Eleven-year follow-up after tricuspid valve replacement and pulmonic valvulotomy in the carcinoid syndrome

MYOCARDIAL INFARCTION CLASSIFICATION The careful study of Newman et al’ indicates that myocardial scanning can indicate whether ischemic myocardium is caused by right or left circumflex coronary artery disease. If this work can be extended to the setting of myocardial infarction (MI), it would presumably outdate the present electrocardiographic classification of myocardial infarcticm, which merely locates infarcted myocardium on the front or back of the left ventricle. The heart has 3 major arteries and MI ideally should be subdivided (by designating the diseased artery that has caused the infarction) into 3 types: right, left anterior descending (LAD) and left circumflex (LC). This obvious classification has not been used because accurate electrocardiographic criteria for LC infarction have not been established, and the clinical diagnosis of LC infarction has seldom been achieved. Some caution has therefore been required in the interpretation of studies that show a variation in complications and prognosis between anterior and posterior wall M12*3because it has not been clear whether LC infarction has been excluded or bunched in with right or LAD infarction in these reports. However, recent coronary angiographic studies performed during the early stage of acute MI verify that a significant percentage of infarctions are LC infarctions,4 and the study by Newman et al indicates that it may be possible to correlate these studies with location of infarction seen by nuclear scan. If this is so, MI could be classified by myocardial scan according to the artery that has caused the MI even if angiography has not been performed. Such a 3vessel classification should yield more accurate information on clinical variation than the 2-wall electrocardiographic classification. The effect of infarct site on the outcome of MI will have to be reexamined with respect to infarct size and incidence of complications as well as prognosis. Herbert E. Cohen, MD Philadelphia, Pennsylvania Newman HN, Dunn RF, Harris PJ, Bautovich GJ, McLaughlin AF, Kelly DT. Different!atlon between right and circumflex coronary artery disease on thallium myocardial perfusion scanmng Am J Cardiol 1983: 51.1052-1056 Bulkley BH. Site and sequelae 01 myocardlal Infarction

ELEVEN-YEAR FOLLOW-UP AFTER TRICUSPID VALVE REPLACEMENT AND PULMONIC VALVULOTOMY IN THE CARCINOID SYNDROME The second known successful operation for carcinoid valvular heart disease was reported by Carpena et al (AJC, August 1973). Preoperatively, the patient, a 26-year-old woman, had severe subcutaneous edema, ascites, hepatic metastases and dyspnea. Operation was performed on January 28, 1972, for tricuspid stenosis and regurgitation and pulmonic stenosis and regurgitation. At operation, the tricuspid valve was replaced with a Kay-Shiley disc valve with complete muscle guard, and a pulmonary valvotomy was performed. The patient did well postoperatively. In June 1982, chest x-ray disclosed a normal-sized heart and cardiac configuration. The lungs were expanded and clear. An isotope liver scan showed the spleen to be 3 times larger than normal, but devoid of space-occupying lesions. The liver was markedly enlarged and contained multiple space-occupying lesions up to 6 X 8 cm in diameter. The SCOT was 19, the SGPT 11 and the alkaline phosphatase was 62. Albumin was 5.3 and globulin was 2.2 g/dl. The 5-hydroxyindoleacetic acid was 82.5 mg in 24 hours (well above normal). She was last seen by her cardiologist (Reuben Zucker, MD) in December 1982,lO years after the open heart operation. At that time, the patient was working full time in the drama department at the University of Nevada, Las Vegas. She had no chest pain, dyspnea or orthopnea. The blood pressure was 180/72 mm Hg, with sinus rhythm at a rate of 72 beats/min. The heart was not enlarged. The opening and closing sounds of the disc valve were noted at the tricuspid area, along with a grade 3/6 systolic ejection murmur at the base due to the thickened pulmonic valve cusps. Ascites was absent. At present, she takes digoxin, chlorthiazide, chlorthalidone, 5 FU, and warfarin.

