Near miss sudden death in an infant with Wolff-Parkinson-White syndrome.

A 6 month old infant with known Wolff-Parkinson-White syndrome presented with an out of hospital cardiac arrest. An electrocardiogram in the emergency department demonstrated atrial fibrillation with rapid ventricular response. The child subsequently was resuscitated and underwent successful interruption of an accessory connection after failing medical therapy. This case underlines the need to reassess the indications for invasive electrophysiologic testing in young children.

Anomalous mitral arcade: a rare cause of mitral valve disease in an adult.

Anomalous mitral arcade is a rare congenital abnormality of the mitral valve not previously described in an adult. Familiarity with this anomaly may facilitate interpretation of left ventricular abnormalities detected with echocardiography or contrast ventriculography in patients with evidence of mitral valve disease.

Left main-stem coronary artery disease: surgical versus medical management.

The survival of surgically and medically treated patients with left main-stem coronary artery stenosis has been analysed in detail. From 1978 to 1981, 85 patients with stenosis of the left main coronary artery greater than 50% were divided into two groups; 47 were treated surgically and 38 medically. Left ventricular function, previous myocardial infarction, associated right coronary artery occlusion and extent of the left main coronary artery disease were analysed using the chi 2 and independent Student's t-tests. These important variables were comparable in both groups. Severity of angina in the two groups both pre- and postmanagement were compared using the chi 2 test and Stuart-Maxwell test. These showed that the majority of surgically treated patients improved markedly as compared with the medically treated group. Survival was examined using the Kaplan-Meier product limit estimate. The difference between the survival curves was statistically significant (p less than 0.005, generalized Wilcoxon and Savage tests), with the surgical group having the more favourable outcome. One-year and 2-year survival for the surgically treated group was 97.8% and 91.3%, compared with 79.9% and 74.9% for the medically treated group.

Budd-Chiari syndrome with inferior vena cava obstruction associated with systemic lupus erythematosus.

The Budd-Chiari syndrome is an uncommon condition in which hepatic venous outflow is obstructed by thrombosis of the major hepatic veins. Many of the cases are idiopathic, but it has been described in association with vena caval webs, abdominal trauma, retroperitoneal neoplasms, and hypercoagulable states. A patient with systemic lupus erythematosus (SLE) who developed the Budd-Chiari syndrome with inferior vena cava thrombosis led to a review of the possible association between SLE and the Budd-Chiari syndrome. The therapy of the Budd-Chiari syndrome with associated vena cava thrombosis is also discussed.

Vancomycin blood levels during cardiac bypass surgery.

Because of the allergic reaction that some patients have to penicillin and cephalosporins, there is a need for an alternative antimicrobial agent to protect the patient who undergoes coronary artery bypass grafting from infection perioperatively. Vancomycin, a bactericidal antibiotic active against gram-positive organisms was studied in 13 men who underwent aortocoronary bypass grafting. For 60 minutes from the time the patient arrived in the operating room, vancomycin (15 mg/kg) was given intravenously. Blood levels were assayed up to 12 hours thereafter. Adequate antistaphylococcal levels of the drug were maintained throughout operation. Twelve hours later levels were subtherapeutic. There was no cardiovascular, cutaneous or renal toxicity. Two patients had minor wound infections.

Improved long-term survival following myocardial revascularization in patients with severe left ventricular dysfunction.

The natural history of patients with coronary artery disease associated with poor left ventricular (LV) function is dismal. This report analyzes the efficacy of myocardial revascularization in this subset of patients with coronary artery disease manifesting severe LV dysfunction on the basis of LV angiography, LV ejection fraction (LVEF), and left ventricular end-diastolic pressure (LVEDP). For the 2 1/2 year period ending November, 1977, 59 consecutive patients with coronary artery disease complicated by severe LV dysfunction underwent aorta-coronary bypass at the University of Western Ontario. All patients had angina refractory to medical therapy. Objective criteria for compromised LV function included the presence of three or more dysfunctional (hypokinetic of akinetic) segments on biplane LV angiography. Eighty-three percent (49/59) of patients had triple-vessel coronary artery disease. The mean LVEF for the series was 0.28 and the mean LVEDP was 18 mm Hg. The duration of follow-up was 24 to 60 months (mean 37 months), with follow-up survival data available on 100% of patients. The hospital mortality was 1.7% (1/59), and there were nine late deaths. The 5 year actuarial survival rate (+/- SEM) was 80% +/- 6%. Of the 44 long-term survivors available for direct assessment, 98% (43/44) report improvement with respect to angina and 66% (29/44) are totally asymptomatic. Eighty percent (28/35) of the long-term survivors under the age of 65 years are currently employed. These results indicate that myocardial revascularization can be performed in patients with severe ischemic LV dysfunction at very low risk and, further, that operation results in a dramatic improvement in survival expectations compared with optimal medical therapy.

Surgical aspects of regional myocardial blood flow and myocardial pressure.

The surgical technique of cardiopulmonary bypass with either an empty beating or an empty fibrillating ventricle produces marked changes in the regional blood flow and oxygen demand of the left ventricle. This paper describes the changes which occurred in the regional perfusion of both the normal and the hypertrophied left ventricle during these conditions and relates them to the known changes in oxygen demand. It also correlates the changes in flow with the measurable changes in myocardial tissue pressure-systolic when the heart is beating and continuous when fibrillating. The various types of filbrillation had identical effects on both regional tissue pressure and regional flow. The subendocardial blood supply was adequate or more than adequate under each of these conditions so long as the coronary perfusion pressure was maintained at an adequate level. A low perfusion pressure during ventricular fibrillation of any type led to a marked reduction in flow to the subendocardial portion of the left ventricle: The presence of ventricular hypertrophy accentuated this danger.