Prognosis of patients with a first episode of sustained monomorphic ventricular tachycardia.

AIMS: To evaluate the cardiac mortality in patients suffering from a first episode of sustained monomorphic ventricular tachycardia (SMVT). METHODS: 100 patients less than 75 years old were evaluated during a 50-month follow-up period. Patients were classified into four groups: myocardial infarction, dilated cardiomyopathy, normal heart and miscellany. Seventeen patients underwent a cardioverter-defibrillator implantation, two heart transplant, three aneurysmectomy and 10 other types of cardiac surgical proceedings. RESULTS: Patients with a left ventricle ejection fraction (EF)> or =50% presented a cardiac mortality of 5% compared with 38% of those with EF<50%. Etiology of underlying cardiomyopathy with an EF> or =50% was associated with a cardiac mortality of 5% (normal heart), 5% (myocardial infarction) and 9% (miscellany) compared to those with EF<50%: 33% (dilated cardiomyopathy) and 40% (myocardial infarction). Patients who experienced syncope during the first episode of SMVT showed a cardiac mortality of 31% compared to those 14% (P < 0.05) who did not experience. Patients with syncope, myocardial infarction and EF<50% showed a cardiac mortality of 68%. CONCLUSION: The present study shows that survival after the first episode of SMVT is closely related to EF and the existence of syncope. Patients with myocardial infarction and EF<50% had a worse prognosis when the site was the inferior wall.

In situ right gastroepiploic artery. A conduit for coronary revascularization.

The internal mammary artery is widely recognized as the graft of choice for coronary artery bypass grafting at present. Alternative conduits have been investigated in order to find other adequate long-term grafts. The right gastroepiploic artery has been recently used as a graft to bypass distal coronary vessels. From November 1989 to June 1990, we have implanted this artery in 46 cases. Pedicled grafts were implanted in 20 patients to the main right coronary artery, in 21 patients we grafted the right distal branches, in 3 patients the left anterior descending, and in 2 the circumflex branches. Mean grafts per patient were 3 in this series, with a mean of 2.2 arterial grafts per patient. One patient died in the early postoperative period. The remaining patients had an uncomplicated postoperative evolution. Thirteen patients underwent graft and coronary angiography. Direct or indirect graft patency was confirmed in all cases. The final important issue concerning the long-term patency of this graft will be solved in the future, but short-term patency rates of the right gastroepiploic artery can be anticipated when proper techniques are used.

Intermittent aortic regurgitation following aortic valve replacement.

Intermittent aortic regurgitation is an unusual complication following a mechanical prosthesis replacement in the early postoperative period. Arterial pressure recording and echocardiographic assessment were enough to diagnose the prosthetic dysfunction. Reexploration of the valve confirmed the dysfunction, which was caused by a pannus of previous aortic valve replacement with the pulmonary valve. The pannus impeded normal closure of the leaflet in an intermittent way during diastole. Reorientation of the valve corrected the aortic insufficiency. Doppler ultrasound was a very useful noninvasive technique in order to evaluate the suspected prosthetic valve dysfunction in the immediate postoperative period.

[Doppler analysis of mitral flow in mild to moderate hypertension]. / Análisis de la curva de flujo Doppler mitral en la hipertensión arterial leve a moderada.

We evaluate by Echo-Doppler the left ventricular relaxation disturbance produced by mild to moderate hypertension. It's a comparative study between 15 healthy and 40 patients with hypertension (diastolic blood pressure between 90-114 mmHg and/or systolic greater than 160 mmHg). Echocardiography was performed in all cases and diameters, thickness, volumes, ejection fraction, mass, transmitral flow by Doppler and cardiac output were evaluated . In hypertensive patients the septal and posterior wall thicknesses were significantly higher (1.39 +/- 0.2 cm vs 1.1 +/- 0.1, p less than 0.001 cm. and 1.26 +/- 0.12 cm vs 0.98 +/- 0.1 cm, p less than 0.001), and also the absolute mass and corrected according to corporal surface (339 +/- 58 g vs 203 +/- 44, p less than 0.001, and 185 +/- 34 g/m2 vs 115 +/- 16, p less than 0.001). In transmitral flow Doppler the higher isovolumetric period and lower diastolic filling in the first 1/3 (71 +/- 19 msec vs 53 +/- 20, p less than 0.05, and 35 +/- 5% vs 52 +/- 4%, p less than 0.001) are indicators of relaxation disturbance. A lower deceleration of early inflow and a higher deceleration time (265 +/- 98 cm/sec2/vs 454 +/- 139, p less than 0.001, and 226 +/- 38 msec vs 156 +/- 15, p less than 0.001) show compliance damage. The atrial filling was significantly higher in hypertensive patients (37 +/- 7% vs 20 +/- 8%, p less than 0.001). The E/A ratio, separate both groups but corrected by the age the signification was rather lower.(ABSTRACT TRUNCATED AT 250 WORDS)

[Congenital stenosis of pulmonary veins in the adult]. / Estenosis congénita de venas pulmonares en el adulto.

