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Cystic hydatid disease is responsible for the loss of 1 to 3 million disability-adjusted life years every year. Infestation of the heart, though rare, can result in serious complications if left untreated. We retrospectively collected information on 19 patients with cardiac hydatid cyst admitted at the Center for Cardiac Surgery of Ibn Al-Bitar Hospital in Baghdad from July 2007 to July 2011 who were either in need of a cardiac surgery for treating hydatid cysts or presented with emergency conditions. Nine (47%) patients presented with left-sided heart failure and mitral valve dysfunction, 5 (26%) patients had hydatid cysts in the pericardium, 3 (16%) patients had hydatid cyst in the right ventricle and presented with right-sided heart failure, and 2 (11%) patients who presented with cardiac arrhythmias had infestation in the interventricular septum. Removal of cysts following open-heart surgery was successful and was followed by the use of mebendazole or albendazole for 5 years. We conclude that cardiac hydatid cyst that leads to various cardiac symptoms can be successfully managed and should be considered as a diagnostic possibility in patients with cardiac symptoms in endemic areas. [ABSTRACT FROM AUTHOR]

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. These lesions are primarily responsible for embolic events that can clinically manifest with neurological and cardiovascular symptoms. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. The case of a 60-yearold man who presented with a neurological deficit caused by a papillary fibroelastoma of the noncoronary cusp of the aortic valve is described. Diagnosis was made by transesophageal echocardiogram, and the tumor was resected surgically. [ABSTRACT FROM AUTHOR]

The authors examine the clinical significance of radial augmentation index (rAI) and brachial-ankle pulse wave velocity (baPWV). In 78 hypertensive patients, rAI correlates inversely with pulse rate (PR; r = -0.57, P < .001), but baPWV does not. A weak correlation between rAI and systolic blood pressure (SBP) is observed (r = 0.28, P < .05). rAI has no significant correlation with diastolic blood pressure (DBP). In contrast, baPWV correlates positively with both SBP (r = 0.54, P < .001) and DBP (r = 0.43, P < .001). In 56 of these patients, baPWV correlates with the diastolic parameters—the mitral E/A ratio (r = -0.35, P < .01), pulmonary vein S/D ratio (r = 0.41, P < .01), and deceleration time (r = 0.28, P < .05)—by echocardiography, but AI.P75 (rAI corrected for PR 75 bpm because of PR dependence) does not. Therefore, for detection of diastolic dysfunction, baPWV may be more sensitive than rAI. [ABSTRACT FROM AUTHOR]

Not only antiphospholipid antibodies (aPLs) but also other factors should be considered in assessing the risk of thrombosis development in patients with systemic lupus erythematosus (SLE) and antiphospholipid antibodies (aPLs). The kinds of risk factors, including past history of thrombotic event (PHTE), hypertension, hypercholesterolemia, diabetes mellitus (DM), obesity, and smoking, in conjunction with aPLs, that contribute to the development of new thrombotic events in patients with SLE and aPLs were studied prospectively over a 5-year observation period. One-hundred and sixty-six Japanese patients with SLE (55 patients with aPLs and 111 patients without aPLs) were examined and followed up for 5 years. Five major risk factors for ischemic coronary disease and stroke according to the Framingham heart cohort study were evaluated objectively in these patients. A significant difference was seen for 4 factors: past history of thrombotic event (PHTE; odds ratio: 101.93; 95% confidence interval: 12.29–845.22: p«0.0001), hypertension (odds ratio: 8.87; 95% Cl: 2.58–30.53; p«0.001), DM (odds ratio: 5.42; 95% Cl: 1.44–20.46; p«0.05), and lupus anticoagulant (LAC: odds ratio: 47.41; 95% Cl: 5.88–382.03, p«0.0001) as aPLs, when the incidence of these risk factors was compared between patients with and without new thrombotic events. Furthermore, PHTE (odds ratio: 30.19, 95% Cl: 1.33–683.13), hypertension (odds ratio: 15.44; 95% Cl: 1.77–134.80), and LAC (odds ratio: 14.11; 95% Cl: 0.48–412.42) showed higher odds ratios than DM (odds ratio: 11.53; 95% Cl: 0.83–159.94) on multivariate logistic analysis as well as analysis of the combination of risk factors, suggesting that these are important risk factors for the development of new thrombotic events in patients with SLE and aPLs. [ABSTRACT FROM AUTHOR]

A case of pericardial hydatid cyst adjacent to the inferoposterial wall of the left ventricle is reported. Significant ST segment elevations in leads D2, D3, aVF, V5, and V6 on surface electrocardiography and sudden onset of severe chest pain mimicked acute inferolateral myocardial infarction. However, cardiac catheterization and coronary angiography showed normal coronary arteries and normal left ventricular cavity. The ST segment elevation in the inferolateral leads disappeared a few days after surgical resection of the cyst. Cardiac hydatid cyst should be considered in the differential diagnosis of patients with angina-like chest pain in endemic areas. [ABSTRACT FROM AUTHOR]

The case of a 45-year-old man suffering from a catecholamine-sensitive ventricular tachycardia originating from the right ventricular outflow tract is reported. The authors describe a novel noninvasive treatment strategy for the management of this patient. [ABSTRACT FROM AUTHOR]

Headache represents a rare manifestation of myocardial ischemic pain. It is believed that this clinical symptom results from convergence of heart autonomic fibers with somatic inputs originating from the head. The authors describe for the first time the case of a 73-year-old woman who experienced an acute non-ST-elevation myocardial infarction that manifested solely with intense occipital headache associated with vomiting and impaired level of consciousness. This unusual case highlights that the exclusion of an intracranial event in patients presenting with a severe headache and ischemic-like electrocardiographic abnormalities should raise the possibility of an acute coronary event, especially in elderly individuals with cardiovascular risk factors. Furthermore, the occurrence of episodic short-lasting headaches during exertion should direct diagnostic work-up toward ischemic heart disease. [ABSTRACT FROM AUTHOR]

