Lymphocytic myocarditis presenting as unexplained ventricular arrhythmias: diagnosis with endomyocardial biopsy and response to immunosuppression.

During a period of 18 months beginning in January 1982, a total of 65 patients were referred to the Miami Heart Institute for evaluation of either aborted out of hospital sudden death, ventricular tachycardia resistant to standard clinically directed antiarrhythmic medication programs or high grade ventricular arrhythmia (Lown class greater than or equal to IV B) with or without syncope. After complete evaluation including cardiac catheterization in all but 1 patient, 17 patients were identified in whom no obvious cardiac disease could be found. Twelve of the 17 underwent right ventricular endomyocardial biopsy. Six of the 12 biopsies demonstrated clinically unsuspected lymphocytic myocarditis (Group A). Findings in three of the remaining six biopsies were consistent with an early cardiomyopathy and in three were completely normal (Group B). Retrospective review of the clinical, laboratory, electrophysiologic, hemodynamic and angiographic data failed to identify a marker that reliably separated Group A from Group B patients. In addition to antiarrhythmic therapy guided by laboratory electrophysiologic study, all Group A patients were treated with prednisone and azathioprine. After 6 months of immunosuppression, all patients with myocarditis were reevaluated in the hospital without antiarrhythmic medication. Ventricular tachycardia/fibrillation could not be provoked in the laboratory during repeat electrophysiologic testing in five of the six patients. Repeat myocardial biopsy after all immunosuppressive therapy had been discontinued revealed absence of inflammation associated with varying degrees of residual interstitial fibrosis. There were no deaths. It was concluded that a patient with an otherwise clinically silent lymphocytic myocarditis can present with potentially life-threatening ventricular arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

Aneurysmal coronary artery disease.

To examine the clinical and historical features and the natural history of aneurysmal coronary disease, we reviewed the registry data of the Coronary Artery Surgery Study (CASS). Nine hundred seventy-eight patients, representing 4.9% of the total registry population, were identified as having aneurysmal disease. No significant differences were noted between aneurysmal and nonaneurysmal coronary disease patients when features such as hypertension, diabetes, lipid abnormalities, family history, cigarette consumption, incidence of documented myocardial infarction, presence and severity of angina, and presence of peripheral vascular disease were examined. In addition, no difference in 5-year medical survival was noted between these two groups. These findings suggest that aneurysmal coronary disease does not represent a distinct clinical entity but is, rather, a variant of coronary atherosclerosis.

[Variability in the interpretation of coronary angiograms by different specialists based on data from the cooperative Coronary Artery Surgery Study]. / Variabel'nost' interpretatsii koronarnykh angiogramm raznymi spetsialistami po dannym Kooperativnogo izucheniia khirurgicheskogo lecheniia koronarnykh arterii.

Randomly selected cine arteriographic films of 30 diseased patients were read twice by each of three experienced observers. The intrareader variability was less than one-half of the interreader variability in reading the stenosis of segments of the coronary anatomy - a statistically significant difference (p less than 0.001). When extent of disease was evaluated by the number of diseased vessels, interreader variability was larger than intrareader variability (p less than 0.01). One reader read considerably less disease than the other two readers. The films were rated as to quality of the arteriographic films and the completeness of the study. In each case there was a greater interreader than intrareader variability (p less than 0.01). The films were rated good, acceptable, or poor. One of the three interpreters consistently gave worse ratings than the other two readers. It was particularly noteworthy that a larger amount of interreader variability was observed in both the left main coronary artery and the proximal left anterior descending artery.

Reproducibility of coronary arteriographic reading in the coronary artery surgery study (CASS).

Eight hundred seventy arteriograms from the Coronary Artery Surgery Study (CASS) were independently read by readers at two different clinics to evaluate the reproducibility of the interpretation of coronary arteriograms. Among proximal segments, the interpretation of lesions of the left main coronary artery were the least reproducible, P less than .02. When one angiographer reads a stenosis of 50% or more in the left main coronary artery, it is estimated that a second reader will report no lesion 18.6% of the time. In 94.7% of the films, the number of significantly (greater than or equal to 70% stenosis) diseased vessels was the same for both readers (72.1%) or differed by one vessel (22.6%). The reproducibility of interpretation of films of good or acceptable quality or completeness was better than the reproducibility of readings of arteriograms judged to be of poor quality or incomplete studies. The mean absolute difference between readings of the percent stenosis decreased over the time of the patient enrollment, 1975 to 1978. This may have resulted from major collaborative efforts made during the course of the study to improve the quality of angiography and to standardize the reading of the cine films.

Guidelines for effective and safe percutaneous intraaortic balloon pump insertion and removal.

