Acute rupture of myxomatous mitral valve presenting as refractory cardiopulmonary arrest.

A 59 year old white woman had an out of hospital sudden cardiac arrest. Resuscitation at the scene restored spontaneous pulse, blood pressure and respiration but cardiovascular collapse recurred within 30 minutes of hospital arrival. Medically refractory cardiogenic shock of unclear origin prompted the placement of an intraaortic balloon pump, and hemodynamic stabilization was achieved over several hours. Acute rupture of the chordae tendineae of myxomatous mitral valve was diagnosed as the cause of the cardiac arrest. Mitral valve replacement was performed and the patient made an uneventful recovery. This report describes the first known case of rupture of a myxomatous mitral valve presenting as sudden cardiac death. The differential diagnosis of sudden death in this disorder is reviewed, the role of mechanical circulatory assistance in refractory cardiac arrest is discussed and several interesting hemodynamic aspects of the case are considered.

Atrial septal defect with right to left shunt despite normal pulmonary artery pressure.

A 74 year old woman had right to left shunting through an atrial septal defect despite normal right heart pressures. Acute volume expansion temporarily reduced the shunt. Contrast echocardiography and angiography demonstrated that this shunting occurred almost exclusively from the inferior vena cava. At surgery a redundant flap of septum secundum was found that was adjacent to the inferior vena cava orifice, intercepting its blood return like a spinnaker and shunting it into the left atrium.

Unruptured sinus of Valsalva aneurysm with right ventricular outflow obstruction diagnosed by two-dimensional and Doppler echocardiography.

This report presents a case of an unusually large unruptured sinus of Valsalva aneurysm complicated by right ventricular outflow tract obstruction, right coronary artery occlusion and incomplete right bundle branch block. Two-dimensional and Doppler echocardiography were instrumental in preoperative diagnosis and postoperative follow-up.

Ventricular tachycardia in children without heart disease.

To assess the natural history of ventricular tachycardia (VT) in children without heart disease, the clinical course of 26 children, aged 1 day to 15 years at initial detection, was reviewed. Symptoms related to the rhythm were present in 8 children at some time during their course of follow-up. Evaluation included echocardiogram (19 patients), Holter monitoring (22 patients), graded treadmill exercise testing (16 patients) and invasive electrophysiology (4 patients). Exercise induced or exacerbated VT in 9 patients, but suppressed rhythm in 7. Ten patients were never treated. Of the remaining 16 treated patients, therapy was discontinued in 10 on the basis of the electrocardiographic or Holter monitor recordings. Six continued to receive therapy without complications. There were no known deaths over a period of 1 month to 34 years (mean 59 months, median 42 months). Although 2 patients have been lost to follow-up, based on our findings and a review of the reported cases of VT in children to date, after undergoing complete noninvasive cardiac evaluation symptomatic patients should be treated and studied with invasive electrophysiology if antiarrhythmic control is inadequate. The rate of VT or age at onset are not predictive of outcome in asymptomatic patients. As a group, these patients do not appear to benefit from therapy, but warrant follow-up since deaths have been reported in untreated asymptomatic patients.