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Diagnosis and management of cardiac rhythm disorders by transtelephonic electrocardiography in infants and children
6 12
Brief cynical and laboratory observations
The Journal of Pediatrics April 1979
Diagnosis and management of cardiac rhythm disorders by transtelephonic electrocardiography in infants and children Macdonald Dick Ii, M.D.,* Dena McFadden, M.D., Dennis Crowley, M.D., and Amnon Rosenthal, M.D. Ann Arbor, Mich.
T R A N S T E L E P H O N I C E L E C T R O C A R D I O G R A P H Y WaS
initially developed for outpatient monitoring of pacemaker performance in adult patientS. ~-3 Subsequent reports describe its use in the management of paroxysmal arrhythmias. 4-5 There has been little experience, however, with these devices in the diagnosis and treatment of cardiac rhythm disturbances in infants and children. Alternative methods of diagnosis are often Unsatisfactory. An outpatient standard electrocardiogram in unlikely to record an episodic event of short duration. Holter monitors used to obtain a 12- or 24-hour electrocardiographic tape recording are heavy and cumbersome and may be damaged when given to a child. Hospitalization for constant ECG monitoring is disruptive of family life and expensive. For these reasons we have explored the use of transtelephonic electrocardiography in the diagnosis and management of disorders of cardiac rhythm in children. The purpose of this report is to summarize the indications, resultS, advantages, and limitations of transtelephonic electrocardiography in the pediatric age group. M A T E R I A L S AND M E T H O D S The transtelephonic ECG system consists of a batterypowered portable transmitter (Cardiotrack 2112 or Instromedix 9404 Pacer-Tracer), one side of which rests during transmission against the patient's chest with the other adapted to fit an ordinary telephone receiver (Fig. 1). The patient's electrocardiographic signal modulates a constant 1900 Hertz transmitter audible output which is conducted via the telephone to a receiver (Cardiotrack 2100) for translation into an ECG tracing. Recordings are received by a technician or physician during the day, and by the staff of the Intensive Care Unit or tape recording device during the night or weekends. From December 1, 1977, through May 31, 1978, 18 children ranging in age from one month to 19 years, transmitted 125 transteiephonic ECG recordings? IndicaFrom the Section of Pediatric Cardiology, C. S. Mott Children's Hospital, and the Department of Pediatrics, University of Michigan. *Reprint address: Section of Pediatric Cardiology, F- 1117.4 C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, 341 48109,
tions for transmission were classified into three groups (Table): Group I included six patients with undocumented or undiagnosed cardiac complaints; three of these patients presented with palpitations, syncope, or chest pain, and three with poorly documented tachyarrhythmias. Group II: Transtelephonic contacts in this group were used to guide decisions to initiate, maintain, alter, or discontinue therapy. Group I I I : The transtelephonic system was used to monitor beat to beat heart rate (RR interval) to detect early pacemaker failure.
Abbreviation used ECG: electrocardiogram
]
An "abnormal" tracing was defined as a newly recognized disturbance of rate of rhythm. An "intervention" was defined as any change in drug regimen or management resulting from a transtelephonic transmission. The relative weight, size, and cost of the transtelephonic electrocardiography system were compared to those of a Holter monitor. Distances from the patient's homes to the C. S. Mott Children's Hospital in Ann Arbor were estimated. 7 RESULTS The Table summarizes the results of 125 transmissions received from the 18 patients. Eighteen percent of these tracings were abnormal; intervention occurred following 26% of the recordings. The number of interventions exceeded the number of abnormal tracings because in one patient stable tracings permitted withdrawal of drug therapy. Two of the six Group I patients produced abnormal tracings. A 12-year-old boy presented with complaints of episodic dizziness, syncope, and chest pain. Transtelephonic ECG tracings showed frequent premature ventricular beats, with a bigeminal and trigeminal pattern. However, there was no temporal relationship between the ectopy and the symptoms of faintness or dizziness; no therapy was initiated. Another 12-year-old boy complained of frequent and severe palpitations; a transtele-
0022-3476/79/400612+04500.40/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 4
Brief clinical and laboratory observations
613
Fig. 1. A, Transmitting technique. The transmitter rests on the anterior chest wall and the microphone end of the telephone receiver is placed over it. B, Transtelephonic receiver. The telephone receiver is inserted into the cradle of the recorder, and the audible signal is converted into an electrocardiographic tracing. Table Patients
..~
Tracings
~ + , , t.t ~*~ ~ .