’ Letters (from the Unlted States) concernmg a particular article in the Journal must be received within 2 months of the article’s publication, and should be limited (with rare exceptions) to 2 double-spaced typewritten pages Two copies must be submitted

Norbert Treese, MD Wolfgang Kaeper, MD Thomas Meinetir, MO Tiberius Pop, MD Mamz, Federal Republic of Germany 1. Kowey PR, FoILandED, Parisi AF, Lawn 8. Programmed electrIcal stimulation ot the heart in coronary artery disease Am J Cardiol 1983:51.531-536. 2. lraasa N, Rcmer A, Zolr R, Kasper W, Meimrlr T, Pop T. Repetitfve ventncular response and left ventncular Wall motion on patients with coronw artery disease Z Kardiol 1983;72.37-43

Jerome Harold Kay, MD Los Angeles, California 1. Carpana C, Kay JH, Mandez AM, Radlngton JV, Zubiate P, Zucker R. Carcinoid heart disease Surgery for tncuspid and pUhOMy valve lesions Am J Cardlol 1973;32:229-233

(edltorlal). N Engl J Med 1981.305:337-338 Thanavaro S. Kbiger RE, Province MA, Hubert JW, Mlllar JP, Krorm RJ, Oliver GC. Effect of Infarct locatton on the In-hospital prognosis of patients wth first transmural myocardial lnfarctlon Circulation 1982, 66 742-747. 4. Merx W, Dorr R, Rentrop KP. Blanke H, Darsch KR, MatheyDo, Kremer P, RutschW,Schmutzler J. Evaluation of the effectiveness of intracwonary stieptokinase infusion in acute myocardial infarction. postprocedure management and hospital course III 204 patients Am HeartJ 1981,102.1181-1187

ings of these authors. In patients with CAD and no history of ventricular tachycardia, we related the results of PES to the extent of left ventricular (LV) motion abnormalities. PES included single and double extrastimuli during ventricular drive with 3 cycle lengths and was considered positive (+PES) when a repetitive response with 3 or more consecutive beats was induced. LV wall motion was analyzed from the LV angiogram in the 30” right anterior oblique view and scored according to the shortening of 48 radial axes. Patients without previous myocardial infarction, patients in the early and patients in the late postinfarction period differed with respect to the incidence of +PES and the extent of LV wall motion abnormalities. However, patients with positive or negative PES could not be distinguished when the extent of wall motion abnormalities (wall motion score and number of akinetic wall segments) was considered. Only a weak relation was found between positive PES and the presence of either normokinesia, hypokinesia, akinesia or dyskinesia. Similar to Kowey, we concluded that the incidence of +PES is related to the presence of previous myocardial infarction. The degree of LV dysfunction is of minor importance. No relation was found in the extent of LV wall abnormalities. We agree that the response to PES in patients with CAD cannot be predicted by the extent of the atherosclerotic lesion.

PROGRAMMED ELECTRICAL STIMULATION OF THE HEART IN CORONARY ARTERY DISEASE Recently Kowey et al’ described programmed electrical stimulation (PES) of the heart in patients with coronary artery disease (CAD). The study focused on the relation between the number of responses to PES and markers of the severity of CAD. Comparable observations in 136 patients with CAD reported at the same time in German* confirm the find651

REPLY: We genuinely appreciated the letter of Treese et al regarding programmed electrical stimulation in patients with CAD. Theirs was a prodigious undertaking, and their results in a very large group of patients are interesting. We were, of course, gratified to learn that, as in our study, the ability to induce 3 or more extra beats correlated with the presence of a previous myocardial infarction, but that neither the degree of LV dysfunction nor extent of CAD predicted the response to programmed stimulation. Since the submission of our data, we have studied approximately 100 additional patients, and the results in this series are the same as those in the original cohort. From these data myocardial infarction appears to render the heart susceptible to initiation of ventricular arrhythmia, the prognostic importance of which is currently under investigation. Peter I?. Kowey, MD Philadelphia, Pennsylvania