Mitral valve prolapse (MVP) is a common disorder that, in general, has a good prognosis. Rare occasions of sudden death have been reported in patients with MVP and it is presumed that the basis of sudden death is arrhythmic. We report seven patients with moderate to severe MVP and malignant ventricular arrhythmias. All patients had trivial to mild mitral regurgitation and normal left ventricular function. Three patients presented with syncope, two with out-of-hospital cardiac arrest, and three with recurrent palpitations and presyncope. In a mean follow-up period of 2.5 years (range 6 months to 5 years), two patients died suddenly despite successful control of their nonsustained ventricular tachycardia (VT) with sotalol as shown by ambulatory monitoring. Two patients, who had sustained VT despite antiarrhythmic drug therapy, had mitral valve surgery, however, monomorphic VT could be induced in both even after surgery. The arrhythmias in the remaining three patients are controlled on antiarrhythmic drugs. We conclude that a selected subset of patients with MVP, malignant ventricular arrhythmias, and mild mitral regurgitation are at risk of sudden death. Syncope, inferolateral repolarization changes, complex ventricular ectopy, and a markedly myxomatous valve may be pointers to higher risk of sudden death and mitral valve surgery may not provide control of ventricular arrhythmias.
The success rate for angioplasty of chronic total occlusions is acceptable. Long-term clinical benefit in patients with successful angioplasty is suggested by the high freedom from angina and the lesser need for coronary surgery. No major impact on either the incidence of MI or cardiac survival was noted when patients who had coronary surgery were included, although it must be emphasised that the sample size in this study was insufficient to detect a difference in these outcome variables.
In patients with drug refractory paroxysmal atrial fibrillation and flutter and in patients with established atrial fibrillation where control of the ventricular rate is difficult, catheter ablation of the AV junction using RF energy is a safe and effective procedure with a high success rate.
Using RF ablation cure of PSVT was achieved in 90% of patients. Cure of AVJRT was achieved in 95% (55/58) of patients using either fast or slow pathway ablation. Only one patient required permanent pacemaker implantation for Mobitz type I AV block following fast pathway ablation. The overall success rate for ablation of accessory pathways was 85%. There is an operator learning curve for this procedure suggested by the fact that the success rate for accessory pathway ablation at first attempt was 63% in the first 29 patients and 93% in the remaining 29. There was no significant morbidity or mortality during or after the procedure. In a mean follow-up of nine months in the patients with successful ablation only two patients with AVJRT had a recurrence of documented PSVT. Both these patients had successful repeat RF ablation. Catheter ablation using radiofrequency energy is an effective and safe therapeutic option for patients with symptomatic PSVT.
We report a case of acute left main coronary artery occlusion treated with stenting of the left main artery. The patient had a severe ostial left main stenosis and after diagnostic coronary angiography developed a total occlusion of the left main artery with life threatening hemodynamic consequences. Stenting of the unprotected left main coronary artery was successfully performed as a salvage procedure.
Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts. We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism. While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism.
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