Inflammation and Rupture of a Congenital Pericardial Cyst Manifesting Itself as an Acute Chest Pain Syndrome.

We present the case of a 63-year-old woman with a remote history of supraventricular tachycardia and hyperlipidemia, who presented with recurrent episodes of acute-onset chest pain. An electrocardiogram showed no evidence of acute coronary syndrome. A chest radiograph revealed a prominent right-sided heart border. A suspected congenital pericardial cyst was identified on a computed tomographic chest scan, and stranding was noted around the cyst. The patient was treated with nonsteroidal anti-inflammatory drugs, and the pain initially abated. Another flare-up was treated similarly. Cardiac magnetic resonance imaging was then performed after symptoms had resolved, and no evidence of the cyst was seen. The suspected cause of the patient's chest pain was acute inflammation of a congenital pericardial cyst with subsequent rupture and resolution of symptoms.

A novel approach to transvenous dual-chamber pacing lead placement and cardiac defibrillator implantation after tricuspid valve replacement.

Pacing and Defibrillation Therapy. We report the successful use of a percutaneous, totally transvenous endocardial approach to atrioventricular pacing and internal cardiac defibrillation in an adult patient with tetralogy of Fallot who had undergone three previous cardiac operations, including a tricuspid valve replacement. Ventricular pacing and sensing were achieved with a bipolar lead in the lateral cardiac vein, and atrial pacing was attained in the region of Bachmann's bundle. Internal defibrillation was achieved with a coil lead in the middle cardiac vein and an "active can" pulse generator in the retromammary position. This minimally invasive method has significant potential benefits because it avoids epicardial placement via a thoracotomy and allows endocardial placement without crossing the tricuspid valve.

Use of a transvenous dual-chamber ICD after a mustard operation for d-transposition of the great vessels.

A 40-year-old man was admitted to our institution with mild heart failure symptoms, including palpitations and near syncope. Twenty-eight years earlier, he had undergone a Mustard operation to correct d-transposition of the great vessels. At the present admission, echocardiography revealed severe right (systemic) ventricular dysfunction. Continuous monitoring also showed sinus-node dysfunction, sinus bradycardia, and nonsustained ventricular tachycardia. The patient underwent successful transvenous placement of a dual-chamber implantable cardioverter-defibrillator for pacing of the atria and prevention of sudden cardiac death. To our knowledge, there have been no previous reports of transvenous placement of an implantable cardioverter-defibrillator after surgery for d-transposition of the great vessels in the English-language medical literature.

Transvenous bifocal left ventricular pacing after mechanical prosthetic tricuspid valve replacement with use of echocardiography to optimize pacing parameters.

A 56-year-old woman underwent placement of a permanent pacemaker to treat symptomatic bradycardia; she had a documented, severe atrioventricular (AV) conduction abnormality and was not taking any AV node-blocking drugs. She had a mechanical prosthetic valve in the tricuspid position, which had been implanted for severe valvular insufficiency caused by rheumatic heart disease. Pacing leads were successfully placed transvenously in the anterior cardiac and a posterolateral vein, which avoided the need for repeat thoracotomy. Echocardiographic and Doppler parameters were used to optimize interventricular as well as septal-to-lateral left ventricular (LV) time delay and reduce or avoid interventricular and LV mechanical dyssynchrony.

Successful ablation of atrioventricular node reentry tachycardia in a patient with crisscross heart and situs inversus levocardia.

Crisscross heart is a complex congenital anomaly that is rarely seen in the absence of important associated structural defects. We describe a 41-year-old woman with recurrent dizziness and tachycardia but no previous cardiovascular symptoms. Narrow-QRS tachycardia was detected, and magnetic resonance imaging showed situs inversus levocardia with a circulatory pattern typical of crisscross heart. Electrophysiologic study revealed atypical atrioventricular (AV) node reentry tachycardia of the "fast-slow" type. Despite the unusual anatomy, we successfully modified the AV node physiology by ablating the "slow AV node inputs" with the guidance of a multielectrode basket catheter in the anatomic right atrium.

Coronary arteries in crisscross heart.

Crisscross heart, or superoinferior ventricles, is a complex and often confusing congenital anomaly. We report a heretofore unreported presentation of "isolated" crisscross heart in situs inversus levocardia, which allows us to more clearly define the typical features of crisscross ventricles. The case of this 41-year-old woman, who had a peculiar coronary anatomy, underscores the concept that coronary artery anatomy is strictly related to the myocardial mass served. In complex congenital heart defects, development of an anterior descending artery is possible (as a primary artery, along with the circumflex and right coronary arteries) only if the ventricular septum develops properly and is aligned with the semilunar valves. We use the present case of crisscross heart to illustrate the spectrum of anomalies that can occur during formation of the cardiac apex; this spectrum ranges from a normal apex, to a diverted apex (as in dextroversion in situs solitus), to a crisscross anomaly.

Congenital coronary artery-cardiac chamber fistulae: Report of two cases.

Two cases of coronary arteriovenous fistulae are reported. In the first case, the right coronary artery (RCA) drained into the right ventricular outflow tract, and the distal RCA filled through a branch of the left anterior descending coronary artery. In the second case, the RCA drained into the right atrium and filled through a branch of the left circumflex artery. The fistulae were closed with subcoronary mattress sutures that preserved the continuity of the native circulation.

Disturbances in cardiac rhythm caused by the removal of temporary pacemaker wires.

The effects of temporary pacemaker wire removal on cardiac rhythm were studied in 22 open-heart surgery patients who had temporary pacemaker wires implanted at the time of chest wall closure. During wire removal, 16 patients developed premature ventricular contractions (PVCs), most commonly occurring as single PVCs, and less often as ventricular couplets. The authors recommend that external pacemaker wire removal be accompanied by electrocardiographic monitoring or at least by a short period of careful clinical observation.

Recurrent myocardial infarction in a patient with Prinzmetal's angina and normal coronary arteries.

A 55-year-old man was referred for the evaluation of frequent chest pain and syncope. While in the hospital, he experienced severe chest pain accompanied by transient ST segment elevation and a slight elevation of cardiac enzyme levels. Multiple coronary arteriograms were recorded at various times during an interval of 2 months. On one occasion, the results were normal; on another occasion, they showed total occlusion of the left anterior descending, diagonal, and circumflex coronary arteries. The occlusion was completely relieved with sublingual nitroglycerin. Because the patient's clinical condition deteriorated rapidly, double aortocoronary saphenous vein bypass was performed to the left anterior descending and circumflex coronary arteries. During the induction of anesthesia, ventricular fibrillation occurred, and the patient died from refractory recurrent fibrillation 4 hours after surgery. Postmortem examination revealed normal coronary arteries, patent vein grafts, and multiple focal areas of recent and old myocardial fibrosis. Thus, it appears that coronary spasm, in the presence of otherwise normal coronary arteries, can produce myocardial infarction with necrosis, and that medical management may provide a more successful method of treating such patients.

SEGMENTAL AORTITIS AND AORTIC INCOMPETENCE.

An unusual case of a middle-aged male with segmental aortitis and aortic incompetence is described. To our knowledge, only 13 cases have been previously described in the literature, but only two have had anatomopathological confirmation. Aortic incompetence is a rare manifestation of segmental aortitis. Although intrinsic abnormalities of the aortic valve have been proposed, the finding of a normal aortic valve at postmortem examination in 2 of the 3 cases in which the aortic valve was examined, supports the premise that the incompetence is probably secondary to disproportionate dilatation of the aortic root.