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PR prolongation (first-degree AV block) is defined primarily as delayed conduction through the atrioventricular (AV) node, but can also signify delayed electrical impulse propagation through any part of the specialized conduction system. The prevalence of PR prolongation ranges from 1-5% in patients younger than 50 years of age, with increasing prevalence, particularly after the sixth decade of life and in patients with organic heart disease. While classical studies suggest no adverse associations linked to PR prolongation, contemporary studies have documented increased risk of atrial arrhythmias, heart failure, and mortality in patients with PR prolongation. Future studies are needed to risk stratify elderly patients with PR prolongation who may be at increased risk of adverse outcomes and determine the optimal monitoring strategy for future follow-up.

BACKGROUND Dizziness is a common symptom in adults and usually due to peripheral causes affecting semicircular canal function or central causes affecting the pons, medulla, or cerebellum. Arrhythmia is a recognized cause of dizziness in people with structural or ischemic heart disease. We report a case of exercise-induced transient ventricular tachycardia and dizziness in a man with no evidence of organic heart disease. CASE SUMMARY A 42-year-old man presented with a 6 mo history of transient exercise-induced dizziness and prodromal palpitations. The patient was otherwise asymptomatic. Physical examination, otoscopy, vestibular tests, cerebellar tests, laboratory investigations, and imaging investigations were all unremarkable. Twenty-four hour Holter monitoring revealed four episodes of transient ventricular tachycardia during exercise. The patient was started on metoprolol and subsequently underwent radiofrequency catheter ablation. The patient reported a full recovery and no dizziness during daily activities. These results were maintained at the 6 mo follow-up. CONCLUSION Ventricular tachycardia is an uncommon but potentially serious cause of dizziness. The outcome of this case illustrates the benefits of careful clinical examination and communication with specialized centers. High clinical suspicion of arrhythmia in a patient with dizziness merits consultation with a cardiologist and referral to a specialized center to ensure timely diagnosis and treatment.

Fusobacterium necrophorum is a very rare cause of endocarditis. We herein report a case of F. necrophorum endocarditis with liver abscesses in a 51-year-old woman. This is the first reported case of monomicrobial F. necrophorum endocarditis to present in a patient over 50 years old. We also reviewed 10 reported cases, including the present case. Our review indicated that anaerobic bacteria, including Gram-negative anaerobic bacilli such as F. necrophorum, should be considered in the differential diagnosis of infective endocarditis, especially in patients without preexisting organic heart disease.

The aim of our study was to evaluate the influence of the main indicators of type 1 diabetes mellitus (T1DM) control on heart rate variability (HRV). We examined 62 patients at the age of 18-45 years with an average T1DM duration of 11.0 (5.0; 18.0) years. HRV in the time and frequency range was evaluated by analyzing a 24-hour Holter electrocardiogram (ECG). The following laboratory parameters were used as markers of course and compensation of T1DM: C-peptide, HbA1c, blood creatinine, albuminuria (AU), estimated glomerular filtration rate (eGFR) by CKD-EPI formula. In addition, the maximum and minimum blood glucose levels and the blood glucose range (maximum minus minimum blood glucose values) were conducted by continuous glucose monitoring system iPro2 (Medtronic MiniMed, USA). The daily monitoring of electrocardiogram (ECG) was made in parallel with long term monitoring of blood glucose. Echocardiography in all patients was performed to exclude organic heart disease and the possibility of its influence on HRV. Poor control of T1DM negatively influences HRV through decrease in both frequency and time characteristics. The blood glucose range can be an additional negative factor for cardiovascular system in T1DM patients, regardless of HbA1c, whereas it positively correlates with HRV- relative hypersympathicotonia markers: LF/HF 24-h, ρ=0.43 (p

Background Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection. Purpose We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF. Material and Methods we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events. Results During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)). Conclusions GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF

BACKGROUND New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified. PURPOSE We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients. METHODS We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF < 50%, no previous MAE or coronary artery revascularization < 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve. RESULTS During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE CONCLUSIONS Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

The paper presents the special questionnaire «Quality of Life in Children with Arrhythmias» that reflects the subjective assessment of quality of life (QOL) in patients with cardiac arrhythmias and a procedure for the comprehensive assessment of QOL in children with arrhythmias on the basis of subjective and objective data. It gives the results of using the above procedures for assessing QOL in 151 children (71 girls and 80 boys) aged 6–18 years with various cardiac arrhythmias. Complaints were absent in 21,9±3,4% of the children with arrhythmia and were nonspecific, being rarely observed, in 29,8±3,7%, suggesting that there was no reduction in QOL according to their subjective assessments. Comprehensive assessment of QOL showed that its indicators were significantly lower (p

