The fate of elderly patients discharged from the accident and emergency department of a general teaching hospital

This paper describes the experience of a cohort of elderly patients who were discharged after attending the accident and emergency department of a large Australian teaching hospital. Before-and-after comparisons of aspects of physical functioning revealed a considerable loss of independence in the period immediately after the visit to the hospital. Subsequent hospital admission or death was observed in 30 of the 90 patients studied. It is suggested that elderly patients discharged from the accident and emergency department are at risk and require special consideration and a high index of suspicion in terms of evaluation at the time of presentation. Before discharge, account should be taken of aspects of physical and mental function, social networks, and community supports available to each patient. A lowered threshold for admission is recommended on the basis of the high rate of return found in this study.

Will an orange a day keep the doctor away?

An 80 year old man, who relied on a home based meals-on-wheels service was admitted to hospital with non-specific symptoms, but had clinical and biochemical evidence of scurvy. Subsequently, all new admissions (n=37) to the department over a three week period were assessed for evidence of undernutrition. It was found that 73% had hypovitaminosis C, with 30% having concentrations suggestive of scurvy. There were no significant associations between level of vitamin C and type of accommodation, food provision, or age. The commonest symptom associated with vitamin C deficiency was anorexia, but overall, there was a paucity of clinical signs associated with vitamin C deficiency. The possible associations of vitamin C deficiency in the elderly are discussed.

Acute loss of capture due to flecainide acetate

Antiarrhythmic drugs increase pacing threshold, but this is rarely of clinical significance. Administration of flecainide acetate in a 75-year-old woman with an implanted AAIR pacemaker because of sick sinus syndrome caused an abrupt rise of pacing threshold and failure of pacing. Pacing threshold returned to the normal value a few days after flecainide treatment was stopped.

Lead insertion by supraclavicular approach of the subclavian vein puncture

Total occlusion of the left subclavian vein was diagnosed in a 76-year-old patient, 6 years after implantation of an ICD with VVI pacing backup. Replacement of the ICD included upgrading of the ICD system because of the presence of pacemaker syndrome when the patient was VVI paced. Insertion of an atrial lead through the ipsilateral vein system was made possible by using the supraclavicular approach of the subclavian, enabling puncturing of the left subclavian vein medially to the obstruction.

Stents in total occlusion for restenosis prevention. The multicentre randomized STOP study. The Israeli Working Group for Interventional Cardiology

AIMS

This multicentre randomized study set out to evaluate whether coronary stenting improves the results of successful balloon angioplasty for chronic total occlusion. Balloon angioplasty for chronic total occlusion has a high restenosis rate. Several reports have suggested that coronary stenting may decrease the likelihood of restenosis and reocclusion.

METHODS AND RESULTS

Patients with total coronary artery occlusions who had an optimal PTCA result were randomized either to no further treatment or additional stent implantation. The AVE microstent was used and all patients were scheduled for a 1-, 3-, and 6-month clinical follow-up. Repeat coronary angiography to assess the rate and pattern of restenosis was performed at 6 months or earlier if clinically indicated. Ninety-six patients were enrolled in this study. The mean age was 59. 3+/-10.3 years and 15 were females. Forty-eight patients were randomized to the stent arm, receiving 52 stents (lengths 18-39 mm). Stent implantation was successful in all and there were no major procedure-related complications. Sixty-nine patients (72%) were restudied after 6 months. The binary restenosis rates (50%), in the PTCA arm were 70.9% with a minimal lumen diameter of 1.01+/-0.79 mm compared to 42.1% in the stent arm with a minimal lumen diameter of 1.63+/-1.02 mm (P=0.034). Reocclusion occurred in 7.9% in the stent group compared to 16.1% in the PTCA group. Restenosis in the PTCA group was focal in 88% of patients and occurred at the point of total obstruction (within 5 mm), compared to diffuse instent restenosis, which occurred in 54% of the patients in the stent group.

CONCLUSION

Coronary stenting can significantly decrease the rate of restenosis and reocclusion of total occlusions. As restenosis in the stent group was more diffuse, care should be taken to implant short stents at the site of occlusion.

Failure of left-sided implantable cardioverter defibrillator implantation due to absence of left brachiocephalic vein

Implantation of an implantable cardioverter defibrillator by the transvenous approach was impossible from the left side in a patient with on absence of the left brachiocephalic vein; the left subclavian vein was connected by a large left superior intercostal vein to the accessory hemiazygos vein that joined the azygos vein; then the blood flowed into the superior vena cava. Implantation was successfully attempted using the right-sided venous access.

