Paradoxical embolism with a patent foramen ovale and atrial septal aneurysm.

Patent foramen ovale (PFO) and atrial septal aneurysm have been cited as potential risk factors for cryptogenic stroke. We present two cases which we propose to directly illustrate paradoxical embolisation as a mechanism of cerebrovascular accident. The diagnosis of PFO is discussed and the literature reviewed.

Predicting mitral regurgitation following percutaneous mitral valvotomy with the Inoue balloon: comparison of two echocardiographic scoring systems.

BACKGROUND: Percutaneous balloon mitral valvotomy (PBMV) has become the procedure of choice for many patients with symptomatic mitral stenosis. However, the development of significant mitral regurgitation (MR) remains an infrequent but very important complication. The echocardiographic scoring system described by Padial et al. has been successful in predicting the development of severe MR following PBMV using the double balloon technique. HYPOTHESIS: We aimed to assess the applicability of this new scoring system in predicting a significant increase in MR with the Inoue balloon and to compare it with the established Wilkins score. METHODS: The echocardiograms of 23 patients who had undergone PBMV for symptomatic mitral stenosis were analyzed retrospectively using both scoring systems, and the severity of MR was determined from pre- and postprocedural studies. RESULTS: Post PBMV, significant MR occurred in four patients (17%) while severe MR occurred in two patients (9%). Padial scores [mean (standard error of the mean)] in the group of patients with and without significant MR were [9.1 (0.8)] and [6.0 (0.3)], respectively (p = 0.002), while the Wilkins score was [7.5 (1.0)] and [6.4 (0.5)], respectively (p = 0.3). Using 8 as a cutoff point, the sensitivity and specificity of the newer scoring system was 83 and 100%, respectively, while the sensitivity and specificity of the Wilkins score was 50 and 50%, respectively. The positive predictive value > 8 was 100% (4/4) for the Padial and 25% (1/4) for the Wilkins system. Accordingly, the negative predictive value < 8 was 89% (17/19) for the Padial and 73% (14/19) for the Wilkins system. CONCLUSION: The newer scoring system is better at reliably identifying patients at risk of developing significant MR from PBMV with the Inoue balloon.

Comparison of Iotrolan 320 and Iohexol 350 in cardiac angiography: a randomised double-blind clinical study.

OBJECTIVE: A double-blind randomised study was conducted in two British centres, to evaluate the safety, tolerance and efficacy of the new dimeric non-ionic contrast medium Iotrolan 320 in comparison with the monomeric non-ionic compound Iohexol 350 in coronary angiography. METHODS AND MATERIAL: 120 patients were randomised to receive either Iotrolan at a concentration of 320 mgI/ml or Iohexol at a concentration of 350 mgI/ml, during selective coronary angiography and left ventriculography. The variables measured were: maximum increase of the left ventricular end-diastolic pressure up to 6 min after ventriculography, haemodynamic and electrocardiographic variables, arrhythmogenicity, clinical laboratory parameters, tolerance, adverse events and efficacy. RESULTS: Iotrolan resulted in a smaller change of left ventricular end-diastolic pressure compared to Iohexol, but the difference was not statistically significant. Transient changes in left ventricular systolic pressure, intra-arterial systolic pressure, intra-arterial diastolic pressure, and in electrocardiographic parameters, occurred after the injections, but they were not clinically significant. Changes in the clinical laboratory markers from baseline values were comparable between the two groups and confirmed good renal and hepatic tolerance. During the left ventriculogram, Iotrolan resulted in less symptoms compared to Iohexol (P = 0.002). Adverse events, which were mild or moderate in most cases, were observed with no statistical difference between the two agents. The contrast quality of both agents was good with no statistical difference. CONCLUSION: This study did not show a significant difference between Iotrolan 320 and Iohexol 350 with regard to cardiovascular safety or patient tolerance, except for a minor difference in the intensity of heat/warmth sensation.

Screening for atrial fibrillation in primary care.

OBJECTIVE: To investigate a population of elderly people for atrial fibrillation and to determine how many of the cases identified might benefit from treatment with anticoagulants. METHODS: From a practice of four primary care physicians, 1422 patients aged 65 years and over were identified, of whom 1207 (85% of the total population) underwent electrocardiographic screening to detect the presence of atrial fibrillation. Patients with the arrhythmia were further evaluated by echocardiography and interview, to stratify their risk of stroke based on echocardiographic and clinical risk factors, their perceived risk from anticoagulation, and their attitude towards this treatment. Their primary care physician was also interviewed to determine the factors influencing the prescription of anticoagulants. RESULTS: The arrhythmia occurred in 65 patients (5.4% overall), its prevalence increasing markedly with age (2.3% in 65 to 69 years age group; 8.1% in those over 85). Warfarin was being prescribed to 21.4% of these patients, although the findings of the study indicate that a further 20% were eligible for this treatment. Symptoms suggestive of cardiac failure were common (32.1%) and coexisting pathology was often identified by cardiac ultrasound in these patients (left ventricular hypertrophy, 32.1%; impaired left ventricular contractility, 21.4%; left atrial dilation, 80.4%; mitral annular calcification, 42.9%; mitral stenosis, 7.1%; mitral regurgitation, 48.2%; aortic stenosis, 8.9%). In all but one case, the decision to anticoagulate was based on the clinical rather than the echocardiographic findings. CONCLUSIONS: Individual risk-benefit assessment in elderly patients with atrial fibrillation suggests that almost half (41.4%) are eligible for full anticoagulation with warfarin, whereas presently only one fifth are receiving this treatment. The decision to anticoagulate can be made on clinical grounds in most cases. If these results are confirmed, a doubling of the current number of patients taking anticoagulants can be anticipated.

