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Migration of redundant pacing electrode
Letters Table
I
Of bibliographies 1 No. of patients I
New arrhythmia resulted in medication or change in medication Chest pain resulted in change of medication ST segment depression resulted in coronary angiogram No new arrhythmia while on medication and therefore continued same Chest pain resulted in a coronary angiogram Blood pressure drop resulted in angiogram Diminished exercise tolerance resulting in ordering a cardiac rehabilitation program not previously planned Dizziness resulted in delay of discharge Total
5 4 4
2 2
I 23/82
(28%)
The reasons for stopping the test were that the target heart rate was achieved in 41 patients (50%), symptoms of dyspnea, fatigue and leg weakness were seen in 21 patients (25.6%), chest pain was found in eight patients (9.8%), ST drop greater than 1% mm. appeared in seven patients (8.5%), arrhythmia was found in three patients (3.7%), and a significant blood pressure drop was seen in two patients (2.4%). We found that in 23 of the 82 patients (28%) the performing of a function test resulted in a change in the management of the patient by the attending physician. The reasons for a change in management by the attending physicians are shown in Table I. Thus in addition to predicting prognosis, function testing before hospital discharge resulted in a change in patient management in 28% of our patients. Function testing also allows an objective evaluation of a patient’s response to low level exercise that he will experience in his home environment and allows the physician to more accurately determine the type of activities permissible for the patient at home. It also seems possible that in the future, function testing may play an important role in determining which patients should have coronary angiography prior to discharge. John K. Vyden, M.B. Harvey L. Alpern, M.D. Masakuni Kanazawa, M.D. Elaine Mickle, R.N. Harold B. Rose, Sc.D. Cardiac Rehabilitation Service Division of Cardiology Cedars-Sinai Medical Center 8700 Beverly Blud. Los Angeles, Calif. 90048 REFERENCE
1.
Theroux, P., Waters, D. D., Halphen, C., Debaisiex, J. C., and Mizgaza, H. F.: Prognostic value of exercise testing soon after myocardial infarction, N. Engl. J. Med. 301:341, 1979.
American
Heart
Journal
and medical
to the Editor
librarians
To The Editor: This letter is written in response to the Annotation entitled “Of bibliographies” (AM. HEART J. 99:401, 1980). The point made by Dr. George E. Burch that authors do not always research their topile adequately is well taken. As the editor of AMERICAN HEART JOURNAL, Dr. Burch is obviously in a position to observe the quality of literature research done by his colleagues. It is also true that a “careful review of the medical literature on any subject is an ordeal which is difficult and time-consuming.. .” Our role as medical librarians is to aid those authors who do not have the time to do extensive research. If a physician feels that the Medline search is not adequate or preferred, most librarians will be happy to do a manual search and/or provide instruction so that the experience can be “informative, educational and proper,” as Dr. Burch suggests. Medical schools which include a segment on library/research orientations in their curricula are to be applauded for giving the student an appreciation of the literature. Dr. Burch is incorrect, however, in thinking that Medline indexes publications “of only the past 5 years or so”-the Medline data base includes citations from 1966 to the present. Barbara Bury, A.M.L.S. Daniel Jones, M.Ln. Library University of Texas Health Science Center at San Antonio 7703 Floyd Curl Dr. San Antonio. Texas 78284
Reply To the Editor: ‘We thank Ms. Bury and Mr. Jones for their letter. On checking with our librarian, we were informed that Medline has two types of services. The “current” Medline extends back three years, but service may be obtained as far back as 1966. It must be remembered, however, that many important contributions have been made prior to 1966. Unfortunately, a review of the literature beyond 1966 is very time consuming. George E. Burch, M.D. Editor, AMERICAN HEART JOURNAL Tulane University School of Medicine 1430 Tulane Ave. New Orleans, La. 70112
Nligration
of redundant
pacing
electrode
To the Editor: Retting and associates recently described a case of migration of a redundant transvenous pacing electrode (AM. HEART J. 98: 587, 1979). In their case the electrode settled in the pulmonary artery and was retrieved via a thoracotomy. We have had a similar experience but with a more serious consequence. The patient, a 74-year-old man, required permanent pacing because of Stokes-Adams attacks due to complete
591
Letters
to the Editor
heart block. Unfortunately, the skin overlying the box became necrotic and the pacemaker box had to be exchanged, but the electrode could not be removed and was left in situ. Nine months later the patient presented with pleuritic chest pain and screening showed that the abandoned electrode had migrated into the right ventricle and that the cut end of electrode had penetrated the free wall of the heart. He developed signs of pericardial tamponade and required an emergency thoracotomy, at which time free blood was found in the pericardial sac. The redundant wire was removed and the patient made an excellent recovery. This case re-emphasizes the need for secure fixation of the cut end of retained electrodes. M. S. PereZman 34. F. Wiu Dept. of Cardiovascular Medicine East Birmingham Hospital Bordesley Green East Birmingham B9 5ST England
592
To the Editor: We appreciate the interesting comments of Drs. Perehnan and Shiu, whose case report on cardiac tamponade due to catheter perforation of the right ventricular free salt confirms the conclusions drawn in our recently published manuscript from similar experiences (AM. HEART J.98: 587, ?979). However, we should like to point out that in our reported case on catheter embolization into the pulmonary artery the electrode wire was not retrieved via thoracotomy, as erroneously quoted by Drs. Perelman and Shiu, but in fact bad to be left in situ, since thoracotomy was refused by the patient; he died suddenly several days later. Gerd Rettig, M..D. Med. Universitiitsklinik und Po&W&. Innere Medizin 111 O-6650 Homburg/Saar TN. Germany 1_
October,
1980,
Vol.