Effect of isosorbide-5-mononitrate on exercise performance and clinical status in patients with congestive heart failure. Results of the Nitrates in Congestive Heart Failure (NICE) Study

BACKGROUND AND AIMS

Nitrate therapy improves hemodynamics in patients with heart failure, but the chronic effects of oral nitrates on exercise performance and clinical status have not been well studied.

METHODS

Oral isosorbide-5-mononitrate (ISMN) (50 mg once daily) or placebo was administered to 136 patients (NYHA Class 2-3) treated for heart failure, all receiving captopril and most also furosemide. Endpoints were treadmill exercise time at 12 weeks by modified Naughton protocol (primary), with an additional 12-week follow-up period. Secondary endpoints included left ventricular dimensions, ejection fraction, cardiothoracic ratio, functional class, quality of life, hospitalizations and plasma norepinephrine and atrial natriuretic peptide in a four-center substudy.

RESULTS

Intention-to-treat analysis showed that mean change in treadmill exercise duration tended to be greater in patients receiving ISMN than placebo (treatment difference +42 s, 95% CI -5, +90 s at 12 weeks and +21 s, 95% CI -25, +74 s after 24 weeks) (NS). Treatment difference was greater in the prespecified subgroup with ejection fraction 31-40% (+55 s, 95% CI -11, +136 s at 12 weeks and +65 s, 95% CI +3, +147 s) (p = 0.035) at 24 weeks. No deleterious effects (i.e. hypotension) were observed with ISMN, although headache was reported in 19% of the active treatment group (p = 0.0001).

CONCLUSIONS

ISMN added to captopril increased treadmill exercise time in patients with heart failure and a lesser reduction in baseline ejection fraction, although for the group as a whole, the increase in treadmill time was not significant.

[Propafenone dose for emergency room conversion of paroxysmal atrial fibrillation]

Paroxysmal atrial fibrillation (AF), a frequent cause of repeated hospitalization, is effectively treated with propafenone. The time to conversion to sinus rhythm is a consideration when managing AF in the emergency room. We investigated the conversion rates of paroxysmal AF by 3 different oral propafenone (P) regimens, in terms of time to conversion. 188 patients with onset of AF within 48 hours were treated with propafenone (P): 48 received 600 mg as a first oral dose followed after 8 hrs by 150 mg (Group A); 82 received 300 mg as a first dose, followed by the same dose 3 and again 8 hrs later (B); 58 received 150 mg every 3 hrs, up to a total dose of 600 mg (C). P was stopped when sinus rhythm was achieved. Rates of conversion to sinus rhythm after 3 hrs in the 3 groups were: 46%, 41% and 26% respectively; after 8 hrs: 77%, 78% and 70%; and after 12 hrs: 81%, 84% and 76%. Treatment was discontinued in 8. There was excessive QRS widening (> 25% of the basal value) in 1 in group A, 1 in group B and 2 in group C; wide-QRS tachycardia occurred in 4 in group B. In Group A there was a higher rate of early successful conversion, with a lower incidence of side-effects than with the other regimens.

Implantation of permanent dual chamber pacemaker in a pregnant woman by transesophageal echocardiographic guidance

A 37-year-old woman complained of fatigue and dizziness because of intermittent sinus arrest and asystole up to 5.2 seconds. She was 3 months into her pregnancy and a dual chamber permanent pacemaker was implanted by transesophageal echocardiographic guidance.

Aortic valve mass and sudden blindness

Images

Treatment and outcome of patients with acute myocardial infarction and prior cerebrovascular events in the thrombolytic era: the Israeli Thrombolytic National Survey

BACKGROUND

Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE).

METHODS

Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis.

RESULTS

Patients with a PCE (n = 115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n = 1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n = 29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n = 29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and beta-blockers more often than their counterparts (n= 46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64).

CONCLUSIONS

These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE.

Insulation lead failure: is it a matter of insulation coating, venous approach, or both?

