Right coronary artery-pulmonary artery arteriovenous fistula secondary to open heart surgery.

A patient is described who underwent atrial septal defect repair at age 12 and presented 16 years later with angina. Coronary angiography revealed a right coronary artery to pulmonary artery fistula that had developed at the site of the previous thoracotomy. This is the first report of an acquired fistula of this type developing secondary to trauma associated with open heart surgery. Diagnosis, shunt quantification and treatment are discussed.

Left ventricular function in mild hypertension after adrenergic blockade.

We previously used the Doppler transmitral flow velocity ratio A/E (A = late ventricular filling peak velocity; E = early ventricular filling peak velocity) and the age-adjusted ratio A/E/Age to detect left ventricular filling abnormalities in untreated mild hypertension. This study is a double-blind assessment of the effect of combined alpha- and beta-blockade (labetalol) and beta-blockade alone (atenolol) on left ventricular filling in mild hypertension. Twenty-seven patients blindly randomized to labetalol (12 patients) and atenolol (15 patients) treatment completed the echocardiographic and Doppler studies. Clinical and echo-Doppler data obtained at baseline and 6 weeks after initiation of therapy showed no difference between the two groups for age (49 +/- 10 vs 46 +/- 10 years), mean blood pressure (before therapy, 118 +/- 9 vs 117 +/- 8 mm Hg; after therapy, 108 +/- 12 mm Hg), left ventricular dimensions, wall thickness, systolic function, and mean late filling velocity A. There was no significant change in left ventricular mass and mass index with labetalol (left ventricular mass, 211 +/- 36 vs 216 +/- 38; mass index, 110 +/- 17 vs 112 +/- 16) or atenolol (245 +/- 41 vs 271 +/- 65; 120 +/- 18 vs 130 +/- 35). The mean velocity E, A/E, and A/E/Age ratios significantly improved with labetalol (p less than 0.05) but did not change significantly with atenolol. The improvement in A/E and A/E/Age ratios was primarily due to an increase in early filling velocity E.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive hemopericardium in a patient with postmyocardial infarction syndrome.

A 44-year-old man sustained a transmural inferolateral myocardial infarction and began to show signs of postmyocardial infarction syndrome (Dressler's syndrome) one week after infarction. Anticoagulant therapy had been initiated for suspected pulmonary thromboembolism. Administration of steroids did not improve the patient's clinical condition or the results of laboratory investigations. A massive pericardial effusion was diagnosed clinically, and this diagnosis was confirmed by a pericardial scan using 99m technetium. Subsequently, 1,800 ml of bloody fluid was removed from the pericardial cavity, and following the pericardiocentesis, the patient became asymptomtic. This case reemphasizes the hazards of anticoagulant therapy in patients with the postmyocardial infarction syndrome.

Familial myxomas in four siblings.

Familial myxomas of the heart are very rare, with only two previous reports noted in the literature. This report documents four siblings with myxomas, and three of these patients had two or more myxomas. One sibling had four myxomas excised. The clinical findings, history, examination, and surgical treatment are described.

Effect of age on left ventricular filling in children of hypertensive parents.

Doppler transmitral flow velocity A/E ratio is a useful noninvasive estimate of left ventricular (LV) filling. However, the A/E ratio increases with age. To evaluate the effect of age on LV filling in children, Doppler transmitral flow velocity A/E ratios and echocardiographic measurements were obtained in 51 normal children (mean age 12 +/- 4 years) of hypertensive parents (study children), sex- and age-matched against 28 normal children (mean age 12 +/- 4 years) from normotensive parents (control children). There was a significant correlation between age and LV systolic and diastolic internal dimensions (r = 0.74 and 0.83, respectively, P less than .0001, in study children, and r = 0.70 and 0.79, respectively, P less than .0001, in control children), total wall thickness (r = 0.72, P less than .0001, in study children, and 0.61, P less than .001, in control children), and with LV mass index (r = 0.56, P less than .0001 and r = 0.45, P less than .02, respectively). In contrast, there was no correlation between age and transmitral flow velocity A/E ratio in either group (r = 0.12 and 0.07, respectively). In conclusion, age does not have an effect on LV filling in normal children from either normotensive or hypertensive parents. Therefore, age correction of A/E ration, which is necessary in adults, is not required in children. Because of a strong correlation between age and LV mass as well as LV mass index, age should be taken into account when defining criteria for LV hypertrophy in children.

