Interpolated premature ventricular contractions with postponed compensatory pauses: a misnomer?

Selected strips of a Holter recording obtained from a healthy young person with rare unifocal premature ventricular contractions (PVCs) were obtained. Occasionally, the PVCs were interpolated and showed the phenomenon originally named postponed compensatory pause by Langendorf [Am Heart J 1953;46:401]. But this is a misnomer because, by definition, interpolated PVCs do not have compensatory pauses. Thus, it follows that what does not exist cannot be postponed. In reality, the basic manifest feature is a prolongation of the first RR interval that follows the interpolated beat. However, in view of its use for more than half a century, it is probably best to continue using this terminology, but only as long as its underlying mechanism and fundamental manifestations are properly understood.

Relation of Activated Clotting Times During Percutaneous Coronary Intervention to Outcomes.

Monitoring anticoagulation using the activated clotting time (ACT) in patients treated with heparin and undergoing percutaneous coronary intervention (PCI) is one of the most frequently used tests in invasive cardiology. However, despite its widespread use and guideline endorsement, uncertainty remains regarding the association of ACT with outcomes in contemporary practice. We reviewed all PCI procedures performed at the Mayo Clinic (Rochester, Minnesota) from October 2001 to December 2012 and evaluated the association between the ACT before device activation and in-hospital and 1-year outcomes. ACT values were grouped into tertiles for descriptive purposes and analyzed as a continuous variable for assessment of outcomes. We used logistic and Cox proportional hazards regression models to estimate the association of ACT and outcomes. Of the 12,055 patients who underwent PCI with an ACT value before device activation, 3,977 (33.0%) had an ACT <227, 4,046 (33.6%) had an ACT 227 to 285, and 4,032 (33.4%) had an ACT >285. Baseline and procedural characteristics were similar across ACT tertiles. In unadjusted analysis, higher ACT values were associated with death (p <0.001), bleeding (p = 0.024), procedural complication (p <0.001), and higher 1-year events (cardiac death, p <0.001; cardiac death/myocardial infarction, p = 0.022). After multivariable adjustment for baseline and procedural characteristics, ACT was not independently associated with in-hospital or 1-year ischemic, thrombotic, or bleeding outcomes. In conclusion, ACT values before device activation are not independently associated with clinically important outcomes in contemporary PCI practice.

Large vessel involvement in ANCA-associated vasculitides: report of a case and review of the literature.

Vasculitides are currently classified according to the size of the vessels involved and characteristic clinical and histopathologic findings. Antineutrophil cytoplasmic antibodies (ANCA) and other serologic tests have been used to further characterize small vessel vasculitides. Large vessel involvement in ANCA-associated small vessel vasculitides has been overlooked in the medical literature. Here, we report a case of fatal aortitis and aortic dissection in a patient with microscopic polyangiitis and review reported cases of large vessel involvement in ANCA-associated vasculitides since 1990. We have attempted to characterize this subgroup of patients. Large vessel disease in ANCA-associated vasculitis may present as stenosing large vessel arteritis, aneurysmal disease, aortic dissection, aortic rupture, aortic regurgitation, and death. Prominent perivascular inflammation may present as mediastinal, cervical or abdominal soft tissue masses. ANCA-associated large vessel disease should be considered in the differential diagnosis of these disorders. The epidemiologic, clinical and pathologic characteristics of these patients differ from those of the well-defined large vessel vasculitides such as giant cell (temporal) arteritis or Takayasu's arteritis. We suggest that large vessel involvement is part of the spectrum of ANCA-associated vasculitis rather than an overlap with other large vessel vasculitides. It occurs in both myeloperoxidase- and proteinase 3-positive patients with either Wegener's granulomatosis or microscopic polyangiitis, but has not been reported in Churg-Strauss syndrome. Large vessel vasculitis can precede small vessel vasculitis or occur in the absence of small vessel involvement. We hope this report will contribute to the ongoing development of classification systems for the vasculitic syndromes.