Obvious Heart Disease Research Articles

Cardiac hypertrophy and function in asymptomatic acromegaly

Heart disease frequently occurs in advanced acromegaly. In order to investigate cardiac mass and function in acromegaly in the absence of obvious cardiac disease, we performed Doppler echocardiography in 15 asymptomatic acromegalic patients (six of them had systemic hypertension). The data were compared with those of a group of 10 age-matched controls. Left ventricular mass index (LVMI) was increased in acromegaly (110 +/- 32 vs 32 +/- 12 g m-2, P = 0.02), but shortening fraction and systolic time intervals did not differ. Mitral EF slope was decreased (80 +/- 21 vs 101 +/- 30 mms-1, P less than 0.02), while the duration of the isovolumic relaxation period (IRP) was increased (92 +/- 13 vs 69 +/- 16 ms, P less than 0.01). Hypertensive acromegalic patients (n = 6) had a higher LVMI than normotensive acromegalic patients (n = 9) (133 +/- 27 vs 94 +/- 24 g m-2, P = 0.02) and this was confirmed by a meta-analysis of data in the literature: the prevalence of hypertrophy was 76% in the presence of hypertension vs 50% in its absence, P less than 0.002. IRP was prolonged in normotensive acromegalic patients vs normal controls (90 +/- 11 vs 69 +/- 16 ms, P less than 0.01). In conclusion, subclinical cardiac abnormalities occur frequently in acromegaly in the absence of obvious heart disease, and hypertrophy is observed in asymptomatic hypertensive acromegaly. Moreover, diastolic abnormalities are found in asymptomatic acromegaly and could be caused by several heart-related factors.

Right Ventricular Tachycardia with Left Bundle Branch Block and Inferior Axis Morphology: Clinical and Arrhythmological Characteristics in 15 Patients

Fifteen patients (mean age 30) presenting with right ventricular tachycardia (VT) of the outflow tract type (left bundle branch block with inferior axis morphology), in the absence of obvious organic heart disease, were studied. Seven patients had palpitations, one presyncope and seven were asymptomatic. The echo and/or angiographic findings were normal in 11 patients (73%), suggesting arrhythmogenic right ventricular dysplasia (ARVD) in three (20%) and dubious in one (7%). The VT was sustained in three patients (20%), nonsustained (11 +/- 6 beats) in twelve (80%), inducible during exercise in two out of 15 patients (13%) and with ventricular stimulation in one out of eight (12.5%). Four patients were treated with sotalol, three with Class IC drugs and one with amiodarone. At follow-up of 36 +/- 30 months, only three patients had VT recurrences due to drug withdrawal. (1) abnormal echo and/or angiographic findings suggested that ARVD was observed in a minority of the patients (22%); (2) the low inducibility of VT and the good response to sotalol suggested a possible mechanism of abnormal automaticity; and (3) at a 3-year follow-up the prognosis appeared to be good in both patients with or without echo-angiographic signs suggestive of right ventricular dysplasia.

Mechanism and prediction of sudden cardiac death in arrhythmia patients using electrophysiological studies.

Thirty nine cases, in which sudden cardiac death (SCD) was suspected, were studied to evaluate the mechanism and the prediction of SCD in arrhythmia-patients using electrophysiological studies (EPS). The 39 cases (28 male and 11 female) were located by surveying 2098 patients who underwent EPS for the evaluation of arrhythmias. Age at time of EPS ranged from 4 to 86 years, average 50.5 years. Time from EPS to death was 2 to 163 months, average 27.9 months. Underlying heart disease was: dilated cardiomyopathy in 11, old myocardial infarction in 5, ischemic heart disease in 5, hypertensive heart disease in 5, valvular heart disease in 3, hypertrophic cardiomyopathy in 2, arrhythmogenic right ventricular dysplasia in 1, myocarditis in 1, sarcoidosis in 1, cor pulmonale in 1, and no obvious heart disease in 4. Fifteen had a permanent pacemaker implanted. SCD in cases without a permanent pacemaker (24 cases): 2 had chronic complete A-V block (one BH block, one HV block), 1 had advanced A-V block (HV block), 3 had bundle branch block with first degree HV block, 9 had ventricular tachycardia (VT), 3 had sick sinus syndrome (SSS), 3 had paroxysmal atrial flutter, 1 had WPW syndrome and paroxysmal atrial fibrillation, 1 had paroxysmal atrial tachycardia, and 3 had premature ventricular beats and first degree HV block. SCD in cases with permanent pacemaker (15 cases): 5 had SSS, and 10 had A-V block. In 3 of the 5 with SSS and 7 of the 10 with A-V block, VT was found before pacemaker implantation. In our study, brady and tachyarrhythmias coexisted in 25 cases (64%).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of intracardiac right-to-left shunting in adults without obvious congenital heart disease

