Paroxysmal atrial flutter and fibrillation associated with preexcitation syndrome: treatment with ajmaline.

Ajmaline was administered intravenously to six patients with the Wolff-Parkinson-White syndrome for the acute management of paroxysmal atrial flutter (three patients) or fibrillation (three patients) with a fast ventricular response (over the accessory pathway). Ajmaline increased refractoriness in the accessory pathway in all three patients with atrial flutter and stopped the flutter in one. The drug completely abolished preexcitation in two of the three patients with atrial fibrillation, decreasing the means ventricular rate of 240 and 300 beats/min to 110 and 180 beats/min, respectively. In the third patient with atrial fibrillation, ajmaline increased refractoriness over the accessory pathway, decreasing the mean ventricular rate of 300 beats/min to 160 beats/min. In two patients ajmaline was continued as an intravenous maintenance infusion until sinus rhythm was restored. It is concluded that ajmaline is an effective drug for the acute management of atrial flutter or fibrillation with a fast ventricular response in patients with the Wolff-Parkinson-White syndrome.

Multiform accelerated idioventricular rhythm in acute myocardial infarction: electrocardiographic characteristics and response to verapamil.

Thirteen patients with acute myocardial infarction with multiform accelerated idioventricular rhythm (AIVR) occurring during the first 12 hours of monitoring in the coronary care unit are described. This arrhythmia, similar to the more common uniform AIVR, was intermittent, did not cause hemodynamic compromise, and was not related to more serious ventricular arrhythmias. There was no correlation between the bundle branch block pattern of the multiform AIVR and the electrocardiographic location of the myocardial infarction, but there was a perfect correlation between the frontal plane electrical axis of the multiform AIVR and the electrocardiographic location of the myocardial infarction. The presence of fusion beats between the different forms of AIVR suggests multifocality rather than multiformity. Intravenous verapamil (3 to 5 mg bolus) was administered to 6 patients with multiform AIVR in whom the arrhythmias were persistent enough to allow the evaluation of the effect of verapamil on the arrhythmia. Verapamil caused no change in the rate of AIVR in 1 patient, but in a second patient it decreased the rate by 20 beats/min. In 4 patients, verapamil abolished the arrhythmia: in 2 patients carotid sinus pressure (induced sinus slowing) allowed the emergence of the AIVR at a lower rate, and in the remaining 2 patients the arrhythmia was not observed.

Influence of gender in the therapeutic management of patients with acute myocardial infarction in Israel. The Israeli Thrombolytic Survey Group.

A national study was performed in early 1992 in the 25 operating coronary care units in Israel, which enabled the assessment of whether the therapeutic management of patients with acute myocardial infarction was affected by patient gender. During a 2-month period, 1,014 consecutive patients with acute myocardial infarction were hospitalized. Thrombolytic therapy was given to 47% of men (362 of 769), and 43% of women (106 of 245) (p = NS). After adjustment for age, no gender differences in the administration of thrombolytic therapy were noted (odds ratio 0.95; 95% confidence interval 0.73-1.23). Coronary angiography was more frequently performed in men (22%) than in women (16%) (p < 0.05). However, no gender differences in the use of angioplasty or coronary bypass surgery performed during the index hospitalization were found (10% in men, and 8% in women). The main reasons for ineligibility for thrombolytic therapy were: late hospital arrival, absence of qualifying ST-T changes on admission electrocardiogram, and contraindications to thrombolytic therapy. Hospital death was significantly lower in patients receiving thrombolytic therapy (37 of 456; 8%) than in those excluded from thrombolysis (70 of 540;13%) (p < 0.01). This difference was significant for men, but not for women. The 1-year postdischarge mortality was 4% in patients treated compared with 12% in those ineligible for thrombolysis (p < 0.01). This significant difference persisted among men and women.

Malignant course of a benign anomaly: myocardial bridging.

A 35-year-old man, with recent onset angina, developed recurrent episodes of syncope due to ventricular tachycardia. His coronary angiogram showed normal coronary arteries and myocardial bridging of the left anterior descending causing severe systolic milking effect. Extensive invasive and noninvasive investigations did not reveal cardiac pathology other than the myocardial bridging. Electrophysiologic studies, not previously reported in myocardial bridging, demonstrated inducible sustained ventricular tachycardia at a rate of 280 beats/min. The possible relationship between the arrhythmia and the myocardial bridge is suggested. Combined medical treatment with amiodarone and diltiazem proved to be an effective alternative to surgical myotomy of the bridge.

Acceleration of ventricular tachycardia induced by a chest thump.

