Right atrial-esophageal fistula and hydropneumopericardium after esophageal dilation.

Esophagoatrial fistula formation is a rare and heretofore fatal event. A patient presented with esophageal reflux and stricture that later developed into a right atrial-esophageal fistula during biweekly esophageal dilation. Clinical recognition and surgical therapy led to a successful outcome. There were several unique features of this case, including fistulous connection to the right rather than the left atrium, concomitant hydropneumopericardium and esophagoatrial fistula, occurrence during esophageal dilation and surgical cure.

Silent ischemia during coronary occlusion produced by balloon inflation: relation to regional myocardial dysfunction.

Thirty patients with stable exertional angina undergoing percutaneous transluminal coronary angioplasty of an isolated obstructive lesion of the proximal left anterior descending artery were prospectively evaluated to investigate the relation between angina induced by balloon inflation and the quantity and severity of myocardial ischemia as determined by electrocardiographic (ECG) monitoring and by echocardiographic assessment of regional and global left ventricular wall motion. Anginal pain interviews, continuous two-dimensional echocardiographic recordings and 12 lead ECG recordings at 10 second intervals were obtained for the first two inflation sequences. Seventeen patients had angina with both inflations (symptomatic group), seven patients had no angina or related symptoms during either inflation (asymptomatic group) and six patients had both painful and painless inflations (mixed response group). Comparison of the three groups revealed that they did not differ in mean age, sex distribution, prior history of angina or the incidence of comorbid conditions. Echocardiographic measurements of global and regional left ventricular dysfunction during balloon inflation were comparable in the symptomatic and asymptomatic groups. Similarly, there were no significant differences in the time to onset or magnitude of ST segment changes. The results of the wall motion and ECG studies in the mixed response group paralleled the results in the symptomatic and asymptomatic groups, with no significant differences in any of the variables measured between the painful and painless inflations. These data demonstrate that silent myocardial ischemia occurs in an appreciable proportion of patients during coronary angioplasty and the absence of angina does not imply that a lesser amount of myocardium is jeopardized than with painful inflations.

Resetting of ventricular tachycardia: implications for localizing the area of slow conduction.

Analysis of local endocardial electrograms recorded during reentrant ventricular tachycardia does not provide direct information as to the participation of the recording site in the tachycardia circuit. To determine if programmed electrical stimulation at the recording site can assist in localizing areas of slow conduction that are participating in the tachycardia circuit, seven patients with sustained monomorphic ventricular tachycardia were studied. The cardiac cycle was scanned with single stimuli delivered during ventricular tachycardia at multiple endocardial sites. In four patients, an endocardial site was identified at which stimuli advanced the tachycardia with marked conduction delay and without alteration of the ventricular activation sequence, as indicated by a lack of change in the configuration of the QRS complex and endocardial electrograms distant from the stimulation site. This finding was seen only during stimulation at sites displaying abnormal electrograms and is consistent with premature depolarization of an area of slow conduction within the tachycardia focus by stimuli delivered at or near that area. Attempted endocardial catheter ablation at or adjacent to these sites in three patients was followed by persistent noninducibility of ventricular tachycardia in one patient, marked modification of the configuration and cycle length of inducible tachycardia in one patient and transient noninducibility of tachycardia in one patient. Programmed electrical stimulation during ventricular tachycardia at sites with abnormal electrograms may provide information about the proximity of the stimulation site to the tachycardia circuit.

Regional myocardial dysfunction during coronary angioplasty: evaluation by two-dimensional echocardiography and 12 lead electrocardiography.

Balloon inflation performed during percutaneous transluminal coronary angioplasty causes transient total occlusion of the coronary artery and thus provides a model for evaluation of the regional myocardial responses to transient ischemia. Twenty patients with normal left ventricular function undergoing angioplasty of isolated stenosis of the proximal left anterior descending coronary artery were studied. In group A (14 patients) analysis of one inflation-deflation sequence per patient was performed. Group B (six patients) had multiple (greater than 5) inflations; the first and last sequences were analyzed. Assessment included continuous two-dimensional echocardiography with computerized quantitative analysis of regional left ventricular wall motion, and continuous 12 lead electrocardiographic recordings. The mean duration of inflation in group A was 62 +/- 6 seconds (mean +/- SD). The onset of regional left ventricular dysfunction was 12 +/- 5 seconds after inflation. Profound dysfunction was noted in all patients. After 60 seconds of balloon occlusion of the coronary artery, 29% of patients had severe hypokinesia of the ischemic region and 71% had akinesia or dyskinesia. With deflation there was prompt recovery of regional function, with full recovery at 43 +/- 17 seconds. Comparison of data from first and last inflations in group B revealed no significant differences in time to onset of dysfunction, magnitude of dysfunction or time to complete recovery of function. The onset of ischemic electrocardiographic changes lagged behind the onset of wall motion abnormalities, with only 64% of patients showing evidence of ischemia on 12 lead electrocardiograms at 20 seconds of inflation. After 60 seconds, 86% had ischemia detectable by electrocardiography. Thus, balloon inflation during coronary angioplasty leads to profound but reversible regional left ventricular dysfunction. Repeated occlusions of the coronary artery during angioplasty do not have a cumulative ischemic effect. It may be hazardous to apply these findings to patients who have underlying major left ventricular dysfunction and in whom the reversibility of dysfunction and lack of cumulative ischemic effect may not be assured.

