The postpericardiotomy syndrome as a cause of pleurisy in rehabilitation patients.

Pleuritic chest pain in patients on a rehabilitation unit may be caused by several conditions. We report 2 cases of postpericardiotomy syndrome (PPS) as a cause of pleuritic pain. PPS occurs in 10% to 40% of patients who have coronary bypass or valve replacement surgery. The syndrome is characterized by fever, chest pain, and a pericardial or pleural friction rub. Its etiology is believed to be viral or immunologic. The syndrome can be a diagnostic challenge, and an increase in length of hospitalization because of it has been documented. Identified risk factors for PPS include age, use of prednisone, and a history of pericarditis. A higher incidence has been reported from May through July. Many patients undergo a battery of expensive procedures before PPS is diagnosed. The pain is sharp, associated with deep inspiration, and changes with position. Pleural effusions may be present and tend to occur bilaterally. Pericardial effusions are a documented complication. A pericardial or pleural rub may be present and is often transient. Serial auscultation is important. Laboratory work provides clues with a mild leukocytosis and an elevated erythrocyte sedimentation rate. However, this does not provide the definitive diagnosis. Cardiac enzymes are not reliably related to the syndrome. An electrocardiogram will show changes similar to those associated with pericarditis. The patient may have a fever, but it is rarely higher than 102.5 degrees F. Complications include pericardial effusions, arrhythmias, premature bypass graft closure, and cardiac tamponade. Treatment consists of a 10-day course of nonsteroidal anti-inflammatory drugs.

Pergolide mesylate: lack of cardiac toxicity in patients with cardiac disease.

In a 12-month open-label trial, pergolide mesylate was administered in doses with antiparkinsonian efficacy to six patients with stable heart disease. Cardiac status did not worsen in any patient. Parkinson's disease improved in all patients. Pergolide is a safe and effective therapy for Parkinson's disease, even in patients with heart disease.

Dual AV nodal pathways--vagal influences on AV nodal conduction.

This 52-year-old male presented with syncope and demonstrated two distinct PR intervals on the electrocardiogram. Electrophysiologic studies showed dual AV nodal pathways. Right-sided carotid sinus massage induced prolonged periods of sinus arrest with no change in AH interval. Left-sided carotid sinus massage produced long AH intervals (slow pathway conduction) with some slowing of sinus rate. Whenever sinus rhythm with slow pathway conduction was observed (long AH) a 20-30 mmHg drop systolic pressure was seen. Following implantation of an AV sequential pacemaker, the patient has been asymptomatic.

Limitation of the surface electrocardiogram in diagnosis of atrial arrhythmias. Further observations on dissimilar atrial rhythms.

Electrophysiologic studies with recordings of multiple intracavitary electrograms were performed in two patients with atrial dysrhythmias. In Case 1 the arrhythmic pattern in the surface electrocardiogram resembled atrial flutter. Electrophysiologic studies revealed the arrhythmia to be paroxysmal left atrial tachycardia, with separation of left and right atrial components of the P wave by an isoelectric period secondary to marked interatrial conduction delay. In Case 2 the surface electrocardiogram indicated paroxysmal atrial tachycardia with block. Electrophysiologic studies revealed right atrial standstill with atrial inexcitability and two dissimilar rhythms involving the left atrium. The electrocardiograms did not accurately reflect atrial arrhythmias in these two patients and only multiple direct recordings permitted the correct diagnoses. New electrophysiologic observations concerning intraatrial block and dissimilar atrial rhythms are presented.