Thromboembolic risk of atrial flutter (AFI) types has not been elucidated sufficiently in previous reports. The authors classified the patients according to surface electrocardiogram and electrophysiologic characteristics as those with typical AFI (37 patients, 78.4% male, mean age 59.8 ±9.5 years) and atypical AFI (13 patients, 69.296 male, mean age 60.9 ±6.9 years) and compared them regarding some clinical, echocardiographic, and hematologic parameters. An age- and gender-matched control group composed of 20 individuals without any organic heart disease in sinus rhythm was chosen (80% male, mean age 60.3 ±7.9 years). Clinical features such as age, gender, organic heart disease, hypertension, diabetes mellitus, AFI duration, and the prevalence of paroxysmal atrial fibrillation were similar in both AFI groups. Echocardiographic parameters such as left ventricular ejection fraction, left atrial (LA) diameter, LA spontaneous echo contrast, and LA appendage emptying velocities were similar in both AFI groups. Fibrinogen, fibrin D-dimer, and thrombin-antithrombin III levels reflecting coagulation system activity were found to be increased in the patients with atypical AFI when compared with those with typical AFI and the control group (p « 0.001). In Pearson's correlation analysis, significant correlation between these hematologic markers and clinical and echocardiographic parameters were not found (p » 0.05). The coagulation system activity was found to be increased in patients with atypical AFI. Thus, anticoagulation due to the increased thromboembolic risk should be considered in patients with atypical AFI. [ABSTRACT FROM AUTHOR]

Impaired diastolic function is related to subjective symptoms, reduced exercise capacity, and poor prognosis in patients with congestive heart failure, and an angiotensin II type-l receptor blocker might have a beneficial effect on diastolic function in such patients with heart failure. A 53-year-old woman underwent valvuloplasty of the mitral valve and later presented with heart failure symptoms, including exertional dyspnea and easy fatigue. Although no pathological changes could be Identified by radiography of the chest, electrocardiography, or routine echocardiography, the assessment of diastolic function with Doppler echocardiography revealed left ventricular diastolic dysfunction. Her neurohumoral parameters and left ventricular diastolic dysfunction improved after 1 month of treatment with Valsartan, an angiotensin II type-l receptor blocker, accompanied by improvement of her subjective symptoms. This case implies that angiotensin II type-l receptor blocker could improve left ventricular diastolic dysfunction and that Doppler echocardiography might be useful for detecting diastolic dysfunction in high-risk patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

In Turkey as well as in the whole world, cardiac catheterization is an invasive intervention that is being increasingly used both for diagnosis and treatment. With technological and pharmacologic development and experience, the indications for this intervention are ever increasing. This invasive intervention brings, of course, some complications with it. These may range from local ones to death. In this study the authors analyzed the local cardiac complications and those related to other systems that they encountered in 10,445 catheterizations conducted for diagnosis and treatment in their clinic over a 26-month period. They found the rate of all complications to be 3.54% (2.05% diagnostic, 9.1 % therapeutic). Of these complications, 1.89% (0.80% diagnostic, 6.02% therapeutic) were cardiac, 1.27% (0.97% diagnostic, 2.4% therapeutic) local. They found that the ratios of death were 0.09% for diagnostic interventions, 1.13% for therapeutic interventions, and 0.31% altogether. In the diagnostic group 0.02% required urgent coronary bypass surgery, and 0.41% needed urgent coronary bypass surgery in the therapeutic group. In conclusion, despite the noticeable changes in patient profile and application, the ratios for cardiac catheterization have changed little over the years. [ABSTRACT FROM AUTHOR]

The benefits of mobile cardiac catheterization laboratories include keeping patients closer to their families, communities, local hospitals, and primary care physicians while receiving services comparable to those available at tertiary centers. However, there are very few studies regarding the safety of performing cardiac catheterization in mobile laboratories at remote locations. Thus, the authors performed an observational study of 1,775 consecutive patients undergoing a diagnostic cardiac catheterization in a mobile catheterization laboratory at primary care hospitals served by the Appleton Heart Institute (AHI) from August 1, 1991, to December 31, 1998. Twenty-three percent (1,775/7,637) of all AHI diagnostic cases in this time period were performed in the mobile catheterization laboratory. Urgent transfer to the tertiary care facility via ambulance or helicopter was used for 2.3% of patients (n=41). The overall complication rate was 1.2% (n = 21). Of the patients who underwent cardiac catheterization in the mobile laboratory, 32.6% (n = 579) were subsequently referred for interventional or surgical revascularization. There were no deaths. Cardiac catheterizations can be performed safely in a mobile laboratory at primary care hospitals, provided that immediate transfer is available for those in need of urgent intervention or revascularization and that unstable patients are not studied in the mobile laboratory. [ABSTRACT FROM AUTHOR]

Evaluates the clinical usefulness of corrected QT interval (QTc) dispersion measurement in assessing risk of syncope in patients with aortic stenosis. Correlation of prolongated maximum QTc and QTc dispersion with clinical and hemodynamic parameters; Relationship of increased maximum QTC and QTc dispersion with the syncope risk in patients with aortic stenosis.

Assesses giant noninflammatory and nonatherosclerotic coronary arterial aneurysm in the left main trunk of the heart. Use of intravascular ultrasound (IVUS) imaging in the study; Etiology and symptoms of coronary aneurysm; Advantages of a combined evaluation of coronary angiogram and IVUS images.

Examines transient U wave inversion during treadmill exercise testing in patients with left anterior coronary artery disease. Consideration of exercise-induced transient U wave inversion as positive; Prevalence of abnormal exercise-induced S-T segment shift; Difference in coronary angiographic data between patients with and without U wave inversion.