Fractionated endocardial electrograms are associated with slow conduction in humans: evidence from pace-mapping.

Fractionated ventricular electrograms recorded during catheter mapping may arise from areas of asynchronous depolarization associated with slow conduction, the substrate for reentrant ventricular tachycardia, but can also be a nonspecific abnormality or even artifact. To determine whether fractionated sinus rhythm electrograms are associated with slow conduction in humans, the results of endocardial catheter mapping and pacing at 133 endocardial sites in 13 patients were analyzed. Eleven patients had sustained monomorphic ventricular tachycardia and two patients had old myocardial infarction without ventricular tachycardia. Functional evidence of slow conduction at the recording site was assessed by pacing at that site and measuring the interval between the stimulus artifact (S) and the onset of the QRS complex in the 12 lead electrocardiogram (ECG). During pacing at 89 of 90 sites without fractionated sinus rhythm electrograms, the S-QRS interval was less than 40 ms, a value consistent with rapid propagation of the stimulated wave front away from the pacing site. During pacing at 21 (49%) of 43 sites with fractionated sinus rhythm electrograms, the S-QRS interval was greater than 40 ms (range 40 to 140), consistent with slow conduction at the pacing site (p less than 0.001 versus nonfractionated sites). In 9 of the 11 patients with ventricular tachycardia analysis of the paced QRS configuration, electrograms during induced ventricular tachycardia or programmed stimulation during tachycardia suggested that a site with a long S-QRS interval during pacing was located at or near a ventricular tachycardia circuit. Therefore, fractionated sinus rhythm electrograms are often associated with slow conduction, which may be the substrate for reentrant ventricular tachycardia.(ABSTRACT TRUNCATED AT 250 WORDS)

Infection with CDC group DF-2 gram-negative rod: report of two cases.

Two patients had bacteremia with Center for Disease Control group DF-2 Gram-negative rods. Previously described patients infected with this organism had clinical syndromes including cellulitis, meningitis, and endocarditis, and generally were severely ill. One of our patients had acute oligoarticular arthritis. The other had fever, headache, malaise, and a generalized rash. In neither case was bacterial infection considered likely at onset, and neither patient received antibiotic therapy. Both patients recovered completely. The organism is a fastidious Gram-negative rod that only recently has been characterized. Methods for isolating and identifying the organism are reviewed. The spectrum and frequency of illnesses caused by this organism are probably greater than previously recognized.

Percutaneous transluminal coronary angioplasty of the "culprit lesion" for management of unstable angina pectoris in patients with multivessel coronary artery disease.

The efficacy of 1-vessel percutaneous transluminal coronary angioplasty (PTCA) directed at the presumed angina-producing stenosis, or "culprit lesion," in the treatment of unstable angina pectoris and multivessel coronary artery disease (CAD) was assessed in 27 patients with unstable angina refractory to optimal medical therapy. Eighteen patients had 2-vessel and 9 had 3-vessel CAD. The culprit lesion was identified in all patients by analysis of the qualitative appearance of the coronary lesions and detection of angiographic evidence of plaque fissuring or coronary thrombosis. Intracoronary filling defects were evident in 26% and eccentric stenoses with irregular edges were noted in 41% of patients. Subtotal obstructions were seen in 33%. Confirmation of the identity of the culprit lesion was also available in 78% of patients by analysis of the pattern and distribution of spontaneous electrocardiographic changes. The PTCA primary success rate was 89%, with no procedure-related complications. All patients in whom PTCA was successful had immediate resolution of their unstable angina. Follow-up of the successfully treated patients after a mean of 16 months (range 12 to 20) showed maintenance of long-term clinical improvement, with only 17% of patients having recurrent angina. These data suggest that 1-vessel PTCA of the culprit lesion may serve as a feasible therapeutic option in the treatment of selected patients with multivessel CAD and unstable angina.

Intact systolic left ventricular function in clinical congestive heart failure.