Chest thump is accepted as a simple and effective maneuver for terminating a paroxysm of ventricular tachycardia. This report describes three patients receiving digitalis in whom chest thump caused an acceleration of the rate of ventricular tachycardia. Following discontinuation of digitalis therapy, chest thump converted to sinus rhythm recurrence of ventricular tachycardia in two patients and did not cause acceleration of the ventricular rate in the third. It is suggested that in patients taking digitalis with ventricular tachycardia, chest thump should be used with caution.

[Aortic dissecting aneurysm during pregnancy].

Aortic dissecting aneurysm is a rare, serious complication of pregnancy. This condition was diagnosed in a 34-year-old woman in the 38th week of pregnancy. Cesarean section was immediately performed, and was followed by surgical repair of the dissection. A normal male infant was delivered.

[Right ventricular dysplasia].

Right ventricular dysplasia (RVD) is characterized by partial or total replacement of part of the right ventricular musculature by fatty and fibrous tissue. In its typical form it presents with ventricular tachycardia, usually in the fourth decade of life. 6 men and 2 women (mean age 55.6 years), referred for evaluation of arrhythmias or other cardiac symptoms, were diagnosed as having RVD on echocardiography after other causes of right ventricular enlargement were excluded. The mean age was 55.6 years, older than originally reported. 5 presented with supraventricular arrhythmias, including atrial flutter, atrial fibrillation, supraventricular tachycardia and sick-sinus syndrome. Only 2 had ventricular tachycardia; in 1 patient no arrhythmia was found. We conclude that RVD includes a wide spectrum of arrhythmias, of which ventricular tachycardia is probably not the most common. The incidence of RVD in the older population may be greater than originally reported, and may include a slowly developing form of the disease. In some cases RVD may be the pathophysiological basis of lone atrial fibrillation and sick-sinus syndrome.

Giant left main pseudoaneurysm obstructing the left anterior descending coronary artery demonstrated by transesophageal echocardiography and coronary angiography.

Left main pseudoaneurysm is a rare angiographic finding in young adults. We describe a 23-year-old male who presented with an acute anterior wall myocardial infarction. Coronary angiography and transesophageal echocardiography reveal a huge aneurysm of the distal left main obstructing the left anterior descending artery (LAD), which was defined by history as a pseudoaneurysm. The pseudoaneurysm was successfully resected and mammary artery was used to repair the distal left main and to bypass the LAD.

Smitten by a kitten.

Mammalian bite wounds are commonly encountered in the emergency department. When patients come early (<8 hours after injury), local infection is not usually evident. At this stage, the issue of providing prophylactic antibiotic therapy arises. We report a complication of a cat bite to the hand in a previously healthy 32-year-old man. This patient did not seek medical treatment immediately after the cat bite, and distinct local infection did not develop. Nevertheless, his course was complicated with acute Staphylococcus aureus endocarditis. We discuss the common pathogens involved in a cat bite infection, including S aureus, and delineate the indications for prophylactic antibiotic therapy after a mammalian bite wound.

Twelve-lead electrocardiogram recording during percutaneous transluminal coronary angioplasty. Analysis of reciprocal changes.

Coronary angioplasty was used as a human model of transient myocardial ischemia to evaluate the electrocardiographic characteristics and significance of "reciprocal" ST-segment depression and T wave changes. Continuous 12-lead ECGs were recorded before and during coronary angioplasty in 20 patients, 19 of whom had single vessel disease. In 12 of 14 patients, LAD occlusion produced ischemic changes (peaked T and/or ST elevation) in L1, AVL and at least two precordial leads. "Reciprocal" changes (ST depression and/or T inversion) were observed in at least two inferior wall leads. One patient had ST depression in V4-V6 with no change in the inferior leads and in the other the only ECG change was inferior ST depression with partial inversion of the T wave. In four of six patients, RCA occlusion produced ischemic changes in at least two inferior wall leads and "reciprocal" changes in L1, AVL and at least two anterior wall leads. In LAD as well as RCA occlusions "reciprocal" changes were characterized by inversion of the T wave or inversion of its ascending limb with or without ST depression. The magnitude of the ischemic changes tended to be proportional to the magnitude of the "reciprocal" changes. Our data suggest that: (1) "Reciprocal" changes are not a specific indicator of distant myocardial ischemia due to multivessel disease; (2) the magnitude of ischemic changes correlates with the magnitude of "reciprocal" changes; (3) "Reciprocal" changes may be the only manifestation of acute myocardial ischemia; and (4) "Reciprocal" changes may be represented by inversion of the T wave without displacement of the ST-segment.