~ tt ~
InterAge yenrange Total Abnormal tions
No. I. Diagnosis PSVT 4 VT 1 NSHD 1 II. Drug management PSVT 5 VT 2 JT 1 Ventricular bigeminy 1
(yO (No.)
(No.)
(No.)
6 10 to 13
14
2
1
9
1/12 to 15
97
21
32
III, Pacemaker 3 2/12 Congenital CHB 1 to 19 Surgical CHB 2
14
0
0
125
23
33
Total
18
Abbreviations used: CHB = Complete heart block; JT =junctional tachycardia; NSHD = no significantheart disease; PSVT = paroxysmal supraventriculartachycardia; VT = ventriculartachycardia. phonic tracing, obtained during a symptomatic episode, demonstrated paroxysmal supraventricular tachycardia. Conversion to normal sinus rhythm was achieved with immersion of his face in cold water. Therapy with digoxin was begun, with a subsequent decrease in the frequency of paroxysmal episodes. The remaining three children with poorly documented arrhythmias have remained free of arrhythmias. Among the nine patients in Group II, premature atrial contractions were present in two tracings, premature
Fig. 2. These transtelephonic tracings illustrate paroxysmal supraventricular tachycardia in a 12-year-old boy. A, An abnormal broad QRS morphology. B, A few minutes later; the difference in QRS morphology, now more clearly indicating a supraventricular impulse, was obtained by changing the orientation of the transmitter on the chest wall so that the lead system of the transmitter was more parallel to the QRS mean electrical axis,
ventricular contractions in seven, and junctional tachycardia in one. During each of these observations there were no associated symptoms; thus no further control of the arrhythmias was considered necessary. Eleven tracings demonstrated supraventricular tachycardia; digoxin a n d / or propranolol dosage was increased with successful conversion to sinus rhythm in ten of these episodes. In one 2-month-old infant, supraventricular tachycardia persisted for 36 hours despite increases in digoxin and propranolol, and hospitalization was advised. A 5-year-
6 14
Brief clinical and laboratory observations
old girl who had ventricular tachycardia associated with myocarditis was readmitted to the hospital when ventricular bigeminy returned while on propranolol therapy. No tracings requiring intervention were received from Group III (pacemaker) patients. Distance from the patient's home to the C. S. Mott ChiMren's Hospital averaged 82 miles (range one to 450 miles). The transmitter (Cardiotrack 2112) weighs five ounces and is eight cubic inches. Holter monitors vary in weight and size from 14 ounces, 22 cubic inches (Oxford Medilog) to 32 ounces, 50 cubic inches (ICR Dyna-Gram recorder). Another widely used Holter recorder is 26 ounces, in weight and 43 cubic inches (Avionics Electrocardiocorder MN 445). Purchase of the transmitter is borne by the institution, and charge to the patient or third party payer is initiated upon each transmission. After diagnosis or cessation of drug monitoring, the transmitter is returned. Pacemaker patients purchase ($I00 to $200) and receive the transmitter at the time of pacemaker implantation. Comparison of relative cost at our institution disclosed that one transtelephonic electrocardiogram cost approximately 75% of that of a 12-lead diagnostic electrocardiogram and 10% of that of a 24-hour Holter monitor or one day hospitalization. No complications related to the use of this technique occurred during the period of study. DISCUSSION Transtelephonic electrocardiography is a safe, useful, and economic procedure in the management of pediatric patients with disturbances of cardiac rhythm. In the six patients with cardiac symptoms, arrhythmias were identified in two and a temporal relationship between symptoms and cardiac rhythm established in one of these. In the nine patients monitored for drug management, interventions were made in five patients; the remaining four had stable rhythms requiring no change. In the three Children requiring pacemaker implantation, we anticipate that the system will detect early pacemaker failure, as it does in adults. 1-3 The use of this device permits rapid, accurate assessment of a symptom suggestive of a cardiac dysrhythmia. In the past, these patients would have to rush to an emergency room or physician's office to obtain an ECG, or receive a 24-hour Holter monitor. Holter monitoring, especially if done as an inpatient, is very expensive. The equipment is bulky, heavy, and subject to breakage, especially by the young child. The recording electrodes must be attached to the body surface, and the recorder carried from the shoulder or waist. Finally, Holter monitoring does not provide an instantaneously available method of correlating symptoms and cardiac rhythm. In
