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Relationship of vegetations on echogram to the clinical course and systemic emboli in bacterial endocarditis
ABSTRACTS
RELATIONSHIP OF VEGETATIONS ON ECHOGRAM TO THE CLINICAL COURSE AND SYSTEMIC EMBOLI IN BACTERIAL ENDOCARDITIS Craig Pratt, MD; Charles Whitcomb, MD; Alexander Neumann, BS; Dean T. Mason, MD, FACC; Ezra A. Amsterdam, MD, FACC; Anthony N. DeMaria, MD, FACC, University of California, Davis, California Since vegetations occurring in infectious endocarditis have been suggested to correlate with valve destruction and subsequent embolization, we evaluated the relationship between vegetations on M-mode echogram with the clinical course and emboli in patients with bacterial endocarditis. The study group was comprised of 32 patients fpts): 13 with vegetations on echogram (VEG)(ll aortic, 2 mitral and aortic) and 19 pts (all aortic) without ultrasound evidence of vegetations (NO-VEG). All pts manifested the classic clinical features of endocarditis, and a causative organism was cultured from the blood in all cases. The prevalence of etiologic organisms was similar in both groups. Congestive heart failure was present on admission in 3 of 13 VEG pts, but no NO-VEG pts. The clinical course of the pts with VEG was progressive congestive failure refractory to digitalis and diuretics in all cases. Cardiac catheterization was performed within 2 months of admission and revealed 4+ aortic regurgitation in all VEG patients. The mean left ventricular filling pressure of the VEG group was 30 mm Hg, and 12 of 13 pts required aortic valve replacement within 3 months. Importantly, a systemic embolus was not sustained by any VEG pt. In contrast, only 2 of 19 NO-VEG pts developed congestive heart failure (pq.01) and both pts required aortic valve replacement. Thus, the presence of vegetations on echogram indicates extensive valve destruction and predicts the appearance of congestive heart failure in nearly all cases. However, pts with vegetations on echogram do not appear to be at increased risk of systemic emboli.
NONINVASIVE PULSED DOPPLER STUDY OF MITRAL BLOOD FLOW Benoit Diebold, MD; Pierre Theroux, MD; Martial G. Bourassa, MD, FACC; Jean-Leon Guermonprez, MD; Alain Barbet, Pierre PBronneau, Montreal Heart Institute, Montreal, Quebec and H8pital Broussais, Paris, France. The potential value of pulsed Doppler for detecting mitral regurgitation (MR) and assessing the severity of mitral stenosis (MS) was studied. The systolic flow of MR was recorded by scanning the left atrium behind the aorta with the transducer in the left parasternal position. Of 57 consecutive pts thus screened, 47 had adequate recordings which were interpreted without knowledge of the clinical or angiographic findings. MR was diagnosed by Doppler in 2 of 15 pts without angiographic MR, 8 of 16 with mild MR, 5 of 6 with moderate MR and 9 of 10 with severe MR. 40 pts were examined for MS with the transducer at the apex and the sampling site close to the mitral orifice. In the 24 pts in sinus rhythm, 3 patterns of diastolic flow could be defined which were then compared to middiastolic gradients obtained at cardiac catheterization: DOPPLER FLOW PATTERN smooth, bifid flow turbulent, dome-like flow turbulent, ascending flow
t PTS 11 7 6
GRADIENT (mmHg) 0.2r0.2 1 p
In pts in atria1 fibrillation, the mid-diastolic gradient was 9 mm.Hg or more in all 5 showing a sustained flow throughout long diastoles while it was 8 tmnHg or less in 9 of the 11 pts with a flow curve terminating before enddiastole (p
384
February 1978
The American Journal of CARDIOLDGY
TUESDAY, MARCH 7, 1978 PM ELECTROCARDIOGRAPHY AND ELECTROPHYSIOLOGY-II 2:oo to 5:30 TYPE AND PROGNOSIS OF INTRAHISIAN BLOCKS IN PATIENTS WITH ISCHEMIC HEART DISEASE. H.C. Cohen, M. Ali, I.A. D'Cruz. Cardiovascular Institute, Michael Reese Hospital, Chicago, Illinois. The prognosis and spectrum of intrahisian block in patients with ischemic heart disease were evaluated based on His bundle recordings during atria1 pacing and on serial ECGs. Fifteen of 130 patients (11.5%) with bundle branch block (BBB) or AV block were found to have intrahisian blocks (IHB). IHB could be divided into three groups: (1) proximal His bundle (HB) block, including type II 2:1, and u:l; (2) mid HB block, including narrowly split H, widely split H (H-H 380 msec), splintered type H, type I, 2:1, 3:1, and alternate beat 2:l; (3) distal HB block, including 221, 3:l with 4:3 A-H block, and type II. Both unidirectional and bidirectional blocks were observed, and IHB in all 3 groups were either bradycardia or tachycardia dependent. Type I block was rare (1 patient). "Classical" type II block in which sudden HB block occurred was seen in only 1 of 15 patients and was bradycardia-dependent. The most common types of IHB were fixed-ratio blocks of 2:1, 3:1, or 4:l. Four of 5 patients with IHB but without BBB developed complete AV block within 3 months, whereas only 2 of 10 patients with IHB with BBB followed a similar course in 3 years. Thus, more thanlO% of patients with ischemic heart disease and AV block have IHB. These blocks are likely to be 2:1, 3:1, or 4:l. In this study rapid progression to complete AV block was common in patients with IHB but without BBB.