Previous studies using intracoronary electrocardiography have demonstrated that ST-T alternans can develop during standard balloon coronary angioplasty. Total occlusion with a large amount of myocardium in jeopardy is the postulated prerequisite. In this study, the authors used perfusion balloons instead of standard balloons, so coronary perfusion was maintained and ischemia was minimized. Fourteen patients with standard balloon technique and 11 patients with perfusion balloon technique were studied. The ST segment was less elevated during perfusion angioplasty (0.15 ±0.05 mV vs 1.04 ±0.19 mV, p<0.001). There were six (43%) patients with ST-T alternans with standard balloon technique compared with none in the perfusion balloon group (p<0.001). In this study, the authors found that there was less ischemia, less ST segment elevation, and lack of ST-T alternans on the intracoronary electrocardiogram during perfusion balloon angioplasty. These findings support the postulate that a large amount of ischemic myocardium is a prerequisite for ST-T alternans. [ABSTRACT FROM AUTHOR]

It has been suggested that QT dispersion (maximal minus minimal QT interval calculated on a standard 12-lead electrocardiogram) could reflect regional variations of ventricular repolarization and could provide a substrate for reentry ventricular arrhythmias. The present study evaluates QT dispersion in patients with acute myocardial infarction, assessing its relation with early severe ventricular arrhythmias and some clinical features. Three hundred three patients with acute myocardial infarction and a control group of 297 healthy subjects were studied, QT and QTc dispersion were determined on the electrocardiogram taken after 12 hours and on days 3 and 10 after symptoms onset and on the electrocardiogram taken in the control group. The average values of QT and QTc dispersions (ms) were as follows: 70.5 ±42,5-87 ±45.6 (12th hour), 66.7 ±37.6-76.8 ±43.6 (day 3), 68.8 ±42.7–76.8 ±42,8 (day 10), versus 43 ±13.2–53.9 ±16.2 (control group). There were statistically significant differences between QT and QTc dispersion recorded in normal subjects and in each of the three electrocardiograms taken in patients with infarction. A greater QT dispersion was recorded in patients with anterior infarction (78.9 ±38.5 vs 64.9 ±42.8 in inferior/lateral infarction). In the first 3 days QT dispersion was not different in patients treated and untreated with thrombolysis, whereas on day 10 it was greater in untreated patients (74.9 ±45.3 vs 60.5 ±37.2). Creatine kinase peak level did not influence QT dispersion. In the first 72 hours of infarction, 37 patients developed ventricular fibrillation or sustained ventricular tachycardia. Higher early values of QT and QTc dispersion were found in patients who developed severe ventricular arrhythmias (107.8 ±62 and 124.8 ±67.5 ms) than in patients without serious arrhythmias (62.9 ±32.2 and 80.1 ±37.9 ms). These data suggest that: (1) QT dispersion increased during acute myocardial infarction. (2) The values were higher in the early hours and fell late after infarction with thrombolysis. (3) Greater QT dispersion is associated with severe ventricular arrhythmias. [ABSTRACT FROM AUTHOR]

Six normal subjects and 12 patients with clinical angina and significant ST depressions during baseline ambulatory cardiac monitoring were given a single treatment with the end-diastolic pneumatic compression boot, the Circulator Boot™. With the use of continuous electrical impedance measurements, multiple hemodynamic variables were followed in five situations: (1) baseline before pumping; during end-diastolic pumping (2) on both legs after every heartbeat, (3) on one leg after every heartbeat, and (4) on both legs on alternate beats; and (5) during pumping on both legs during every systole. Both an increase in venous return and a reduction in afterload likely contributed to significant increases in cardiac output (CO) (51.1 ±33.6%), stroke volume (SV) (52.1 ±35.6%), change in impedance over time (dZ/dT) (72.0 ±68.1%), cardiac index (CI) (51.2 ±33.8%), and acceleration index (50.7 ±62.2%) during end-diastolic pumping on both legs after every heartbeat. A crucial role for afterload reduction was implied by opposite effects observed on CO, CI, dZ/dT, and SV during systolic pumping. Again, reductions (or a lack of an increase) in ventricular ejection time and/or the preejection period suggested a decrease in afterload during end-diastolic pumping. Pumping on one leg after every beat and on both legs on alternate beats was also effective but less so. After the initial study, the patients were given 14 additional end-diastolic treatments to both legs over 3 weeks. A clinical benefit for the patients was shown by symptomatic improvement in all patients along with a significant reduction in the amount and duration of the RST abnormalities in their ambulatory heart monitoring (p = 0.012). [ABSTRACT FROM AUTHOR]

The authors describe a patient with ventricular fibrillation associated with right bundle branch block-like QRS morphology and persisting ST segment elevation in the precordial leads, in whom the morphology of the ST segment changed from the coved type to the saddle-back type or vice versa on a beat-to-beat basis. Such an observation has never been reported in the previous literature. [ABSTRACT FROM AUTHOR]