The Journal of Pediatrics April 1979
the patients with implanted pacemakers, beat-to-beat analysis of pacemaker rate provides precise monitoring of pacemaker output, and diminishes the need for pulse checking. Symptoms suspected of pacemaker malfunction can be evaluated without travel to a medical facility. The management of recurrent or chronic arrhythmias requiring drug therapy can be achieved as an outpatient. Changes in drug regimen can be accomplished and monitored efficiently and effectively. The need for office visit or hospitalization for serum drug levels or other studies can be based on data obtained via the transtelephonic ECG. The disadvantages of transtelephonic monitoring are few. Most commercially available systems transmit one lead; with the proper equipment one can obtain a 12-lead diagnostic electrocardiogram, increasing the likelihood of detecting obscure P waves and ST-T wave changes. The potential for artifacts was thought to be ~eat, but, in fact, reliable recordings were obtained from all patients. Artifacts from lead placement can be corrected by asking the patient to change the orientation of the transmitter on his chest so that the lead system is parallel to the P wave and QRS mean electrical axis (Fig. 2). The signal generated is recorded only as long as the transmitter is placed upon the chest wall; thus recordings of prolonged time periods (12 to 36 hours as with Holter tapes) surveying the cardiac rhythm for very transient (single ectopic beats) events or asymptomatic alterations cannot be obtained by this method. At this time most transmissions are made during working hours; however, signals can be recorded on standard phone answering-recording devices and played back the next morning for analysis. Alternatively, a receiver may be placed in an area where there is a constantly manned telephone, such as in an intensive care unit. The transtelephonic system offers several intangible benefits for all patients. The instrument is lightweight and portable, so it can be carried to school and away from home during a family vacation. It can be returned by mail to the medical facility when no longer needed. It is simple and convenient to use, so a young patient can initiate the call. Outpatient management decreases travel time, inconvenience, and expense. Ready access to professional personnel relieves patient and family anxiety, allowing accurate observation of worrisome symptoms and providing reassurance that medical care is available. ADDENDUM Since preparation of this manuscript 16 additional patients have received transtelephonic transmitters, initiating an additional 57 transmissions. Seven of these patients had permanent implanted pacemakers. One 18-
Volume 94 Number 4
Brief clinical and laboratory observations
month-old boy with syncopal episodes was shown to have a prolonged QT interval and transient ventricular fibrillation; further evaluation demonstrated the prolonged QT sydrome with congenital deafness. Propranolol was administered with virtual elimination of syncope (one undocumented 1- to 2-second episode without loss of consciousness occurred while on therapy). REFERENCES
1. Furman S, Parker B, and Escher DJW: Transtelphone pacemaker clinic, J Thor Cardiovasc Surg 61:827, 1971. 2. Furman S, and Escher DJW: Transtelephonic pacemaker monitoring: Five years later, Ann Thorac Surg 20:326, 1975.
6 15
3. Starr A, Dobbs J, Dabolt L, and Pierie W: Ventricular tracing pacemaker and teletransmitter follow-up system, Am J Card 32:956, 1973. 4. Hasin Y, David D, and Rogel S: Diagnostic and therapeutic assessment by telephone electrocardiographic monitoring of ambulatory patients, Br Med J 2:609, 1976. 5. Scheidt S, McCAll J, Wilner G, and Killip T: Remote electrocardiography clinical experience with telephone transmission of electrocardiograms, JAMA 230:1293, 1974. 6. WilliamsRL: Use of transtelephonic electrocardiography in patients with symptoms suggesting cardiac arrhythmias, Pediatrics 61:493, 1978. 7. Crippled Children's Representative Manual, Bureau of Personal Health Services, Regional Offices, Michigan Department of Public Health, Appendix, Exhibit 2, 1976, p 4.
Premature ventricular contractions as the presenting feature of mitral valve prolapse in childhood Arthur S. Pickoff, M.D., Henry Gelband, M.D., Pedro Fetter, M.D., Otto Garcia, M.D., and Dolores Tamer, M.D.,* Miami, Fla.