100,
No.
4
I
Of bibliographies 1 No. of patients I
New arrhythmia resulted in medication or change in medication Chest pain resulted in change of medication ST segment depression resulted in coronary angiogram No new arrhythmia while on medication and therefore continued same Chest pain resulted in a coronary angiogram Blood pressure drop resulted in angiogram Diminished exercise tolerance resulting in ordering a cardiac rehabilitation program not previously planned Dizziness resulted in delay of discharge Total
5 4 4
2 2
I 23/82
(28%)
The reasons for stopping the test were that the target heart rate was achieved in 41 patients (50%), symptoms of dyspnea, fatigue and leg weakness were seen in 21 patients (25.6%), chest pain was found in eight patients (9.8%), ST drop greater than 1% mm. appeared in seven patients (8.5%), arrhythmia was found in three patients (3.7%), and a significant blood pressure drop was seen in two patients (2.4%). We found that in 23 of the 82 patients (28%) the performing of a function test resulted in a change in the management of the patient by the attending physician. The reasons for a change in management by the attending physicians are shown in Table I. Thus in addition to predicting prognosis, function testing before hospital discharge resulted in a change in patient management in 28% of our patients. Function testing also allows an objective evaluation of a patient’s response to low level exercise that he will experience in his home environment and allows the physician to more accurately determine the type of activities permissible for the patient at home. It also seems possible that in the future, function testing may play an important role in determining which patients should have coronary angiography prior to discharge. John K. Vyden, M.B. Harvey L. Alpern, M.D. Masakuni Kanazawa, M.D. Elaine Mickle, R.N. Harold B. Rose, Sc.D. Cardiac Rehabilitation Service Division of Cardiology Cedars-Sinai Medical Center 8700 Beverly Blud. Los Angeles, Calif. 90048 REFERENCE
1.
Theroux, P., Waters, D. D., Halphen, C., Debaisiex, J. C., and Mizgaza, H. F.: Prognostic value of exercise testing soon after myocardial infarction, N. Engl. J. Med. 301:341, 1979.
American
Heart
Journal
and medical
to the Editor
librarians
To The Editor: This letter is written in response to the Annotation entitled “Of bibliographies” (AM. HEART J. 99:401, 1980). The point made by Dr. George E. Burch that authors do not always research their topile adequately is well taken. As the editor of AMERICAN HEART JOURNAL, Dr. Burch is obviously in a position to observe the quality of literature research done by his colleagues. It is also true that a “careful review of the medical literature on any subject is an ordeal which is difficult and time-consuming.. .” Our role as medical librarians is to aid those authors who do not have the time to do extensive research. If a physician feels that the Medline search is not adequate or preferred, most librarians will be happy to do a manual search and/or provide instruction so that the experience can be “informative, educational and proper,” as Dr. Burch suggests. Medical schools which include a segment on library/research orientations in their curricula are to be applauded for giving the student an appreciation of the literature. Dr. Burch is incorrect, however, in thinking that Medline indexes publications “of only the past 5 years or so”-the Medline data base includes citations from 1966 to the present. Barbara Bury, A.M.L.S. Daniel Jones, M.Ln. Library University of Texas Health Science Center at San Antonio 7703 Floyd Curl Dr. San Antonio. Texas 78284
Reply To the Editor: ‘We thank Ms. Bury and Mr. Jones for their letter. On checking with our librarian, we were informed that Medline has two types of services. The “current” Medline extends back three years, but service may be obtained as far back as 1966. It must be remembered, however, that many important contributions have been made prior to 1966. Unfortunately, a review of the literature beyond 1966 is very time consuming. George E. Burch, M.D. Editor, AMERICAN HEART JOURNAL Tulane University School of Medicine 1430 Tulane Ave. New Orleans, La. 70112
Nligration
of redundant
pacing
electrode
To the Editor: Retting and associates recently described a case of migration of a redundant transvenous pacing electrode (AM. HEART J. 98: 587, 1979). In their case the electrode settled in the pulmonary artery and was retrieved via a thoracotomy. We have had a similar experience but with a more serious consequence. The patient, a 74-year-old man, required permanent pacing because of Stokes-Adams attacks due to complete
591
Letters
to the Editor
heart block. Unfortunately, the skin overlying the box became necrotic and the pacemaker box had to be exchanged, but the electrode could not be removed and was left in situ. Nine months later the patient presented with pleuritic chest pain and screening showed that the abandoned electrode had migrated into the right ventricle and that the cut end of electrode had penetrated the free wall of the heart. He developed signs of pericardial tamponade and required an emergency thoracotomy, at which time free blood was found in the pericardial sac. The redundant wire was removed and the patient made an excellent recovery. This case re-emphasizes the need for secure fixation of the cut end of retained electrodes. M. S. PereZman 34. F. Wiu Dept. of Cardiovascular Medicine East Birmingham Hospital Bordesley Green East Birmingham B9 5ST England
592
To the Editor: We appreciate the interesting comments of Drs. Perehnan and Shiu, whose case report on cardiac tamponade due to catheter perforation of the right ventricular free salt confirms the conclusions drawn in our recently published manuscript from similar experiences (AM. HEART J.98: 587, ?979). However, we should like to point out that in our reported case on catheter embolization into the pulmonary artery the electrode wire was not retrieved via thoracotomy, as erroneously quoted by Drs. Perelman and Shiu, but in fact bad to be left in situ, since thoracotomy was refused by the patient; he died suddenly several days later. Gerd Rettig, M..D. Med. Universitiitsklinik und Po&W&. Innere Medizin 111 O-6650 Homburg/Saar TN. Germany 1_
October,
1980,
Vol.
100,
No.
4