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BACKGROUND AND OBJECTIVES: Retained foreign bodies or embolization in cardiac chambers is a relatively common clinical problem. As experience was acquired, it became apparent that failure to remove such fragments could result in morbility or mortality. In the past, surgical removal was the only method available. We present our experience of percutaneous extractions of embolized foreign bodies. The technical aspects are discussed. PATIENTS AND METHODS: Twenty eight cases (age between 1 and 80 years) of cardiac and intravascular foreign bodies seen in two hospitals are reported. Seventeen were plastic catheters or fragments (two were radiotransparent), 5 guide wires in vena cava, right atrial and ventricle, pulmonary artery and abdominal aorta, 4 patients had pacemaker electrodes in the right atrium or ventricle. Stent embolization was observed in two patients. The stents were stripped from the delivery catheter and removed from iliac artery. A pigtail catheter was sometimes used to remove the fragment found in the right ventricle. In 8 cases the capture and extraction was made using a loop snare with a 0.025 inch guide J-wire device folded in half at its midsection and inserted through a long introducer, and in another 20 cases a Dormia basket system was used. In all four patients with pacemaker electrodes, simple counteraction was used with a 10 F left coronary directional atherectomy guide catheter. RESULTS: In two patients removal was impossible--in one the pacemaker electrode was caught but not retrieved because was densely adhered to the endocardium for several years; in another a guide wire was found in a child one year old--. In the other 26 patients, foreign body extraction was performed percutaneously without any complication with a basket or snare; only in one case (a radiotransparent catheter) both systems were used. CONCLUSIONS: Percutaneous removal of centrally embolized foreign bodies, cardiac or vascular, is a safe and successful procedure. The basket system needs to be used more carefully.

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OBJECTIVE: The aim of the present study was to determine the reliability of early exercise test to detect multivessel disease in survivors of an uncomplicated first anterior Q-wave myocardial infarction. METHODS: Among 100 consecutive patients 64 (aged 55 +/- 10 years) were included in the study. Thirty-four patients (53.1%) received thrombolytic therapy and this was considered successful, by means of non-invasive criteria, in 24 patients (37.5%). A standard symptom-limited exercise test, 11-15 days after myocardial infarction, and coronary arteriography, < 72 hours later, were performed in all patients. RESULTS: On exercise test 6 (9.3%) patients developed significant ST segment depression, 48 (75%) significant ST segment elevation, 5 (7.8%) ST depression in inferior leads together with ST elevation in anterior leads and 3 (4.6%) angina. Of the 18 patients with multivessel disease 5 (27.8%) developed ST depression, 10 (55.5%) ST elevation, 1 (5.5%) ST depression in inferior leads together with ST elevation in anterior leads and 1 (5.5%) angina. CONCLUSIONS: Our study indicates that ST depression in a symptom-limited exercise test performed early after an anterior Q-wave acute myocardial infarction is unusual and has low sensitivity (27.8%) to detect multivessel disease. ST elevation is the more common finding in this test (75%) and has no relation with the severity of CAD.

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INTRODUCTION AND OBJECTIVES: The underlying mechanism of syncope induced by head-up tilt test is still incompletely understood. It has been proposed a sudden increase in parasympathetic's activity induced by the excessive activation of the cardiac mechanoreceptors. The aim of our study was to evaluate the clinical, electrocardiographic and hemodynamic responses to head-up tilt test before and after treatment with transdermal Scopolamine (anticholinergic agent). METHODS: We studied 17 patients (8 females, 9 males; mean age 43 +/- 19 years) with > or = 2 syncopal episodes of unknown origin and a positive tilt test (a positive response to tilt testing alone or in conjunction with an infusion of isoproterenol was defined as the appearance of syncope or presyncope associated to hypotension and/or bradycardia). Symptoms developed in 12 patients during the baseline tilt (Group I) and in 5 patients after infusion of isoproterenol (Group II). Mean time to symptoms was 8.5 +/- 7.9 minutes in group I. All patients were them treated with transdermal Scopolamine (1.5 mg/24 hours) and 48 hours later tilt test was repeated. RESULTS: In group I, 8 patients (66.6%) became tilt test negative and in the remaining 4 patients mean time before the appearance of symptoms was increased (8.5 +/- 7.9 vs 16.2 +/- 2.5 minutes; p < 0.05). In group II, 3 patients (60%) became tilt test negative and in the remaining 2 patients symptoms developed after an infusion of higher doses of isoproterenol than in the first study. So, with transdermal scopolamine 11 out of 17 patients became tilt test negative and time to symptoms was increased in all of the remaining 6 patients. CONCLUSIONS: Our study suggest that transdermal scopolamine is an usefull treatment in the prevention of neuro-cardiogenic syncope induced by head-up tilt test.