Clinical congestive heart failure (CHF) is traditionally associated wtih significant left ventricular (LV) systolic dysfunction. Over a 1-year period, 58 patients with CHF and intact systolic function (LV ejection fraction [EF] 62 +/- 11%) were identified. An objective clinical-radiographic CHF score was used to document the clinical impression. Based on radionuclide evaluation of peak filling rate, 38% of these patients were found to have a significant abnormality in diastolic function as measured by peak filling rate (less than 2.50 end-diastolic volume/s). An additional 24% of the patients had probable diastolic dysfunction with borderline abnormal peak filling rate measurements (2.5 to 3.0 end-diastolic volume/s). The disease states most frequently associated with CHF and intact systolic function were coronary artery disease and systemic hypertension. During a 3-month sampling period 42% of patients with clinical diagnosis of CHF referred to the nuclear cardiology laboratory were found to have intact systolic function; thus, intact systolic function is not uncommon in patients with clinical CHF. Abnormal diastolic function is the most frequently encountered mechanism for the occurrence of CHF. Definition of systolic and diastolic function appears relevant for development of optimal therapeutic strategies for the treatment of patients with CHF.

Cardiovascular evaluation of adolescents and young adults. Salient aspects of the examination.

Cardiac findings in adolescents and young adults are usually normal, and most murmurs and other abnormalities that are found are benign. However, the primary care physician needs to obtain a complete personal and family history and perform a thorough physical examination to rule out cardiovascular disease and its precursors. Of primary concern are a personal or family history of syncope, family history of sudden death, and several pathologic murmurs such as those caused by mitral valve prolapse and hypertrophic cardiomyopathy. The physician may need to reassure the patient until a definitive diagnosis is made and can also provide accurate information on cardiac disease prevention.

Prevention of ischemia during percutaneous transluminal coronary angioplasty by transcatheter infusion of oxygenated Fluosol DA 20%.

Catheter balloon inflation performed during percutaneous transluminal coronary angioplasty (PTCA) results in temporary interruption of coronary blood flow and subsequent myocardial ischemia. This produces transient but profound regional left ventricular dysfunction. In an effort to mitigate this inflation-related dysfunction, oxygenated Fluosol DA 20%, a perfluorochemical oxygen transport fluid, was infused distal to the balloon through the central lumen of the dilating catheter during balloon inflation. Regional wall motion during PTCA was assessed by simultaneous continuous two-dimensional echocardiography and was quantified by computer analysis. During control inflations accompanied by no intracoronary infusion or by transcatheter infusion of Ringer's lactate solution or nonoxygenated Fluosol DA 20%, there was profound regional left ventricular dysfunction with a greater than 90% decrease in regional contraction. In contrast, regional contraction during transcatheter infusion of oxygenated Fluosol DA 20% remained at normal levels throughout balloon inflation. Distal infusion of Fluosol DA 20% during balloon inflation is a useful adjunct to PTCA, allowing longer inflation times and perhaps permitting PTCA to be performed safely in patients with significant myocardium at ischemic risk or with limited left ventricular reserve for whom the procedure is currently believed to be too hazardous.

Complicated atherosclerotic lesions: a potential cause of ischemic ventricular arrhythmias in cardiac arrest survivors who do not have inducible ventricular tachycardia?

Sudden cardiac death that is not due to acute myocardial infarction may be due to primary ventricular tachycardia or to an arrhythmia secondary to a transient episode of ischemia. The purpose of this study was to determine if the incidence of complicated coronary lesions, which may be a cause of unstable ischemic syndromes, is increased in survivors of an aborted sudden death, especially those without ventricular tachycardia inducible by programmed ventricular stimulation. Nineteen consecutive survivors of an aborted sudden death not due to an acute infarction who underwent coronary angiography and programmed ventricular stimulation within 3 weeks of the event were matched for age, sex, previous infarction, and severity of coronary artery disease with 38 control patients with stable coronary artery disease. There was no difference in the incidence of complicated coronary lesions between the total group of sudden death victims and controls (47% vs 42%). However, 6 of the 11 (64%) sudden death patients who did not have inducible ventricular tachycardia had a complicated lesion as compared to only two of the eight (25%) patients with inducible ventricular tachycardia (p = 0.10). Angiograms identified a complicated lesion or functioning myocardium supplied only by collateral vessels as possible sources of transient ischemia in 73% of noninducible sudden death patients and in 25% of inducible sudden death patients (p = 0.04). Thus coronary angiography in cardiac arrest survivors who do not have inducible ventricular tachycardia often suggests a possible mechanism of transient ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic and discoid lupus erythematosus: analysis of pulmonary function.