Background: Anaemia is one of the commonest clinical problems in our country. It affects various organs including the heart. Clinical manifestations of anaemia referable to cardiovascular system may closely simulate symptoms and signs of organic heart disease. It includes some electrocardiogram (ECG) changes also. ECG changes in anaemia show correlation to haemoglobin (Hb) concentration and the changes are reversible after correction of anaemia. In this study, the main objective was to study electrocardiographic changes in patients with severe anaemia and ECG reversibility after treatment of anaemia.Methods: 50 patients admitted in medicine wards of Shri B. M. Patil Medical College, Hospital and Research Center, Vijayapura for severe anaemia (Hb concentration less than or equal to 7 gm %) were studied for ECG changes. All patients were reassessed for reversibility of changes after treatment.Results: Out of 50 patients with severe anaemia, 20 patients were having Hb % of 3 to 5 gm %. Of which 16 patients were having ECG changes (10 were females and 6 were males). All ECG changes were reverted to normal after correction of anaemia, except one patient (showed pre-treatment T wave inversion and post-treatment flat T waves).Conclusions: ECG abnormalities in patients with severe anaemia are more common in females. ECG abnormalities in patients with severe anaemia (Hb 5 gm %) can get reverted to normal after correction of anaemia.

Non-invasive left ventricular (LV) pressure-strain loop is a new method to quantify myocardial work. However, its prognostic value remains to be clarified and no threshold has been defined yet to distinguish patients at high or low risk of adverse events. We enrolled 216 patients with 2D LV

A 12-year-old girl with occasional symptoms of chest discomfort was diagnosed with ventricular tachycardia on cardiac evaluation. No evidence of organic heart disease was apparent, but a laboratory evaluation revealed hypomagnesemia. Ventricular tachycardia disappeared after treatment with 200 mg/day of oral magnesium hydroxide, and no further chest discomfort was reported. In addition to routine cardiac evaluation for arrhythmia, serum magnesium levels should be checked in patients with suspected idiopathic benign ventricular tachycardia. Treatment with oral magnesium is a physiologic therapy and should be considered for patients with ventricular tachycardia due to hypomagnesemia.

The comparative usefulness of 10 min of beat-to-beat 12-lead QT dispersion (QTd) and QT interval variability index (QTVI) analysis for identifying patients with organic heart disease (OHD) at risk for ventricular arrhythmias was assessed in 86 subjects: 54 had OHD without a history of ventricular arrhythmias, 15 had OHD with documented ventricular tachycardia, and there were 17 controls. The following parameters were analyzed among the groups: (1) the average QTd (mean QTd), (2) the difference between the maximum and minimum QTd observed over the recording time (QTd variation), (3) the maximum difference of QTd between consecutive beats (QTd maximum), (4) the QTd standard deviation (QTd variability), and (5) QTVI, calculated in lead I or II according to an established formula: log 10 [(QTv/QTm2) / (HRv/HRm2)]. All the analyzed parameters were significantly increased in the patients with and without ventricular tachycardia when compared with the controls. QTd variation, QTd maximum and QTd variability were the only variables that remained significantly increased in the group of patients with documented ventricular tachycardia, compared with those without arrhythmia. Thus, beat-to-beat fluctuations of both the QT interval and QTd may be markers of temporal electrical instability in patients with OHD. (Circ J 2003; 67: 125 - 128)

