Cryoablation of incessant ventricular tachycardia: case report and long-term follow-up.

We report the case of a 52-year-old man who had incessant ventricular tachycardia despite treatment with antiarrhythmic agents. Placement of an implantable cardioverter/defibrillator, radiofrequency ablation, and antitachycardia pacing were ineffective. He underwent intraoperative arrhythmia mapping and cryoablation at our institution. Eighteen months later, he remained free of arrhythmia. He was in New York Heart Association functional class II with an ejection fraction of 30%.

Mobilization of the anterior mitral leaflet for excision of a left ventricular myxoma.

Left ventricular myxomas are extremely rare. We report use of a left atrial approach with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma entangled within the chordal apparatus, lying between the anterolateral papillary muscle and the left ventricular wall. The detached mitral leaflet was reattached to the annulus with a continuous suture. The tumor was completely excised, thus avoiding a separate transventricular or transaortic approach.

Total occlusion of the left main and proximal right coronary artery: case report and review of the literature.

Chronic total left main coronary artery occlusion at angiography is very rare, and there are only four cases reported with concomitant total right coronary artery occlusion. We describe a case of total left main and proximal right coronary artery occlusion and review the clinical and angiographic characteristics of this condition which represents the most severe from of coronary artery disease compatible with life.

Myocarditis-associated ventricular fibrillation. An unusual cause of syncope in Wolff-Parkinson-White syndrome.

We report the case of a 60-year-old man with long-standing symptomatic Wolff-Parkinson-White syndrome who presented with recurrent syncope and documented spontaneous ventricular fibrillation. This primary ventricular fibrillation, which was not preceded by atrial fibrillation, was associated with lymphocytic myocarditis and not with Wolff-Parkinson-White syndrome. The patient was treated with radiofrequency ablation of the accessory pathway and a drug regimen of prednisone, amiodarone, and metoprolol. At the 6-month follow-up, he was asymptomatic and had returned to work. To our knowledge, the association of acute lymphocytic myocarditis and Wolff-Parkinson-White syndrome has not been previously reported.

Balloon aortic valvuloplasty: the Texas Heart Institute experience.

Between October 1986 and January 1989, 73 percutaneous catheter balloon aortic valvuloplasty procedures were performed in 68 adult patients (32 men and 36 women; mean age, 77 +/- 9 years) with severe symptomatic aortic stenosis. Following the procedures, significant improvements were documented in aortic valve area, mean transvalvular pressure gradient, peak-to-peak pressure gradient, left ventricular systolic pressure, radionuclide ejection fraction, and left ventricular end-systolic volume index. There were no procedure-related deaths, but 2 patients (3%) required emergency surgery for acute aortic regurgitation. During hospitalization, 4 patients had persistent symptoms (3 died; 1 subsequently underwent repeat valvuloplasty and later, valve replacement). Short-term clinical improvement was noted in 59 of 65 patients (91%). During the follow-up period (mean, 11.6 +/- 8.4 months), 22 patients died (including the 3 who died during hospitalization). Sixteen underwent aortic valve replacement (including the 2 who underwent emergency aortic valve replacement); all 16 are alive. A total of 6 patients (1 with an initial balloon aortic valvuloplasty at an outside institution) underwent repeat valvuloplasty; of those, 4 subsequently underwent aortic valve replacement, and 2 died. Of the remaining 30 patients, 27 continue to experience relief of symptoms, and 3 have clinical symptoms that have not improved or have worsened since the valvuloplasty procedure. Multivariate predictors of clinical outcome (p<0.05) included post-valvuloplasty aortic valve area, pre- and post-valvuloplasty ejection fraction, absence of coronary artery disease, and absolute change in valve area. Overall actuarial and event-free survivals were 83% and 49%, respectively, at 1 year. Although clinical improvement is frequently noted after balloon aortic valvuloplasty, the procedure is associated with a high recurrence of symptoms and restenosis. Balloon aortic valvuloplasty is at best a palliative procedure; when feasible, surgical valve replacement is the more definitive therapy.

Aneurysm of an aortocoronary saphenous vein bypass graft presenting as an anterior mediastinal mass.

Fifteen years after aortocoronary bypass surgery, a 52-year-old asymptomatic man was found to have a large anterior mediastinal mass. Angiographic studies showed no evidence that a vascular structure was responsible. At operation, a saphenous vein graft to the left anterior descending artery was found to be affected by a large thrombus-filled aneurysm. This is one of the few known cases in which such an aneurysm has presented as a mediastinal mass.