To determine the prevalence of pulmonary dysfunction in lupus erythematosus, 24 patients with systemic lupus erythematosus (SLE) and 5 patients with discoid lupus erythematosus (DLE) were studied. Diffusing capacity for carbon monoxide was abnormal in 17 (71 percent) SLE patients. A restrictive ventilatory defect was present in 6 (25 percent) and arterial hypoxemia in 4 of 23 (17 percent). The mean ratio of forced expiratory volume in one second to forced vital capacity (FVC) was 83 percent. To test for the presence of small airways disease, maximum expiratory flow rate at 50 percent of FVC was measured on air and on an 80 percent helium-20 percent oxygen mixture. Ten patients (5 smokers and 5 nonsmokers) with SLE were nonresponders to helium suggesting small airways disease. Pulmonary dysfunction was present in 90 percent (9/10) of SLE patients with a previous history of pleuritis and/or pneumonitis, and in 71 percent (10/14) without respiratory symptoms or history of lung disease and with a normal chest radiograph. Pulmonary function tests were normal in DLE patients except for an abnormal response to helium and/or mild arterial hypoxemia in two patients, all of whom were smokers. These data indicate that there is a high prevalence of pulmonary function abnormalities in SLE including patients without clinically evident pleuropulmonary disease.

Myocardial dysfunction during percutaneous transluminal coronary angioplasty.

Balloon inflation during percutaneous transluminal coronary angioplasty (PTCA) transiently occludes the coronary artery, causing temporary ischemia. In patients without collaterals, regional hypokinesis of the ventricular myocardium at risk occurs within the first 20 seconds and persists throughout balloon inflation. Early PTCA procedures were performed with brief balloon inflations, but the desire to improve procedural results has led many operators to extend balloon inflation times to 45 seconds or longer. Although the ischemic indicators of pain and electrocardiographic changes are commonly noted with these longer inflations, actual hemodynamic consequences are often obscured by physiological compensation. The PTCA-induced ischemic period is often too short to measure changes in cardiac output by conventional methods, but it is increasingly evident that profound regional myocardial dysfunction, in fact, occurs. Continuous two-dimensional echocardiography with quantitative assessment of regional wall motion and ejection fraction is particularly effective in detecting the location, extent, and temporal change of ischemic regional contractile dysfunction. Echocardiographic recordings during baseline, ischemia, and post-balloon-deflation periods permit examination of PTCA-caused alterations in ejection fraction and ventricular volumes and allow the use of testing techniques aimed at mitigation of ischemia.

Preservation of left ventricular ejection fraction during percutaneous transluminal coronary angioplasty by distal transcatheter coronary perfusion of oxygenated Fluosol DA 20%.

The cardioprotective efficacy of coronary perfusion during angioplasty was evaluated. Forty-two patients underwent transcatheter infusion of oxygenated Fluosol DA, 20% emulsion (FDA-20), a perfluorocarbon oxygen transport fluid, into the distal coronary artery during balloon inflations. Left ventricular function was continuously monitored by two-dimensional echocardiography, and left ventricular ejection fraction was quantitatively analyzed from the video record by an area-length method with a validated computer algorithm. Each patient had multiple nonperfused and perfused balloon inflations lasting more than 45 seconds. Nineteen of the 42 patients also received control solutions of oxygenated Ringer's lactate and nonoxygenated FDA-20. The ejection fraction of nonperfused sequences fell from a baseline value of 57 +/- 15% to 36 +/- 14% at 45 seconds of inflation time (p less than 0.0005). Falls of similar magnitude were seen in the lactated Ringer's and nonoxygenated FDA-20 perfused balloon inflations. The ejection fraction fall was associated with a 54% rise in end-systolic volume (p less than 0.0005) and a 4% rise in end-diastolic volume (p = ns) compared to baseline. Inflations perfused with oxygenated FDA-20 showed a 45-second, left ventricular ejection fraction of 53 +/- 13% (p = ns compared to baseline), which was significantly greater (p less than 0.0001) than the 45-second ejection fraction of the nonperfused, or control solution perfused sequences. Results indicate that the profound fall in ejection fraction occurring during percutaneous transluminal coronary angioplasty can be ameliorated by distal coronary perfusion with an oxygenated perfluorocarbon emulsion.

Detection of coronary artery disease with positron emission tomography and rubidium 82.

Myocardial blood flow was evaluated in 31 subjects with not only visual but also, for the first time, circumferential profile analysis of rubidium 82 (82Rb) images acquired with positron emission tomography. Fifteen were control subjects and 16 subjects had significant coronary artery disease, defined as 50% or greater diameter stenosis in a major coronary artery or a first-order branch. Simultaneous 82Rb images at three myocardial levels were obtained before and after intravenous dipyridamole plus handgrip stress. In patients with significant coronary artery disease, visual analysis correctly identified significant disease in 26 (76%) of 34 arteries and its absence in 12 (86%) of 14 normal arteries. According to circumferential profile analysis, these numbers were 91% and 86%, respectively. Thus circumferential analysis of 82Rb images, obtained before and after intravenous dipyridamole plus handgrip stress, yielded improved sensitivity and comparable specificity compared with visual analysis.