A review of 6938 computer-generated electrocardiogram interpretations was undertaken by a single cardiologist. The computer-assisted program correctly interpreted 51.6% of the tracings. One or more corrections were necessary in 48.4%. The greatest number of incorrect interpretations involved repolarization (T wave) abnormalities, followed by ST segment changes. It is mandatory that computer-generated ECG interpretations be reviewed by an experienced electrocardiographer. Reliance on nonreviewed ECG interpretations may result in incorrect diagnoses that could lead to inappropriate management decisions. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the usefulness of ultrasonography to that of angiography for studying arterial lesions in Takayasu's arteritis. Ultrasonographic and angiographic findings from 44 carotid arteries of 22 patients with Takayasu's arteritis (2 men and 20 women; mean age, 41.2 years) were compared. Angiography was used to classify the patency of the carotid arteries into three groups: nonstenotic, stenotic, and occlusive. Ultrasonography was also used to classify the same arteries into four groups: nonstenotic, mildly stenotic, moderately stenotic, and occlusive. Thickness of the wall (intima-media complex) of the carotid artery was measured with high-frequency transducers. Angiography showed 23 carotid arteries to be nonstenotic; 12, stenotic; and 9, occlusive; whereas ultrasonography showed 16 to be nonstenotic; 18, mildly stenotic; 7, moderately stenotic; and 3, occlusive. Results of the two diagnostic modalities correlated closely (P c 0.000 1). Ultrasonography, aided by color flow imaging, detected six instances of a marginal but definite blood flow that angiography had failed to reveal. Arterial wall thickness correlated closely with the severity of ultrasonographic stenosis (P < 0.005). This thickness was 1.3 ±0.4 mm in the nonstenotic group, 1.6 ±0.5 mm in the mildly stenotic group, 2.2 ±0.8 mm in the moderately stenotic group, and 1.9 ±0.2 mm in the occlusive group. Even the walls of the nonstenotic arteries were significantly thicker than those of the normal carotid arteries (0.7 ±0.1 mm, P < 0.01). Ultrasonography appeared to be more useful than angiography in estimating stenotic severity of the carotid artery in Takayasu's arteritis. Characteristic ultrasonic findings included luminal stenosis or occlusion on two-dimensional ultrasonograms, decrease in or lack of flow shown by color Doppler flow imaging, and concentric thickening of the carotid arterial walls. Ultrasonographic mural thickness was the most sensitive indicator of early, latent inflammation. [ABSTRACT FROM AUTHOR]

Pulmonary embolism is a rare but life-threatening complication of cardiac catheterization. Underlying deep venous thrombosis (DVT) is often not detectable clinically. To determine the true incidence of DVT the authors prospectively studied 450 consecutive patients (29% women, 71% men, mean age: fifty-eight years) undergoing a diagnostic cardiac catheterization. Patients were examined clinically and by duplex sonography with a high- resolution (5 or 7.5 MHz) transducer before and twenty-four hours after catheterization before mobilization. Duplex sonography excluded complete proximal DVT in all patients. Only partial occluding thrombi (pDVT) were detected in 11(2.4%) patients. The thrombi were always localized at the puncture site. In 2 patients a difference was found in the circumferences of the legs, but no other clinical signs of DVT were seen. With use of continuous wave (cw) Doppler sonography, only 3 of these 11 patients (27%) showed a spontaneous (s) sound. Phlebography was performed in 4⁄11 patients (36%). In 2 patients the diagnosis was confirmed; in 1 patient extravenous compression was assumed, and the other demonstrated a normal-appearing phlebography at the time of investigation. Logistic regression analysis yielded a 3.5 times higher risk for developing a pDVT if a venous puncture was performed in addition to arterial puncture. Furthermore a 9.8 times higher risk was found if more than one venous puncture was necessary. During the follow-up no patient developed clinical signs of pulmonary embolism. The results of this study demonstrate that DVT is a rare complication of cardiac catheterization (0⁄450 patients), but pDVT occurred in 2.4%. Risk factors for pDVT are the venous puncture itself and multiple puncture attempts. Clinical relevance of pDVT remains to be determined. [ABSTRACT FROM AUTHOR]

This Study investigated the feasibility of four-dimensional electrocardiography (4-D ECG), a new display in which the vector loop was rotated and scanned along a timed axis to overcome the shortcomings of vectorcardiography (VCG). The subjects consisted of 38 patients with premature atrial complexes and 30 controls. The orthogonal Frank electrocardiograms were rotated three-dimensionally according to the right-hand rectangular coordinate system and scanned along a timed axis. The P wave delineation score, signifying good agreement with the intraobserver and interobserver variability, was significantly higher in 4-D ECG than those in the orthogonal leads or those on the transverse and frontal projections (P < 0.001). The authors measured the premature P loop areas as viewed from 361 directions. P loop areas were best delineated when viewed from cranial directions of 42.6 ± 34.0 degrees and from rightward directions of 11.3 ± 30.7 degrees. Adequate cranial rotation followed by scanning along a timed axis will maximally delineate premature atrial signals and provide comprehensive visualization of electrical forces. [ABSTRACT FROM AUTHOR]

The rare and self-cured complication of cortical blindness following coronary arteriography is presented in 2 patients who underwent cardiac catheterization. Both patients were submitted to an aortocoronary bypass grafting procedure a few years before and were under clinical investigation for a new onset of unstable angina pectoris. [ABSTRACT FROM AUTHOR]

Cor triatriatum is a rare cardiac malformation presenting with symptoms and signs of pulmonary venous obstruction. Although diagnosis of this defect has been facilitated by diagnostic procedures such as echocardiography and angiocardiography, it could be missed preoperatively. The authors report a case of cor triatriatum that is unique in having two separate atrial septal defects in each side of the fibromuscular membrane and that was undiagnosed preoperatively with transthoracic echocardiography and cardiac catheterization. [ABSTRACT FROM AUTHOR]

Transcranial Doppler (TCD) measurements of middle cerebral artery (MCA) blood flow velocities were recorded and synchronized with electrocardiographic (ERG) recordings in 52 EKG/TCD complexes in 4 patients. Thirty-seven normal sinus beats and 13 conductive and 2 nonconductive premature ventricular Contractions (PVCs) were examined. Mean velocities averaged 45 ±4 cm/sec for normal sinus rhythm (NSR) vs 26 ± 4 cm/sec in the PVC group (P = 0.007). Peak systolic velocities averaged 74 ±6 cm/sec for the NSR and 45 ± 7 cm/sec in the PVC group (P = 0.016). The latency between the QRS complexes and Corresponding TCD wave forms (QRS-SU) averaged 0.12 ± 0.03 sec in NSR and 0.17 ± 0.04 sec for the PVC group (P <0.001). In addition, QRS-SU was inversely related to all velocities. PVCs appeared to be less hemodynamically efficient than NSR. The Lower blood flow velocities and increased QRS-SU may result from lower stroke volume and delayed ventricular contraction associated with the aberrant QRS complex. [ABSTRACT FROM AUTHOR]