A L T H O U G n the association of various cardiac arrhythmias and mitral valve prolapse is well described in the adult literature, 1, ~ little is known about this association in childhood. Most reports of children with arrhythmias and MVP have described patients with the typical auscultatory findings of MVP, specifically, nonejection systolic clicks or late systolic murmurs or both2 Although echocardiographic surveys have demonstrated findings of MVP in up to 6% of "normal" young women, 3 there is no doubt that there exists a definite population with the same echocardiographic findings who experience, in varying degrees of severity, symptoms that have been described frequently in the context of the MVP syndrome. These symptoms include chest pain, dizziness, palpitations, episodes of syncope, and, in a small number of cases, sudden death.' Cardiac arrhythmias, which can be associated with MVP, may play a role in the genesis of some of these symptoms? Over the past four years we have included an echocardiagram as part of the evaluation of any child presenting with ventricular arrhythmias of undetermined etiology. During this time, we have examined 51 patients and encountered six patients with echocardiographic evidence of MVP. From the Division of Pediatric Cardiology, the Department of Pediatrics, University of Miami School o f Medicine. *Reprint address: Pediatric Cardiology, Department of Pediatrics, P.O. Box 016820, Miami, FL 33101.
13022-3476/79/400615+ 03500.30/0 9 1979 The C. V. Mosby Co.
MATERIALS
AND METHODS
All patients were referred for cardiac evaluation of ventricular arrhythmias of unknown etiology. A multipositional auscultatory examination of the heart was performed in all. The diagnosis of the arrhythmia was made by standard electrocardiographic criteria in all patients. The diagnosis of MVP in six patients was made according to previously published echocardiographic 5 or angiocardiographic criteria? Five of six patients had exercise stress testing using a treadmill and following the Bruce protocol for graded exercise. Three of the patients had 24-hour electrocardiographic Holter monitoring. Abbreviations used MVP: mitral valve prolapse ECG: electrocardiogram PVC: premature ventricular contraction RESULTS The group consists of five girls and one boy ages 6 to 16 years (Table). Symptoms included nonspecific chest pain in three patients, fatigability in one, and palpitations in two patients; "dizzy spells" were encountered in one patient, and near or actual syncope in two patients. Only one patient (Patient 3) could be considered totally asymptomatic from the cardiovascular point of view. The family history revealed a sibling with documented MVP in one patient (Patient 5): in Patient 2 there was an
Brief cynical and laboratory observations
The Journal of Pediatrics April 1979
Diagnosis and management of cardiac rhythm disorders by transtelephonic electrocardiography in infants and children Macdonald Dick Ii, M.D.,* Dena McFadden, M.D., Dennis Crowley, M.D., and Amnon Rosenthal, M.D. Ann Arbor, Mich.
T R A N S T E L E P H O N I C E L E C T R O C A R D I O G R A P H Y WaS
initially developed for outpatient monitoring of pacemaker performance in adult patientS. ~-3 Subsequent reports describe its use in the management of paroxysmal arrhythmias. 4-5 There has been little experience, however, with these devices in the diagnosis and treatment of cardiac rhythm disturbances in infants and children. Alternative methods of diagnosis are often Unsatisfactory. An outpatient standard electrocardiogram in unlikely to record an episodic event of short duration. Holter monitors used to obtain a 12- or 24-hour electrocardiographic tape recording are heavy and cumbersome and may be damaged when given to a child. Hospitalization for constant ECG monitoring is disruptive of family life and expensive. For these reasons we have explored the use of transtelephonic electrocardiography in the diagnosis and management of disorders of cardiac rhythm in children. The purpose of this report is to summarize the indications, resultS, advantages, and limitations of transtelephonic electrocardiography in the pediatric age group. M A T E R I A L S AND M E T H O D S The transtelephonic ECG system consists of a batterypowered portable transmitter (Cardiotrack 2112 or Instromedix 9404 Pacer-Tracer), one side of which rests during transmission against the patient's chest with the other adapted to fit an ordinary telephone receiver (Fig. 1). The patient's electrocardiographic signal modulates a constant 1900 Hertz transmitter audible output which is conducted via the telephone to a receiver (Cardiotrack 2100) for translation into an ECG tracing. Recordings are received by a technician or physician during the day, and by the staff of the Intensive Care Unit or tape recording device during the night or weekends. From December 1, 1977, through May 31, 1978, 18 children ranging in age from one month to 19 years, transmitted 125 transteiephonic ECG recordings? IndicaFrom the Section of Pediatric Cardiology, C. S. Mott Children's Hospital, and the Department of Pediatrics, University of Michigan. *Reprint address: Section of Pediatric Cardiology, F- 1117.4 C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, 341 48109,
tions for transmission were classified into three groups (Table): Group I included six patients with undocumented or undiagnosed cardiac complaints; three of these patients presented with palpitations, syncope, or chest pain, and three with poorly documented tachyarrhythmias. Group II: Transtelephonic contacts in this group were used to guide decisions to initiate, maintain, alter, or discontinue therapy. Group I I I : The transtelephonic system was used to monitor beat to beat heart rate (RR interval) to detect early pacemaker failure.
