Three cases of sinoatrial block induced by anticonvulsants

Diphenylhydantoin (DPH) and Carbamazepine have been widely used as anticonvulsants and known to have antiarrhythmic properties. Previous reports have shown that arrhythmias such as sinus bradycardia and atrioventricular block can be induced by these agents. In this paper, sinoatrial block (SA block) induced by these agents which were used as anticonvulsants in 3 aged patients is reported. Thre patients, 2 women and 1 man, were over 60 years old. In 2 cases, administration of DPH for recurrent epileptic seizures was followed by SA block. After withdrawal of DPH, SA block disappeared, but resumption of DPH resulted in SA block again. In 1 of these 2 patients, overdrive suppression test revealed normal sinus node recovery time. In the third patient, in addition to DPH which was administered for epileptic seizures, Carbamazepine was given for shoulder pain, then SA block occurred. Withdrawal of these agents restored normal sinus rhythm and combined administration of these 2 agents again induced SA block. Autopsy revealed decreased conduction cells in the sinus node.

Clinical and electrophysiologic studies on the Wolff-Parkinson-White syndrome in aged cases

Clinical and electrophysiologic studies were performed in 10 aged cases (50-82 years of age) with WPW syndrome and following results were obtained: 1) Episodes of paroxysm of supraventricular tachyarrhythmias were observed in 7 and complication of sinus node dysfunction was noted in 3. 2) P-delta intervals on electrocardiogram exceeding 0.12 sec were observed in 4 cases. 3) Patterns of normalization of QRS complex in 4 cases were characterized by tachycardia-dependent in 2 and bradycardia-dependent in 2. 4) Effective refractory period of the accessory pathway (AP) in antegrade direction exceeded that of A-V node in 5 cases and the former exceeding 500 msec was observed in 2 cases. The relations between the changes of the electrophysiologic properties of the AP and altered clinical manifestations of the WPW syndrome in aged cases were discussed.

A clinicopathological study on the papillary muscle dysfunction

A total of 11 cases of papillary muscle dysfunction (PMD) was found among 600 consecutive autopsy (1.8%). There were 5 men and 6 women, with their ages ranging from 64 to 92 years. Auscultation and phonocardiograms revealed holosystolic murmurs in 9 cases and early systolic murmurs in 2. There were accentuated 1st sound in 8 cases, 3rd sound in 7, and 4th sound in 5. PMD was classified into 3 types according to the clinical course and pathologic examinations. In type A (6 cases), myocardial infarction (MI) preceded the occurence of mitral regurgitation (MR) by 3 or 4 years, with pathological verification of old MI. In type B (1 case), MR developed during acute MI. In type C (4 cases), pathological examinations disclosed various degrees of myocardial fibrosis, in which clinical diagnosis was MR of unknown etiology. In a total of 113 cases of MI, 36 cases (32%) showed papillary muscle infarction (PMI), which occurred with significantly high incidence in (1) male, (2) large MI, and (3) subendocardial or lateral MI. Among 36 cases of PMI, 9 cases developed PMD, which showed high incidence in inferior MI and in female. Various other factors concerning PMD and PMI were examined, and it was pointed out that not only PMI but also severe lesions in corresponding ventricular wall were necessary for the development of PMD.

A clinicopathological study on mitral ring calcification

The incidence, the size of mitral ring calcification (MRC) and its relation to the mitral valve disease were examined in a total of 600 consecutive autopsy cases of over 60 years of age. (1) The incidence of MRC was 10% (60 cases among 600), and the sex difference was statistically significant with 6.7% in male and 13.3% in female (p less than 0.01). The age was 82 years in average, and an increase of its incidence with aging was significant only in female (p less than 0.005). (2) MRC was found in the annulus of the posterior mitral leaflet. The length of MRC was 12.5 +/- 10.3 mm in male, and 31.8 +/- 23.5 mm in female (p less than 0.01). Large MRC more than 30 mm were found in 1 man and 19 women. (3) The relationship between the length and cross sectional diameter of the MRC showed a positive correlation (r=0.75). Three cases of mitral stenosis or combined stenosis and regurgitation belonged to the extremely large MRC group. (4) There were 27 cases with systolic murmur; 3 holosystolic and 24 ejection type. In large and small MRC groups, systolic murmurs were found in 70% and 33% (p less than 0.05), MRC extending to the anterior leaflet in 65% and 2.5% (p less than 0.005), moderate to severe calcification of the aortic valve in 40% and 20% (n.s.), respectively. (5) X-ray films were examined retrospectively, and large MRC was diagnosed in 85%, and incidence of calcification in the other soft tissues (trachea, bronchi, costal cartilage, aortic arch, thoracic and abdominal aorta) was higher in large MRC group than in the control group (87 cases) without MRC (p less than 0.005).

A study on sinoatrial conduction in the aged

Sinus node response to premature atrial stimulation (PAS) was studied in 30 aged patients (group I:21 cases without sinus node dysfunction, group II:9 cases with sick sinus syndrome). Sinoatrial conduction time (SACT) was calculated according to the method reported by Strauss et al. As coupling interval of PAS decreased, there noted 5 patterns of sinus node response. In Type A, return cycle length (RC) initially increased (fully compensatory pause) and then became constant; RC progressively increased either along the compensatory reference line (Type B1) or along the less-than-compensatory line (Type B2) without being constant. In 2 other cases, RC showed similar pattern as in Type A up to 32-37% of sinus cycle length where they showed abrupt prolongation below or above the compensatory reference line (Types C and D, respectively). The incidence of abnormal response (Types B1, B2, C, and D) was high both in group I (38.0%) and group II (33.3%). The calculated SACT in group I showed a high correlation with basic sinus cycle length, while no correlation was observed in group II. The possible factors influencing return cycle length and significance of frequent observation of abnormal sinus nodal responses in the aged subjects were discussed.

