Runaway in a modern "soft top" pacemaker.

Although runaway pacemaker was a relatively common occurrence, modern pacemaker design has made it extremely rare. We report a case occurring with a modern "soft-top" pacemaker that resulted from a loss of hermeticity. Although the different treatment options are discussed, the definitive maneuvre is explantation of the faulty pacemakers

Increased mortality from inadequate provision of coronary care unit facilities.

Over a 6-month period, all patients admitted to the Royal United Hospital, Bath, with acute ischaemic heart disease were prospectively followed for the period of their hospital stay. Strict admission and discharge criteria were defined for the Coronary Care Unit (CCU), so that groups of patients could be identified in which the treatment was not ideal. The mortality in the groups of patients who were admitted to the CCU without delay and for an appropriate length of time was 5.1% (18/355). It was significantly higher overall in the groups of patients who were either not admitted (14.3%, 4/28) or whose admission was delayed (17.4%, 4/23). The results underline the importance of the provision of adequate coronary care facilities.

Cardiopulmonary resuscitation in a district general hospital: increased success over 7 years.

In a 12-month prospective survey of CPR (cardiopulmonary resuscitation), 32 out of 192 patients (16.6%) survived to go home. This is a clear improvement compared with 7 years previously. This is attributed to better training in the use and management of CPR and more widespread availability of defibrillators. Certain patients could not be resuscitated--those with electromechanical dissociation, carcinoma, or multiple pathology. Age by itself was not a bar to resuscitation. There is still a high rate of inappropriate calls, often because of uncertainty by nurses about the use of CPR. This could be improved with clearer guidelines in hospitals about the value of CPR in selected patients.

Recurrent symptoms after ventricular pacing in unexplained syncope.

We report clinical and hemodynamic data in two cases of recurrent syncope. Both patients received permanent demand ventricular pacing (VVI) for unexplained syncope. Both patients experienced recurrent syncope after pacemaker implantation. They later underwent 60 degrees head-up tilt testing, initially noninvasively and then with hemodynamic profile. A vasovagal response to tilt occurred with bradycardia and was complicated by the onset of ventricular pacing and retrograde atrioventricular conduction (RAVC) with hemodynamic deterioration and rapid reproduction of syncope. Limited intracardiac electrophysiological study (EPS) excluded atrioventricular (AV) conduction disease, sinus node disease, and carotid sinus syndrome, and confirmed RAVC. Both patients were upgraded to dual chamber pacing, DDI mode, with 50/80 rate hysteresis. One patient was asymptomatic at repeat tilt testing; the other experienced continued symptoms due to the vasodepressor component of vasovagal syncope. Cardiac pacing alone is ineffective treatment for this phenomenon, and no proven therapy is presently available. Ventricular pacing applied to patients with unexplained syncope may lead to an increase in or continuation of symptoms rather than an amelioration. There is a need for full investigation of such patients, which must include tilt testing, to allow for the most accurate diagnosis possible and guide the most appropriate therapy.

Acquired abnormalities of the tricuspid valve--an ultrasonographic study.

In a retrospective ultrasonographic study, 32 cases of acquired disease of the tricuspid valve were detected amongst 7000 consecutive patients. Patients with congenital heart disease (except when the seat of an acquired disease) and with prosthetic heart valves, were excluded. There were twenty-one cases of rheumatic disease, all having additional involvement of the mitral valve. Prolapse (5 patients), bacterial endocarditis (2 patients), rupture of papillary muscle (1 patient), cardiac tumours (2 patients) and carcinoid heart disease (1 patient) were also identified. Acquired disease of the tricuspid valve is infrequently encountered during routine cross-sectional echocardiography but its recognition is clinically important.

Visualisation of left atrial thrombi by coronary arteriography.

Abnormal vascularity in the region of the left atrial appendage was demonstrated by coronary arteriography in 5 patients with mitral stenosis. Subsequently, three of these patients proceeded to operation, and left atrial thrombi were confirmed in all three cases. Neovascularity must be differentiated from congenital fistulae, tumours, and coronary artery disease. Thrombus in the left atrial appendage is difficult to diagnose even with the use of cross-sectional echocardiography and may occasionally be demonstrated by coronary arteriography.

The use of impedance cardiography in heart failure.

The suitability of the impedance cardiograph for studying patients with cardiac failure in a District General Hospital was assessed over a 12-month period. Over 200 recordings were made from 60 patients. Stroke volume, using the derived formulation of Kubicek and his colleagues, and the Heather Index (a measure of cardiac contractility) were calculated in each case. Serial recordings provided an objective assessment of the efficacy of treatment. An abnormal diastolic O wave was found in the majority of patients. This may indicate an excessive accumulation of blood in the thorax as a result of myocardial dysfunction.

Reversal of aplastic anaemia secondary to systemic lupus erythematosus by high-dose intravenous cyclophosphamide.

Aplastic anaemia is rare as a primary feature of systemic lupus erythematosus and is more commonly a complication of treatment with cytotoxic drugs. Three years after starting treatment for systemic lupus erythematosus a 22-year-old woman developed bone-marrow depression. Azathioprine was thought to be responsible and was withdrawn. The aplastic anaemia worsened despite treatment with prednisolone. In view of clinical and serological evidence of lupus disease activity the patient was given high-dose intravenous cyclophosphamide and the aplastic anaemia responded in a sustained manner.In such cases of continued disease activity high-dose immunosuppressive agents may prove effective.