Abbreviation used ECG: electrocardiogram
]
An "abnormal" tracing was defined as a newly recognized disturbance of rate of rhythm. An "intervention" was defined as any change in drug regimen or management resulting from a transtelephonic transmission. The relative weight, size, and cost of the transtelephonic electrocardiography system were compared to those of a Holter monitor. Distances from the patient's homes to the C. S. Mott Children's Hospital in Ann Arbor were estimated. 7 RESULTS The Table summarizes the results of 125 transmissions received from the 18 patients. Eighteen percent of these tracings were abnormal; intervention occurred following 26% of the recordings. The number of interventions exceeded the number of abnormal tracings because in one patient stable tracings permitted withdrawal of drug therapy. Two of the six Group I patients produced abnormal tracings. A 12-year-old boy presented with complaints of episodic dizziness, syncope, and chest pain. Transtelephonic ECG tracings showed frequent premature ventricular beats, with a bigeminal and trigeminal pattern. However, there was no temporal relationship between the ectopy and the symptoms of faintness or dizziness; no therapy was initiated. Another 12-year-old boy complained of frequent and severe palpitations; a transtele-
0022-3476/79/400612+04500.40/0 9 1979 The C. V. Mosby Co.
Volume 94 Number 4
Brief clinical and laboratory observations
613
Fig. 1. A, Transmitting technique. The transmitter rests on the anterior chest wall and the microphone end of the telephone receiver is placed over it. B, Transtelephonic receiver. The telephone receiver is inserted into the cradle of the recorder, and the audible signal is converted into an electrocardiographic tracing. Table Patients
..~
Tracings
~ + , , t.t ~*~ ~ .
~ tt ~
InterAge yenrange Total Abnormal tions
No. I. Diagnosis PSVT 4 VT 1 NSHD 1 II. Drug management PSVT 5 VT 2 JT 1 Ventricular bigeminy 1
(yO (No.)
(No.)
(No.)
6 10 to 13
14
2
1
9
1/12 to 15
97
21
32
III, Pacemaker 3 2/12 Congenital CHB 1 to 19 Surgical CHB 2
14
0
0
125
23
33
Total
18
Abbreviations used: CHB = Complete heart block; JT =junctional tachycardia; NSHD = no significantheart disease; PSVT = paroxysmal supraventriculartachycardia; VT = ventriculartachycardia. phonic tracing, obtained during a symptomatic episode, demonstrated paroxysmal supraventricular tachycardia. Conversion to normal sinus rhythm was achieved with immersion of his face in cold water. Therapy with digoxin was begun, with a subsequent decrease in the frequency of paroxysmal episodes. The remaining three children with poorly documented arrhythmias have remained free of arrhythmias. Among the nine patients in Group II, premature atrial contractions were present in two tracings, premature
Fig. 2. These transtelephonic tracings illustrate paroxysmal supraventricular tachycardia in a 12-year-old boy. A, An abnormal broad QRS morphology. B, A few minutes later; the difference in QRS morphology, now more clearly indicating a supraventricular impulse, was obtained by changing the orientation of the transmitter on the chest wall so that the lead system of the transmitter was more parallel to the QRS mean electrical axis,
ventricular contractions in seven, and junctional tachycardia in one. During each of these observations there were no associated symptoms; thus no further control of the arrhythmias was considered necessary. Eleven tracings demonstrated supraventricular tachycardia; digoxin a n d / or propranolol dosage was increased with successful conversion to sinus rhythm in ten of these episodes. In one 2-month-old infant, supraventricular tachycardia persisted for 36 hours despite increases in digoxin and propranolol, and hospitalization was advised. A 5-year-
6 14
Brief clinical and laboratory observations
old girl who had ventricular tachycardia associated with myocarditis was readmitted to the hospital when ventricular bigeminy returned while on propranolol therapy. No tracings requiring intervention were received from Group III (pacemaker) patients. Distance from the patient's home to the C. S. Mott ChiMren's Hospital averaged 82 miles (range one to 450 miles). The transmitter (Cardiotrack 2112) weighs five ounces and is eight cubic inches. Holter monitors vary in weight and size from 14 ounces, 22 cubic inches (Oxford Medilog) to 32 ounces, 50 cubic inches (ICR Dyna-Gram recorder). Another widely used Holter recorder is 26 ounces, in weight and 43 cubic inches (Avionics Electrocardiocorder MN 445). Purchase of the transmitter is borne by the institution, and charge to the patient or third party payer is initiated upon each transmission. After diagnosis or cessation of drug monitoring, the transmitter is returned. Pacemaker patients purchase ($I00 to $200) and receive the transmitter at the time of pacemaker implantation. Comparison of relative cost at our institution disclosed that one transtelephonic