A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation

Diagnosis of disseminated intravascular coagulation (DIC) was made in 64 cases (16.2%) among a total of 395 autopsy cases. There were 31 men and 33 women. Their ages ranged from 31 to 91 years (mean 76.3). Underlying diseases were mainly malignancy and sepsis. Fresh cardiac lesions were found in 40 cases (62.5%). Coronary thrombosis was found in 13 cases (20.3%) and myocardial necrosis in 24 cases (37.5%), with acute myocardial infarction in 9 and focal necrosis in 15. Nonbacterial thrombotic endocarditis was found in 17 cases (26.6%), mural thrombi in 11 (17.2%), and bleeding of the heart in 11 (17.2%). Platelet count, fibrinogen and euglobulin lysis time were not correlated with myocardial necrosis nor coronary thrombosis. Increase of fibrin degradation products correlated with the presence of coronary thrombosis with or without myocardial necrosis. DIC was found with a high incidence in the aged, and many of them were complicated with fresh cardiac lesions. Development of acute myocardial infarction depends on the small thrombi in the severe stenosis of the main coronary arteries or on the multiple microthrombi in the peripheral coronary branches.

A clinicopathological study on the sick sinus syndrome

A total of 6 cases of sick sinus syndrome were presented, including 2 cases of sinoatrial (SA) block and 4 cases of bradycardia-tachycardia syndrome. There were 2 men and 4 women, and their ages ranged from 69 to 91 years. Electrophysiological studies were performed in 3 cases, showing positive overdrive suppression in 1 and normal atrioventricular (AV) conduction in 3. Syncopal attacks were found in 4 cases, and 2 cases died suddenly. Histological examination of the SA node and AV conduction system disclosed (1) marked reduction of the SA nodal muscle fibers by 70 t0 80%, (2) moderate to marked proliferation of connective tissues in the SA node, and (3) moderate fibrosis in part of the left bundle branch. The SA node artery was patent.

Severity of coronary sclerosis in the aged: a pathological study in 968 consecutive autopsy cases

Severity of the coronary sclerosis was estimated in a total of 968 aged cases of consecutive autopsy. Incidence of myocardial infarction was elevated in the high stenotic indices (sum of the coronary stenosis of the 3 vessels). There were 594 cases (61.4%) of balanced stenosis, 238 cases (24.6%) of unbalanced stenosis, and 136 cases (14.0%) of rare type (extreme difference of degree of stenosis between 3 vessels). There were 155 cases (16.0%) of 3 vessel disease, 154 cases (15.9%) of 2 vessel disease, 215 cases (22.2%) of 1 vessel disease, and 444 cases (45.9%) of no significant coronary sclerosis. Incidence of myocardial infarction in these 4 groups was 47.1%, 22.1%, 9.3%, and 2.3%, respectively. The left anterior descending artery was the leading artery in 1 and 2 vessel diseases, followed by the right coronary artery and then the left circumflex coronary artery.

A case of tumor embolism of the coronary artery, resulting in myocardial infarction and cardiac rupture

A case of tumor embolism of the coronary artery in a 78-year-old woman was presented. The tumor embolus originating from cancer of the breast resulted in massive large myocardial infarction in the lateral wall of the left ventricle, and she died of cardiac rupture. Metastatic lesions were found in the bilateral lungs, the endocardial and subendocardial layers of the left ventricle, with a growth of tumor thrombus into the left atrium, and also other extracardiac organs.

A clinicopathological study on the electrical axis of the heart in 1,000 autopsy cases

The electrical axis of the heart in 1,000 aged people more than 56 years of age was classified as normal axis in 58%, left axis deviation in 17.4%, mild left axis devaition in 21.9%, and right axis deviation in 2.7%. Pathological examination disclosed that left axis deviation was associated with myocardial infarction in 20%, right bundle branch block in 16%, but showed no significant relationships with coronary sclerosis, myocardial fibrosis and cardiac hypertrophy. Right axis deviation was associated with right bundle branch block in 66.7% and right ventricular hypertrophy in 22.2%

A clinicopathological study of the heart diseases in the aged. The morphological classification of the 1,000 consecutive autopsy cases

Consecutive autopsy of 1,000 cases of the aged disclosed coronary sclerosis in 428 cases, myocardial infarction in 137, cardiac hypertrophy in 237, valvular heart disease in 120, conduction disturbances in 96, cor pulmonale in 41, pericarditis in 39, and congenital heart disease or anomalies in 28. There were 343 morphologically normal hearts. A total of 1,022 heart diseases were found in 657 cases, corresponding 1.6 heart diseases per one heart. Heart diseases in the aged were divided into (1) those continuing from the younger period and (2) those specifically found in the aged. The latter were non-inflammatory valvular diseases and chronic conduction disturbances. Mitral regurgitation, including mitral ring dilatation (10), mitral ring calcification (9), spontaneous rupture of the chordae tendineae (2) and calcified aortic stenosis (12) and degenerative aortic regurgitation of prolapsed cusp (35) were produced by various degeneration of the connective tissue of the valves. A total of 59 cases of conduction disturbances consisted of complete or advanced heart block (15), right bundle branch block (RBBB) (16), RBBB with left axis deviation (17), and left bundle branch block (LBBB) (11). Forty-seven cases showed main lesions in the branching portion of the AV bundle and origin of the bilateral bundle branches, which were closely related to the degeneration of the central fibrous body and fibrosis at the summit of the ventricular septum. The common field, where the valvular diseases and conduction disturbances occurred, was the fibrous trigone of the heart.