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Transesophageal echocardiography (TEE) has provided an accurate new window for the evaluation of diseases of the thoracic aorta. Experience with TEE has led to an increased recognition of atherosclerosis of the thoracic aorta as a source of cerebral and systemic embolism. Certain features of aortic plaque morphology detected by TEE may prove to have prognostic and therapeutic significance. The intraoperative assessment of thoracic aortic atherosclerosis by TEE may guide modifications in surgical techniques and aortic manipulations that reduce the incidence of perioperative neurologic complications. TEE has also become a valuable tool for the diagnostic evaluation of patients with blunt chest trauma. The precise role of TEE in the management of these disorders is currently under investigation.

Dramatic changes in the management of acute myocardial infarction (AMI) have occurred in the past decade. While previous management strategies were primarily supportive, current strategies focus on achieving and maintaining patency of the infarct-related artery restoring blood flow to jeopardized myocytes, preserving left ventricular function, and preventing recurrences and complications in addition to promoting healing. Restoration of blood flow can be achieved pharmacologically with thrombolytic agents or mechanically with percutaneous transluminal coronary angioplasty (PTCA). Early use of antiplatelet agents and anticoagulants helps maintain patency of the infarct-related arteries and prevents thromboembolic complications. Administration of beta-blockers and angiotensin enzyme inhibitors are more specific means of conserving myocardium and preserving ventricular function. Additionally, several strategies for preventing arrhythmias such as prophylactic lidocaine use and routine long-term suppression of premature ventricular contractions with antiarrhythmic drugs are no longer routinely advocated. Basically, in the era prior to the eighth decade of this century, the primary direction of the therapeutic strategy for AMI was to reduce the oxygen demands in the infarcted myocardium; whereas in the subsequent years, the emphasis shifts to improvement in oxygen delivery, via thrombolysis, PTCA, and coronary artery bypass graft surgery. These interventional changes, when added to greater sophistication in the use of drugs to reduce oxygen demands, resulted in significant lowering of myocardial mortality.

This study was designed to determine whether ambulatory electrocardiography in patients with recent stroke would lead to a change in clinical management or outcome and to express these findings in terms of cost benefit. A prospective, consecutive sample of patients (n = 100) with recent stroke referred from the neurology or medical services for ambulatory electrocardiography was identified. Ambulatory electrocardiograms were reviewed to identify patients with potentially important bradyarrhythmias, tachyarrhythmias, or atrial fibrillation. Patients were then followed up without interference with ongoing care to determine whether these findings led to changes in clinical management that might influence patient outcome. Of the 100 patients, 16 had an index "important" arrhythmia. No significant bradyarrhythmias were noted. Nonsustained ventricular tachycardia (> or = 6 complexes) in two patients and supraventricular tachycardia (> or = 10 complexes) in seven patients did not lead to management changes. Four patients had a history of atrial fibrillation who were in sinus rhythm; anticoagulation had been addressed in three; the fourth patient died before the issue could be addressed. Of three patients in atrial fibrillation, there was a history of atrial fibrillation and a decision regarding anticoagulation in each before monitoring. The cost of these 100 ambulatory electrocardiograms was about $55,000. In conclusion, these findings do not support the routine use of ambulatory electrocardiography in the evaluation of patients with stroke.

The medical complications of cocaine abuse are being encountered by clinicians with increasing frequency. The cardiovascular manifestations of cocaine abuse include chest pain, myocardial ischemia and infarction, congestive heart failure, arrhythmias, infective endocarditis, and aortic dissection. The pathogenesis of these cardiovascular complications has not been fully elucidated but may be related to a combination of the sympathomimetic and membrane anaesthetic effects of cocaine. We present these concepts in a case discussion format.

A patient presented with an acute right ventricular infarction characterized by an electrocardiographic current of injury in both the inferior (2,3,aVF) and anterior precordial leads (V1-V6). Cardiac catheterization demonstrated normal left ventricular wall motion, a codominant circulation, and severe disease of the right coronary artery. We propose that this coronary anatomy explains the injury currents on the electrocardiogram. This case illustrates a rare presentation of right ventricular myocardial infarction mimicking an extensive anterolateral wall injury.

Iatrogenic aortocoronary vein fistula following coronary artery bypass surgery is a rare complication. We describe the first reported case of inadvertent anastomosis of the left internal mammary artery to cardiac vein. The clinical characteristics and consequences as well as the angiographic characteristics of this fistula are described. Precautions that may be taken to prevent this complication are also addressed.

Cardiac disease associated with congestive heart failure was found to be the most common cause (22 of 76) of pericardial effusion in patients referred for echocardiography. Parameters of left heart function were markedly abnormal in these patients with congestive heart failure and pericardial effusion, but were not significantly different from a group of patients with congestive heart failure without pericardial effusion. Clinical findings consistent with cardiac decompensation also failed to discern between these two groups. Nonetheless, patients with congestive heart failure with pericardial effusion had significantly larger right ventricular internal dimensions than those without effusion. Patients with pericardial effusion related to congestive heart failure (P < .01), heart disease without congestive heart failure (P < 0.001) and those patients post recent myocardial infarction (P < 0.05) had significantly larger right ventricular internal dimensions in diastole than normal subjects. Patients with pericardial effusions related to recent open heart surgery, idiopathic pericarditis or of miscellaneous causes had normal right ventricular internal dimensions. It is likely that right ventricular dilation indicates abnormal volume/pressure relationships of the right heart and that this abnormality, through alterations in venous and lymphatic drainage, underlies the accumulation of pericardial effusion in these patients with heart disease with or without congestive heart failure.