A right atrial mass in the presence of a permanent pacemaker electrode in a patient with polycythemia vera.

A case of a huge right atrial mass that developed 2 years after a permanent pacemaker implantation is described. The patient had a history of polycythemia vera, which is known to present a high tendency towards the development of thrombosis. In light of this fact, we suggest that in similar cases a full echocardiography follow-up should be performed, and long-term anticoagulant therapy should be considered in selected cases.

Myocardial rupture in acute myocardial infarction: urgent management.

Myocardial rupture complicated acute myocardial infarction in a 50 year old man. Resuscitation was started immediately and he was treated with pericardiocentesis and a massive intravascular infusion of fluid. The torn area was plicated with Teflon felt and reinforced with an uninterrupted suture. The postoperative course was uncomplicated. This report points out the crucial importance of prompt clinical recognition and management of the acute stage of cardiac rupture in acute myocardial infarction.

Ventricular pacing as the preferable mode for long-term pacing in patients with carotid sinus syncope of the cardioinhibitory type.

This study was designed to determine the efficacy of long-term VVI pacing in patients having the isolated cardioinhibitory type of carotid sinus syncope. The study included 20 patients suffering from repeated syncopal attacks; all were proven by electrophysiological studies to have isolated forms of cardioinhibitory type carotid sinus syncope. Long-term pacing by the VVI mode was carried out in all patients by programming the pacemaker rate well below the patient's sinus rate. The follow-up period after pacemaker implantation, which ranged from 2 to 54 months (average, 20 months), revealed that none of the patients had any recurrence of syncopal attack. Repeated Holter monitoring showed that ten had permanent sinus rhythm without any artificial pacing activity, while in the other ten, pacemaker activity was recorded--predominant in two patients and rare in the other eight. During Holter monitoring, attacks of weakness were reported by four patients; however, they were not related to pacemaker activity. This report indicates the importance of electrophysiological studies in patients suffering from carotid sinus syncope. These studies make possible the diagnosis of the isolated form of cardioinhibitory type syncope for which VVI pacing offers complete relief of symptomatology, thus rendering AV sequential pacing superfluous.

Mitral valve prolapse in hyperthyroidism of two different origins.

The prevalence of mitral valve prolapse was investigated in 126 patients with hyperthyroidism due to Graves' disease or toxic nodular goitre and that of hyperthyroidism in 64 patients with mitral valve prolapse. One hundred and eleven asymptomatic healthy subjects comprised a control group. The patients with hyperthyroidism were divided into those with Graves' disease and those with toxic nodular goitre. Of the group as whole, 12 (9.5%) patients had mitral valve prolapse compared with six (5.4%) in the control group, but the difference was not statistically significant. The prevalence of mitral valve prolapse in the patients with toxic goitre was also not significantly different from that in the controls. When the prevalence in the group with Graves' disease was compared with that in the control group (16.3% vs 5.4%) the difference was significant. Only one patient with mitral valve prolapse had hyperthyroidism.

Carotid sinus hypersensitivity: diagnosis of vasodepressor type in the presence of cardioinhibitory type.

The diagnosis of carotid sinus syncope may sometimes be difficult because its symptoms are not specific, especially in the older age group where carotid sinus hypersensitivity and syncope are not uncommon events. Of major diagnostic importance is the screening of the vasodepressor type of carotid sinus syncope in the presence of the cardioinhibitory type, as this diagnosis has important therapeutic applications. This work is based on the electrophysiological studies performed on seven men with a mean age of 61.9 years who had syncope of unknown cause and hypersensitive carotid sinus reflex. The studies revealed no evidence of sinus node dysfunction or high degree atrioventricular block that would explain the neurological symptoms. The studies also included carotid sinus stimulation with simultaneous interarterial pressure recordings with and without atrial or A-V sequential pacing. The pacing assured the maintenance of normal heart rate during carotid sinus stimulation. The results of these studies revealed that five patients suffered from cardioinhibitory type and two from a combined form of cardioinhibitory and vasodepressor type (mixed form) of carotid sinus syncope. A permanent cardiac pacemaker was implanted in the five patients with the isolated cardioinhibitory type and in one patient with the mixed type of carotid sinus syncope.

Exit block in myxedema, treated effectively by thyroid hormone therapy.

A case of a 71-year-old female who developed exit block one year after implantation of a pervenous pacemaker is reported. The pacemaker had been implanted for sick sinus syndrome; the exit block was probably due to the development of severe myxedema which caused high pacing threshold. Normal pacing threshold was obtained on the seventh day of adequate thyroid hormone therapy and a follow-up one year later revealed effective control of the myxedema and no abnormalities in the function of the pacemaker system.

An unusual form of mitral insufficiency accompanying atrial septal defect.

An unusual case of atrial septal defect secundum type, associated with intermittent severe mitral insufficiency due to billowing anterior mitral leaflet, in a 56-year old female is described. The degree of mitral insufficiency ranged from severe to none. This phenomenon manifested itself by an intermittent systolic apical thrill and intermittent mitral regurgitation on angiocardiography. Pulling the anterior mitral leaflet at operation through the atrial septal defect demonstrated that this leaflet could be caught in the left atrium, thus causing intermittent mitral insufficiency. Closure of the atrial septal defect and replacement of the mitral valve was performed.

Life-threatening "vagal reaction" to emotional stimuli.

"Vagal reactions" may follow sudden emotional or physical strain in "vagotonic individuals" and are usually benign. In the case described, emotional stimuli caused life-threatening vagal reactions in a "healthy individual." Implantation of an artifical pacemaker was necessary to control the attacks.