Objectives. This study sought to identify the risks and benefits of adding the maze procedure in patients with atrial fibrillation (AF) undergoing operation for underlying organic cardiac disorders. Background. Persistent AF often leaves patients symptomatic even after otherwise successful cardiac surgery. Methods. Fifty-one patients undergoing valvular operation and the maze procedure (n = 43) or repair of congenital anomalies (n = 8) combined with the maze procedure were compared with 51 patients (control group) matched for underlying diseases and procedures except for the maze operation. Each group, including 31 patients with a concomitant tricuspid annuloplasty and 12 undergoing reoperation, were similar in age, duration of arrhythmia, degree of cardiomegaly and New York Heart Association functional class. Results. Patients undergoing the maze procedure had longer cardiopulmonary bypass time (213 vs. 144 min, p < 0.0001), longer cardiac arrest (134 vs. 93 min, p < 0.0001) and greater blood loss with longer respiratory care (39 vs. 18 h, p = 0.021) and intensive care unit stay but no mortality. No significant differences were found in catecholamine or transfusion requirements immediately after operation. Sustained AF was much less frequent in the maze group (12% at 1 year) than the control group (86%, p < 0.0001), with an average follow-up period of 32 months (range 25 to 42). Atrial contraction was documented in 41 (80%) and 40 (78%) patients for right and left ventricular filling, respectively, after the maze procedure, resulting in a significantly smaller cardiac size and improved functional capacity. Medication was discontinued in seven patients in the maze group compared with two in the control group. Conclusions. Improved restoration of atrial rhythm and contraction with combined maze operation appeared to justify the increased operative time and complexity and postoperative care.

We analyzed the long-term outcome of antiarrhythmic therapy, each of which had been evaluated at electrophysiologic study (EPS), to identify the high risk group of sudden death and cardiac mortality. The subject consisted of 72 patients with ventricular tachyarrhythmias. All patients had spontaneous sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Sustained ventricular tachyarrhythmias were induced in 65 (91 %) patients at control EPS. Antiarrhythmic therapy was considered effective if VT induction was suppressed to fewer than six ventricular complexes. In 43 patients (Group I), antiarrhythmic therapy (antiarrhythmic agents, cathether ablation or surgery) was judged to be effective by EPS, and in 22 (Group II) antiarrhythmic therapy ineffective. During a mean follow-up period of 35 months, sudden death occurred in one (2 %) patient in group I and 6 (27%) in group II (p=0.049), and cardiac mortality was 4 % in group I and 36 % in group II (p=0.002). By life table analysis, the 5-year sudden death free-survival was 82.9 % in group I and 46.7 % in group II (p

The very expression “well built” has become a part of our language. It implies that persons of a particular build or structure are better coordinated or somehow can function better than other people and may, therefore, be expected to have a greater life span. Variations in the structure of individuals are marked and serve to distinguish fairly definite types. Insurance experience has crystallized into a number of fairly definite conclusions with regard to the relative longevity of certain of these types. Extremes of stature, for example, are decided handicaps. Extreme overweight and underweight carry with them increased mortality and correspondingly shorter life. Very heavy people are more likely to succumb prematurely to such conditions as diabetes, organic heart disease, renal impairment, hardening of the arteries, and very light persons, particularly at the younger ages, are more likely to develop tuberculosis. Insurance experience has confirmed the popular judgment that the individuals who approach the mean of these body measures are better able to withstand the hazards of life and to round out a fairly full expectation.

The newer implantable loop recorders recently introduced (Reveal Plus. Medtronic Inc, Minneapolis, MN, U.S.A.). equipped with auto activation capabilities, are expected to expand our diagnostic abilities in the investigation of syncopal episodes. The case presented here is that of a man with pre-syncopal and syncopal episodes, without organic heart disease, in whom the device was auto-activated due to undersensing and the recorded strip imitated complete heart block. Increased attention should be given by the interpreter of the device's recordings to avoid false positive diagnoses that might lead to serious therapeutic actions.

Eighty-three children were monitored by Holter electrocardiography for ventricular premature contraction (VPC), and the relationship between the preceding RR interval and the coupling interval was plotted using a two-dimensional RR interval plotting method. With this method, the slope (a) and standard deviation (SD) of the linear regression (Y=aX+b) were determined. These parameters were used to classify the patients into one of two types: a fixed type (SD

The purpose of this study was to investigate whether the ideal control of atrial fibrillation (AF) associated with hypertensive patients depends on the usage of renin-angiotensin system (RAS) inhibitors or whether it occurs regardless of the kind of antihypertensive agents used. The control of AF was compared in 112 outpatients between 1) those with or without the administration of RAS inhibitors, and 2) those with an ideal or poor control of the blood pressure (BP) regardless of the kind of antihypertensive therapy used. The therapies with or without RAS inhibitors did not yield any significant difference in the AF control states, even though RAS inhibitors had been administered to the patient group with a high proportion of organic heart disease. The ideal BP control group exhibited a significantly better AF control in comparison to the poor BP control group. The former group had a significantly smaller left atrial diameter determined by ultrasonic echocardiography. BP control itself may essentially be important for preventing AF in the general patient population. Poor BP control seemed to have an affect on worsening AF possibly via left ventricular diastolic dysfunction, followed by left atrial overload.