electrocardiogram cost approximately 75% of that of a 12-lead diagnostic electrocardiogram and 10% of that of a 24-hour Holter monitor or one day hospitalization. No complications related to the use of this technique occurred during the period of study. DISCUSSION Transtelephonic electrocardiography is a safe, useful, and economic procedure in the management of pediatric patients with disturbances of cardiac rhythm. In the six patients with cardiac symptoms, arrhythmias were identified in two and a temporal relationship between symptoms and cardiac rhythm established in one of these. In the nine patients monitored for drug management, interventions were made in five patients; the remaining four had stable rhythms requiring no change. In the three Children requiring pacemaker implantation, we anticipate that the system will detect early pacemaker failure, as it does in adults. 1-3 The use of this device permits rapid, accurate assessment of a symptom suggestive of a cardiac dysrhythmia. In the past, these patients would have to rush to an emergency room or physician's office to obtain an ECG, or receive a 24-hour Holter monitor. Holter monitoring, especially if done as an inpatient, is very expensive. The equipment is bulky, heavy, and subject to breakage, especially by the young child. The recording electrodes must be attached to the body surface, and the recorder carried from the shoulder or waist. Finally, Holter monitoring does not provide an instantaneously available method of correlating symptoms and cardiac rhythm. In
The Journal of Pediatrics April 1979
the patients with implanted pacemakers, beat-to-beat analysis of pacemaker rate provides precise monitoring of pacemaker output, and diminishes the need for pulse checking. Symptoms suspected of pacemaker malfunction can be evaluated without travel to a medical facility. The management of recurrent or chronic arrhythmias requiring drug therapy can be achieved as an outpatient. Changes in drug regimen can be accomplished and monitored efficiently and effectively. The need for office visit or hospitalization for serum drug levels or other studies can be based on data obtained via the transtelephonic ECG. The disadvantages of transtelephonic monitoring are few. Most commercially available systems transmit one lead; with the proper equipment one can obtain a 12-lead diagnostic electrocardiogram, increasing the likelihood of detecting obscure P waves and ST-T wave changes. The potential for artifacts was thought to be ~eat, but, in fact, reliable recordings were obtained from all patients. Artifacts from lead placement can be corrected by asking the patient to change the orientation of the transmitter on his chest so that the lead system is parallel to the P wave and QRS mean electrical axis (Fig. 2). The signal generated is recorded only as long as the transmitter is placed upon the chest wall; thus recordings of prolonged time periods (12 to 36 hours as with Holter tapes) surveying the cardiac rhythm for very transient (single ectopic beats) events or asymptomatic alterations cannot be obtained by this method. At this time most transmissions are made during working hours; however, signals can be recorded on standard phone answering-recording devices and played back the next morning for analysis. Alternatively, a receiver may be placed in an area where there is a constantly manned telephone, such as in an intensive care unit. The transtelephonic system offers several intangible benefits for all patients. The instrument is lightweight and portable, so it can be carried to school and away from home during a family vacation. It can be returned by mail to the medical facility when no longer needed. It is simple and convenient to use, so a young patient can initiate the call. Outpatient management decreases travel time, inconvenience, and expense. Ready access to professional personnel relieves patient and family anxiety, allowing accurate observation of worrisome symptoms and providing reassurance that medical care is available. ADDENDUM Since preparation of this manuscript 16 additional patients have received transtelephonic transmitters, initiating an additional 57 transmissions. Seven of these patients had permanent implanted pacemakers. One 18-
Volume 94 Number 4
Brief clinical and laboratory observations
month-old boy with syncopal episodes was shown to have a prolonged QT interval and transient ventricular fibrillation; further evaluation demonstrated the prolonged QT sydrome with congenital deafness. Propranolol was administered with virtual elimination of syncope (one undocumented 1- to 2-second episode without loss of consciousness occurred while on therapy). REFERENCES
1. Furman S, Parker B, and Escher DJW: Transtelphone pacemaker clinic, J Thor Cardiovasc Surg 61:827, 1971. 2. Furman S, and Escher DJW: Transtelephonic pacemaker monitoring: Five years later, Ann Thorac Surg 20:326, 1975.