Lead insulation material and implant route have a major impact on lead reliability and durability. We compare the incidence of lead insulation failure resulting from both the venous approach and insulation type. Two hundred ninety consecutive leads were followed for a mean period of 57 +/- 30 months; leads with < 1 year follow-up were excluded. There were 116 Silicone Rubber insulated leads and 174 with polyurethane (151 Pellethane 80A and 23 Pellethane 55D) insulation; 279 leads were bipolar and 11 unipolar; 274 leads were implanted in the ventricle and 66 in the atrium. The venous route was the subclavian vein for 170 leads (58%) and the cephalic vein for 120 leads (42%). Insulation failure was diagnosed when a single sign of oversensing, undersensing, failure to capture, early pulse battery depletion, and lead impedance < 250 omega was present. Measurement of lead impedance was performed intraoperatively at implantation and during lead revision or pulse generator replacement. Lead failure caused by conductor coil fracture was not considered. There were 13 lead insulation failures, all among leads with polyurethane insulation (12 Pellethane 80A and 1 Pellethane 55D). Eleven failures (10%) occurred when the subclavian vein and 2 (3%) when the cephalic vein approach was used. The cumulative survival rate of polyurethane and silicone rubber insulated leads was 88.7% and 100%, respectively (P = 0.02); the cumulative survival rate of polyurethane insulated leads was 83.2% when the subclavian vein and 95.1% when the cephalic vein were used (P = 0.03). The mean time to polyurethane lead failure when the subclavian vein approach was used was 54 +/- 17 months and when the cephalic route was 73 +/- 4 months (P < 0.02). By multivariate analysis, the route of entry was found to be a significant variable related to polyurethane insulated lead failure (P < 0.05). At lead revision failure to capture was present in 7, oversensing in 4, and undersensing in 2 instances; impedance was < 250 omega in all cases. Pellethane 80A insulated leads are prone to insulation failure, but more when the subclavian vein is used, rather than the cephalic vein.

Deglutition syncope associated with carotid sinus hypersensitivity

A 78-year-old patient complained of syncope, near syncope, and dizziness when eating; complete atrioventricular block, with ventricular asystole for 3.6 seconds, was recorded on continuous electrocardiographic monitoring. Left and right carotid sinus massage produces sinus arrest and ventricular asystole lasting 6.4 and 4.8 seconds, respectively. These phenomena were prevented by atropine administration. The symptoms were completely relieved by permanent pacing, but the patient died 6 months later because of large cell undifferentiated carcinoma of the lower third of the esophagus.

Implantation of dual chamber pacemaker in a patient with persistent left superior vena cava

A 35-year-old patient underwent permanent pacemaker implantation because of symptomatic sinus bradycardia. During the procedure, persistent left superior vena cava was found. The ventricular lead crossed the tricuspid valve only after curving the stylet to form a loop in the right atrium (RA); subsequently, the curved stylet was changed to a straight one and the lead was positioned and screwed into the right ventricular apex. The atrial lead positioning was possible when the stylet was slightly curved and the lead could reach the anterior wall of the RA. At 18 months, a follow-up revealed normal pacemaker function and stable lead position.

Alterations in connexin expression and cell communication in healing corneal epithelium

PURPOSE

The aim of this study was to examine cell-to-cell metabolite transfer and connexin distribution in the rabbit corneal epithelium, in the stationary state, and during wound healing.

METHODS

Rabbit corneas were wounded with a surgical tool, producing a 3-mm-wide elongated debridement. Corneas were allowed to heal in vivo for up to 45 hours. Monoclonal antibodies against connexins Cx 26, Cx 32, Cx 43, and Cx 50 were used to stain cryostat sections. Cell-to-cell metabolite transfer capacity was assessed by a modification of the scrape-loading technique using lucifer yellow as the organic ion tracer.

RESULTS

The rabbit corneal epithelium contains Cx 43 and Cx 50, localized in the cell's plasma membrane, as shown previously for other species. Cx 26 and Cx 32 are not detectable. Tracer transfer occurred in both basal and suprabasal cell layers. After wounding, the migrating epithelial monolayer lacked Cx 43 and Cx 50. This change was apparent 6 hours after injury and persisted until complete wound closure (approximately 24 hours). The Cx 50 membrane stain was increased elsewhere, in particular in the transition zone between monolayered and multilayered epithelium. Consistent with the expression changes, migrating cells displayed no or minimal cell-to-cell tracer transfer, whereas in the periphery of the wound, tracer transfer was enhanced in comparison to the control specimen.

CONCLUSIONS

Corneal epithelial healing involves biphasic changes in the expression of connexins and cell-to-cell communications. These alterations may be critical for the optimization of the healing response.