The purpose of this study was to evaluate the impact of computed tomography coronary angiography (CTCA) on the appropriate utilization of catheter angiography (CA). This observational trial analyzed all patients undergoing CA in 2006 and 2007 in one hospital. In 2007, patients having a low to intermediate cardiovascular risk and suspicion of coronary artery disease (CAD) and those with suspicion of progression of known organic heart disease (OHD) underwent CTCA either prior to CA or as the sole imaging modality. Appropriate utilization of CA was defined as: (1) percentage of patients showing normal or non-significant findings at CA, (2) percentage of self-referred patients to CA, and (3) percentage of patients with known OHD undergoing CA without immediate operative or interventional consequences. Use of CTCA resulted in a significant drop in the percentage of CA examinations in patients with suspected CAD showing normal or non-significant findings (19% in 2006, 10% in 2007, P < 0.001). The percentage of self-referred CA significantly dropped (29% in 2006, 10% in 2007, P < 0.001). CT ruled-out CAD in 74/151 (49%) patients, obviating subsequent CA. During a follow-up of 15 ± 4 months, CA and percutaneous interventions was considered necessary in 2/74 patients. CT ruled-out progression of known OHD in 53/60 (90%) patients, while one patient underwent CA and percutaneous intervention during a follow-up period of 16 ± 4 months. No reduction of CA examinations without immediate consequences was found in patients with known OHD (13% in 2006, 27% in 2007). In patients with suspicion of CAD, CTCA improved the appropriate utilization of CA without jeopardizing patient safety, along with a decrease of self-referred patients for CA. CTCA did not influence the appropriate utilization of CA in patients with known OHD.

The characteristics of the coupling interval (CI) of ventricular premature contraction (VPC) were studied in 100 patients with frequent VPCs using 24 h ambulatory ECG recording. All R-R intervals were registered on computer to determine the mean value of CIs (Mean CI) and the standard deviation of CIs (SD-CI). We compared the Mean CI and the SD-CI between idiopathic VPCs and VPCs with organic heart disease (OHD). In addition, we evaluated the efficacy of disopyramide (DP) and mexiletine (MX) and we examined the relationship between the efficacy of these drugs and the characteristics of CI. The Mean CI of VPCs with OHD was longer than that of idiopathic VPCs (530 vs. 494 msec, p less than 0.05). The SD-CI of VPCs with OHD was larger than that of idiopathic VPCs (54.1 vs. 39.3 msec, p less than 0.01). In all treated cases, the drug efficacy was not different between DP (11/18, 61%) and MX (9/19, 47%). However when we isolated cases of OHD, we found a tendency that DP (9/12, 75%) was more effective than MX (7/16, 44%). In cases where DP was administered, the Mean CI of VPCs was not different between effective and ineffective cases, while in cases where MX was administered, the Mean CI of ineffective cases had a tendency to be longer than that of effective cases (552 vs. 506 msec, p less than 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Background and aims: atrial fibrillation (AF) increases the risk of stroke and also has adverse haemodynamic consequences. Cardioversion of AF to sinus rhythm may obviate the need for long-term anticoagulation and improve cardiovascular haemodynamics, but is probably underused. We therefore investigated the views of hospital consultants about cardioversion for AF. Methods: 336 postal questionnaires were sent to all 186 consultant physicians, 54 cardiologists and 96 geriatricians in Scotland, followed by one reminder letter to non-responders. Results: 71% of questionnaires were returned. Cardiologists referred 18% of AF patients for cardioversion, while physicians referred 11% and geriatricians 5%. Cardiologists had better access to cardioversion facilities and were less likely to consider an enlarged left atrium and organic heart disease to be contra-indications to cardioversion. Anticoagulation was given for less than 3 weeks before cardioversion by 9% of cardiologists, 39% of physicians and 65% of geriatricians (P < 0.001), and for less than 3 weeks after cardioversion by 17% of cardiologists, 45% of physicians and 47% of geriatricians (P = 0.7). Summary: the wide variation in practice both between and within the different specialties suggests that consensus guidelines based on the best available evidence should be developed.

