Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases.

Atrial septal aneurysms have been related (either by association or as potential causes) to systolic clicks, atrial arrhythmias, systemic and pulmonary embolism, atrioventricular valve prolapse and atrial septal defect. To study these associations and the incidence of atrial septal aneurysm, we reviewed 80 consecutive patients (female to male ratio 1.9:1, mean age 47 years, range 1 day to 89 years) who had been identified prospectively as having an atrial septal aneurysm. These were found in 36,200 two-dimensional echocardiographic studies (incidence: 0.22% overall; 0.29% in the last year of the study done between 1978 and 1984). Three types of fossa ovalis aneurysm and one type of aneurysm involving the entire atrial septum were observed; a fossa ovalis aneurysm with leftward projection and excursion of less than 5 mm or an aneurysm involving the entire atrial septum with rightward projection was not observed. Atrial septal aneurysm occurred more often as an isolated abnormality than in association with other cardiac malformations, although all patients with an aneurysm involving the entire atrial septum had complex congenital cardiac anomalies of the hypoplastic right heart type. The reported associations between atrial septal aneurysms and atrial septal defect, atrioventricular valve prolapse, midsystolic clicks, atrial arrhythmias and cerebral ischemic events were examined. A hypothesis based on interatrial pressure gradients is proposed to explain the different motions and configurational characteristics of fossa ovalis aneurysms observed in these patients. All patients in whom atrial septal aneurysm is demonstrated should undergo examination for atrial septal defect. Atrial septal aneurysm should be specifically looked for in patients who have these associations and who undergo two-dimensional echocardiography, especially if these abnormalities are unexplained.

Gender-related differences in cardiac response to supine exercise assessed by radionuclide angiography.

This study examines the recently reported gender differences in cardiac responses to exercise. The study group consisted of 192 men and 67 women with a low probability of coronary artery disease who underwent supine exercise radionuclide angiography. Men had a lower rest ejection fraction than that of women (0.63 versus 0.66, p = 0.02) and greater increases in ejection fraction with exercise (0.08 versus 0.02, p = 0.0001). The slope relating ejection fraction to metabolic equivalents of exercise (METs) was greater (p = 0.004) for men, even after adjustment for differences in rest ejection fraction and end-diastolic volume index. Compared with men, women had a smaller rest end-diastolic volume index (87 versus 97 ml/m2, p = 0.003) and a greater increase in end-diastolic volume index with exercise (6 versus -2 ml/m2, p = 0.002). The slope relating end-diastolic volume to METs was greater for women, even after adjustment for differences in rest end-diastolic volume index and peak work load. There are clear gender differences in the supine exercise response of ejection fraction and end-diastolic volume that are not explained by differences in exercise capacity.

The divergent recovery of ST-segment depression and radionuclide angiographic indicators of myocardial ischemia.

This study evaluated the recovery after exercise of both ST-segment depression on the exercise electrocardiogram (electrical evidence of ischemia) and exercise-induced abnormalities in wall motion or ejection fraction as detected by radionuclide angiography. The study group of 31 patients was selected to undergo prolonged electrocardiographic and radionuclide imaging after exercise because they had persistent ST-segment depression greater than 3 minutes after exercise and radionuclide angiographic evidence of ischemia at peak exercise. In 27 (87%) of the 31 patients, radionuclide evidence of ischemia recovered more quickly than the electrocardiogram. Only 15 of the 31 patients had exercise-induced radionuclide abnormalities after exercise. Compared with the 16 patients without such findings of ischemia after exercise, these 15 patients had a worse wall motion score at peak exercise (5.3 vs 3.9; p less than 0.01) and a smaller increase in systolic blood pressure with exercise (p less than 0.05) and after exercise (p less than 0.01). Radionuclide angiographic evidence of ischemia recovers more quickly after exercise than ST-segment depression. When there is radionuclide evidence of ischemia after exercise, it is associated with more severe ischemia during exercise.

Constrictive pericarditis associated with combined idiopathic retroperitoneal and mediastinal fibrosis.