[Balloon mitral valvuloplasty]

Since March 1990 we performed 100 balloon mitral valvuloplasties (BMV) in 82 females and 18 males (mean age 37 +/- 1 years; range 16 - 81) Initially we used the single shaft, dual or triple balloon system, while during the past 3 years we have been using the Inoue balloon system with step-wise inflation, monitoring with trans-thoracic echo (TTE) for immediate evaluation of mitral valve area (MVA) and/or severity of mitral regurgitation (MR), with 93% technical success. Hemodynamic data before and immediately after the procedure are in table below: [table: see text] C.O. cardiac output, DGR diastolic gradient, LAP left atrial pressure, MVA mitral valve area; all differences significant, p < 0.05. Acute complications included cardiac tamponade in 4/100; severe, acute MR in 2/100; only 5 were referred for urgent surgery. Neither cardiac tamponade nor severe MR were noted in the past 3 years. There was no periprocedural mortality in the past 5 years. Of 93 patients followed for 27 +/- 6 months (range 0-60), 90 (96%) were in NYHA classes I and II, 5 had late MVR, 2 underwent repeated BMV, and there was 1 death 16 months after the procedure. Immediate hemodynamic improvement followed BMV in most patients with pliable mitral stenosis. The Inoue system, with step-wise inflation and monitoring by TTE, proved to be a safe procedure. Symptomatic improvement continues during more than 4 years of follow-up.

Calcium antagonists and mortality in patients with coronary artery disease: a cohort study of 11,575 patients

OBJECTIVES

This study sought to establish the risk ratio for mortality associated with calcium antagonists in a large population of patients with chronic coronary artery disease.

BACKGROUND

Recent reports have suggested that the use of short-acting nifedipine may cause an increase in overall mortality in patients with coronary artery disease and that a similar effect may be produced by other calcium antagonists, in particular those of the dihydropyridine type.

METHODS

Mortality data were obtained for 11,575 patients screened for the Bezafibrate Infarction Prevention study (5,843 with and 5,732 without calcium antagonists) after a mean follow-up period of 3.2 years.

RESULTS

There were 495 deaths (8.5%) in the calcium antagonist group compared with 410 in the control group (7.2%). The age-adjusted risk ratio for mortality was 1.08 (95% confidence interval [CI] 0.95 to 1.24). After adjustment for the differences between the groups in age and gender and the prevalence of previous myocardial infarction, angina pectoris, hypertension, New York Heart Association functional class, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and current smoking, the adjusted risk ratio declined to 0.97 (95% CI 0.84 to 1.11). After further adjustment for concomitant medication, the risk ratio was estimated at 0.94 (95% CI 0.82 to 1.08).

CONCLUSIONS

The current analysis does not support the claim that calcium antagonist therapy in patients with chronic coronary artery disease, whether myocardial infarction survivors or others harbors an increased risk of mortality.

[Transseptal left heart catheterization: a new application of an old invasive technique]

In this evolving era of balloon mitral valvotomy (BMV), radiofrequency ablation (RF) of left-sided bypass tracts via catheter, and hemodynamic evaluation of aortic mechanical prostheses, there has been renewed interest in transseptal left heart catheterization (TSLHC). In the 3 years 1990-1994, 122 consecutive patients were referred for TSLHC to our institute (which lacks thoracic surgical facilities). 12 patients were excluded; 10 with a LA mass proven by transesophageal echocardiography (TEE), 1 with a vascularized thrombus in the circumflex coronary system and 1 with congenital interruption of the inferior vena cava with azygous continuity. In the remaining 110 cases TSLHC was performed for interventions in 90 cases (82%) of BMV, and for left-sided catheter radiofrequency (RF) ablation in 3 (3%). For diagnostic purposes it was performed in 17 (15%) cases for hemodynamic evaluation of mechanical aortic valve prostheses. Using the Brockenbrough needle, the adult Mullins sheath system (MSS) and single plane fluoroscopy, 100% technical success was achieved. Needle puncture was not needed in 30 (27%) due to direct crossing with the MSS through a stretched foramen ovale. In 2 we had to perform SVC dye injection for better interatrial septum localization. There were no complications when TSLHC was only used for diagnostic procedures. 1 patient had perforation of the LA due to right lower pulmonary vein laceration following septal dilatation. Following stabilization by immediate pericardiocentesis, the patient was transferred for open heart surgery. There were no great vessel perforations, systemic embolization or periprocedural deaths. TSLHC can be performed quite safely with single-plane fluoroscopy without an onsight surgical team, as with an experienced staff this procedure has very low morbidity and mortality.