Results of 232 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in single- and double-vessel coronary artery disease.

Over a 3-year period, we performed 232 consecutive percutaneous transluminal coronary angioplasty (PTCA) procedures in 171 patients, 132 (77%) of whom were men and 39 (23%) of whom were women. The patients' ages ranged from 26 to 85 years (average, 56.5 years). All of the patients had symptoms of coronary insufficiency, manifested by stable angina in 106 cases, unstable angina in 44 cases, post myocardial infarction angina in 19 cases, arrhythmia in 1 case, and syncope in 1 case. All PTCA dilatations were done by the same operators, using the same technique. The procedures were categorized as follows: Group 1 included 157 single-vessel PTCA procedures, which had a success rate of 87.3%; these included 52 dilatations of the right coronary artery (success rate, 84%), 94 dilatations of the left anterior descending artery (success rate, 86%), and 11 dilatations of the left circumflex system (success rate, 90%). Group 2 included 29 double-vessel PTCA procedures (58 total procedures), which had an 88% success rate, and group 3 comprised 17 vein-graft PTCAs, with an 86.9% success rate. Complications included coronary artery occlusion in 15 cases (9.0%), myocardial infarction in four cases (2.3%), and cardiac arrhythmia in one case (0.6%). There were no deaths. Fifteen patients (8.8%) underwent coronary artery bypass surgery during the same hospitalization (3.8% of these operations were performed on an emergency basis). Thirty-six patients (15.5%) had a second PTCA procedure owing to restenosis, which occurred either before the patient was discharged from the hospital (eight cases) or 3 to 30 months after the original procedure. We conclude that, when performed by experienced operators with optimal technical resources, PTCA results in an acceptable success rate; therefore, this procedure should be a satisfactory method of myocardial revascularization in well-selected patients with either single- or double-vessel coronary artery disease.

Asymptomatic cavitary pneumonitis due to amiodarone pulmonary toxicity.

A 52-year-old woman presented with ventricular tachycardia after receiving amiodarone for the previous 18 months. The chest roentgenogram revealed evidence of multiple pleural-based cavitary nodules despite the absence of respiratory disease on clinical examination. The nodules were attributed to amiodarone because of histologic changes noted at open-lung biopsy. The cavitating nodules cleared with the discontinuation of amiodarone.

Cardiac sarcoidosis: two cases with ventricular tachycardia and review of cardiac involvement in sarcoid.

Patients with significant cardiac sarcoidosis are at increased risk of sudden death from ventricular dysrhythmias or conduction disturbances. We report two patients whose initial manifestation of cardiac sarcoidosis was nonsustained ventricular tachycardia unresponsive to standard antiarrhythmic measures. Endomyocardial biopsy aided the diagnosis in each patient. This technique is helpful in establishing the diagnosis of cardiac sarcoidosis, which causes life-threatening ventricular dysrhythmias.

Percutaneous balloon catheter angioplasty of coarctation of the abdominal aorta: report of two cases.

Two patients with coarctation of the abdominal aorta are reported. They both underwent successful transluminal balloon angioplasty. The immediate and short-term results have been excellent. This method and its role in the treatment of coarctation of the abdominal aorta are discussed.

Saphenous vein bypass from the aorta to the anterior interventricular vein.

A patient is described who had myocardial revascularization with saphenous vein grafts. One of the grafts was inadvertently anastomosed to the anterior interventricular vein instead of the anterior descending coronary artery. He also underwent saphenous vein bypass to the right coronary artery and resection of a left ventricular aneurysm. The patient remained free of angina up to 3 1/2 years after operation, at which time he was seen with tachyarrhythmia and a continuous murmur. Coronary arteriography revealed patent bypass grafts to both the distal right coronary artery and the anterior interventricular vein. Whether the patient benefited from the graft to the anterior interventricular vein remains indeterminable because of the successful bypass to the right coronary artery and the left ventricular aneurysmectomy. He did experience clinical improvement for 3 1/2 years, and the symptom when he was seen at our institution was tachyarrhythmia, not chest pain. Additionally, his exercise tolerance had improved markedly. We believe the potential advantages of bypass from the aorta to the coronary veins is still unexplored.