Sudden cardiac death in patients with organic heart disease is usually due to ventricular tachycardia (VT) degenerating to ventricular fibrillation (VF).1 In many cases, implantable cardiac defibrillators (ICDs) have been successful in treating these lethal arrhythmias. However, for the large number of at-risk patients who either do not receive ICDs or who fail to meet criteria for ICD implantation, additional treatment approaches are required. Development of novel antiarrhythmic approaches will require an understanding of the electrophysiologic (and ultimately, cellular) mechanisms that underlie VT and VF in the human heart. Progress in the understanding of VT and VF mechanisms has been made possible by recent technological innovations in cardiac mapping and advances in studying of cellular and molecular aspects of heart disease. Studies in diseased human hearts using three-dimensional electrical mapping (as well as recent optical mapping approaches) have demonstrated the complexity of mechanisms that initiate, maintain and terminate VT, as well as initiate and maintain VF in the heterogeneous myocardial architecture of the diseased human heart. Here we will focus on mechanistic insights into ventricular arrhythmias that have been obtained from such high resolution cardiac mapping studies in patients with ischemic and nonischemic heart disease.

WOS:000258785000006 PubMed: 18834461 Background: Heart rate turbulence (HRT) and heart rate variability (HRV) have been shown to be independent and powerful predictors of mortality in a specific group of cardiac patients. Pacing has unfavorable effects on autonomic function. Our aim is to investigate autonomic responses to atrial synchronous ventricular pacing (VDD) by evaluating HRT and HRV parameters. Methods and Results: The study groups comprised 12 control and 12 patients without organic heart disease and with normal sinus function who were implanted with a permanent VDD pacing system for high-degree atrioventricular block. The HRV and HRT analysis were assessed from a 24-hour Holter recording. There was no statistically significant difference between the two groups for HRV parameters. When HRT parameters were compared, turbulence onset was significantly higher in the cardiac paced group than the controls group (2.729 +/- 8.818 vs -1.565 +/- 8.301, P = 0.006), but no statistically significant difference was found between the two groups for turbulence slope (11.166 +/- 10.034 vs 31.675 +/- 28.107, P = 0.68). The number of patients who had abnormal HRT onset was significantly higher in the paced group than controls (9 vs 2, P = 0.004). Conclusion: Atrial synchronous pacing has unfavorable effects on autonomic function. Altered ventricular depolarization sequence may lead to changes in autonomic response. Although we found no difference in HRV parameters between the control and VDD patient groups, the HRT onset and number of patients with abnormal HRT onset was significantly higher in VDD patients. HRT onset can be a better way of noninvasive autonomic response predictor in VDD patients.

En 9.896 historias clínicas de varios servicios de Medicina Interna de los hospitales 2 de Mayo, Central de Policía y Arzobispo Loayza, hemos encontrado 1,724 cardiopatías orgánicas (16.51%), 474 esclerosis de las arterias coronarias (27.53% de las cardiopatías) y en éstas últimas 182 casos de infarto del miocardio (38.31%).

Aims To assess the diagnostic yield of the head-up tilt test and electrophysiology in different groups of patients with syncope of unknown origin established according to simple clinical criteria. Methods and Results Six hundred consecutive patients with syncope of unknown origin submitted to a tilt test. Two hundred and forty seven of them also underwent electrophysiology. Patients were divided into groups according to age at the time of first syncope, ECG findings and the presence of organic heart disease. Positive responses to the tilt test were more common in patients who had suffered their first syncope at an age equal to or below 65 years (group I) than in older patients (group II) (47% vs 33%, P

When the Silesian physician Adam Christian Thebesius described the valve guarding the ostium of the coronary sinus, he could hardly imagine that this structure would attract attention of many researchers and clinicians more than 300 years later.1 However, the advent of novel therapeutic techniques such as catheter ablation of cardiac arrhythmias, cardiac resynchronization therapy, and most recently percutaneous mitral repair have turned interest to this structure as an integral part of anatomy of the coronary sinus. The Thebesian valve is a caudal remnant of the embryonic sinoatrial valves. Whether it has any role in normal physiology is not known and some believe that it may prevent the regurgitation of blood into the sinus during the contraction of the atrium. However, experience from clinical practice suggests that the valve may pose difficulties in cannulation of the coronary sinus. Therefore, studies on anatomy of the Thebesian valve have potential practical implications. The paper by Mak et al. ,2 published in the current issue of the journal, provides another piece of knowledge in a mosaic. In a series of 75 autopsied human hearts (54 with organic heart disease), these authors confirmed a wide variety of Thebesian valve patterns. The valve was present in 73% of examined hearts. Most of these valves were membranous in composition (46%), followed by fibrous (24%), fibromuscular (11%), and muscular composition (18%). Fenestrations were noted in 26% of valves. Importantly, 16% of hearts showed a valve that … *Corresponding author. Tel: +420 261 365 009, Fax: +420 2 4172 82 25, Email: joka{at}medicon.cz