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INTRODUCTION AND OBJECTIVES: Atrial pacing has been proposed as an alternative method to the isotonic exercise, to induce ischemia, and, joined to two-dimensional echocardiography, as one of the main modalities in stress echo. In order to analyse its applicability and diagnostic value in assessing coronary artery disease this study was undertaken. PATIENTS AND METHODS: 52 patients referred to coronarography for suspicion or evaluation of ischemic disease, were submitted to this technique. RESULTS: The study was completed in 44 patients (applicability rate of 84,7%). The results obtained showed a sensitivity, specificity and diagnostic accuracy for the regional wall motion abnormalities echocardiographically detected, of 88%, 68% and 79%, respectively. When electrocardiographic changes or presence of angina during atrial pacing were added to echocardiographic data, sensitivity increased to 96%. In 41 patients in which a conventional stress test was available, sensitivity was 55% electrocardiographically, 33% clinically and 68% globally. CONCLUSIONS: It is concluded that transthoracic two-dimensional echocardiography during atrial pacing is a safe, highly sensitive method for coronary artery disease detection. The limitations of the method for its routine clinical application are also analysed.

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To determine whether ventricular short-term enlargement following acute myocardial infarction is related to increased left filling pressures and whether early treatment with captopril alters this process we studied 68 patients with a first acute myocardial infarction. Forty patients with a pulmonary capillary pressure equal or above 17 mmHg were randomized to treatment with conventional therapy plus captopril (n 20) or placebo (n 20), in a double blind fashion. The remaining 28 patients (non-dysfunction group) were treated conventionally. During the first 72 h, afterload showed a prompt decrease in the captopril group as compared to placebo. Changes from baseline to 14 days in end-diastolic and end-systolic left ventricular volume indexes determined by radionuclide ventriculography were: non-dysfunction, 85.6 (+/- 21) vs 88 (+/- 20) and 44 (+/- 17) vs 44 (+/- 17) ml.m-2; captopril (n 20), 96.6 (+/- 18) vs 99 (+/- 19) and 66 (+/- 22) vs 65 (+/- 22) ml.m-2; placebo (n 20), 96 (+/- 25) vs 113 (+/- 19) (P < 0.001) and 63 (+/- 18) vs 74 (+/- 22) ml.m-2 (P < 0.01). This study indicates that short-term ventricular enlargement is related to the degree of ventricular dysfunction and that captopril may improve this process.

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Seventy consecutive patients with recurrent unexplained syncope were evaluated by use of an up-right tilt-table test for 45 minutes (with or without an infusion of isoproterenol) in an attempt to reproduce symptoms. There were 42 males and 28 females with a mean age of 49 +/- 20 years (range 7-86), and with a mean symptoms duration of 35.2 +/- 16 months. All the patients underwent clinical examination which includes cardiological and neurological evaluation. Some tilt positive patients received therapy with either transdermal scopolamine, metoprolol or clonidine, the efficacy of which was evaluated by another tilt-table test. Syncope occurred in sixteen patients (22.9%), during the baseline tilt associated with hypotension (2 patients), bradycardia-asystolia (3 patients), or both (11 patients). In 11 patients with normal baseline tilt test, isoproterenol infusion was used appearing 4 new cases of abnormal response. Some patients who had positive test results, eventually became tilt-table negative by therapy (5 out of 8 patients treated with scopolamine, 5 out of 6 patients with metoprolol, and 3 out of 5 patients with clonidine). Time before syncope during tilt-test was increased with therapy, being of 45 min in normalized cases, and increasing from 11.9 +/- 16 basal to 34.4 +/- 17 min with scopolamine (p < 0.05), to 40 +/- 12 min with metoprolol (p < 0.05) and to 33.7 +/- 16.7 min with clonidine (p = NS). We conclude that upright tilt-table alone or combined with isoproterenol infusion is an useful test in the diagnosis of vasovagal syncope and in the evaluation of therapy.