During the 12 month period beginning February 1980, a total of 54 consecutive patients had 60 attempts at percutaneous insertion of an intraaortic balloon because of medically uncontrollable angina, cardiogenic shock either in the setting of an acute myocardial infarction or within hours of cardiac surgery and as a prophylactic measure in high risk patients before cardiac surgery. The balloon was successfully inserted in 49 patients (91 percent). In five patients the balloon could not be inserted in spite of eight attempts because of tortuosity of the iliac artery. All nine patients in whom balloon insertion was attempted without fluoroscopy had the device inserted successfully. The four insertion attempts during cardiac massage were all successful. Experience with use of the new longer introducer sheath is described. Since its acquisition there has not been a single balloon pump insertion failure in 20 consecutive patients including 6 patients in whom initial attempts through the conventional short death were unsuccessful because of iliac tortuosity. The major complications encountered in the present series were thromboembolic: femoral arterial thrombosis developed in five patients (10.2 percent) and an asymptomatic pulse loss in the contralateral foot developed in another. There were no cases of pseudoaneurysm, groin hematoma, aortic dissection or infection related to the percutaneous balloon. On the basis of this experience, several guidelines are suggested for safe and effective percutaneous insertions and removal of the intraaortic balloon pump.

Safe transthoracic left ventricular puncture performed with echocardiographic guidance.

Retrograde aortic left ventricular pressure recording is difficult to obtain and often unreliable in the presence of a mechanical aortic valve prosthesis. Under echocardiographic guidance, we have safely performed transthoracic left ventricular puncture for pressure recording in seven patients with an aortic valve prosthesis. The transducer is placed at the left sternal border and then slid laterally until the right ventricular cavity and interventricular septal echoes disappear, but before the echoes from the left lung are recorded. The chest wall is marked and the transducer is angled until the mitral valve echoes are identified. The transducer angle and direction are recorded with external markers, and the left ventricular cavity depth is measured. An 18-gauge needle is then inserted the determined depth into the left ventricle, guided exactly by the echocardiographic external markers. The procedure was successful in each patient on the first attempt without a single complication. We conclude that this technique affords the operator greater control when left ventricular pressure must be recorded by transthoracic puncture and that it may reduce the risk of potentially serious complications.

An unusual form of the bradycardia-tachycardia syndrome: paroxysmal A-V block and ventricular tachycardia.

An unusual case of alternating bradycardia-tachycardia, paroxysmal Mobitz II A-V block and ventricular tachycardia is described. The patient presented with a normal resting (control) electrocardiogram and intracardiac conduction times (A-H and H-V intervals). The clinical evaluation, electrophysiology, and importance of defining the cause of serious rhythm disturbances prior to therapy are discussed.

Obscure syncope and the sick sinus syndrome.

This report describes a 25-year-old vigorous young man who had a history of eight years of near syncope and syncope of unknown etiology. Repeat in-hospital observation and laboratory electrophysiologic functional testing did not elucidate the origin of the symptoms. Prolonged Holter monitoring finally showed that the syncopal attacks were caused by a sick sinus syndrome (SSS). On electrophysiologic study, a concealed rate-dependent unidirectional antegrade accessory A-V pathway (AP) was found to be present. The AP was an incidental finding and was unrelated to the patient's symptoms. The symptomatic SSS may occur in the young as well as in the elderly. Sinoatrial dysfunction may be intermittent and difficult to detect, may cause severe symptoms, and may even be life-threatening. Prior to definitive therapy (such as the permanent implantation of a pacemaker), the importance of relating symptoms to a rhythm disturbance has been stressed. In cases where the cause of the symptoms is not obvious, this is best accomplished by continuous Holter monitoring.

Sodium nitroprusside as a coronary vasodilator in man. I. Effect of intracoronary sodium nitroprusside on coronary arteries, angina pectoris, and coronary blood flow.

The effect of the intra-arterial injection of 5 to 10 microng of sodium nitroprusside on the caliber of normal and diseased coronary arteries was evaluated in 21 patients during diagnostic cardiac catheterization. In addition, the effect of intra-graft injection of 5 microng of the same agent on the blood flow in aorta-right coronary artery saphenous vein bypass grafts was also evaluated intra-operatively in two patients. The compound induced an increase in the caliber of both normal and stenosed coronary arteries as well as an increase of flow in the grafts. Consistent with measurements of coronary flow response to sodium nitroprusside, angina pectoris which developed in four patients during cardiac catheterization was immediately relieved and the ischemic ST-segment depression significantly reversed after injection of 5 to 10 microng of the drug into the left main coronary artery. Within the dose range used, the drug caused no significant effect on systemic blood pressure or apparently deleterious electrophysiologic changes. No side effects were observed. We conclude that the primary direct action of sodium nitroprusside in the human coronary artery is vasodilatory.

Sodium nitroprusside as a coronary vasodilator in man: a comparison of the effects of sodium nitroprusside and papaverine hydrochloride on aortocoronary saphenous vein graft flow.

Blood flow in aortocoronary saphenous vein grafts was studied in response to intragraft injection of sodium nitroprusside and papaverine hydrochloride. Following injection of 50 mug of sodium nitroprusside, mean graft flow increased from 40.1 +/- 4.5 to 81.3 +/- 8.5 ml per minute. Administration of 30 mg of papaverine hydrochloride caused mean graft flow to rise from 35.4 +/- 3.9 to 70 +/- 7.9 ml per minute. Sodium nitroprusside increases aortocoronary graft flow, the doubling effect of 50 mug of the drug being of the same order of magnitude as that induced by 30 mg of papaverine hydrochloride.