left ventricular function during hemodialysis—an echocardiography study
Authors: Alfurayh Osman , Galal Omar , Sobh Mohamed , Fawzy Mohamed , Taher Saadi , Qunibi Wajeh , Almeshari Khalid , Philipp Thomas
Published: February 2009

The effect of increased extracorporeal blood flow rate on left ventricular (LV) function has been studied during volume‐controlled bicarbonate hemodialysis. Ten stable patients on chronic hemodialysis, with a mean age of 28 years (range 19‐38) were studied using two‐dimensional and Doppler echocardiography. The mean time on hemodialysis was 32 months (range 3‐60). All patients were investigated during three dialysis sessions on the first day of the week for 3 consecutive weeks. The blood flow rate was chosen randomly as 250, 350, or 450 cc/min. Apart from the time of hemodialysis and blood flow rate, other parameters of the hemodialysis were kept stable during all three sessions. Echocardiographic studies were done before, at mid dialysis, and during the last 15 min of each dialysis session. The following parameters were evaluated: heart rate, mean blood pressure, shortening fraction, ejection fraction, cardiac output, and pre‐ejection period/LV ejection time ratio. The changes of the measured cardiac parameters at the beginning, middle and end of each session were not significantly different. Furthermore, the differences in changes between the three different sessions were comparable. Our results indicate that an increase in dialysis blood flow rate up to 450 cc/min does not have an adverse effect on the left ventricle in patients on maintenance hemodialysis and with stable cardiovascular function.
The heart in polymyositis: A prospective evaluation of 26 patients
Authors: Taylor Allen J. , Wortham Dale C. , Robert Burge J. , Rogan Kevin M.
Published: February 2009

Although cardiac abnormalities have been reported in patients with idiopathic polymyositis‐dermatomyositis (PM), the nature and extent of these abnormalities have varied. The purpose of this study was to determine the prevalence and to obtain a better description of the spectrum of cardiac abnormalities in a cohort of patients with PM by use of a thorough noninvasive cardiac evaluation. Accordingly, we studied 26 patients with a history of PM and clinically inactive myositis (22 polymyositis, 4 dermatomyositis) between June 1984 and June 1991. Examination included history, physical examination, 12‐lead electrocardiography, 24‐h ambulatory electrocardiographic monitoring, chest radiography, transthoracic echocardiography, and radionuclide ventriculography. Of the patients studied, 77% were taking corticosteroid medications at a mean dose of 39 ± 27 mg at the time of their evaluation. All 26 patients were identified as having two or more cardiac abnormalities. Cardiac symptoms and signs were common (62 and 81%, respectively), but were generally nonspecific. Electrocardiographic findings were most common (in 85% of cases), followed by findings on ambulatory monitoring (77%), echocardiography (42%), and radionuclide ventriculography (15%). The prevalence of mitral valve prolapse (8%) and hyperkinetic left ventricular contraction (12%) was significantly lower than previously reported. A secondary aim of this study was to determine associations between demographic variables including age, disease duration, cardiovascular symptoms, immunosuppressive therapy, autoantibody status, and creatinine phosphokinase level, and the presence of cardiac abnormalities. Of these patient variables, only increasing patient age was associated with an increased likelihood of cardiac abnormalities on noninvasive testing. In conclusion, abnormalities on noninvasive cardiac testing, many of which are minor and nonspecific, are prevalent in patients with PM. Our findings differ from previous reports in the demonstration of a low prevalence of mitral valve prolapse and hyperkinetic left ventricular contraction. In this population of patients with stable PM, only increased patient age was associated with a greater likelihood of abnormal cardiac findings.
Beta‐blocker infusion did not improve left ventricular diastolic function in myocardial infarction: A doppler echocardiography and cardiac catheterization study
Authors: Caramelli Bruno , Santos Raul Dias Dos , Abensur Henry , Gebara Otavio Celso Eluf , Tranchesi Bernardino , Bellotti Giovanni , Pileggi Fulvio
Published: February 2009

Left ventricular (LV) diastolic function changes after myocardial infarction. It has been suggested that beta blockers may improve diastolic function in hypertensive and heart failure patients. Doppler echocardiographic filling patterns and invasive hemodynamic indices have been used to analyze LV diastolic function. To determine the effect of beta blockers on LV diastolic function, we studied 32 patients with anterior wall myocardial infarction with a mean age of 53 years. Peak early and late flow velocities, peak early‐to‐late flow velocities ratio, pressure half time, diastolic filling period, isovolumic relaxation time, cardiac index, mean arterial pressure, wedge pressure, and systemic and pulmonary vascular resistance indices were obtained simultaneously before and after an intravenous infusion of 10 mg of atenolol. Cardiac index decreased from 4.27 ± 0.97 to 3.19 ± 0.911/min/m2 (p=0.0001); mean arterial pressure decreased from 85 ± 10 to 80 ± 11 mmHg (p=0.004); wedge pressure increased from 11 ± 5 to 13 ± 4 rnmHg (p = 0.002); systemic vascular resistance index increased from 1586 ± 409 to 1980 ± 634 dynm2s/cm5 (p = 0.0002); pulmonary vascular resistance index increased from 115 ± 58 to 163 ± 72 dynm2s/cm5 (p = 0.0004); peak late flow velocity decreased from 64 ± 15 to 49 ± 14 cm/s (p = 0.0001); early‐to‐late ratio increased from 0.95 ± 0.35 to 1.29 ± 0.36 (p = 0.0001); diastolic filling period increased from 300 ± 108 to 400 ± 110 ms (p=0.0001) and isovolumic relaxation time increased from 133 ± 29 to 143 ± 29 ms (p = 0.009). No significant changes were observed for peak early flow velocity and pressure half‐time. Multivariate regression analysis suggests that significant changes observed on Doppler echocardiographic parameters can be attributed in part to beta‐blocker effect on heart rate analyzed as diastolic filling period. We concluded that beta‐blocker infusion changes LV diastolic function analyzed by Doppler echocardiography in patients with anterior wall myocardial infarction. Moreover, the increase observed on wedge pressure suggests deterioration in cardiac function.
Unplanned admissions after outpatient cardiac catheterization
Authors: Clark Vivian L. , Dolce Joseph
Published: February 2009

Increasing numbers of patients are undergoing diagnostic catheterization as outpatients; however, a small proportion of patients requires hospital admission following the procedure. Unplanned admissions after consecutive outpatient cardiac catheterizations performed during 1 year were prospectively reviewed to determine the incidence of and reasons for admission. Among 847 patients undergoing outpatient cardiac catheterization, 130 patients (15%) required hospital admission after the procedure. Admitted patients were divided into four groups: patients undergoing immediate percutaneous transluminal coronary angioplasty (PTCA) (Group 1; 33%), patients with severe cardiac disease requiring urgent intervention (Group 2; 48%), patients suffering complications or hemodynamic instability (Group 3; 15%), and patients whose procedures were completed too late to allow same‐day discharge (Group 4; 4%). Patients over 65 were more likely to require admission and women were more likely to be admitted with complications or hemodynamic instability. Findings are compared with results of other outpatient series, and implications regarding appropriate setting for outpatient catheterization are discussed.