Left ventricular filling in hypertensive blacks and whites following adrenergic blockade.

Left ventricular diastolic filling was investigated in 12 black and 15 white subjects before and after double-blinded randomized treatment of mild to moderate hypertension with combined alpha- and beta-adrenergic receptor blockade (labetalol) and beta-blockade alone (atenolol). At baseline (off medication), both groups were similar for age (46 +/- 8 years v 48 +/- 12 years), mean blood pressure (121 +/- 8 mm Hg v 115 +/- 8 mm Hg), left ventricular dimensions, left ventricular mass index (118 +/- 24 g/m2 v 113 +/- 13 g/m2), and left ventricular filling as reflected by transmitral flow velocity ratio A/E (0.97 +/- 0.33 v 0.92 +/- 0.19, normal age-matched control A/E ratio is 0.64 +/- 14). There were 6 blacks and 6 whites in the labetalol group; 6 blacks and 9 whites in the atenolol group. At six weeks of treatment, whites in the labetalol group showed a significantly greater drop in mean blood pressure (114 +/- 7/102 +/- 11, P less than .007 v 123 +/- 9/114 +/- 11, P = NS) and correspondingly greater improvement in A/E ratio (1.04 +/- 0.14/0.74 +/- 0.23, P less than .024 v 1.02 +/- 0.23/0.89 +/- 0.16, P = NS). However, this difference was no longer significant when controlling for age and blood pressure level. In the atenolol group, whites showed a significant increase in the rapid filling phase velocity E, while late filling phase velocity A significantly dropped only in blacks, without significant improvement in A/E ratio in either subgroup. In conclusion, greater improvement in left ventricular filling is seen with combined alpha-beta-blockade than beta-blockade alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac tamponade complicating percutaneous catheterization of subclavian vein.

Cardiac tamponade has not been reported previously as a complication of central venous pressure (CVP) monitoring catheters inserted via the percutaneous subclavian vein approach. In one patient perforation of the vein by the catheter resulted in the catheter lying free in the mediastinum. Deterioration of the patient prompeted increasing infusion of fluids through this catheter with incresing cardiac compression. Relief was obtained after a thoracotomy. Ti is suggested that this complication may be recognized in the future and corrected without thoracotomy if radiopaque dye is infused through the CVP catheter.

The surgical resection and chemotherapy of metastatic osteogenic sarcoma of the right ventricle.

The case report of a patient with metastatic osteogenic sarcoma of the right ventricle who had had an interscapulothoracic amputation in October, 1970, and a left lower lobectomy in June, 1973, for pulmonary metastasis is presented. The patient was hospitalized in October, 1974, with signs and symptoms of right ventricular outflow obstruction and arrhythmia, and cardiac workup established the presence of a right ventricular tumor. The lesion was successfully resected using cardiopulmonary bypass, and the diagnosis of metastatic osteogenic sarcoma was confirmed. The patient did well after the operation and returned to normal activity. She was placed on adjuvant Adriamycin (doxorubicin) chemotherapy, but 6 months later died of Adriamycin toxicity.

Intracardiac myxomas: twenty-year echocardiographic experience with review of the literature.