[The benefit of combined therapy with captopril and nitrates in severe congestive heart failure]

We compared the acute hemodynamic effects of captopril and nitrates in 11 patients with severe congestive heart failure and grade IV cardiac disability. Pressures were measured using a Swan-Ganz catheter system; cardiac output and stroke index were measured by thermodilution, and left-ventricular (LV) volumes and ejection fraction were calculated simultaneously with the hemodynamic measurements from radionuclide ventriculography. Measurements were made in each of 4 treatment states: control, sublingual isosorbide dinitrate (ISDN; 5 and 15 mg), oral captopril (50-200 mg daily) and during combined therapy with captopril and ISDN. Captopril produced a fall in mean arterial pressure (p < 0.01) from 81 +/- 14 to 72 +/- 13 mm Hg and a rise in stroke index from 30 +/- 5 to 35 +/- 91/min/m2 (p < 0.05), while LV ejection fraction increased from 18 +/- 5 to 21 +/- 7% (p < 0.05). ISDN reduced mean arterial, pulmonary arterial, right-atrial and wedge pressure. The combination of captopril and ISDN produced a greater fall in mean arterial pressure, a further rise in ejection fraction to 22 +/- 8% (p < 0.05), a fall in systemic (p < 0.05) and pulmonary vascular resistance (p < 0.01) and a rise in cardiac (p < 0.01) and stroke work index (p < 0.01), while the beneficial effects of ISDN on right-atrial, pulmonary arterial and wedge pressure were again achieved. LV contractility, assessed from end-systolic stress-shortening relations, was essentially unaltered or decreased very slightly. The study showed that combined therapy with captopril and nitrates produced acute hemodynamic benefits superior to those achieved by treatment with captopril or nitrates alone.

Transiliac vein approach to a rate responsive permanent pacemaker implantation

A 60-year-old patient was admitted for elective replacement of a depleted pulse generator. The pacemaker was implanted 5 years before because of sick sinus syndrome and it was connected to an epicardial lead due to total occlusion of the superior vena cava. The pacing threshold of the epicardial electrode was unacceptably high, so an endocardial lead was inserted through the iliac vein. The lead was connected to a VVIR pacemaker, which was located in the abdomen just lateral to the umbilicus. During a 1-year follow-up period, the patient felt well and pacemaker performance was satisfactory.

A Soviet nuclear pacemaker

A Soviet nuclear pacemaker is described. It is a large VOO bipolar pacemaker, probably nonprogrammable. It has unique electrode connectors. No isotope leak or excessive radiation hazard was detected. Because we had no knowledge of its end-of-life markers and because of the impossibility of assuming long-term safety, the device was removed.

[Balloon mitral valvuloplasty during pregnancy]

A 26-year-old woman with severe pliable mitral stenosis underwent successful balloon mitral valvuloplasty at the end of the second trimester of pregnancy. The indication for intervention was severe shortness of breath during most daily activities, despite combined beta-blocker and diuretic treatment (FC III, NYHA). After use of a 2 x 19 bifoil balloon there was significant clinical and hemodynamic improvement. Shortness of breath disappeared, the mean mitral valve diastolic gradient decreased from 24 to 7 mmHg and the mitral valve area increased from 0.8 to 1.8 cm. There were no complications of the treatment, and estimated radiation exposure of the fetus was less than 0.2 rad. Subsequent abdominal ultrasound examination revealed normal fetal functioning. 2.5 months after mitral dilatation delivery was normal. Balloon mitral valvuloplasty may safely be used instead of surgery as a palliative procedure for relief of symptoms in pregnant women with severe pliable mitral stenosis.

Scabies presenting as bullous pemphigoid-like eruption

Several diseases, at times, may be confused with scabies. We report the diagnosis and treatment of scabies in two patients. Their eruptions recurred and persisted and eventually developed blisters. The skin biopsy specimens submitted for light microscopy and immunofluorescence were considered to be consistent with bullous pemphigoid. Both patients were treated successfully with lindane and remained disease free for up to 6 months of follow-up.

[Effect of hemodialysis on hemodynamic assessment and cardiac flows determined by Doppler echocardiography]

25 patients with end-stage renal failure were studied by different echocardiographic techniques before and immediately after hemodialysis using M-mode, 2-dimensional and Doppler echocardiography. Preload reduction after dialysis was manifested by a decrease in body weight, in left atrial diameter and in the left ventricular end-diastolic dimension. Doppler flow patterns immediately after dialysis showed reduction in early diastolic velocities across the atrioventricular valves and increase in the flow velocities across the semilunar valves and the peripheral A-V fistula. The flow velocity integral, calculated by Doppler echocardiography, was lower after dialysis. Significant improvement in left ventricular myocardial function after dialysis was correlated with reduction in afterload and increase in myocardial contractility.

Intermittent to-and-fro murmur in cardiac pseudoaneurysm: Doppler echocardiographic findings

A case is presented in which a to-and-fro murmur was heard at auscultation. Cross-sectional echocardiography, combined with Doppler examination, showed that the murmur was produced by flow across the neck of a left ventricular pseudoaneurysm.