We report a case of congenital bilateral pulmonary vein stenosis associated with a double-chambered right ventricle, ventricular septal defect and persistence of the ductus arteriosus in a 29 year-old female. The angiographic, echocardiographic and surgical findings are discussed. A precise diagnosis, the utility of the echocardiography and the surgical correction of this type of ostial stenosis is also reported.

[Acute right ventricular insufficiency reversible following anthracycline treatment]. / Insuficiencia ventricular derecha aguda reversible tras tratamiento con antraciclinas.

Anthracyclines are very effective antineoplastic agents for the treatment of acute leukemia. Early and late dose-related cardiotoxicity can occur. We present a 33 year old women who developed a reversible right heart failure fifteen days after receiving a treatment with doxorubicine. Severe regional wall motion abnormalities were appreciated through two-dimensional and Doppler-flow echocardiography, there was no evidence of impaired systolic or diastolic left ventricle function. Two weeks later, remission of acute right ventricle failure was obtained, echocardiographic assessment was normal at this time. Incidence of right ventricle abnormalities after treatment is discussed.

[The efficacy of verapamil in sustained monomorphic ventricular tachycardia]. / Eficacia del verapamilo en la taquicardia ventricular monomorfa sostenida.

We present a 36-year-old male without overt cardiac disease who suffered, since he was 15 years old, from sustained monomorphic ventricular tachycardia of left bundle branch block with a right axis, lasting for several hours; sometimes, syncope was a clinical form of manifestation. Electrophysiologic study, twenty-four hours Holter recording, cardiac catheterization and blood analysis were not useful in order to find its etiology. Efficacy of different drugs, like Mexiletil, Amiodarone, Atenolol and Verapamil (at a dose of 240 mg/day) were tested through multistaged graded-treadmill stress-testing using the Bruce protocol. Ventricular tachycardia was suppressed by administration of Lidocaine. Oral verapamil given at a dose of 360 mg/day prevented the induction of the arrhythmia, the efficacy was tested with maximal treadmill exercise and twenty-four hours Holter recording.

[Propafenone efficacy in preventing supraventricular tachycardia in childhood]. / Eficacia de la propafenona en la prevención de la taquicardia supraventricular en la infancia.

OBJECTIVES: In order to study the efficiency of oral dose of propafenone in preventing childhood supraventricular tachycardias, we have treated 38 children without left ventricular dysfunction. METHODS: The mean age has been 8 +/- 4.7 years old. All of them had suffered at least two episodes of supraventricular tachycardia, and eleven had undergone a previous antiarrhythmic treatment. The initial dose of propafenone has been 6.5 +/- 2.1 mg/kg/24 h (in 3 doses), which has been increased in case of inefficacy. RESULTS: We have not advised neither side-effects, nor proarrhythmic effects, during a follow-up of 13 +/- 6 months. Propafenone has been efficient in preventing supraventricular tachycardias in all patients. The initial dose has been efficient in 17 patients, and we have increased the initial dose up to 11.1 +/- 3.7 mg/kg/24 h in 21 patients. The mean effective dose has been 8.9 +/- 3.6 mg/kg/24 h. We stopped treatment in 14 patients after been 6 months without supraventricular tachycardias. CONCLUSION: From our study, we conclude that propafenone has been efficient in preventing supraventricular tachycardias in childhood with a dose of 8.9 mg/kg/24 h. We have not found side-effects.

[Thrombocytosis and coronary disease. Report of a case]. / Trombocitosis y enfermedad coronaria. A propósito de un caso.

We report the case of a young male with an inferior myocardial infarction who was treated with fibrinolytic agents and displayed a good evolution. The only cardiovascular risk factor that this patient had was an idiopathic thrombocytosis with abnormal platelet hyperreactivity tests. The angiogram showed an eccentric lesion of 60% in the left main coronary artery. A week later, after treatment based on anticoagulants and antithrombotic agents the angiogram was normal, and the lesion had disappeared. The association between these conditions is discussed the therapeutic approach is also discussed. A review of the literature is conducted.

