Coronary arterial bypass operations without antibiotic coverage.

In this study, six of 693 consecutive patients in 29 months who underwent only myocardial revascularization, without prophylactic systemic therapy with antibiotics, experienced infection of a clean wound. This incidence of infection (0.86 percent) in such patients is the lowest reported in the literature. Prevention of infection of clean mediastinal wounds in patients undergoing only myocardial revascularization is related to preoperative preparation of the skin and local antibiotic irrigation of the wound, rather than to prophylactic systemic therapy with antibiotics.

Blind atrial pacing for patients with sinus node disease who develop atrial fibrillation during permanent pacemaker implantation.

During a 6-year period, six of 110 patients implanted with AAI pacemakers for sick sinus syndrome developed atrial fibrillation at the time of pacemaker implantation (5.5%). In all cases a passive fixation lead was sited in the right atrial appendage, its stability being ensured by rotation of the lead and phrenic nerve stimulation excluded by pacing at 10 V. One patient remained in chronic atrial fibrillation. In the other five, who subsequently reverted to sinus rhythm, atrial P-wave sensing and lead threshold values were satisfactory, allowing programming of the pacemaker output down to 2.5 V to conserve the battery. One out of these five patients continued to have intermittent atrial fibrillation. We conclude that in sick sinus syndrome, atrial fibrillation complicates AAI pacemaker implantation procedure in 5.5% of cases. As an alternative to an unplanned general anaesthetic to cardiovert the patient, it is reasonable to implant an atrial lead in the right atrial appendage in the expectation of a spontaneous reversion to sinus rhythm with a good lead threshold and P-wave sensing. In contrast to inappropriate pacing of the right ventricle in VVI mode, this strategy avoids pacemaker syndrome and reduces the risk of subsequent attacks of atrial fibrillation.

A case of spontaneous hypothermia.

It is important to recognise any condition, however rare, which can be cured. We report a case of chronic hypothermia and its dramatic response to treatment.

Failure of Quintech Tx pacemaker caused by loss of stimulus-T interval shortening during exercise.

A 74 year old man with a Quintech Tx pacemaker experienced a reduction in his exercise capacity because his heart rate failed to increase with effort. This was shown to be caused by the failure of the interval between the delivered stimulus and evoked T wave to decrease during effort where previously it had done so. Although the stimulus-T interval did not change during exercise, it did decrease in response to isoprenaline infusion and in response to pacing the heart at increasing rates. Catecholamine concentrations increased during exercise and the patient had normal thyroid function.

A health centre E.C.G. services: its use and abuse.

An average of 10-5 E.C.G.s were recorded weekly in a health centre used by 32 general practitioners serving a population of almost 65,000. The main indication for an E.C.G. was chest pain (73%). 47% of the E.C.G.s were abnormal. A change in clinical diagnosis occurred in 28% of cases and in patient management in 16%. A significant number of these changes were unwarranted, however. It is recommended that the E.C.G.s should be recorded by suitably trained nurses and reported by a specially trained general practitioner. Further education of general practitioners in the clinical use of the E.C.G. is required.

Phenol sympathectomy in the treatment of intermittent claudication: a controlled clinical trail.

Twenty-five patients with intermittent claudication were randomly allocated to treatment either by injection of phenol into the lumbar sympathetic chain or by injection of local anaesthetic subcutaneously. On the day after the injection, sympathectomy, assessed by skin temperature change, was achieved in 85 per cent of the phenol group. At 1 month subjective improvement was claimed by 45 per cent of the patients in the sympathectomized group and by 64 per cent in the control group; at 3 months the figures were 25 and 45 per cent respectively. Treadmill testing at two exercise loads showed no significant difference in claudication distance or stopping time between the two groups. Calf blood pressure response following exercise was not affected by sympathectomy. There is no subjective or objective evidence that phenol sympathectomy improves intermittent claudication.

Exercise testing in the diagnosis of sick sinus syndrome in the elderly: implications for treatment.

Twenty-three elderly patients underwent treadmill exercise testing to fatigue; 11 patients had sick sinus syndrome (7 males, 4 females; age range 71-91 years; mean, 78 years); 12 elderly persons were controls (5 males, 7 females; age range 70-93 years; mean, 76 years). All were euthyroid. The study showed that patients with sick sinus syndrome compared with the control group demonstrated a lower resting heart rate, a smaller increase in heart rate during exercise, poorer exercise tolerance, and differences in heart rate during the recovery phase. The value of the effort test in relation to the diagnosis of sick sinus syndrome is discussed, together with its possible implications in the choice of pacemaker.