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Post-myocardial infarction constrictive pericarditis
358
Letters
to the Editor
sodium bicarbonate for maximum benefit.” Correction of bypovolemia and acidosis per se may improve cardiotoxicityi The authors noted that bypotension was the second most prominent cardiovascular manifestation of TCA overdose.’ Since the most common manifestation of TCA overdose in their study was sinus tachycardia,’ agents such as dopamine and isoproterenol appear relatively contraindicated. Dobutamine would seem a better choice in bypotension accompanying TCA poisoning, since this agent exerts a lesser effect on heart rate without the same vasodepressor or arrhytbmogenic potential of dopamine or isoproterenol.2. 8- 9 In serious overdose of TCA, myocardial depression is usually marked and can be worsened by propranolol.* Therefore propranolo1 should be added to lidocaine only with considerable caution.> Whereas respiratory depression was not observed in the recent report,’ this complication was a common feature in one study of TCA overdose.‘” Because fatal TCA poisoning appears to be increasing in frequency,‘O these comments are intended to heighten clinical awareness and enhance management of this problem. Saeed Ahmad, M.D., M.R.C.P., l?C.C.P Wepartment of Medicine Fairmont General Hospital Fairmont, WV 26554
remains uncertain. Nevertheless, pericardial constriction appears to be a rare but possible late complication of AMI and should be considered as a potential cause of right ventricular failure developing during follow-up evaluation. Robert Ha&t, M.D., F.A.C.C. Service de Cardioiogie @en&-e Hospitdker Saint Germ&n en Eaye 78104 France REFERENCES 1. 2.
3.
4.
5.
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9. 10.
Langou RA, Van Dyke C, Tahan SR, Cohen LS: Cardiovascular manifestations of tricyclic antidepressant overdose. AM HEART J 100:458, 1980. Abmad S: Management of cardiac complications in tricyclic antidepressant poisoning. J R Sot Med 73:79, 1979. Ahmad S: Cardiovascular complication of tricyclic antidepressant overdose. Ann Emergency Med 9:281, 1980. Abmad S: Verapamil therapy. AM HEART J 100:271, 1980. Moriarty R: Acute poisoning emergencies. Mod Med 48:139, 1980. Wright SP: Feedback on poison emergencies, Mod Med 46:139, 1980. Ahmad S: Poison emergencies. Mod Med 48:I39, 1980. Koch-Weser J: Bretylium. N Engl J Med 300:473, 1979. Tuttle RR, Mills J: Dobutamine. Circ Res 36:185, 1975. Crome P, Newman B: Fatal tricyclic antidepressant poisoning. J R Sot Med 72649, 1979.
POST-MYOCARDIAL INFARCTION CONSTRICTIVE PERICARDITIS To the Editor: Dressier’s syndrome is known to occur in the course of acute myocardial infarction (AMI).’ Although accompanied by one or multiple symptomatic recurrences, it is usually benign. However, attention has recently been focused on the possibility that this post-AM1 syndrome may result in constrictive pericarditis.‘. 1 Constrictive pericarditis developed within 3 to 18 months in patients post-AM1 without pre-AM1 history of pericardial disease.” The clinical features were characteristic of right heart failure with prominent ascites. Differential diagnosis from ventricular failure secondary to myocardial damage was difficult by standard clinical means. Phonography and echography were not definitive as to etiology.‘.j Cardiac catheterization allowed recognition of constrictive pericarditis and pericardiectomy resulted in dramatic clinical improvement. The mechanism by which postAM1 pericardial syndrome may result in such involvement
Dressier W: The post-myocardial infarction syndrome: A report on 44 cases. Arch Intern Med 103:28, 1959. Beaufils Ph, Bardet J, Temkin J, Masquet Ch, Sebastien Ph, Zelasko Y: Syndrome de Dressler: Pericardite cons post-infarctus operee avec sue&s. Arch Ma1 Coeur 1975. Haiat R, Desoutter P, Stoltz JP, Chousterman M, Cattan P, Gandjbakhch I: Pericardite constrictive secondaire a un infarctus du myocarde. Guerison chirurgicale. Coeur Med Int 19:420, 1980. Khullard S, Lewis RP: Usefulness of systolic time intervals in differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy. Br Heart J 38:43, 1976. Voelkel AG, Pietro D, Folland E, Fisher M, Paris A: Echocardiographic features of constrictive pericarditis. Cticulation 58:871, 1979.