Transesophageal echocardiography (TEE) demonstrated the left main coronary trunk in 30 of 32 patients. Of these 30 patients, 10 had angiographically normal and 20 stenotic left main coronary arteries. The TEE study revealed no stenosis in 9 of 10 patients with normal left main trunks and atherosclerotic lesions in all 20 patients with stenotic left main trunks. TEE demonstrated additional areas of stenosis in the left main coronary artery in 3 patients, which included ostial lesions in 2 patients. These features were not observed by angiography. Furthermore, when compared with angiography, TEE overestimated severity of stenosis in 4 patients. In conclusion, TEE is a useful test in demonstrating normal as well as stenotic left main coronary trunks. [ABSTRACT FROM AUTHOR]

In a five-year case-control study (1988 to 1993) at Assir Central Hospital (ACH), Abha (8,000 feet above sea level), Saudi Arabia, 92 of 129 patients suspected of deep venous thrombosis (DVT) were studied with ascending contrast venography (CV) (74 patients, 80.4%) or Doppler ultrasonography (DUS) (18 patients, 19.6%). Female-to-male ratio was 2.3 to 1. Age range of patients was twelve to ninety years; mean age was 44.45 yrs ±17.38 years. DVT hospital incidence was 18 per 10,000 admissions. The most common associated factors included immobilization due to chronic diseases (21.7%), trauma and surgery (19.6%), and pregnancy and oral contraceptives usage (16.3%). The most common symptom and sign were limb pain and tenderness (95.6%). Limb swelling was noted in 93.5% of patients. The left lower limb was more commonly affected than the right. There was a definite increase of DVT during the winter months. Altitude was not a contributory factor. Pulmonary embolism was the greatest complication. [ABSTRACT FROM AUTHOR]

This case report presents a patient who inadvertently received transvenous permanent left ventricular pacing through an unexpected atrial septal defect. This lead malpositioning was proved by two-dimensional and transesophageal echocardiography. The abnormal pattern of electric activation was demonstrated by radionuclide phase image analysis. He has been followed up for a total of forty-three months with antiplatelet therapy and has been free from systemic embolic phenomena. A simple and readily available method that could lead to early recognition of lead malpositioning is reiterated and the various causes, methods of detection, and prognosis of left ventricular pacing are discussed. [ABSTRACT FROM AUTHOR]

The acute effect of glyceryl trinitrate (GTN) is mainly the reduction of systolic blood pressure (SBP) rather than diastolic blood pressure (DBP). To examine the mechanisms for decrease in SBP by GTN, the authors measured arterial compliance (AC), cardiac output (GO), stroke volume (SV), pulmonary capillary wedge pressure, right ventricular end-diastolic pressure, right atrial pressure, and left ventricular end-diastolic pressure before and after administration of GTN. Fourteen patients who underwent cardiac catheterization were included in this study. The change of each variable was estimated by the differences between values just before and at three minutes after GTN. After administration of GTN, SBP was significantly decreased from 158 ±21 to 138 ±12 mmHg (P < 0.01). AG was significantly increased, and pulmonary capillary wedge pressure, GO, and SV were significantly decreased. The change in SBP was inversely correlated with the change in AG and positively correlated with the change in GO or SV. The authors conclude that the mechanism for decrease in SBP by GTN is associated with both an increase in AG and a decrease in venous return. [ABSTRACT FROM AUTHOR]

The correlation between echocardiographically and angiographically calculated ejection fraction and systolic excursion of the mitral annulus was studied in 81 patients. Knowing that the mitral annulus changes its size, shape, and position during the cardiac cycle, the authors measured systolic excursion of the annulus by 2D echocardiography. Displacement of the mitral annulus was measured from four different points (medial, lateral, anterior, posterior) by apical four-chamber and apical two-chamber approaches. Patients with and without regional wall motion abnormalities were included. Left ventricular volumes and ejection fraction (EF) were calculated in the standard manner introduced by Teichholz et al and also with biplane left ventriculography. As a result, EF calculated by cineangiography, was moderately correlated with the Teichholz method (r=0.66) while it was highly correlated with measurements of mitral annular motion (MAM) (r=0.87). The correlation can be expressed by the regression equation, EF (angiography) = 5.7 MAM (in mm) -6.5. They conclude that measurements of annular motion is an easy and reliable index of left ventricular function as an alternative to traditional methods. [ABSTRACT FROM AUTHOR]

From January 1992 to January 1993 the incidence of sudden cardiac death among the population of the Media Valle del Serchio area (Tuscany, Italy), composed of a population of 35,000, was found to be twice that of the European average; 32 cases have been reported over this period in that area (9 per 10,000 in the examined year), with a male/female (M/F) ratio of 2.5:1 (23 M, 9 F). In Italy the mean incidence of sudden death was calculated as 6/10,000 and in Europe 5/10,000. In the examined population hypertension was the coronary risk factor present most frequently (87%). A previous diagnosis of coronary artery disease was documented in 21 cases (66%); 5 of these exhibited previous myocardial infarction and 3 previous myocardial infarction associated with left ventricular heart failure. In 7 subjects no previous cardiovascular disorders were discovered. Prodromal symptoms had been reported in 20 cases (62%), which included chest pain in 8 and dyspnea in 8. In the examined geographic area a high prevalence of coronary artery disease was verified through the records of the Public Health Service, which documents the main causes of mortality in Tuscany, and through the hospitalization data and the services provided for ischemic heart disease at the local coronary care unit compared with the national average. Moreover, research was accomplished on physical and chemical properties of drinking water in the same area, and this revealed a very low total hardness due to the paucity of calcium and magnesium salts. In conclusion, this research demonstrated a close relationship between the incidence of sudden death and the incidence of ischemic heart disease in a mountain area with low-hardness drinking water. [ABSTRACT FROM AUTHOR]