To the Editor: In the May 6, 1997, issue of Circulation, Kasanuki et al1 reported a “new mechanism of idiopathic ventricular fibrillation (VF),” ie, “increased vagal activity,” in patients who had VF in the absence of organic heart disease and had the “Brugada sign” (“rSR′ and ST elevation” in the precordial leads).2 Before we accept their proposed mechanism as “new” and their patient characteristics as “different,” a few observations are pertinent: 1. The patients described were (presumably) of Asian origin; almost all (five of six) were males; and all the male patients had VF while sleeping or resting (at an unspecified time of the day). Yet the literature on the syndrome of nocturnal sudden death in southeast Asian males3 4 5 was ignored by the authors and by the reviewers of this article. It is important to point out this omission in view of some evidence linking the “nocturnal sudden death syndrome” and the “Brugada sign.”6 2. Our own work7 was quoted to support the authors’ statement that in idiopathic VF, “ventricular arrhythmias are exacerbated by psychological and physical stress.” In fact, we have stated that only a minority of patients with idiopathic VF have symptomatic arrhythmias during any form of stress.7 8 3. The authors’ assertion that “vagal hyperactivity” is the mechanism underlying the onset of spontaneous VF in their patients is supported by scarce data: (1) the sinus rate preceding VF was not reported, and (2) the “abrupt rise in high frequency (HF) values” during heart rate variability assessment was seen before VF episodes in only two patients (and the relevant figure in the article shows convincing HF rises before only one of three VF episodes). 4. Further support for the “vagal hyperactivity” theory proposed by the authors is interesting but inconclusive. …

Purpose: To elucidate whether the delayed enhancement (DE) distribution on cardiac MRI (CMR) correlates with the rate adaptation pattern and QT/RR diurnal variability in patients with lethal ventricular arrhythmias. Methods: CMR and QT/RR analyses using Holter monitoring were performed in 34 patients (24 males, 59.7±10.5 years) with VT and/or VF. DE on CMR was depicted and the depth was scored as 1 to 4 from the endocardium to epicardium in 17 left ventricular segments. The sum of the scores (Total DE score) was calculated in each patient. The QT/RR slope and day-time/night-time QT/RR ratio (Day/Night ratio) were calculated. The correlation of the slope or Day/Night ratio and DE findings were analyzed. Results: All patients were divided into 23 DE positive (DE(+)) and 11 DE negative (DE(−)) patients. The QT/RR slope was significantly steeper in the DE(+) than DE(−) patients (0.212±0.026 vs. 0.128±0.021 (p

A 28-year-old man is described with no demonstrable organic heart disease and recurrent paroxysmal attacks of sustained ventricular tachycardia. Lignocaine and ajmaline failed to terminate the first attack but a bolus infection of verapamil succeeded. This drug was subsequently successful on six more occasions. During electrophysiological study of the eighth attack, slow intravenous administration of verapamil significantly reduced the rate of the tachycardia and prevented its subsequent reinitiation by pacing. Two mechanisms are postulated to explain both the arrhythmia and the beneficial effects of verapamil in this case.

Normal auscultatory findings were studied during a heart survey in which 12 050 Black schoolchildren, aged 2 to 18 years, were examined by cardiologists. Physiological third heart sounds were detected in 96 per cent of children, innocent systolic murmurs in 72 per cent, and innocent mid-diastolic murmurs in 0.27 per cent. The term 'innocent systolic murmur" was used for vibratory systolic murmurs (70%) and pulmonary ejection systolic murmurs (4.2%) but distinct separation of these two murmurs was often difficult. Vibratory systolic murmurs were present throughout the age range. Important features in differentiating innocent systolic murmurs from those caused by mild organic heart disease included the intonation, site of maximal intensity, timing in systole, and behaviour with postural change. Innocent mid-diastolic murmurs are short murmurs occurring immediately after the third heart sound in children, with no supportive evidence of organic heart disease.