Infections in transvenous cardiac pacemakers: two more cases.

Two patients with metastatic pacemaker infections, one caused by Pseudomonas aeruginosa, 5 months after implantation, and the second by Streptococcus pneumoniae, 8 years after implantation, were treated successfully by removal of the pacemaker systems. Infection reoccurred in the patient with Pseudomonas aeruginosa, who initially underwent partial pacing system removal allowing the atrial lead to remain. Repeat partial atrial lead removal and contralateral pacemaker implantation was followed by clinical infection, which was resolved when both the implanted atrial lead fragment and the recently implanted pacemaker were both removed. Removal of all hardware is required for cure of pacemaker infection.

Early clinical experience with a hot tip laser wire in patients with chronic coronary artery occlusions.

Chronic coronary artery occlusions remain one of the problems limiting the use of percutaneous transluminal coronary angioplasty (PTCA). We have studied the use of an 0.018 inch laser hot tip wire. It was coupled either to a continuous wave argon or Nd-YAG laser generator and introduced through a balloon catheter to try and cross and dilate a series of chronic coronary artery occlusions in which initial conventional attempts had failed. Four LAD and 6 RCA occlusions were attempted; we successfully crossed and dilated 6 (60%) lesions, 4 (40%) using the laser wire alone to recanalize the occlusion and in 2 a combination of laser wire and conventional means.

The athletic heart.

The clinical features of athletic hearts are confusing to physicians who are unfamiliar with them. In particular, the diagnosis of hypertrophic cardiomyopathy may be suggested. The clinical signs of athletes' hearts are discussed with special reference to this difficult diagnosis. Emphasis is placed on the results of special investigations including the electrocardiogram and echocardiogram. The changes seen in athletic hearts are physiologic adaptations that do not appear to cause significant problems. Long-term follow up of the more extreme examples, however, is very limited, and this is an area where further information is needed. Resting bradycardia is a common feature in athletes, but abnormal tachyarrhythmias on exertion signify cardiac disease and are not a part of the athlete heart syndrome.

Ambulatory monitoring of the ST segment in diabetic men with and without peripheral neuropathy.

To assess whether myocardial ischaemia is more common in diabetic patients with neuropathy, 24-hour ambulatory monitoring of the ST segment was performed on 27 diabetic men without peripheral neuropathy and in 28 with neuropathy. The patients were matched for age 54 +/- 7 years (mean +/- SD) versus 54 +/- 7 years and for duration of diabetes (16 +/- 9 years versus 16 +/- 12 years). None had clinical evidence of heart disease. Episodes of ST segment depression were seen during ambulatory monitoring in 12 diabetics (22%) but were not more common in patients with peripheral neuropathy. Four of the 13 diabetics with autonomic neuropathy had ST depression during ambulatory monitoring. During a median follow-up period of 50 months, four patients developed clinical heart disease. Three of these patients had shown ST depression during ambulatory monitoring. ST depression during ambulatory monitoring is common in diabetic men without cardiac symptoms but is not related to the presence of peripheral neuropathy. Diabetics with ST depression during ambulatory monitoring are at increased risk of developing heart disease in subsequent years.

Asymptomatic myocardial ischemia in diabetes and its relationship to diabetic neuropathy: an exercise electrocardiography study in middle-aged diabetic men.

The incidence of painless ischemic heart disease is increased in diabetic patients, and it has been suggested that this may be partly due to diabetic neuropathy involving cardiac afferent nerves. We have performed exercise electrocardiography in middle-aged diabetic men without cardiac symptoms to see if silent myocardial ischemia is more common in patients with neuropathy. Thirty patients had diabetic neuropathy (group 1), and 30 did not (group 2). The groups were matched for age and duration of diabetes. The exercise test was abnormal in 14 patients. A positive test was no more common in patients with diabetic neuropathy. During a mean follow-up period of 50 mo, five patients developed clinical heart disease, four of whom had a positive exercise test. An abnormal exercise ECG is common in diabetic men without cardiac symptoms, but our study does not suggest that the high incidence of silent myocardial ischemia in diabetic patients is related to the presence of diabetic neuropathy. In patients with diabetes a positive exercise test is associated with a high risk of developing clinical heart disease in subsequent years.

Probable adverse interaction between oral metoprolol and verapamil.

A combination of an oral beta-adrenergic blocking agent and verapamil has been advocated as a safe treatment for angina. A case of Wenckebach type atrioventricular block occurring in a patient on metoprolol and verapamil is reported. It is suggested that this combination is used with caution.

Early and late patency of expanded polytetrafluoroethylene vascular grafts in aorta-coronary bypass.

Expanded polytetrafluoroethylene (PTFE) (Gore-Tex) grafts were used in 16 patients with ischemic heart disease undergoing aorta-coronary bypass graft operations. PTFE was used only when insufficient suitable vein was available. A total of 27 grafts were inserted in 16 patients. Eighteen grafts (in 11 patients) were studied in the early (3 months) postoperative period. Eleven were patent. Nine expanded PTFE grafts in six patients were restudied between 12 and 29 months after insertion. Six were patent. Factors affecting graft patency were similar to those governing patency of vein grafts. There was a high incidence of complications, but the patients constituted a poor-risk group. It is reasonable to use expanded PTFE grafts when insufficient vein is available. Such grafts can remain patent and functional for at least 2 years.