Clinical and transthoracic echocardiographic findings in 92 patients who had atrial mass lesions identified by transesophageal echocardiography were retrospectively analyzed. Transthoracic echocardiography failed to diagnose or misdiagnosed 16 patients with small (< 3 cm) atrial thrombi, patients with thrombi localized to the appendage, or patients with technically difficult studies. The 3 patients with atrial myxoma who were not detected or were misdiagnosed by transthoracic echocardiography had small tumors (< 3 cm) or origin from the free wall of the atrium away from the atrial septum. Transthoracic study also failed to diagnose or misdiagnosed normal anatomic variants in 17 of 32 patients. In conclusion, transesophageal echocardiography is superior to the transthoracic study in evaluating the etiology and significance of atrial mass lesions. [ABSTRACT FROM AUTHOR]

The authors report a case of early peripartum myocardial infarction resulting from spontaneous dissection of the left anterior descending coronary artery and right coronary artery in a twenty-four-year-old woman. This is the first report of double-vessel coronary dissection involving both the left and right coronary arteries diagnosed antemortem and successfully treated. [ABSTRACT FROM AUTHOR]

To investigate long-term follow-up and identify prognostic factors in patients with dilated cardiomyopathy (DCM) the authors investigated 167 consecutive patients on an outpatient basis. All patients underwent left- and right-heart catheterization; follow-up comprised clinical and echocardiographic investigations. Results: After a mean follow-up period of ninety-three ± thirty-six months 82 patients (49%; 71 men, 11 women, mean age fifty-five ± eleven years) were alive. 29 of them (27 men, 2 women, mean age fifty-two ± nine) showed normal left ventricular ejection fraction (LVEF) after a mean follow-up period of one hundred four ± forty months. The remaining 53 patients (44 men, 9 women, mean age fifty-six ± eleven) revealed LVEF similar to that of the first examination. Eighty-five patients died (51%; 73 men, 12 women). Causes of death were the following: progressive heart failure, 24; sudden death, 23; stroke, 3; pulmonary embolism, 2; noncardiac death, 4; unknown causes, 29. The median period from the onset of first symptoms until definite diagnosis was two months in patients with stable conditions, three months in those with normalization of LVEF and twenty-four months in those who died, respectively (P < 0.01). At the time of diagnosis, patients with stable outcome had a mean LVEF (LVEF 1) of 37%, those who returned to normal had 40% (ns). Patients who died had a mean LVEF 1 of 32% and therefore differed significantly from both groups of survivors (P < 0.001). Left ventricular end-diastolic pressure (LVEDP) at the time of diagnosis was highest in patients who died (22 mmHg) and therefore differed significantly from both groups of survivors (normalization: 16 mmHg, stable patients: 18 mmHg, P < 0.001). Conclusions: According to their results, time until diagnosis, LVEF, and LVEDP are prognostic indicators. No difference was noted between the groups concerning etiology, medical treatment, or functional classification according to the New York Heart Association. [ABSTRACT FROM AUTHOR]

A sixty-three-year-old man presented himself with atrial flutter and congestive heart failure. Cardiac catheterization revealed that left ventricular diverticulum was located on the anterobasal wall with narrow connection to the left ventricular cavity Coronary angiography revealed normal coronary arteries. The patient had been asymptomatic until adult life with no other thoracoabdominal or cardiac anomalies. This is an extremely rare finding in the adult population. [ABSTRACT FROM AUTHOR]

Right bundle branch block was diagnosed in electrocardiograms of 37 of 1085 patients with essential hypertension. Echocardiographically left ventricular hypertrophy was diagnosed in 14 of these 37 patients. Eighteen electrocardiographic (ECG) criteria, which were previously recommended, were determined in these 37 patients. The sensitivities of five criteria were found to be better than 50%. These are SV1 ≥ 2 mm; RV6 > RV5; S III + (R + S) maximum precordial lead ≥ 30 mm; P/PR ≥ 1.6; R aVL ≥ 11 mm. However, their specificities ranged from 56.5% to 95.6%. When the combination of RV6 > RV5 and S III + (R + S) maximum precordial lead ≥ 30 mm was used, sensitivity was 57.1 and specificity was 100%. It is concluded that the presence of right bundle branch block these ECG criteria can be used for the diagnosis of left ventricular hypertrophy. [ABSTRACT FROM AUTHOR]

The purpose of this study is to examine how frequently myocardial ischemia was manifested on the surface electrocardiogram (ECG) during percutaneous transluminal coronary angioplasty (PTCA) and to select the most sensitive leads for the duration of ischemic ST changes. The study population consisted of 126 patients (pts), 116 men and 10 women, who underwent PTCA for one-vessel coronary artery disease. A 12-lead ECG was recorded in ail patients before inflations and at ten-second intervals during each inflation. ST segment deviation, R wave amplitude, and rhythm disturbances were analyzed on all ECG tracings. Ischemic ST changes occurred in 114 pts (90%), 80 with left anterior descending (LAD) artery occlusion, 22 with right coronary artery (RCA) occlusion, and 12 with left circumflex (LCX) artery occlusion (p < 0.01 LAD vs LCX, p < 0.01 RCA vs LCX). Angina pectoris occurred in 74 pts (59%) and coincided with ST changes in 68 of these pts (92%). No significant changes of R wave amplitude were found during balloon inflations. The most sensitive ECG leads for detection of ST elevation were V2 or V3, V4 and V1 for the LAD, leads aVF and II for RCA, and leads III, aVF, or II, and V6 for LGX. The best leads for detection of ST depression were III, aVF and II for LAD, V2 or V3 and aVL for RCA, and V2 or V3, V1, and V4 for LCX. [ABSTRACT FROM AUTHOR]

