Pulmonary edema following conversion of tachyarrhythmia. A case following burst atrial pacing.

Restoration of normal sinus rhythm is usually followed by improved hemodynamics. By contrast, pulmonary edema and cardiovascular collapse have been reported following successful electrical reversion of various tachyarrhythmias to normal sinus rhythm. The mechanism for this adverse reaction is not clear but has been thought to relate, at least in part, to electrical myocardial damage from the countershock. This report describes a patient in whom this complication occurred on two occasions, first following external countershock and subsequently following burst atrial pacing. Thus, conversion to sinus rhythm may be responsible for this phenomenon independent of the method of conversion.

Effects of beta-adrenergic blocking drugs on sensitivity and specificity of radionuclide ventriculography during exercise in patients with coronary heart disease.

We examined the impact of beta-adrenergic blocking drugs on the sensitivity and specificity of radionuclide ventriculography in 95 patients with angiographically proved coronary disease and in 22 angiographically normal subjects. Sixty of the former and seven of the latter were receiving beta-adrenergic blocking agents. All had normal regional and global left ventricular function at rest. Exercise-induced asynergy and failure of exercise to increase ejection fraction by at least 0.05 were considered abnormal findings. The specificity of the criterion, failure to increase ejection fraction, was so impaired (0.87 vs 0.29) by these agents as to negate the usefulness of that observation for the diagnosis of coronary disease. The utility of the ejection fraction measurement to assess the severity of occlusive disease is also compromised, since that response is ameliorated by these drugs. An exercise-induced decline in ejection fraction of at least 0.05 was observed significantly less frequently in patients receiving beta blockers (30% vs 54%; p less than 0.025).

Radionuclide ventriculography following coronary bypass surgery: correlation with arteriographic findings.

Radionuclide ventriculography demonstrates improved left ventricular performance during exercise following coronary bypass operation, but few data are available that compare the nuclear ventriculographic findings with arteriographic evaluation. We report the findings in 25 patients in whom both tests were performed within a short period of time. coronary bypass operations had been performed six weeks to nine years previously. Ejection fraction (EF) increased during stress in 5 completely revascularized patients. Exercise provoked deterioration in regional wall motion in 9 of 20 (45%) patients with incomplete revascularization, and EF failed to rise during exercise in 15 (75%). Although resting EF was similar in both completely revascularized patients and in those who were not (0.06 versus 0.58), EF during exercise was significantly greater in completely revascularized patients (0.68 +/- 0.02 versus 0.55 +/- 0.03, p less than 0.01). Exercise-provoked decline in EF in patients with coronary artery bypass grafts reflects continued significant occlusive disease.

Radionuclide evaluation of the interventricular septum following coronary artery bypass surgery.

The cases of 25 consecutive patients who had undergone radionuclide ventriculography both before and after coronary artery bypass surgery and who had had normal septal motion before surgery were reviewed. Abnormal septal motion was present in 22 patients (88%) postoperatively. In contrast, a new motion abnormality appeared following surgery in the apical segments of only 5 of 21 patients (24%) and in the lateral segments of 1 of 22 (5%) patients. All patients improved clinically following surgery, and only two had evidence of intraoperative myocardial infarction. Postoperatively, thallium imaging revealed normal septal perfusion in all six patients who underwent this examination. Thus, it appears that ischemic injury does not always account for this phenomenon, which is a potential source of confusion in patients after coronary bypass operations. It is concluded that radionuclide ventriculography identifies the same aberration of ventricular septal motion that is seen during echocardiographic examination of patients who have undergone surgery.

The usefulness of radionuclide ventriculography for the identification and assessment of patients with coronary heart disease.

To assess the usefulness of radionuclide angiography for the identification and evaluation of patients with coronary heart disease, we analyzed 100 consecutive patients who had undergone that examination and coronary arteriography. Regional wall motion abnormality during exercise was detected in 65 of 76 (86%) patients with occlusive coronary disease and in one of 11 (9%) with normal coronary arteries and normal left ventriculograms. The changes in the left ventricular ejection fraction in response to exercise were not helpful for the identification of individual patients with coronary disease, since changes were often small and within the error of the technique. Substantial decline of the ejection fraction during exercise indicated multivessel disease or severe proximal left anterior descending artery occlusion.

Fibrosing mediastinitis causing pulmonary arterial hypertension without pulmonary venous hypertension. Clinical and necropsy observations.

Clinical and morphologic observations are described in two patients with severe pulmonary arterial hypertension without pulmonary venous hypertension from fibrosing mediastinitis. In one patient, both main pulmonary arteries and one major pulmonary vein were severely narrowed by dense fibrous tissue; in the second patient, only the right main pulmonary artery was severely narrowed. Both patients had normal intrapulmonary arteries and normal pulmonary parenchyma. Of nine previously described necropsy patients with pulmonary hypertension due to fibrosing mediastinitis, seven had severe narrowing of multiple large pulmonary veins and in six of them the pulmonary hypertension was entirely due to pulmonary venous obstruction. In one other patient, the pulmonary hypertension was due to obstruction of one main pulmonary artery and several large pulmonary veins. Each of these seven previously described patients had severe changes in the small intrapulmonary arteries. Of the other two previously described patients with pulmonary hypertension from fibrosing mediastinitis, one had severe narrowing of only the main right pulmonary artery, and the other, of both main pulmonary arteries. Thus, although pulmonary arterial hypertension in patients with fibrosing mediastinitis is usually due to obstruction of multiple large pulmonary veins and to severe secondary changes in small intrapulmonary arteries, fibrosing mediastinitis can cause severe pulmonary hypertension by obstructing the right or both main pulmonary arteries.

Surgical management of life-threatening coronary artery disease: experience in 18 consecutive patients with left main trunk or equivalent coronary artery obstruction associated with an obstructed or a nondominant right coronary artery.

Eighteen patients with obstruction of the left main trunk or equivalent coronary artery associated with an obstructed or a nondominant right coronary artery were studied. All patients had coronary artery bypass surgery because of their symptoms and coronary anatomy. Five patients had coronary artery bypass without the use of preoperative elective intra-aortic balloon counterpulsation, and 3 of these patients had cardiac arrest prior to insertion of the grafts. The other 13 patients received elective intra-aortic balloon counterpulsation prior to induction of anesthesia and cannulation. None in this second group of patients developed any hypotensive episodes or cardiac arrest, and all have done well following the bypass operation. This experience suggests that the use of elective preoperative intra-aortic balloon assist in patients who have a very critical coronary artery obstruction is indicated in view of the high incidence of cardiac arrest observed in patients who did not receive the preoperative elective intra-aortic balloon support.