Predictors of psychosocial adjustment in patients with implantable cardioverter defibrillators.

Predictors of psychological distress/adjustment were examined in 25 patients following placement of ICDs. Patients completed a demographic questionnaire and a standardized questionnaire of psychological symptoms (i.e., Symptom Checklist-90 Revised; SCL-90-R). The number of discharges categorized by the patient as inappropriate and appropriate were also ascertained. The number of ICD discharges categorized as inappropriate and diminished levels of physical activity (r = 0.53 and 0.63, P < 0.01, respectively) did significantly relate to overall psychological distress. In addition, after controlling for age and prior psychiatric and physical health status through a stepwise multiple regression analysis, the occurrence of ICD discharges categorized as inappropriate and diminished physical activity continued to significantly predict overall psychological distress (R2 = 0.41, P < 0.01). However, the number of ICD discharges categorized as appropriate did not significantly predict overall psychological distress. The results of this investigation suggest that further refinement of the ICD could reduce the risk of exposure to potential psychological distress, and an analysis of prior and anticipated patient physical activity levels should be a factor when calibrating minimum ICD discharge threshold levels.

Modified technique for dual chamber pacemaker insertion.

Insertion of a permanent dual chamber pacemaker by the Seldinger technique usually requires two needle punctures of the vein or the use of a large introducer, thus increasing the risks associated with this procedure. We describe a modified technique using a relatively small introducer and a single subclavian vein puncture that we have found to be safe and simple to perform.

Sudden death associated with alcohol consumption.

Evaluation of a binge drinker who died suddenly after a weekend of heavy beer consumption, and had been resuscitated successfully, revealed no evidence of clinically detectable heart disease. Baseline electrophysiological testing was normal. Following intravenous ethanol infusion, paired ventricular extrastimuli from the right ventricle induced a rapid polymorphic ventricular tachycardia requiring cardioversion. Repeat electrophysiological testing 24 hours later without alcohol infusion was again normal. The patient was discharged on no medications and was instructed to refrain from drinking alcohol. Approximately 3 months later the patient died suddenly after heavy beer consumption. Alcohol should be considered in the evaluation of survivors of cardiac arrest and alcohol challenge may be useful in their evaluation.

Outpatient dobutamine and dopamine infusions in the management of chronic heart failure: clinical experience in 21 patients.

Dobutamine (and dopamine) are potent positive inotropic drugs which are frequently given to treat decompensated congestive heart failure. This study reports on the use of ambulatory dobutamine (and dopamine) infusions in 21 outpatients with advanced congestive heart failure. Each patient was initially hospitalized, and hemodynamic and clinical efficacy to dobutamine (and dopamine) was assessed. These 21 patients were carefully selected from a larger population of approximately 40 patients referred for this therapy. Chronic venous access was established and a drug infusion pump was supplied. Patients and family members were trained in the use of these devices. Eleven patients were treated with intermittent dobutamine infusions for 48 consecutive hours weekly, six patients with continuous (i.e., 24 hours daily) dobutamine infusions, and four patients with continuous, daily dobutamine and dopamine infusions. Significant (p less than 0.001) increases in cardiac index (1.8 +/- 0.6 to 2.7 +/- 0.7 L/min/m2) occurred during the initial dobutamine titrations. Functional classification (3.8 +/- 0.4 to 2.8 +/- 0.7) also improved significantly (p less than 0.01) during the 1.8 to 24 (mean 7.8) months of outpatient infusion therapy with dobutamine (and dopamine). Complications during outpatient therapy included drug tolerance (two instances), infection (two with bacteremias, eight with exit site infections), drug extravasation (three instances), and pump malfunction (two instances). Twenty patients have died: eleven from heart failure, four suddenly (one of them 9 months after dobutamine was stopped), and five from noncardiac causes. Our data suggest that outpatient dobutamine (and dopamine) infusions may be an effective form of therapy for selected patients with severe congestive failure who are refractory to more conventional treatment or who are awaiting cardiac transplantation.

Vasodilator therapy.

Vasodilators are a group of drugs with various degrees of arteriolar or venous dilatation used in the treatment of congestive heart failure when symptoms persist after digoxin and diuretic therapy. Nitrates and captopril provide the most consistent improvement in symptoms. Reduced mortality rates in congestive heart failure with vasodilator therapy has not been demonstrated, and prediction of clinical response to therapy is difficult.

Intermittent dobutamine hydrochloride infusions in outpatients with chronic congestive heart failure.

Patients with severe chronic congestive heart failure were treated with intermittent dobutamine hydrochloride infusions administered on an outpatient basis with a portable infusion device. Eleven patients (eight women and three men), ages 28-71 years, were given initial dobutamine hydrochloride infusions at a rate of 1-2 micrograms/kg/min, and the dose was gradually increased to a maximum dose of 15 micrograms/kg/min. Patients were considered dobutamine responders if their cardiac output increased by at least 30% and pulmonary-capillary wedge pressure did not rise. After a sustained hemodynamic response was demonstrated, the infusion was discontinued to assess the patients' symptoms during drug-free intervals. The patients were instructed and trained in proper catheter care after a venous-access catheter was surgically implanted. Patients were also shown how to use the ambulatory infusion pump. The patients were treated with long-term intermittent dobutamine hydrochloride infusions for 3-24 months. All patients adjusted easily to the routine of catheter and pump care and drug administration. The mean dose of dobutamine hydrochloride resulting in the maximum improvement in cardiac index was 9.4 micrograms/kg/min. All patients observed an improvement in their symptoms of congestive heart failure during the drug infusions and the intervals between the infusions. There was a mean reduction of 1.2 in New York Heart Association functional class. There were 18 congestive heart failure-related hospital readmissions among the 11 patients during 108 cumulative months of long-term dobutamine therapy. The intermittent administration of dobutamine hydrochloride via a portable infusion system appears to have improved the functional capacity of the 11 patients studied. This may be a viable treatment alternative for selected ambulatory patients with severe heart failure who demonstrate hemodynamic improvement with dobutamine.

Intermittent, continuous outpatient dobutamine infusion in the management of congestive heart failure.

The use of outpatient dobutamine infusions by a small, portable infusion pump in 3 patients with intractable congestive heart failure (CHF) is described. With this therapy left ventricular function improved and CHF resolved in each. Tolerance to dobutamine was obviated by giving infusions twice weekly. Except for 3 mild infections around the catheter exit site, there have been no complications of this therapy is 58 cumulative patient weeks.

The late appearance of chronic pericardial disease in patients treated by radiotherapy for Hodgkin's disease.

Radiation-induced chronic pericardial disease was recognized in nine patients 53 to 124 months (mean, 88 months) after radiotherapy for Hodgkin's disease. Depending on whether abnormal cardiac hemodynamics occurred before or after a fluid challenge, patients were considered to have either constrictive pericarditis (Group I) or occult constrictive pericarditis (Group II). There were no differences between these groups in various radiotherapy data, the use of chemotherapy, or the interval after treatment when the diagnosis of chronic pericardial disease was made. There were no consistent noninvasive variables to support the diagnosis of radiation-induced chronic pericardial disease before cardiac catheterization. Four patients underwent pericardiectomy. Two of the four operated patients had an excellent surgical result; a third patient died 4 months postoperatively of drug-induced granulocytopenia; the fourth patient has persistent visceral constrictive pericarditis 18 months after surgery. Speculation over the causes of radiation-induced chronic pericardial disease is made and our recommendations for its treatment given.