The possible associations between coronary heart disease (CHD) and peripheral arterial disease (PAD), detected by echo-Doppler analysis, with restriction fragment length polymorphism (RFLP) of apo AI/CIII cluster and apo B gene were investigated in a group of men with premature CHD (n=39) and in a control group of men without evidence of CHD (n=40). The genetic analysis of SstI RFLP of apo AI/CIH cluster showed a significantly higher frequency of the rare SstI allele (S2) in CHD patients (0.16) as compared with controls (0.06). No significant differences were found in the frequencies of XbaI RFLP for the apo B gene between CHD patients and controls. Moreover, patients with PAD showed no significant differences in the frequencies of XbaI RFLP for the apo B gene and of SstI RFLP for the apo AI/CHI cluster as compared with patients without evidence of peripheral arterial disease detected by echo-Doppler analysis. [ABSTRACT FROM AUTHOR]

This Is a case report of a twenty-two-year-old woman who had attacks of ventricular tachycardia that could be prevented by the use of various antiar-rhythmic drugs for three months. Electrophysiologic study showed that the mechanism of the tachycardia was "reentry". In cardiac catheterization a non-contractile mass having calcification was seen on the apical portion of the left ventricle. Angiographically, the mass resembled a diverticulum. Recurrence of attacks was terminated by resection of this mass, which had a cystic appearance. [ABSTRACT FROM AUTHOR]

The clinical effects and the maximal hemodynamic and electrocardiographic effects of two low-osmoIality radiographic contrast media (ioxaglate and iohexol) were directly compared during diagnostic cardiac catheterization in a double- blind, randomized study in 80 patients. Because small changes were expected alter injection of both of these agents, sensitive ECG and intracardiac-pressure-monitoring methods were used, and maximal changes, as well as mean changes in variables, were analyzed. Symptoms were absent, mild, or moderate in 67-77% of patients after left ventriculography and in 97-100% of patients after coronary arteriography. After left ventriculography, maximum and minimum left ventricular systolic pressure and end-diastolic pressure, the first derivative of left ventricular pressure (dp/dt), heart rate, were significantly altered over the two-minute observation period but were not different from the preinjection values at two minutes after both agents. Small but significant increases in mean aortic pressure, cardiac out-put, and pulmonary arterial wedge pressures were seen at two minutes alter both agents. Persistent prolongation of QTc interval over two minutes after ioxaglate injection was not associated with ectopy or clinical events. After coronary arteriography maximum and minimum aortic pressures, ST and T wave segment displacements, and QTc intervals were significantly altered after both agents, but all variables had returned to preinjection values by two minutes. Comparison of the mean changes over time showed that only QTc intervals were altered after tell ventriculography. Direct comparison of the maximum changes between the two agents showed that both contrast agents caused similar hemodynamic and electrocardiographic changes except for small but significantly greater decreases in heart rate with iohexol after left ventriculography and after right coronary arteriography. These contrast agents have small differences in osmolality and significant differences in sodium content. Clinical events of nausea and heat sensation were noted more often in the ioxaglate group, but the frequency did not reach statistical significance. Analyses of maximal changes using sensitive monitoring devices showed that the two agents have substantially similar hemodynamic and electrocardiographic effects. Analysis of mean changes over time was less sensitive in identifying small, transient changes and differences between the two agents. [ABSTRACT FROM AUTHOR]

The accuracy of electrocardiograms (ECGs) in predicting the success of coronary reperfusion by Intravenous (IV) thrombolytic therapy was studied in 49 canine acute myocardial infarctions (Ml), induced by occlusive thrombus in the left anterior descending (LAD) coronary artery. Two hours after the onset of MI, urokinase (UK, 3 × 104 U/kg) was administered IV and the heart was observed for one further hour. LAD flow and epicardial ECGs were recorded continuously. LAD flow was restored by UK in 26 of 49 animals (Group I); restored LAD flow was stable in 17 of the 26 (Group IA) and unstable with repeated fluctuations in the other 9 (Group TB) during the follow-up period. No coronary reflow was obtained by thrombolysis In 23 of 49 animals (Group II). The best electrocardiographic criterion for predicting coronary reperfusion was reduction of ST elevation by more than 25%, which had a predictive accuracy of 86%. There was a significant correlation between the grade of improvement of coronary blood flow and reduction of ST elevation in Group IA (p < 0.01), but not in Group TB, indicating that unstable coronary blood flow following thrombolysis due to residual thrombus appears to be one of the major factors preventing accurate prediction of coronary reperfusion with thrombolysis on the basis of changes In ST elevation. [ABSTRACT FROM AUTHOR]

Three different computer methods for analysis of systolic and diastolic left ventricular function (ejection fraction, peak ejection rate, time to peak ejection rate, peak filling rate, time to peak filling rate, duration of fast filling phase, and fast filling fraction) as derived from ECGegated radionuclide cardiography were compared in 30 patients with various diseases. The patients had two gamma camera recordings of the left ventricle performed Immediately following one another during radionuclide (99roTc) equilibrium (3 × 106 counts, 16 frames/cycle, 64 × 64 pixels). Mean ECC R-R interval of the patients remained unchanged from first to second recording. The three computer methods were: (1) end-diastolic (ED) region of interest (ROI) analysis based on manually defined ED-ROI; (2) multi (M) ROI, manually defined ROI for each frame; and (3) semiautomatic (SA) ROI, ROI for each frame defined by an SA edge detection technique. With the 16 frame points as nodes, a 160-point time-activity curve was constructed for each of the three methods by use of a spline function. A tailored multiway analysis of variance showed that the M-ROI method had the highest interindividual range of values of the function parameters and the smallest interrecording, interobserver, and intraobserver variabilities. In theory this implies a better diagnostic sensitivity and specificity for the M-ROI method as compared with the other two methods. [ABSTRACT FROM AUTHOR]