Idiopathic retroperitoneal fibrosis and mediastinal fibrosis are localized expressions of a systemic sclerosing disease of unknown cause which, on rare occasions, may coexist in the same patient. Although pericardial involvement may occur, recurrent constrictive pericarditis that is unrelieved by pericardiectomy has not previously been reported in association with either idiopathic retroperitoneal or mediastinal fibrosis. Reported herein is a case of recurrent constrictive pericarditis that was unrelieved by two pericardiectomies , and autopsy revealed unsuspected combined idiopathic retroperitoneal and mediastinal fibrosis. The clinical, echocardiographic, and pathologic findings are described.

Revival of the transseptal approach for catheterization of the left atrium and ventricle.

Since 1980, use of the transseptal approach to catheterization of the left side of the heart has increased at our institution. In our experience, the transseptal technique has been used most commonly in adult patients with aortic stenosis, in whom the ease of access and the more reliable hemodynamics make it preferable to the retrograde approach. Several recent innovations in equipment and refinement of the transseptal technique have rendered it a safer procedure than was reported in earlier experiences. Specific precautions, however, should be observed in all patients in whom the procedure is attempted and particularly in those with conditions that distort the usual anatomy of the inferior vena cava or atrial septum. Transseptal catheterization is a versatile and relatively safe procedure when it is done by experienced personnel. Because we have noted fewer complications with prolonged experience, we recommend that the procedure be restricted to high-volume cardiac catheterization laboratories that are equipped with biplane fluoroscopy.

Indications for coronary angiography: changes in laboratory practice over a decade.

The indications for coronary angiography have been changing in recent years. To characterize these changes, we examined the records of Mayo Clinic patients referred for 400 coronary angiography procedures in 1973 and 1983 (200 procedures in each study year). We retrospectively assigned patients to one of seven general indication categories to determine the changes in indications used for referral during that decade. We observed a relative increase in angiographic studies related to acute myocardial infarction and percutaneous transluminal coronary angioplasty and a relative decrease in studies for nonspecific chest pain. No change was noted in the relative frequencies of indications related to assessment of anginal chest pain, possible coronary artery disease but no chest pain, assessment after coronary artery bypass grafting procedures, major ventricular arrhythmias, and investigational protocols. We believe that the differences noted primarily reflect the accumulation of new knowledge and new technologic capabilities.

Two decades of cardiac pacing at the Mayo Clinic (1961 through 1981).

Pacemaker procedures performed at the Mayo Clinic for the years 1961, 1971, and 1981 were reviewed to examine the changes that have occurred in a large pacemaker practice during the 2 decades since the advent of pacemaker therapy. Major changes in trends and practice have occurred; in addition to numerical growth, the indications for permanent pacing and the technologic alternatives available have expanded considerably. The increasing choices available today (in all areas of pacemaker practice) provide a challenging stimulus to physicians as they seek the best clinical options in patient care.

Value of radionuclide-determined changes in pulmonary blood volume for the detection of coronary artery disease.

We employed gated equilibrium radionuclide angiography to measure the ratio of pulmonary blood volume at exercise to PBV at rest. We compared this ratio to more commonly utilized ejection fraction measurements in the detection of coronary artery disease. Sensitivity was assessed in 28 patients with angiographically-proven coronary artery disease. Specificity was assessed in 25 patients with a low likelihood of coronary artery disease on the basis of Bayes' theorem. Receiver operator characteristic curves demonstrated that the peak exercise ejection was clearly superior to the PBV ratio in the diagnosis of coronary artery disease. The PBV ratio appears to be less useful for the diagnosis of coronary artery disease than the peak exercise ejection fraction.

Intracavitary cardiac melanoma diagnosed by endomyocardial left ventricular biopsy.

A patient was evaluated for a persistent pericardial effusion and on two-dimensional echocardiography was found to have an intracavitary left ventricular mass. Twenty-two years earlier, a melanoma of the ethmoid sinus had been excised. An electrocardiogram revealed impressive T-wave abnormalities and pathologic Q waves, initially suggestive of "myocardial infarction." However, the coronary arteries were normal at angiography. At catheterization, the left ventricular mass was biopsied, using a transvenous catheter-directed technique, and proved to be a metastatic melanoma. This procedure obviated the need for diagnostic thoracotomy. We believe that this is a unique application of the use of catheter-directed biopsy to make a histologic diagnosis of a left ventricular neoplasm.