Aortic valve replacement during pregnancy. A case report and review of the literature

Aortic stenosis (AS) is an uncommon complication during pregnancy, but when it occurs it results in significant maternal and fetal morbidity and mortality. We present a gravida with severe AS in which aortic valve replacement was performed in the 3rd trimester of her pregnancy. She had severe AS with mild aortic regurgitation and severe congestive heart failure. Fetal heart rate and uterine activity were monitored and recorded during the operation. The pregnancy was carried uneventfully to term and the patient was delivered of a healthy baby. The literature is reviewed and recommendations are made for the management of AS during pregnancy.

Noonan's syndrome associated with hypoplastic left heart

A case of a week old female baby, admitted because of apathy, hypothermia, dyspnea, jaundice and cyanosis is described. She had the characteristic phenotype of Turner's syndrome with normal karyotype. Signs of severe heart failure were present. Therapy with diuretics, digoxin, dopamine and mechanical ventilation were unsuccessful, and the patient died several hours after her admission. The anatomopathological examination revealed the presence of hypoplastic left heart syndrome with mitral atresia and aortic atresia, atrial septal defect, double outlet right ventricle, and a patent ductus arteriosus.

Intermittent superior caval venous syndrome due to permanent transvenous electrode

A 75-year-old man began suffering from intermittent episodes of superior caval venous syndrome, seven years after implantation of an endocardial pacemaker via the right cephalic vein. The obstruction of the superior caval vein was confirmed by venography and computed tomography of the chest. Changes of the intrathoracic pressure were considered to be the mechanism responsible for the intermittence of the syndrome.

Short-term thrombosis after transvenous permanent pacemaker insertion

In order to assess prospectively the incidence and significance of venous thrombosis early after permanent transvenous pacemaker implantation venographic studies were carried out in 40 consecutive patients. The venograms performed between 1 and 6 months (mean 4 months) after the implantation were normal in 31 patients (77%), in six patients (15%) they showed partial venous obstruction and in three patients (8%) total obstruction. Between 6 and 12 months (mean 9 months) the venograms of five patients, that were previously normal, showed partial venous thrombosis. No changes were found in the venograms performed later. Only two of 14 patients with thrombosis of the great veins was clinically symptomatic and developed arm edema, that resolved spontaneously within about a month. No difference in incidence of abnormal venograms was found according to the type of insulation, the polarity of the electrode and the route of entry.

Cardiovascular malformations in lecanosomatopagus conjoined twins: a cardiologic curiosity

Female conjoined twins were delivered after 42 weeks' gestation, but they died within a few minutes of birth. They were dicephalus, dibrachius and dipus conjoined twins with two separate spines and fusion of the trunk and the pelvis. The pericardial sac was common, and the heart was a single structure. The atrial complex was a common chamber with an attempt at division into two parts by a circular ridge of tissue; the ventricular complex was formed by three chambers which were all communicating between each other in the superior margin of their muscular interventricular septum.

[Severe left heart failure long after acquired arteriovenous fistula]

Gunshot wounds and traumatic injuries are the main causes of acquired arteriovenous fistulas. The high cardiac output associated with such fistulas depends mainly on the size of the pathological communication and the degree of reduction in the systemic vascular resistance that results. Since the findings on cardiac examination in these patients may mimic those of valvular heart disease or dilated cardiomyopathy, careful attention should be paid to noncardiac physical findings, such as thrill and/or continuous murmur over the traumatic or surgical scar. We describe a 64-year-old man who developed severe left heart failure 39 years after a gunshot injury in the left lower quadrant of the abdomen. This had led to an acquired arteriovenous fistula between the left internal iliac artery and the left common iliac vein.

Advantage of combined therapy with captopril and nitrates in severe congestive heart failure