6 15
3. Starr A, Dobbs J, Dabolt L, and Pierie W: Ventricular tracing pacemaker and teletransmitter follow-up system, Am J Card 32:956, 1973. 4. Hasin Y, David D, and Rogel S: Diagnostic and therapeutic assessment by telephone electrocardiographic monitoring of ambulatory patients, Br Med J 2:609, 1976. 5. Scheidt S, McCAll J, Wilner G, and Killip T: Remote electrocardiography clinical experience with telephone transmission of electrocardiograms, JAMA 230:1293, 1974. 6. WilliamsRL: Use of transtelephonic electrocardiography in patients with symptoms suggesting cardiac arrhythmias, Pediatrics 61:493, 1978. 7. Crippled Children's Representative Manual, Bureau of Personal Health Services, Regional Offices, Michigan Department of Public Health, Appendix, Exhibit 2, 1976, p 4.
Premature ventricular contractions as the presenting feature of mitral valve prolapse in childhood Arthur S. Pickoff, M.D., Henry Gelband, M.D., Pedro Fetter, M.D., Otto Garcia, M.D., and Dolores Tamer, M.D.,* Miami, Fla.
A L T H O U G n the association of various cardiac arrhythmias and mitral valve prolapse is well described in the adult literature, 1, ~ little is known about this association in childhood. Most reports of children with arrhythmias and MVP have described patients with the typical auscultatory findings of MVP, specifically, nonejection systolic clicks or late systolic murmurs or both2 Although echocardiographic surveys have demonstrated findings of MVP in up to 6% of "normal" young women, 3 there is no doubt that there exists a definite population with the same echocardiographic findings who experience, in varying degrees of severity, symptoms that have been described frequently in the context of the MVP syndrome. These symptoms include chest pain, dizziness, palpitations, episodes of syncope, and, in a small number of cases, sudden death.' Cardiac arrhythmias, which can be associated with MVP, may play a role in the genesis of some of these symptoms? Over the past four years we have included an echocardiagram as part of the evaluation of any child presenting with ventricular arrhythmias of undetermined etiology. During this time, we have examined 51 patients and encountered six patients with echocardiographic evidence of MVP. From the Division of Pediatric Cardiology, the Department of Pediatrics, University of Miami School o f Medicine. *Reprint address: Pediatric Cardiology, Department of Pediatrics, P.O. Box 016820, Miami, FL 33101.
13022-3476/79/400615+ 03500.30/0 9 1979 The C. V. Mosby Co.
MATERIALS
AND METHODS
All patients were referred for cardiac evaluation of ventricular arrhythmias of unknown etiology. A multipositional auscultatory examination of the heart was performed in all. The diagnosis of the arrhythmia was made by standard electrocardiographic criteria in all patients. The diagnosis of MVP in six patients was made according to previously published echocardiographic 5 or angiocardiographic criteria? Five of six patients had exercise stress testing using a treadmill and following the Bruce protocol for graded exercise. Three of the patients had 24-hour electrocardiographic Holter monitoring. Abbreviations used MVP: mitral valve prolapse ECG: electrocardiogram PVC: premature ventricular contraction RESULTS The group consists of five girls and one boy ages 6 to 16 years (Table). Symptoms included nonspecific chest pain in three patients, fatigability in one, and palpitations in two patients; "dizzy spells" were encountered in one patient, and near or actual syncope in two patients. Only one patient (Patient 3) could be considered totally asymptomatic from the cardiovascular point of view. The family history revealed a sibling with documented MVP in one patient (Patient 5): in Patient 2 there was an