Previous studies during cardiac catheterization or postmortem examination 1 show that a small but patent foramen ovale (PFO) is present in 10 to 35% of patients. More recent reports using contrast echocardiography have demonstrated right-to-left atrial shunting in 5% of healthy volunteers during normal breathing and in 18% during the Valsalva maneuver 2; such right-to-left atrial shunting has been detected in 27 to 40% of patients with known or suspected PFO during normal breathing and in 54 to 60% during Valsalva. 3,4 With contrast echocardiography, therefore, right-to-left atrial shunting appears to occur often in patients without obvious congenital heart disease, 2–4 especially during a maneuver (such as Valsalva) designed to induce a transient increase in right atrial pressure higher than that in the left atrium. In none of these studies, however, has the reliability of contrast echocardiography been compared with more established techniques of detecting intracardiac shunting, such as indocyanine green. No previously published report has used indocyanine green to assess the overall incidence of right-to-left atrial shunting in patients without obvious congenital heart disease. The present study was performed for this purpose.

Panic attack symptoms in patients with chest pain and angiographically normal coronary arteries

It is often difficult to explain anginal chest pain in patients with angiographically normal coronary arteries and no other obvious heart disease. We reviewed a series of 123 such patients for the characteristics of their chest pain and for other somatic symptoms of panic attacks. Our findings suggest that many of these patients are likely to have panic attacks and should be considered for psychiatric evaluation. A significant number in this group have left-sided, sharp chest pain and palpitations.

Idiopathic paroxysmal ventricular tachycardia with a QRS pattern of right bundle branch block and left axis deviation: A unique clinical entity with specific properties

Eiectrophysiologic evaluation before and after the serial administration of verapamil, lidocaine, propranolol, and procainamide was undertaken in 4 young, asymptomatic patients with recurrent, sustained ventricular tachycardia (VT). No patient had obvious organic heart disease. The electrocardiogram during sinus rhythm showed S-T depression and T-wave inversion over the inferior and lateral precordial leads in 3 patients. QRS morphologic characteristics during episodes of VT showed a pattern of right bundle branch block and left axis deviation. In all 4 patients, VT could be both induced and terminated with electrical stimulation. Verapamil terminated VT and prevented the induction of sustained VT in 3 patients, and markedly slowed the rate of VT in 1 patient. Procainamide effectively prevented the induction of sustained VT in 2 patients, and although ineffective in preventing induction in 2 patients, it slowed the rate of tachycardia in both. Lidocaine and propranolol did not prevent the induction of VT in any patient. These findings suggest that slow-response tissues may be involved in the genesis of VT in these patients, and that VT in these patients may represent a unique clinical entity with distinct electrocardiographic, electrophysiologic, and electropharmacologic properties.

Sinus Node Dysfunction in Children, Adolescents, and Young Adults

Thirty children and young adults with electrocardiographic and clinical evidence of sinus node dysfunction (SND) are described. Ages ranged from 3 days to 25 years. Of these, 10 patients had inappropriate sinus bradycardia, 16 had periods of sinus arrest, and 9 had sinoatrial exit block. A total of 22 patients had significant heart disease and SND developed in 13 after cardiac surgery. Eight patients with SND had no obvious heart disease. Seven patients were symptomatic, having either syncopal (three) or near-syncopal episodes (four). The three with syncope have received permanent demand pacemakers. Although significant SND occurs most frequently in children with congenital heart disease, particularly following corrective cardiac surgery, it may occur in otherwise normal individuals.

SINUS NODE DYSFUNCTION IN CHILDREN

Over a three year period, 30 pedlatric patients (pts) with electrocardiographic evidence of sinus node dysfunction (SND) were identified. Their ages ranged from 3 days to 21 years. Twenty-two pts had significant heart disease. In 13, the onset of SND followed corrective cardiac surgery, and of these, 8 were operations for atrial septal defect and transposition repair. In two pts, SND followed acute myocarditis. Eight pts with SND had no obvious heart disease. Three groups of patients were identified. Ten pts had persistent bradycardia (<50 beats/min) which failed to respond appropriately to exercise or atropine administration (Group I). Sixteen pts had periods of sinus arrest with no spontaneous atrial activity for periods greater than the equivalent of two P-P intervals (Group II). Nine pts had repeated episodes of Mobitz type I or II 2° sino-atrial exit block (Group III). Four pts satisfied criteria for more than one group. Only one child had tachy-bradyarrhythmias. Seven pts with SND were symptomatic, having either syncopal (3) or near syncopal (4) episodes. Of these, three had prolonged sinus node recovery times following overdrive atrial stimulation and two had prolonged sino-atrial conduction utilizing the atrial extrastimulus technique. The three children with syncope have received permanent demand pacemakers. These data show that: a) symptomatic and asymptomatic SND is not uncommon in children; b) SND in children may result either from a failure of impulse formation or from impaired sino-atrial conduction.