We compared the acute hemodynamic effects of captopril and nitrates in 11 patients with severe congestive heart failure and Grade IV cardiac disability. Pressures were measured using a Swan-Ganz catheter system; cardiac output and stroke index were measured by thermodilution, and left-ventricular (LV) volumes and ejection fraction were calculated simultaneously with the hemodynamic measurements from radionuclide ventriculography. Measurements were made in each of four treatment states: control, sublingual isosorbide dinitrate (ISDN) (5 and 15 mg), oral captopril (50 to 200 mg daily) and during combined therapy with captopril and ISDN. Captopril produced a fall in mean arterial pressure (P less than 0.01) from 81 +/- 14 to 72 +/- 13 mm Hg, and a rise in stroke index from 30 +/- 5 to 35 +/- 91/min per m2 (P less than 0.05), while LV ejection fraction increased from 18 +/- 5 to 21 +/- 7% (P less than 0.05). ISDN reduced mean arterial, pulmonary arterial, right-atrial and wedge pressure. The combination of captopril and ISDN produced a greater fall in mean arterial pressure, a further rise in ejection fraction to 22 +/- 8% (P less than 0.05), a fall in systemic (P less than 0.05) and pulmonary vascular resistance (P less than 0.01) and a rise in cardiac (P less than 0.01) and stroke work index (P less than 0.01), while the beneficial effects of ISDN on right-atrial, pulmonary arterial and wedge pressure were again achieved. LV contractility, assessed from end-systolic stress-shortening relations, was essentially unaltered or decreased very slightly. The study showed that combined therapy with captopril and nitrates produced acute hemodynamic benefits superior to those achieved by treatment with captopril or nitrates alone.

Recurrent sustained ventricular tachycardia solely responsive to verapamil in a patient with a remote myocardial infarction

A 49-year-old man with a silent remote postero-inferior wall myocardial infarction exhibited recurrent episodes of sustained ventricular tachycardia which was hemodynamically well tolerated. Ventricular tachycardia was neither terminated nor prevented by therapy with multiple class I and class III antiarrhythmic drugs. In contrast, ventricular tachycardia was repeatedly terminated within a few minutes following intravenous administration of 10 mg verapamil and did not recur during oral therapy with verapamil (360 mg daily). Electrophysiologic study suggested that ventricular tachycardia was due to a reentrant mechanism rather than to triggered or abnormal automaticity. Thus, in contrast to previous reports, findings in this patient indicate that verapamil may be very effective and safe in certain types of ventricular tachycardia occurring late after a myocardial infarction.

Variant angina induced by biliary colic

A 65 year old woman with gall stones presented with crushing chest pain after an attack of biliary colic. The electrocardiogram showed ST segment elevation in leads I, aVL, and V1-V3 while leads II, III, and aVF showed ST segment depression. Cardiac enzyme activity remained within the normal range. During the next three weeks attacks of epigastric and right hypochondrial pain preceded by crushing chest pain with identical electrocardiogram changes occurred with decreasing frequency. Coronary arteriography showed 60% obstruction of the left anterior descending coronary artery and good left ventricular function. During the next three years the patient complained both of mild abdominal pain, probably biliary colic, and mild effort related angina pectoris without a relation between the two symptoms. It is suggested that the attack of variant angina was triggered by biliary colic through sympathoadrenal discharge causing vasospasm.

Long term survival and late repair of massive cardiac pseudoaneurysm

Myocardial rupture of the left ventricle after an acute myocardial infarction resulted in the formation of a massive pseudoaneurysm in a middle aged man. Cross sectional echocardiography was useful in identifying the defect which was successfully closed at operation nine years after its formation.

Effect of captopril on left ventricular end-systolic pressure-volume and stress-shortening relations in severe cardiac failure

The effects of captopril on cardiovascular dynamics and left ventricular (LV) contractility were studied in 11 patients with severe congestive heart failure and very poor global LV function. Pressures were measured using a flow-guided catheter, cardiac output by thermodilution, and LV contraction and ejection fraction by simultaneous radionuclide angiography. Ventricular loading conditions were altered by sublingual isosorbide dinitrate to facilitate construction of LV pressure-volume and stress-shortening curves. Captopril decreased mean arterial pressure (p less than 0.02) and systemic vascular resistance, while stroke and cardiac index increased in most patients. Left ventricular ejection fraction increased from 18 +/- 5 to 22 +/- 7% (p less than 0.05), but contractility, assessed from end-systolic pressure-volume and end-systolic pressure-shortening relations, was unchanged or decreased slightly. Heart rate and double product also tended to decrease. In contrast, arteriovenous oxygen difference widened and calculated total oxygen consumption increased during captopril therapy (p less than 0.05). The study showed that captopril improved forward blood flow, total oxygen extraction, and LV ejection fraction following the decrease impedance to LV emptying but not at the expense of an increase in ventricular contractility. This makes captopril an attractive drug for patients with end-stage cardiac failure and a severely damaged myocardium.

