The risk of pericardiocentesis.

The risk and potential risk factors of pericardiocentesis were assessed by a review of a series of 52 pericardiocenteses comprising all those performed in the cardiac catheterization laboratory of one institution from 1971 to 1978. On the basis of the operative results, the patients were separated into two groups for comparison; Group I comprised all patients with a successful uncomplicated (35) pericardiocentesis and Group II all those with a nonproductive (16), nontherapeutic (1) or complicated (8) pericardiocentesis. Complications consisted of one death, one cardiac arrest, one aspiration of a subdiaphragmatic abscess and five ventricular punctures without adverse sequelae. Among the patients who had a nonproductive pericardiocentesis, the condition of 11 had probably been misdiagnosed but at least 4 had a false negative pericardiocentesis. Comparison of the two groups showed no significant difference in the incidence of cardiac tamponade or in the clinical presentation based on historical, physical, electrocardiographic, roentgenographic or echocardiographic findings of pericardial disease. Pericardiocentesis was usually successful when performed for suspected malignant pericardial effusion but often unsuccessful when performed for suspected hemopericardium. Anatomically, all patients in Group II had either minimal or loculated posterior pericardial effusion. It is concluded that pericardiocentesis can be performed at a low risk that can be further minimized by consideration of the disease process and the anatomic location of the pericardial fluid.     

Transient unifascicular, bifasicular and trifascicular block: electrophysiologic correlations in a patient with rate-dependent left bundle branch block and transient right bundle branch block.

Correlations of the His to ventricular (H-V) conduction time were made with the surface electrocardiogram during normal intraventricular conduction, unifascicular block (right bundle branch block), bifascicular block (left bundle branch block) and trifascicular block (right and left bundle branch block) in a patient with rate-dependent left bundle branch block who had transient right bundle branch block during recording of the His bundle electrogram. The results provide a functional confirmation of the theory that a prolonged H-V time is a manifestation of trifascicular disease.     

Pyomyositis. Increasing recognition in temperate climates

Pyomyositis is common in the tropics yet is rarely reported in temperate climates. A woman in whom pyomyositis developed in a temperate climate is presented. Computed tomography was the key in the diagnosis of the disease involving the muscles of the left lateral chest wall. The patient's condition responded to intravenous antibiotics and open abscess drainage. The 31 cases reported in the United States are reviewed. Unfamiliarity still poses a barrier to early diagnosis, although pyomyositis is being more frequently described in temperate climates.     

Polyvalvular mucopolysaccharidosis of the heart in an infant with C-D chromosomal translocation

Patients with a Starr-Edwards mitral ball valve prosthesis tolerate tachycardias poorly. Two patients with this type of mitral valve prosthesis are described who tolerated supraventricular tachycardia with a ventricular response of 220 beats/min. At rapid heart rates, the diastolic filling period is reduced, left atrial pressure is increased and, although continued function of the prosthesis is possible, prompt treatment of arrhythmias accompanied by rapid ventricular rates is indicated.     

Treatment of heart block due to sarcoid heart disease.

The role of glucocorticosteroid therapy for myocardial sarcoidosis is not well defined. This report shows the effect of prednisone therapy on atrioventricular (AV) conduction in a patient with myocardial sarcoidosis and AV block. On three separate occasions AV block was documented prior to prednisone therapy. On the first two occasions the patient had first and second degree AV block which by His bundle electrogram initially was shown to be in the AV node. On the third occasion the patient developed complete heart block. On each occasion treatment with prednisone resulted in improved AV conduction. The results indicate that prednisone therapy can be beneficial in the treatment of AV block due to myocardial sarcoidosis.     

Breast cancer in men. Report illustrating the value of endocrine ablation

A male patient with breast cancer and diffuse osseous metastases had a favorable response for 14 months after orchiectomy and 16 months after adrenalectomy. The role of ablative procedures in the management of breast cancer in men is discussed. Breast cancer in the male appears to be more responsive to hormonal manipulations than its female counterpart. Reporting and study of such patients may provide additional information on hormone-dependent tumors in man.     

Sensitivity and specificity of echocardiography in the assessment of valve calcification in mitral stenosis.

Eighty-seven patients (64 females and 23 males) with mitral stenosis were studied by M-mode echocardiography to assess the sensitivity and the specificity of the echocardiographic technique in the identification of valve calcification. The mitral valves were examined at operation, and the amounts of calcium were graded as heavy, light, or absent. We compared this with the amount of calcification assessed by radiographic, previously accepted echocardiographic, and newly derived echocardiographic criteria. In identifying the presence or absence of valve calcification, radiography was the least sensitive (53.7 per cent), but the most specific (90.9 per cent) technique, and has the highest predictive accuracy (90.6 per cent). Previously accepted echocardiographic criteria had the highest sensitivity (92.6 per cent), but the lowest specificity (12.1 per cent), and the lowest predictive accuracy (63.3 per cent). The newly derived echocardiographic parameter MT/ST (ratio between the maximal thickness of the left ventricular margin of the interventricular septum) was both sensitive (75.9 per cent) and specific (81.8 per cent) and also had a predictive accuracy (87.2 per cent) similar to that of radiographic techniques. The MT/ST ratio is demonstrated to be the most useful non-invasive method for assessing valve calcification in mitral stenosis.     

Mycobacterium fortuitum infection: evidence of bactericidal defect due to hyperactive antigen-specific suppressor cells. Correction in vitro and in vivo by cholinergic agonist and indomethacin

Immunologic studies in a patient with long-standing Mycobacterium fortuitum infection revealed normal numbers of T cells, T inducers, T suppressors, B cells, and monocytes, significant in vitro proliferative response to M. fortuitum antigen, and poor bactericidal activity against M. fortuitum but not against Escherhicia coli. M. fortuitum antigen-activated suppressor cells contributed to the bactericidal defect. The activity of these suppressor cells could be eliminated by the in vitro treatment of blood mononuclear cells with a combination of a cholinergic agonist and indomethacin, but not with either alone. Administration of the two drugs to the patient resulted in reversal of the bactericidal defect and dramatic clinical improvement. Systemic atypical (nontuberculous) mycobacterial infection may activate specific suppressor cells that could compromise the host's phagocytic cell function. Modulation of those suppressor cells by a combination of a cholinergic agonist and prostaglandin synthetase inhibitor could reverse this abnormality and may be beneficial to the patient.