Recurrent Ventricular Tachycardia due to Reentry within the Bundle Branches

A case of recurrent ventricular paroxysmal tachycardia in a young man without obvious heart disease is described. Posttachycardiac T-wave inversion followed the arrhythmic episodes. Programmed stimulation of the heart in association with intracardiac recordings showed evidence in favor of reentry within the bundle branches and its divisions during tachycardia. A critical prolongation of the H2-V3 interval preceded each paroxysm of tachycardia.

Rate dependent aberrancy.

Forty patients with "rate dependent aberrancy" (RDA) were studied. This large group of patients permitted a clear definition of the syndrome and recognition of a number of features not previously described. These proved to have a significant bearing on the recognition and differential diagnosis of RDA and non-rate dependent aberrancy. It was found that a small change in cycle length, perhaps too small to be recognized in the surface ECG, can result in RDA. Consequently, if a critical shortening of cycle length is to be recognized, it is necessary to record not only the onset of aberrant rhythm but also sufficiently long strips with normal intraventricular conduction preceding and following the RDA. In some patients there was no recognizable sudden change in cycle length and the onset of aberrancy was a function of the duration of the accelerated rate. In others only the first cycle of the rhythm with RDA was shortened and the remaining R-R intervals were paradoxically longer than the R-R cycle which initiated the RDA. The aberrancy in RDA occurred at relatively slow heart rates (in 26 of the 40 patients the rate was below 80), and was frequently independent of any significant changes in the duration of the immediately preceding cycle length. There was a striking prevalence of left bundle branch block, and in 35 of the 40 patients obvious organic heart disease was documented.

Studies of quinidine plasma levels and rate of decline following cessation of quinidine administration

1. 1. Quinidine sulfate was administered in divided dosages for forty-eight hours. Serial plasma quinidine levels were measured 2 hours, 26 hours, and 50 hours after the last dosage. Four groups were studied: normal individuals, and patients with obvious heart, renal, and hepatic disease. 2. 2. Individuals with cardiac disease exhibited a slower decline of quinidine level than the other three groups. 3. 3. The peak levels reached by all the groups were the same. 4. 4. Significant levels of quinidine persisted in the blood of all individuals for 26 hours, in many for 50 hours. 5. 5. The slower loss of quinidine from the blood of cardiac patients is not thought to be a function of delayed excretion by liver or kidneys and does not carry with it the threat of excessive cumulation in the blood of these patients.

Short paroxysms of tachycardia due to reciprocating rhythm

A case is herewith reported of a woman 24 years old who, without obvious heart disease, has revealed an unusual arrhythmia consisting of short paroxysms of tachycardia due to reciprocating rhythm, each one initiated by the normal sequence of auricular and ventricular contractions followed by retrograde auricular stimulation.

CLINICAL ASPECTS OF CALCIFICATION OF THE MITRAL ANNULUS FIBROSUS

CALCIFICATION of the mitral annulus fibrosus has been studied by pathologists 1 and is fairly often discovered more or less accidentally during life by radiologists. 2 Both groups of observers, properly enough, have regarded it as a degenerative change of no clinical significance. Yet such calcification is not entirely without clinical interest and was in part the subject of a recent monograph. 3 Its occurrence in the older age groups guarantees that it will be associated at least now and then with obvious heart disease 4 ; in fact, it has long been known 5 as one variety of those calcifications which cause heart block. 6 Then too either the calcification itself or the accompanying valvular changes of aging might reasonably be expected to alter cardiodynamics even in the absence of heart block; practically nothing 7 has been written about murmurs in its presence, and prominent authors 8 dismiss it somewhat vaguely as occasionally associated with mitral

THE RÔLE OF INFECTION IN RHEUMATIC CHILDREN

This study was undertaken in order to find how far the routine supervision of rheumatic children in hospitals and clinics affects the tendency to recurrence of rheumatic manifestations. One hundred and fifty members of the Children's Heart Clinic of Washington University were included in this study. Cases were excluded in which the early history was inadequate or in which obvious rheumatic heart disease was present without a history of exudative signs, as it was on such signs that the study was based. The care in the clinic has been directed chiefly toward the improvement of the general health, whether in the child's own home or at Ridge Farm convalescent home, and has included measures directed toward removal of foci of infection. The periods over which the children have been watched vary between nine months and eleven years; 116 have been followed for more than one year and seventy-three for more

STUDIES ON THE HEARTS OF NORMAL CHILDREN

The clinician is interested in roentgenograms of a child's heart, largely because he hopes to determine by the size and shape of the heart whether physical conditions have pathologic significance. It would be equally important to be able to say that a heart of a given shape is definitely normal or pathologic. We have computed statistics for the normal size of the heart in children of various ages and for the normal relationships between the transverse width of the heart, height and the width of the chest. We have also attempted a classification of the shapes of normal hearts. Many studies of this kind have been made on adult hearts. The literature on the size of children's hearts is not abundant, and a considerable amount of the work was done on small groups and on children in clinics who did not have obvious organic heart disease. This study was made