Paralysis in herpes zoster

Herpes zoster is a relatively common disease which affects predominantly the middle-aged and elderly. The segmentally distributed cutaneous eruption, sensory changes, and pain make up the well known zoster syndrome. Motor loss is another aspect of this syndrome which is less well known but occurs in a significant number of cases, and is probably far more frequent than is recognised because the weakness is readily obscured by pain. Four cases of herpes zoster with motor involvement are described. Two cases had zoster paresis affecting the arm and hand, and one of these had, in limb, and one case had urinary retention owing to an atonic bladder. These cases serve to illustrate many of the clinical features of the zoster syndrome with motor involvement. The significant functional implications of unrecognised motor deficit, particularly in the elderly, are a prominent feature and highlight the importance of early accurate diagnosis and management. The pathogenesis and clinical features of this syndrome are discussed in the literature review.

Prenatal echocardiographic diagnosis of Ebstein's anomaly with pulmonary atresia

Ebstein's anomaly with pulmonary atresia was diagnosed in utero for the first time by fetal echocardiography. The fetus, examined at 35 weeks' gestation, had no extracardiac sonographic evidence of heart failure, but the heart filled the anterior portion of the chest. Two-dimensional echocardiography revealed a huge right atrium. The tricuspid valve, instead of originating from the anulus, was demonstrated as originating from the wall of the right ventricle, thus dividing the ventricle into two parts: the true ventricle and the "atrialized portion" of the right ventricle. These features corresponded with Ebstein's anomaly. Short episodes of supraventricular tachycardia (250 bpm) corresponded with the tachyarrhythmias frequently associated with Ebstein's anomaly. Pulmonary atresia was suspected, as movement of the pulmonary valve could not be demonstrated. The baby was delivered at 40 weeks' gestation and died 3 days later. Postnatal cardiac catheterization and angiocardiography and postmortem examination confirmed the prenatal diagnosis.

Captopril in refractory heart failure: clinical and hemodynamic observations

10 patients suffering from refractory heart failure were treated with an oral angiotensin converting enzyme inhibitor captopril. The etiology of heart failure in 9 patients was related to ischemic heart disease, and to valvular heart disease in 1 patient. All patients experienced subjective improvement and feeling of well-being. The functional capacity improved to class II-IIB. Serial chest X-ray films showed improvement in pulmonary congestion. The time course of the hemodynamic effect appeared to 0.5-1.5 h after intake, and tended to disappear about 6 h later. The optimal dose of the drug achieving maximal hemodynamic benefit without excessive hypotension was 50 mg. Some of the patients exhibited a triphasic response. The cardiac index increased from 1.99 +/- 0.1 to 2.69 +/- 0.151/min/m (p less than 0.001), while pulmonary capillary wedge pressure decreased from 25.3 +/- 5.86 to 13.67 +/- 4.14 mm Hg (p less than 0.001). Mean peripheral arterial blood pressure decreased from 90.06 +/- 3.7 to 71.4 +/- 2.7 mm Hg. The total peripheral resistance decreased from 1,942 +/- 169 to 1,170 +/- 109 dyn X s X cm-5. The total pulmonary resistance decreased from 272.6 +/- 42.9 to 142.34 +/- 13.76 dyn X s X cm-5. Heart rate decreased from 83.4 +/- 10.9 to 70.8 +/- 10.14 bpm (p less than 0.01). During a 6-month follow-up period the beneficial clinical effects of captopril were sustained, without late vasodilator tolerance. 1 death, unrelated to captopril, occurred. 2 patients developed transient rash, and 1 experienced transient dysgeusia.

An unusual case of mitral valve aneurysm: two dimensional echocardiographic and cineangiocardiographic features

A patient is described in whom an aneurysm of the posterior mitral leaflet caused severe mitral incompetence and cardiac failure. The aneurysm was seen as an additional echo-free space within the left atrium in the real time two dimensional echocardiogram. Both echocardiographic and cineangiocardiographic appearances were misinterpreted initially because the aneurysmal leaflet did not more into the left ventricle during diastole. This feature was explained during the successful surgical repair of the valve by the observation that the aneurysm was adherent to the left atrial wall.

Post-infarction ventricular septal rupture combined with acute right ventricular infarction. A case report

An elderly White woman suffering from an acute transmural inferior myocardial infarction, with possible true posterior extension, is presented. Her holosystolic cardiac murmur and hypotension are attributed to rupture of the interventricular septum which occurred between the 2nd and 3rd days after infarction. Strong evidence for concomitant right ventricular infarction is put forward and therapy is discussed. As far as the authors can determine, this combination of cardiac lesions has not been documented ante mortem previously. The apparent beneficial use of intravenous hydrallazine, for the first time in right ventricular infarction, is discussed.