2D ECHO POSITION OF SEPTAL TRICUSPI LEAFLET IN EBSTEIN’S ANOMALY AND NORMAL HEARTS To the Editor: The observations on the two-dimensional echocardiographic appearance of the tricuspid valve in Ebstein’s anomaly by Kambe et al.’ confirm the usefulness of this technique in assessing the anatomic abnormalities of the atrioventricular junction. However, it is imprecise to state there is no displacement of a normal septal leaflet of the tricuspid valve relative to the anterior leaflet of the mitral valve. Normally, the septal tricuspid leaflet arises from the interventricular septum slightly nearer the cardiac apex than the anterior mitral leaflet, when these structures are viewed from either an apical long-axis (four-chamber) view or a subcostal long-axis (four-chamber) view.’ No displacement of the septai tricuspid leaflet relative to the anterior mitral leaflet is a feature of atrioventricular cushion defects,” and reversal of the normal pattern of the two valves is characteristic of atrioventricular discordance (corrected transposition of the great arteries).’ We feel it is important that the normal anatomic relationships of the atrioventricular valves be fully appreciated. Keith Evemy A. Stewart Hunter Cardiothoracic Unit Freeman Hospital Newcastle upon Tyne NE7 7WN England
REFERENCES 1.
Kambe T, Ichimiya S, Toguchi M, Hibi N, Fukui Y, Nishimura K, Sakamato N, Hojo Y: Apex and subxiphoid approaches to Ebstein’s anomaly using cross-sectional echocardiography. AM HEART J 100:53, 1980.
Letters
to the Editor
sodium bicarbonate for maximum benefit.” Correction of bypovolemia and acidosis per se may improve cardiotoxicityi The authors noted that bypotension was the second most prominent cardiovascular manifestation of TCA overdose.’ Since the most common manifestation of TCA overdose in their study was sinus tachycardia,’ agents such as dopamine and isoproterenol appear relatively contraindicated. Dobutamine would seem a better choice in bypotension accompanying TCA poisoning, since this agent exerts a lesser effect on heart rate without the same vasodepressor or arrhytbmogenic potential of dopamine or isoproterenol.2. 8- 9 In serious overdose of TCA, myocardial depression is usually marked and can be worsened by propranolol.* Therefore propranolo1 should be added to lidocaine only with considerable caution.> Whereas respiratory depression was not observed in the recent report,’ this complication was a common feature in one study of TCA overdose.‘” Because fatal TCA poisoning appears to be increasing in frequency,‘O these comments are intended to heighten clinical awareness and enhance management of this problem. Saeed Ahmad, M.D., M.R.C.P., l?C.C.P Wepartment of Medicine Fairmont General Hospital Fairmont, WV 26554
remains uncertain. Nevertheless, pericardial constriction appears to be a rare but possible late complication of AMI and should be considered as a potential cause of right ventricular failure developing during follow-up evaluation. Robert Ha&t, M.D., F.A.C.C. Service de Cardioiogie @en&-e Hospitdker Saint Germ&n en Eaye 78104 France REFERENCES 1. 2.
3.
4.
5.
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8. 9. 10.