[The 2-dimensional and Doppler color echocardiographic study of a congenital aneurysm of the sinus of Valsalva with a fistula of the right atrium in an adult]. / Estudio con ecografía bidimensional y Doppler en color de un aneurisma congénito del seno de Valsalva con fístula a la aurícula derecha en un adulto.

This report describe a 69-year old woman with a congenital aneurysm of the non-coronary sinus of Valsalva ruptured in the right atrium, causing severe hemodynamic derangement of the right ventricle. The site of the communication between the aneurysm and the receiving chamber was accurately diagnosed by two-dimensional color flow Doppler imaging which provided more valuable preoperative information than conventional aortography.

[Syncope associated with glossopharyngeal neuralgia and parapharyngeal tumor]. / Síncope asociado a neuralgia del glosofaríngeo y tumoración parafaríngea.

The reflex-induced cardiovascular syncope is rarely associated with facial neuralgia and neck neoplasms. We report the case of a male with vasopressor and cardioinhibitor syncopes, despite the implantation of a pacemaker. Because of a glossopharyngeal neuralgia, a neoplasm of the left parapharyngeal fossae is diagnosed. The pathophysiology and the therapeutic approach is discussed.

[Exercise-induced atrioventricular block. Significance of the ischemic component. Report of 4 new cases]. / Bloqueo auriculoventricular inducido por el esfuerzo. Importancia del componente isquémico. Presentación de cuatro nuevos casos.

We report four new cases of exercise-induced atrio-ventricular block (appearing during treadmill exercise testing). The mechanism was ischemia in two patients and the conduction disturbance disappeared after coronary artery bypass grafting. The literature on this matter is reviewed. Also the etiology, the natural history and management are discussed in these cases.

[Late reopening of patent ductus arteriosus after complete closure with the Rashkind prosthesis. Possible traumatic origin]. / Reapertura tardía del conducto arterioso tras cierre completo con la prótesis de Rashkind. Posible origen traumático.

We report the case of a symptomatic adult with an occluded persistent duct with a transcatheter proceeding using a Rashkind prosthesis. After a month of follow up the color-coded Doppler-flow echocardiogram did not show residual shunt, posteriorly the patient's symptoms disappeared and the left ventricular dimensions were reduced. At the thirteen month of follow-up, the patient had an accident while working, falling down from a scaffold. Afterwards, a ductal jet was observed in the echocardiogram with an increased size of the left ventricle, symptoms also appeared. A cardiac catheterism was then performed showing a pulmonary/systemic flow rate of 2 and a 3 mm flow jet at the superior border of the prosthesis. A second prosthesis was implanted with no residual shunts.

[Experience with Palmaz stent in pulmonary branch stenosis]. / Experiencia con el stent de Palmaz en la estenosis de rama pulmonar.

INTRODUCTION AND OBJECTIVES: Since 1989, the balloon expandable Palmaz stent (Johnson & Johnson Interventional Systems) has been used for the treatment of congenital heart disease. This study reports the results and the technique used for its implantation in native and post surgical retraction pulmonary branch stenosis. MATERIALS AND METHODS: From february 1995 to june 1996, we have performed this technique in 11 symptomatic children/adolescents with pulmonary branch stenosis, the mean age was 11 +/- 2 years. Fourteen procedures were made and 16 stents were implanted. The mean condition of the patients was: 7 with tetralogy of Fallot after a previous complete correction, 1 with Noonan syndrome and a surgically corrected atrial septal defect, 1 with pulmonary trunk aneurysm and a previous surgical correction for pulmonary valve and branch stenosis, 1 with pulmonary atresia and an intact septum who underwent a surgical valvotomy and posterior percutaneous valvuloplasty with a good ventricular development, and final was a tricuspid atresia with a previous Waterston anastomosis which produced a stenosis at the right pulmonary branch who underwent a modified Fontan operation with the result of a severe stenosis at the medial and inferior right pulmonary artery. The branch ostium was affected in five cases, and in one case with diffuse hypoplasia of the right branch, the stenosis was at both sites. The stenosis was native in nine cases and post surgery in the other five (2 Waterston, 1 Blalock-Taussig, 1 Fontan). We used the right and/or left femoral vein in all cases except two, in which we used the internal jugular vein. We followed the technique reported by the Boston-Houston experience, with an extra stiff guide and Mullins sheath towards the site of the stenosis. RESULTS: The procedure was effective in all cases except one. The mean pulmonary branch and balloon diameter was 11 +/- 3 mm and 14 +/- 2 mm, respectively, rate 1.2. The stenosis diameter rose from 4.8 +/- 1 to 11 +/- 2 mm (p < 0.001) with a percentage fall from 63 +/- 5 to 2 +/- 1% (p < 0.001). The pressure gradient fell from 30 +/- 5 to 5 +/- 1 mmHg (p < 0.001) and the right ventricle systolic pressure fell from 77 +/- 6 to 48 +/- 3 mmHg (p < 0.01). The mean followup was 10 +/- 3 months, a symptomatic and pulmonary perfusion improvement was seen. After 8 +/- 4 months, we evaluated six patients/nine stents with angiography, and we excluded thrombosis, aneurysms and occlusion of lobar or segmental branches. One case had a proximal stent re-stenosis as it did not cover the whole stenosis, so a new stent was implanted. Three patients/four stents underwent redilatation getting a slightly higher diameter than previously. COMPLICATIONS: One patient had a stent migration and he underwent surgical stent retrieval. CONCLUSIONS: Implantation of the Palmaz stent is a useful procedure for the treatment of native or post-operative pulmonary stenosis. It is possible to apply it to hypoplastic and ostial pulmonary stenosis. We confirm the effectiveness of redilatation at mid term.