An investigation was undertaken to evaluate the antiarrhythmic effect of CoQ10 on VPBs using the Holter ECG, in 27 patients with no clinical findings of organic cardiopathies. As a result, the effect of CoQ10 on VPBs was considered beneficial in 6 (22%) of 27 cases, consisting of 1 patient with hypertension and 5 patients with DM. Even in the remaining 2 patients with DM, the frequency of VPBs was reduced by 50% or more during treatment with CoQ10. The mean reduction of VPBs frequency in the 5 responders plus these 2 patients with DM was 85.7%. These findings suggest that CoQ10 exhibits an effective antiarrhythmic action not merely on organic heart disease but also on VPBs supervening on DM.

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A review is presented of 107 cases of paroxysmal ventricular tachycardia. In the majority it was associated with acute coronary thrombosis or coronary sclerosis, in some with rheumatic valvular disease, and in others with no organic heart disease. It is generally critical and demands careful attention. Occasional cases are overlooked because only one heart sound is present for each cardiac cycle and the heart rate is misjudged to be one-half the actual rate. The outlook often is serious if the condition is not effectively treated. Therapy generally is successful in controlling the arrhythmia. The most valuable drug is quinidine. Other medications are magnesium sulfate, atropine, potassium salts, and possibly morphine.

1. 1. Seventeen previously reported cases of auricular paroxysmal tachycardia with auriculoventricular block are reviewed, and eighteen additional cases are reported. 2. 2. This arrhythmia may occur at almost any age, and in persons with otherwise normal hearts or with organic heart disease. 3. 3. The attacks are often of long duration, i.e., they commonly last several days or longer. 4. 4. High-grade disability is common in patients with organic heart disease, but sometimes occurs in those with otherwise normal hearts. One patient without significant organic heart disease died of cardiac exhaustion and failure attributable entirely to the long continued tachycardia. 5. 5. In some cases the auricular deflections of the electrocardiogram are small or not readily apparent in limb leads. In such instances precordial or esophageal leads are especially valuable because they yield prominent auricular waves and thus permit the identification of the arrhythmia. Such curves are quite different from those of auricular flutter, in that the auricular deflections are separated by periods of electrical quiescence, with the curve at rest on the base line. 6. 6. Digitalis in large amounts often restores normal rhythm. Quinidine and quinine are somewhat less effective, but sometimes restore normal rhythm, occasionally even when digitalis has failed to do so. Pressure upon the carotid sinus rarely terminates the paroxysms; it was successful in only one case (Mackinnon 9 ). Mecholyl and acetylcholine have been ineffectual. Some patients may not respond to any of these measures; in one such instance normal rhythm returned spontaneously after a period of rest in bed, whereas, in another, death resulted from cardiac exhaustion caused by the prolonged tachycardia. 7. 7. Auricular paroxysmal tachycardia with partial A-V block resembles auricular flutter in many respects, but differs from it in some important particulars. Most of the features of auricular paroxysmal tachycardia can be accounted for by circus rhythm involving either the sinoauricular node or the auriculoventricular node.

The T waves of the precordial electrocardiograms are upright in healthy adult white subjects. On the other hand, several reports have drawn attention to T-wave inversion "juvenile pattern" in adult Negroes free of organic heart disease. This study demonstrated no increased incidence of the "juvenile pattern" in healthy adult Negroes. The standards for normality are identical for both white and Negro. When abnormalities of the T wave are found in Negroes, an explanation other than that of race should be sought.

The Junior Clerk position vacated by this promotion was filled by another World War II veteran who, after a leg injury at Manila and a later illness, received a medical discharge from the Army. The disabled veteran is, like other individuals, capable of change and development. Persons with orthopedic defects, blindness, hearing defects, arrested tuberculosis, compensated heart disease, psychoneurosis, and other disabilities are found performing satisfactorily in many kinds of occupations in Government. Some of them are carrying heavy responsibilities in technical, scientific, and professional positions. The deaf boilermaker, the blind stenographer, the draftsman with organic heart disease, and the armless telephone operator have proved to be as competent as any other workers, provided they have been given the proper training and have been properly placed.

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Paroxysmal ventricular tachycardia is considered to be a relatively infrequent arrhythmia and commonly observed in the presense of organic heart disease. The purpose of this paper is to present a case of paroxysmal ventricular tachycardia for seven years' duration, which arrhythmia was not completely controlled.

Patients with functional cardiac disturbances, including chest pain, may present electrocardiographic abnormalities (pronounced RS-T depressions and T-wave inversions) after the "2-step" exercise test which are indistinguishable from those found in organic heart disease. Ergotamine tartrate was employed intravenously in conjunction with "2-step" tests in 10 cases for the objective differentiation of functional from organic heart involvement. However, ergotamine was found to be contraindicated as a routine for this purpose because of its anginal-provoking properties. We have substituted dihydroergecornine (DHO-180), a newer, safer ergot alkaloid, in our further investigation of this problem.

