Treatment of life-threatening ventricular arrhythmias with nonguided surgery supported by electrophysiologic testing and drug therapy.

Forty-six patients who had coronary artery disease, left ventricular aneurysm and life-threatening ventricular tachyarrhythmia underwent surgical treatment to eliminate or facilitate control of the arrhythmia. Surgery was performed without the assistance of intraoperative mapping techniques. Forty-three patients underwent preoperative or postoperative electrophysiologic testing, or both, and antiarrhythmic therapy was added, when indicated, postoperatively. The patients had a mean age of 63 years, a mean preoperative left ventricular ejection fraction of 27 +/- 9% and a mean preoperative left ventricular end-diastolic pressure of 23 +/- 9 mm Hg. Twenty-one patients (46%) underwent surgical treatment within 2 months of their last myocardial infarction. The overall operative mortality rate was 6.5% (three patients). Eighteen of the 43 operative survivors were discharged from the hospital on no antiarrhythmic therapy, whereas 25 received additional antiarrhythmic treatment. During a mean follow-up period of 36 months (range 2 to 88), there were 13 deaths; eight patients died suddenly, three died of congestive heart failure, one of myocardial reinfarction and one from a noncardiac cause. The overall cumulative cardiac mortality rate at 1, 2 and 3 years was 16, 22 and 35%, respectively, whereas the sudden cardiac death rate was 5, 12 and 20%, respectively. This experience suggests that high risk patients who undergo nonguided surgery for life-threatening ventricular arrhythmia and left ventricular aneurysm have a relatively low surgical mortality and a better long-term survival than previously reported. However, if utilized, such an approach must be systematically supported by perioperative electrophysiologic testing to determine the need for supplemental antiarrhythmic therapy.

Flecainide acetate for treatment of bypass tract mediated reentrant tachycardia.

Flecainide acetate was administered to 19 patients who had inducible sustained orthodromic atrioventricular reentrant tachycardia. Eleven of 18 patients had no inducible tachycardia and 7 patients continued to have inducible tachycardia while receiving flecainide. The effects of flecainide could not be evaluated because of hypotension during intravenous infusion in 1 patient. The main effect of the drug was a selective depression of retrograde conduction over the bypass tract, resulting in abolition of reentry or prolongation of tachycardia cycle length. The electrophysiologic effects of intravenous flecainide were concordant with those of oral flecainide in 5 patients who were studied during both regimens. Fifteen patients were discharged from the hospital on a regimen of flecainide. One patient received concomitant beta-blocking therapy. During an average follow-up of 18.5 months (range 2 to 48), 9 patients remained symptom free. Recurrences were observed in 5 patients, 3 of whom still had inducible tachycardia during electrophysiologic testing. Treatment had to be discontinued in 1 patient because of drug intolerance. Thus, flecainide is likely to be effective and well tolerated in the long-term treatment of at least 50% of patients who present with bypass tract mediated orthodromic reentrant tachycardia.

Endocarditis caused by beta-lactamase-producing Haemophilus influenzae.

We have described a case of tricuspid valve endocarditis caused by beta-lactamase-producing H influenzae that responded well to four weeks of cefamandole therapy.

Infective endocarditis of a bicuspid aortic valve caused by Hansenula anomala.

Infective endocarditis due to Hansenula anomala developed on a bicuspid aortic valve in a 40-year-old man. H. anomala, an ascomycetous yeast, may be a member of the normal flora of the throat and alimentary tract in humans but has not been previously known to be pathogenic in humans. A past history of intravenous drug use may have contributed to the development of disease in this patient.

Pure vasodepressor carotid sinus hypersensitivity. Unusual cause of recurrent syncope.

Recurrent syncope in a 53-year-old man was found to be due to vasodepressor carotid sinus hypersensitivity. Establishment of the diagnosis required monitoring of both the electrocardiographic changes and the blood pressure during carotid sinus massage. Current therapeutic approaches to patients with symptomatic vasodepressor hypersensitivity are discussed.

Isolated tricuspid valve prolapse diagnosed by echocardiography.

Isolated tricuspid valve prolapse in the absence of mitral valve prolapse or other cardiac defects has not been previously noted. This report describes a patient who on both M-mode and two-dimensional echocardiography demonstrated tricuspid prolapse without other associated abnormalities. The implications of this finding are discussed.

Paradoxical ventricular septal motion with right ventricular dilatation as a manifestation of pure pressure overload due to pulmonary veno-occlusive disease.

Paradoxical interventricular septal motion with right ventricular dilatation has been considered the hallmark of right ventricular volume overload. We report a 43-year-old woman with severe pulmonary hypertension due to pulmonary veno-occlusive disease who exhibited these echocardiographic abnormalities. Right ventricular volume overload was excluded by physical examination, echocardiography with saline contrast study and by cardiac catheterization, angiography, and shunt study. These echocardiographic findings are thus not pathognomonic of right ventricular volume overload and can be seen with pressure overload as well.

High incidence of myocarditis by endomyocardial biopsy in patients with idiopathic congestive cardiomyopathy.

Thirty-five patients with unexplained congestive heart failure were evaluated with endomyocardial biopsy. Utilizing microscopic, ultrastructural and immunofluorescent studies, samples were classified as exhibiting either no inflammation (cardiomyopathy) or active lymphocytic myocarditis, grade I to IV. Twenty-two (63%) of the patients had inflammatory changes. Of these 22 patients, 18 had low grade I or II inflammation, 7 were treated with immunosuppressive agents with improvement in 5 and stabilization in 1. One patient died of progressive congestive heart failure. Three of four patients with high grade III or IV myocarditis died after a fulminant course. The results suggest that inflammatory myocarditis may be more common than previously suspected and add evidence that there may be ongoing inflammation in many cases of congestive cardiomyopathy.