Survival following spontaneous ventricular flutter-fibrillation associated with QT syndrome. Documentation during ambulatory monitoring.

A 56-year-old woman complaining of recurrent syncope was admitted to the coronary care unit after a fainting episode. Three days of continuous monitoring indicated prolongation of the QT interval and occasional premature ventricular beats. After transfer to another hospital wing, the patient was given ambulatory status. On the fifth day, while wearing a Holter monitor recorder, the patient lost consciousness. Review of the ambulatory ECG demonstrated multiple premature ventricular beats and an episode of paroxysmal ventricular flutter-fibrillation. The ventricular arrhythmias were correlated with telephone calls. It is concluded that (1) prolonged monitoring be performed in such subjects, and (2) the absence of ventricular tachyarrhythmias on repeated ECG recording should not preclude pharmacologic intervention in patients with the prolonged QT interval syndrome, ventricular ectopy, and a history of recurrent syncope.

Atrial flutter associated with obstructive sleep apnea syndrome. A case report.

An obese 57-year-old man with the obstructive sleep apnea syndrome had partial tracheostomy occlusion and palpitations. Continuous ECG monitoring demonstrated atrial flutter, occasional premature ventricular beats, and a high degree of atrioventricular block during apneic episodes. A 7-s period of ventricular asystole was demonstrated during one such episode. Revision of the tracheostomy produced an improvement in the patient's condition.

R on T or R on P phenomenon? Relation to the genesis of ventricular tachycardia.

Continuous electrocardiographic monitoring of 225 patients with acute myocardial infarction was performed during the initial 48 hours after admission. Two hundred twelve episodes of ventricular tachycardia occurred in 49 subjects, and 8 patients had primary ventricular fibrillation. Most cases of ventricular tachycardia were associated with late coupling of premature ventricular complexes. Of the 212 instances of ventricular tachycardia, 42 (20 percent) were initiated by a premature complex on the T wave (R on T) (R-R'/Q-T less than 1), and 93 (44 percent) had initiating premature complexes that occurred directly after onset of the sinus P wave (R on P). Of eight episodes of ventricular fibrillation, seven were initiated by a premature ventricular complex and in four of these there was associated R on T phenomenon. The influence of atrial contraction and myocardial stretch on reentry or ectopy is proposed as a possible explanation for the relatively high incidence rate of ventricular tachycardia observed after the onset of the sinus P wave.

Anemia producing mitral valve flutter on the echocardiogram.

Thirty-four patients in sinus rhythm with anemia due to chronic renal failure and one subject with chronic uterine bleeding were studied by means of echocardiography. Six patients (18%) had major diastolic fluttering of the mitral valve, and in 4 others the fluttering was equivocal. No subject had auscultatory or other clinical evidence of aortic insufficiency. In the patient with uterine hemorrhage, diastolic mitral valve motion reverted to normal after blood transfusion. It is concluded that anemia may produce diastolic mitral valve fluttering, which is probably based on increased blood flow in this setting. Caution should be exercised in ascribing diastolic murmurs associated with uremia to aortic regurgitation when anemia is present.

Relation between apexcardiographic a wave and posterior aortic wall motion.

Left ventricular end-diastolic pressure, an apexcardiogram and an aortic root echocardiogram were recorded in 24 patients. Eleven patients (46%) had a ratio of atrial to total amplitude (a/OE ratio) greater than 14% in the apexcardiogram, and all patients had a left atrial systolic posterior aortic wall motion after the conduit period that was greater than 50% of the total posterior aortic wall excursion as measured from the O to V points (A/OV ratio) on the echocardiogram. Only 2 of 24 patients (8%) had an echographic A/OV ratio greater than 0.5 with an apexcardiographic a/OE ratio of less than 14%. There was a significantly (P less than 0.001) high degree of positive correlation between the apexcardiographic a/OE ratio and the echographic A/OV ratio (r = 0.81), the a/OE ratio and left ventricular end-diastolic pressure (r = 0.82), and the A/OV ratio and left ventricular end-diastolic pressure (r = 0.75). It is concluded that the amplitude of posterior aortic root motion during atrial systole in relation to total posterior aortic wall motion may provide a useful index for the noninvasive assessment of left ventricular compliance and end-diastolic pressure.