The prevalence of stroke was investigated in a Finnish population study. The results were based on cross-sectional data from a follow-up examination of a prospective study conducted in 1973-1976. The study population drawn from four regions of the country comprised 11,103 men and 11,096 women aged 20 years and over. The age-adjusted prevalence of stroke was 10.3/1000 in men and 5.8/1000 in women. The prevalence was significantly higher in non-attendants at the examination than in attendants. In 15 per cent of the prevalence cases the stroke was caused by subarachnoid hemorrhage, in six per cent by cerebral hemorrhage and in the remainder by cerebral infarction or the type could not be specified. Over half (57 per cent) of the survivors of stroke had no or only slight disability; eight per cent were totally disabled. Some form of organic heart disease and hypertension was significantly more common in the prevalence cases than in the others.

Propafenone is a potent antiarrhythmic agent with a strong membrane-stabilizing effect (Fill et al. 1977; Zeiler et al. 1981) which has been commercially available in Europe since 1977 under the trade name Rytmonorm. Clinical studies have indicated effectiveness in suppressing chronic recurrent supraventricular and ventricular tachyarrhythmias and ectopic beats (Aldor and Haeger 1977; Baedeker et al. 1977; Harlin 1976; Koch 1977).

Two cases of spontaneous multifocal ventricular parasystolic rhythm are described. One case showed double and the other fivefold parasystole. All seven foci had an enhanced rate of discharge, ranging from 57 to 102/min and at least three of them showed exit block. Though beats from three foci displayed very short coupling intervals, occasionally interrupting the terminal part of the preceding T wave, in none of the cases was repetitive firing or ventricular fibrillation seen. Both patients had organic heart disease and both are still alive six months after the arrhythmia was first recorded. Problems in the diagnosis of multiple parasystole and some mechanisms which may be responsible for irregular interectopic intervals are discussed. It is concluded that multiple parasystole is probably not a very rare arrhythmia if long strips of simultaneously recorded multiple leads are available.

This report details our experience with documented chronic second-degree atrioventricular (AV) nodal block (proximal to His [H]) in 56 patients. Forty-six men (82%) and 10 women (18%), ages 18-87 years, were studied. Nineteen of the patients (34%) had no organic heart disease (including seven trained athletes) and 37 (66%) had organic heart disease. ECGs in all patients demonstrated episodes of type I second-degree block; five patients also had periods of 2:1 block. Prospective follow-up patients with no organic heart disease (157-2280 days, mean 1395 +/- 636 days) revealed one patient with clear indication for permanent pacing because of bradyarrhythmic symptoms (permanently placed on day 220 of follow-up). Two patients died nonsuddenly. In patients with organic heart disease (prospective follow-up of 60-2950 days, mean 1347 +/- 825 days), pacemakers were implanted in 10 patients, primarily for treatment of congestive heart failure in eight and syncope in two. Sixteen patients died -- three suddenly, seven with congestive heart failure, two of an acute myocardial infarction and four of causes unrelated to cardiac disease. In summary, chronic second-degree AV nodal block has a relatively benign course in patients without organic heart disease. In patients with organic heart disease, prognosis is poor and related to the severity of underlying heart disease.

Calibrated jugular pulse tracings and cardiac catheterisation were performed on 50 consecutive patients with organic heart disease. Twenty normal adults had calibrated jugular pulse tracings and served as controls. The height of the jugular 'A' and 'V' waves was quantified as a percentage of a known displacement, rendering measurements independent of the amplification used in recording technique. A close correlation existed between the size of the calibrated jugular 'A' and 'V' waves and the actual magnitude of the right intra-atrial pressure changes (A wave, r = 0.72; V wave, r = 0.80). Patients who were free of pulmonary hypertension or tricuspid disease had calibrated 'A' and 'V' waves similar in height to the control population. An enlarged 'A' wave was usually associated with conditions restricting flow into the right ventricle. An enlarged 'V' wave generally indicated tricuspid regurgitation. These changes are often subtle and are not apparent in conventional venous tracings or at the bedside. We conclude that the calibrated jugular pulse tracings can accurately separate normal from abnormal venous waves and expand the diagnostic potential of the jugular pulse.