Langou RA, Van Dyke C, Tahan SR, Cohen LS: Cardiovascular manifestations of tricyclic antidepressant overdose. AM HEART J 100:458, 1980. Abmad S: Management of cardiac complications in tricyclic antidepressant poisoning. J R Sot Med 73:79, 1979. Ahmad S: Cardiovascular complication of tricyclic antidepressant overdose. Ann Emergency Med 9:281, 1980. Abmad S: Verapamil therapy. AM HEART J 100:271, 1980. Moriarty R: Acute poisoning emergencies. Mod Med 48:139, 1980. Wright SP: Feedback on poison emergencies, Mod Med 46:139, 1980. Ahmad S: Poison emergencies. Mod Med 48:I39, 1980. Koch-Weser J: Bretylium. N Engl J Med 300:473, 1979. Tuttle RR, Mills J: Dobutamine. Circ Res 36:185, 1975. Crome P, Newman B: Fatal tricyclic antidepressant poisoning. J R Sot Med 72649, 1979.
POST-MYOCARDIAL INFARCTION CONSTRICTIVE PERICARDITIS To the Editor: Dressier’s syndrome is known to occur in the course of acute myocardial infarction (AMI).’ Although accompanied by one or multiple symptomatic recurrences, it is usually benign. However, attention has recently been focused on the possibility that this post-AM1 syndrome may result in constrictive pericarditis.‘. 1 Constrictive pericarditis developed within 3 to 18 months in patients post-AM1 without pre-AM1 history of pericardial disease.” The clinical features were characteristic of right heart failure with prominent ascites. Differential diagnosis from ventricular failure secondary to myocardial damage was difficult by standard clinical means. Phonography and echography were not definitive as to etiology.‘.j Cardiac catheterization allowed recognition of constrictive pericarditis and pericardiectomy resulted in dramatic clinical improvement. The mechanism by which postAM1 pericardial syndrome may result in such involvement
Dressier W: The post-myocardial infarction syndrome: A report on 44 cases. Arch Intern Med 103:28, 1959. Beaufils Ph, Bardet J, Temkin J, Masquet Ch, Sebastien Ph, Zelasko Y: Syndrome de Dressler: Pericardite cons post-infarctus operee avec sue&s. Arch Ma1 Coeur 1975. Haiat R, Desoutter P, Stoltz JP, Chousterman M, Cattan P, Gandjbakhch I: Pericardite constrictive secondaire a un infarctus du myocarde. Guerison chirurgicale. Coeur Med Int 19:420, 1980. Khullard S, Lewis RP: Usefulness of systolic time intervals in differential diagnosis of constrictive pericarditis and restrictive cardiomyopathy. Br Heart J 38:43, 1976. Voelkel AG, Pietro D, Folland E, Fisher M, Paris A: Echocardiographic features of constrictive pericarditis. Cticulation 58:871, 1979.
2D ECHO POSITION OF SEPTAL TRICUSPI LEAFLET IN EBSTEIN’S ANOMALY AND NORMAL HEARTS To the Editor: The observations on the two-dimensional echocardiographic appearance of the tricuspid valve in Ebstein’s anomaly by Kambe et al.’ confirm the usefulness of this technique in assessing the anatomic abnormalities of the atrioventricular junction. However, it is imprecise to state there is no displacement of a normal septal leaflet of the tricuspid valve relative to the anterior leaflet of the mitral valve. Normally, the septal tricuspid leaflet arises from the interventricular septum slightly nearer the cardiac apex than the anterior mitral leaflet, when these structures are viewed from either an apical long-axis (four-chamber) view or a subcostal long-axis (four-chamber) view.’ No displacement of the septai tricuspid leaflet relative to the anterior mitral leaflet is a feature of atrioventricular cushion defects,” and reversal of the normal pattern of the two valves is characteristic of atrioventricular discordance (corrected transposition of the great arteries).’ We feel it is important that the normal anatomic relationships of the atrioventricular valves be fully appreciated. Keith Evemy A. Stewart Hunter Cardiothoracic Unit Freeman Hospital Newcastle upon Tyne NE7 7WN England
REFERENCES 1.
Kambe T, Ichimiya S, Toguchi M, Hibi N, Fukui Y, Nishimura K, Sakamato N, Hojo Y: Apex and subxiphoid approaches to Ebstein’s anomaly using cross-sectional echocardiography. AM HEART J 100:53, 1980.