[The effect of antihypertensive therapy on left ventricular mass and diastolic filling in light and moderate hypertension]. / Efecto de la terapia antihipertensiva sobre la masa ventricular izquierda y el llenado diastólico en la hipertensión ligera a moderada.

BACKGROUND: To valorate the effect of four antihypertensive drugs on the regression of cardiac mass and diastolic function, by echocardiography-Doppler, in not treated hypertensive subjects. METHODS: 60 mild-moderate hypertensive subjects were studied randomized in four groups of 15 patients each one: enalapril (10-40 mg/d), atenolol (25-100 mg/d), verapamil-retard (120-240 mg/d), alphametildopa (250 mg/8h to 3 g/d). The active drug therapy phase was 6 months, performing echo-Doppler, evaluating posterior-wall and septal-wall thicknesses, ventricular mass index, ratio of early to atrial peak diastolic filling velocity (E/A), the first-third filling fraction and atrial filling fraction. RESULTS: The cardiac mass index decreased with the four drugs: with enalapril from 178 +/- 28 to 155 +/- 29 g/m2 (p < 0.05), with atenolol from 170 +/- 23 to 154 +/- 19 g/m2 (p < 0.05), with verapamil from 180 +/- 27 to 159 +/- 22 g/m2 (p < 0.05) and with alphametildopa from 176 +/- 30 to 142 +/- 22 g/m2 (p < 0.01). The E/A ratio and first-third filling fraction only improved in the atenolol subgroup, from 0.79 +/- 0.13 to 0.97 +/- 0.16 (p < 0.01) and from 36 +/- 5 to 44 +/- 9% (p < 0.01), decreasing atrial filling fraction from 37 +/- 6 to 30 +/- 8% (p < 0.01), without modifying with enalapril (0.74 +/- 0.14 to 0.76 +/- 0.20, 35 +/- 5% to 36 +/- 7%, 38 +/- 5 to 39 +/- 7%, p = NS), verapamil (0.69 +/- 0.12 to 0.74 +/- 0.17, 35 +/- 6% to 36 +/- 8% to 40 +/- 12%, p = NS) neither alphametildopa (0.72 +/- 0.14 to 0.71 +/- 0.21, 34 +/- 5% to 35 +/- 7%, 40 +/- 6% to 41 +/- 9%, p = NS). The heart rate decreased more with atenolol than with the other drugs (61 +/- 15 vs 71 +/- 12, p < 0.01). CONCLUSIONS: In hypertensive patients the decreasing of cardiac mass is not accompanied of improvement of the diastolic function except in patients treated with atenolol, probably due to bradycardia.

Brugada syndrome in a patient with accessory pathway.

Brugada syndrome in a patient with Wolff-Parkinson-White syndrome. We report a 32-year-old man with orthodromic atrioventricular (AV) reciprocating tachycardia using a right posterior accessory pathway. However, his ECG showed ST segment elevation in leads V1 to V3. After successful radiofrequency ablation of his accessory pathway a cardioverter defibrillator was implanted.