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Seventy-two patients with hypertrophic cardiomyopathy were evaluated by 24 hours of electrocardiographic ambulatory monitoring. The results were related to echocardiographic extent of hypertrophy, left ventricular outflow obstruction at rest, and transmitral flow parameters. Also, the symptoms and functional classification of NYHA were related to ventricular arrhythmias. Ventricular arrhythmias were detected in 68% of our patients: high degree of ventricular ectopia in 26 (36.1%), and ventricular tachycardia in 14 (19.4%). Most important supraventricular arrhythmias were: atrial fibrillation in 7 patients, atrial flutter in one, and supraventricular tachycardia in five. Asymmetric hypertrophy type I of Maron classification showed the lower number of ventricular arrhythmias. High degree of ventricular arrhythmias were more frequent in patients with: apical hypertrophy, worse functional classification of NYHA (I: 20%; II: 50%; III: 80%), and in patients with impaired distensibility detected by Doppler (80.7% vs 56.7%; p less than 0.05). There was no relationship between left ventricular outflow obstruction at rest and ventricular arrhythmias.

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22 patients with normal coronarography but with angina pectoris or angina-like chest pain without evidence of coronary spasms are reviewed. We studied clinical characteristics, basal and exercise electrocardiography and other tests used to obtain a diagnosis, although only in one patient were we able to find an esophageal pathology which caused the clinical picture. After 20.7 +/- 14.4 months follow-up no patients had myocardial infarction or acute coronary events. Most of them still experience chest pain, are physically limited and use antianginal drugs. The fact that their coronarograms were normal decreased significantly the number of admissions to hospital (2.4 +/- 3.3 vs 0.26 +/- 0.95, P less than 0.02) and the amount of drugs prescribed. The lack of improvement of most of them seems to justify the need for other studies looking for a positive diagnosis and other types of treatment.

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Con el fin de comparar los efectos hemodinámicos de las estimulaciones ventricular y secuencial hemos practicado cateterismo cardíaco en 10 pacientes, midiendo las presiones y el gasto cardíaco con ambos tipos de marcapasos. Obtenemos un aumento del 16.4% en el gasto cardíaco durante la estimulación secuencial aumentando igualmente las presiones aórticas y disminuyendo las pulmonares. La mejoría de los parámetros hemodinámicos al comparar con al estimulación ventricular es estadísticamente significativa

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Cardiac catheterization was performed in 10 patients to compare the haemodynamic effects of ventricular stimulation and the sequential stimulation by measuring cardiac output and aortic pressure in both types of pacing. During sequential stimulation we had was an increase of 16.4% in cardiac output while there was increase in aortic and a decrease in pulmonary pressures. They improved significantly the haemodynamic parameters in our patients when compared to the ventricular stimulation.

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Fifty patients with atrio-ventricular arrhythmias were treated with the new antiarrhythmic drug propaferon. A dose of 70 mg (1-1.5 mg/kg), was injected slowly into a vein (2-3 min), in 16 cases. In the other 34 cases a dose of 450-900 mg/24 hours was given orally. Propafenon is a drug which acts on the permeability of the membrane and also as a local anaesthetic. Its efficiency has been demonstrated in the treatment of arrhythmias. In our series, ventricular arrhythmias were suppressed in 76.8% of the cases (33 patients), while the ventricular extrasystoles were reduced in 18.6% of the cases (8 patients). There was no action in 4.6% of the cases (2 patients). The drug was not useful in the treatment of atrial arrhythmias. Unwanted side-effects (arterial hypotension, conduction disorders, etc.), were not seen when intravenous doses of less than 2 mg/kg, were administered. However, electrocardiographic changes (widening of the QRS, prolongation of the PQ interval, etc.), were observed in those patients who received doses greater than 450 mg/24 hours. In these patients, there was a close correlation between the dose administered and the prolongation between the dose administered and the prolongation of the conduction times. We believe that the amount of myocardial degradation and the age of the patient are directly related to the appearance of conduction disorders. This relation is greater when a larger dose is administered. The advantages that this new drug has over other antiarrhythmics are the methods of administration (oral and intravenous). Both these methods may be used simultaneously to maintain a stable sinus rhythm or the rapid intravenous method may be followed by the oral maintenance one.

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In eleven patients with isolated mitral stenosis and regular sinus rhythm a right cardiac catheterization was performed and the wedged pulmonary capillary pressure recorded at rest and during electrical pacing of the right atrium at successive frequencies of 100, 120, 140, and, occasionally, 160 and 180 beats/min, while cardiac output was estimated by the Fick's principle. In all cases a significant elevation of pulmonary capillary pressure with a simultaneous reduction in cardiac output was obtained. The rise of wedged pulmonary pressure was proportional to the increment in cardiac frequency and related also to the calculated area of the mitral valve. The influence of active atrial contraction upon pulmonary pressure and cardiac output is discussed and comparisons with other studies are made. Emphasis is made on the value of atrial pacing as a diagnostic method in mitral stenosis, especially in cases in whom classical effort manoeuvres can not be applied or are insufficient to rise cardiac frequency.

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