We reviewed the echocardiograms of 35 patients with intracardiac myxomas. Patient data were combined from two geographically distant laboratories. No significant variations in the patient profiles were encountered. Most patients were white (33 of 35) with a mean age of 45 years. The diagnosis was suspected on clinical grounds alone in only six of 35 patients before the echocardiogram was done. M-mode recordings were the primary echocardiographic modality available in the first 16 patients, whereas two-dimensional studies were also done in the others. Continuous and pulsed wave Doppler echocardiography were added in eight of the most recent studies. In one patient color flow imaging from both transthoracic and esophageal approaches was possible to better visualize a large left atrial tumor. Thirty-three patients had solitary tumors (29 left atrial, three right atrial, and one left ventricular), and two had multiple tumors. The most characteristic finding, as expected, was the demonstration of abnormal mass echoes produced by the myxoma tissue. Several interesting features not previously emphasized in the literature included abnormal notching of the interventricular septum and posterior left ventricular wall probably produced by displacement from the larger mobile left atrial tumors dropping into the mitral sleeve. This was best appreciated by the M-mode recordings. In one patient with an associated atrial septal defect, movement of the tumor into the defect appeared to alter the expected downward displacement into the mitral orifice. In the patients who were studied by two-dimensional, Doppler, or color flow imaging, tumor movement was evidenced by abnormal frequency shifts, and dispersion of flow around the tumor mass was readily appreciated. Surgical removal was performed in all patients. Follow-up echocardiograms were done postoperatively ranging up to 17 years. Recurrent tumors occurred in two patients, both of whom had congenital myxomas. Echocardiography is proving to be an unparalleled tool in the diagnosis of intracardiac tumors.

Right-to-left interatrial shunt secondary to an extensive right ventricular myocardial infarction.

This case report describes a rare complication of right ventricular myocardial infarction. Hypoxemia in this setting has only been described in two previous cases with a right-to-left interatrial shunt. This is surprising, given the high incidence of probe patent foramen ovale in randomly selected necropsy cases. Two-dimensional echocardiography with contrast is the method of choice for detecting this abnormality.

Diagnosis of recurrent left ventricular pseudoaneurysm by echocardiography with color flow imaging.

Left ventricular pseudoaneurysms are a rare complication of myocardial rupture. The diagnosis is paramount because of the propensity of pseudoaneurysms to rupture. Color flow imaging has been reported to be an aid in the diagnosis of pseudoaneurysms. We recently studied a patient with a myocardial infarction who developed a left ventricular pseudoaneurysm. Diagnosis was made by two-dimensional imaging with color flow imaging. He subsequently had a repair procedure with a gortex graft. One week after repair, repeat echocardiography with color flow imaging showed flow into the aneurysmal sac at multiple sites, consistent with recurrence of the pseudoaneurysm. Echocardiography with color flow imaging provides a safe noninvasive diagnostic tool for evaluating pseudoaneurysms preoperatively and in assessing the competency of the repair postoperatively.

Termination of atrial flutter and atrial tachycardia with rapid atrial stimulation.

The results in this series of fifty-seven patients confirms the safety and reliability of rapid atrial stimulation to terminate atrial flutter and atrial tachycardia. Transthoracic wires implanted at thoracotomy or transvenously placed atrial electrodes can be used for the confident intracardiac electrocardiographic diagnosis of tachyarrhythmias and for atrial stimulation. Our experience represents the second largest reported series of patients to undergo cardioversion by this method. In all but five of fifty-seven patients either the atrial tachyarrhythmia was converted to normal sinus rhythm or the flutter-tachycardia was terminated with resultant atrial fibrillation. In forty-three patients sinus rhythm was eventually re-established after atrial stimulation. Various aspects of rapid atrial stimulation, including it's preference over precordial shock, have been discussed. We feel particular consideration should be given cardioversion by rapid atrial stimulation in patients with possible digitalis toxicity and in all patients who have atrial flutter, atrial tachycardia, or junctional tachycardia after open heart surgery.

The syndrome of nonejection click-late systolic murmur and mitral valve prolapse. A case report and review of the subject.

The syndrome of nonejection click-late systolic murmur and mitral valve prolapse is reviewed. A patient with this syndrome is reported. Physical findings, important diagnostic studies, and possible complications are discussed.