In this double-blind, crossover study the authors have validated stroke volume determination by impedance cardiography against the pulsed Doppler echocardiographic method in elderly hypertensives. They found a good correlation between the stroke volume values obtained by the two methods over a range of values from 30 to 130 mL. The coefficient of linear regression was about .95 at each visit. The mean of the differences was -0.73 mL with a standard deviation of 8.46. Given that individual differences are normally distributed, the values corresponding to 2 standard deviations of the mean define a range covering 95% of the observed differences. From the distribution of the data around the mean plot it appears that, in comparison with pulsed Doppler, impedance cardiography tends to slightly underestimate stroke volumes of >90 mL and to overestimate values of <50 mL. The results of this study indicate that impedance cardiography may represent a reliable alternative to pulsed Doppler echocardiography for the noninvasive estimation of cardiac output at rest in elderly patients. [ABSTRACT FROM AUTHOR]

A forty-two-year-old man was admitted because of chest pain. Electrocardiograms at admission showed horizontal ST depression in leads, II, III, aVF, V4, V5, and V6. Direct blood pressure monitoring revealed cyclic change between 160/100 mmHg and 70/50 mmHg and heart rate between 80/sec and 120/sec at fifteen minute intervals. The plasma norepinephrine and epinephrine concentrations were elevated during the episodes of hypertension. Pheochromocytoma was found in the right adrenal gland. These cyclic changes in blood pressure and heart rate are an aid for diagnosis. [ABSTRACT FROM AUTHOR]

The electrocardiographic abnormalities found in 100 patients with acute cerebrovascular disease and previously normal hearts are described. The abnormalities were more often seen in patients with intracerebral and subarachnoid hemorrhages. The most common changes were Q-Tc Prolongation and ST segment and T wave abnormalities. The mechanisms of these electrocardiographic abnormalities appear to be multiple. [ABSTRACT FROM AUTHOR]

A patient with resting heart rate over 100 beats per minute (bpm) displayed 1.5–2 mm ST segment depression in her ECG during daily activities. She had unprovoked further increase in her heart rate up to 145 bpm, and during these episodes, her ECG displayed further ST segment depression up to 3 mm and of 0.12 second duration. An organic cause could not be found to explain her sinus tachycardia. Results of all laboratory investigations, including coronary angiography, were normal. It was observed that during an episode of reflex vagotonia, when her heart rate was below 95 bpm, her previously depressed ST segments became isoelectric. With the thought that this patient's ST segment depression was rate dependent, carotid sinus massage was performed, and when the heart rate slowed to 95 bpm her depressed ST segments became isoelectric. The same response was accomplished with beta blockers. Sympathetic hyperactivity was thought to be the most likely mechanism of ST segment depression in this patient. A critical increase in heart rate caused these ECG abnormalities. [ABSTRACT FROM AUTHOR]

The clinical, electrocardiographic, and angiographic findings of 90 patients, whose RAO 30° left ventriculograms showed segmental early relaxation (SER), were compared with those of 100 patients without SER. There were no significant differences in age and sex distribution or in clinical and coronary angiographic findings between the two groups. There was, however, a significantly lower prevalence of pathologic Q or QS patterns in the anterior leads of the ECG in the group with SER. SER occurred more frequently in segments with well-preserved systolic contraction and was confined to the anterolateral segments in the great majority of the patients (80%). An inverse correlation was found between SER and geographically related critical coronary artery stenosis. [ABSTRACT FROM AUTHOR]

For quantitative estimation of ischemia, ECG-synchronized digital subtraction angiography was performed for selective coronary arteriography. The authors obtained sequential myocardial perfusion images at the arterial, capillary, and venous phases. Profile densitometry was performed along the cross section perpendicular to the long axis of the left ventricle to assess regional myocardial perfusion at the capillary phase quantitatively. By this densitometry, the volumes of vascular bed perfused by the left coronary artery could be estimated, and further, nontransmural myocardial infarction could be differentiated from transmural myocardial infarction through the profile of its density curve. This method appears to be useful for the analysis of myocardial perfusion of ischemic heart disease. [ABSTRACT FROM AUTHOR]

In order to evaluate the pulmonary hemodynamics in primary pulmonary hypertension, the relation between the standard 12-lead electrocardiogram (ECG) and pulmonary hemodynamics as determined by right-heart catheterization was analyzed. Significant positive correlations were noted between amplitude of the R in V1, the R/S ratio in V1, and the pulmonary artery systolic pressure (r=0.46 and 0.50, respectively, p < 0.01). An amplitude of the R in V1 of more than 1.2 mV indicated a pulmonary artery systolic pressure of more than 90 mmHg with a sensitivity of 94% and a specificity of 47%. The cardiac index showed a significant positive relationship with amplitude of the R in V5 and V6 and the R/S ratio in V5 and V6 (r=0.46, 0.46, 0.39, and 0.48, respectively; each with a p < 0.01). Moreover, an ÂQRS ≥ 100°, and either an SV6 ≥ 0.7 mV, or R/SV6 ≤ 2 indicated a cardiac index of < 2.8L/min/m2 with a sensitivity of 82% and 84% and a specificity of 86% and 100% respectively. This study suggests, therefore, that the 12-lead ECG is useful for the evaluation of the severity of pulmonary hypertension by its ability to predict pulmonary artery systolic pressure and cardiac index with clinically useful accuracy. [ABSTRACT FROM AUTHOR]

The cardiointegram is a noninvasive technique for the analysis of the electrical signals of the heart obtained by a transformation of the voltage versus time format by a series of integrations. The stress thallium perfusion study is a widely used test for the detection of coronary artery disease. In order to evaluate the correlation between the resting cardiointegram and the stress thallium 201 perfusion study, 20 patients with normal resting electrocardiograms underwent stress thallium tests and resting cardiointegrams. The cardiointegram was determined on two resting complexes of leads I, II, V4, V5, and V6 and called abnormal if five of ten complexes deviated outside a normalized template. There was concordance of the cardiointegram and the thallium study in 16 of 20 patients (80%). The sensitivity for the detection of coronary artery disease was 71%, and the specificity was 80%. The overall accuracy was 74%. Thus in patients with normal electrocardiograms, the cardiointegram is a useful noninvasive test for the detection of coronary artery disease. [ABSTRACT FROM AUTHOR]