SIGNIFICANCE OF CHRONIC BIFASICULAR BLOCK WITHOUT APPARENT ORGANIC HEART DISEASE Ramesh Dhingra, MD, FACC; S. Sridhar, MD; Richard Kehoe, MD; Pablo Denes, MD. FACC; Delon Wu, MD, FACC; Fernando Amat-y-Leon, MD, FACC; Christopher Wyndham, MD; Kenneth Rosen, MD, FACC; University of Illinois, Chicago, Ill. The significance of chronic bifasicular block (BFB) without apparent organic heart disease is unknown. In this study, we report our experience in patients (pts) with "primary bffasicular block" (PBFB), as defined by the presence of chronic BFB, no historical or physical evidence of organic heart disease, and normal radiographic heart size. Out of 518 pts in our BFB clinic, 84 have been classified as having PBFB. These 84 pts were detected, studied and followed between l/70 and 9/77. The group consisted of 74 pts with right bundle branch block (BBB) with left or right axis deviation, ei@ with left BBB and two with alternating BBB. There were 69 sales and 15 females with age8 from 19 to 93 years (mean+ SD, 612 18.8). Initial electrophysiological study revealed A-H interval8 of 55 to 188 msec (mean 962 27.2). H-V intervals ranged from 24 to 100 msec (mean 50 + 13.8). with prolonged (>55 msec) H-V in 18 pts (21%). Pts ware prospectively followed for 26 to 2210 days (mean 888 + 563). A-V block developed in three pts (4%). on days 6, 974 and 1453 respectively. In all three, site of block was distal to H (two spontaneous and one secondary to hyperkalcruia). Twenty-two pts died (26'0, nine (10% of total) due to cardiovascular causes (six sudden). In conclusion, PBF8 was associated with a 21% incidence of trifasicular disease , and a small but definite risk of trifasicular A-V block. The relatively high cardiovascular mrtality suggests that PBF8 as defined above, is sometimes associated with clinically significant organic heart disease.
Volume 41
RELATIONSHIP OF VEGETATIONS ON ECHOGRAM TO THE CLINICAL COURSE AND SYSTEMIC EMBOLI IN BACTERIAL ENDOCARDITIS Craig Pratt, MD; Charles Whitcomb, MD; Alexander Neumann, BS; Dean T. Mason, MD, FACC; Ezra A. Amsterdam, MD, FACC; Anthony N. DeMaria, MD, FACC, University of California, Davis, California Since vegetations occurring in infectious endocarditis have been suggested to correlate with valve destruction and subsequent embolization, we evaluated the relationship between vegetations on M-mode echogram with the clinical course and emboli in patients with bacterial endocarditis. The study group was comprised of 32 patients fpts): 13 with vegetations on echogram (VEG)(ll aortic, 2 mitral and aortic) and 19 pts (all aortic) without ultrasound evidence of vegetations (NO-VEG). All pts manifested the classic clinical features of endocarditis, and a causative organism was cultured from the blood in all cases. The prevalence of etiologic organisms was similar in both groups. Congestive heart failure was present on admission in 3 of 13 VEG pts, but no NO-VEG pts. The clinical course of the pts with VEG was progressive congestive failure refractory to digitalis and diuretics in all cases. Cardiac catheterization was performed within 2 months of admission and revealed 4+ aortic regurgitation in all VEG patients. The mean left ventricular filling pressure of the VEG group was 30 mm Hg, and 12 of 13 pts required aortic valve replacement within 3 months. Importantly, a systemic embolus was not sustained by any VEG pt. In contrast, only 2 of 19 NO-VEG pts developed congestive heart failure (pq.01) and both pts required aortic valve replacement. Thus, the presence of vegetations on echogram indicates extensive valve destruction and predicts the appearance of congestive heart failure in nearly all cases. However, pts with vegetations on echogram do not appear to be at increased risk of systemic emboli.
NONINVASIVE PULSED DOPPLER STUDY OF MITRAL BLOOD FLOW Benoit Diebold, MD; Pierre Theroux, MD; Martial G. Bourassa, MD, FACC; Jean-Leon Guermonprez, MD; Alain Barbet, Pierre PBronneau, Montreal Heart Institute, Montreal, Quebec and H8pital Broussais, Paris, France. The potential value of pulsed Doppler for detecting mitral regurgitation (MR) and assessing the severity of mitral stenosis (MS) was studied. The systolic flow of MR was recorded by scanning the left atrium behind the aorta with the transducer in the left parasternal position. Of 57 consecutive pts thus screened, 47 had adequate recordings which were interpreted without knowledge of the clinical or angiographic findings. MR was diagnosed by Doppler in 2 of 15 pts without angiographic MR, 8 of 16 with mild MR, 5 of 6 with moderate MR and 9 of 10 with severe MR. 40 pts were examined for MS with the transducer at the apex and the sampling site close to the mitral orifice. In the 24 pts in sinus rhythm, 3 patterns of diastolic flow could be defined which were then compared to middiastolic gradients obtained at cardiac catheterization: DOPPLER FLOW PATTERN smooth, bifid flow turbulent, dome-like flow turbulent, ascending flow
t PTS 11 7 6
GRADIENT (mmHg) 0.2r0.2 1 p
In pts in atria1 fibrillation, the mid-diastolic gradient was 9 mm.Hg or more in all 5 showing a sustained flow throughout long diastoles while it was 8 tmnHg or less in 9 of the 11 pts with a flow curve terminating before enddiastole (p
384
February 1978
The American Journal of CARDIOLDGY
TUESDAY, MARCH 7, 1978 PM ELECTROCARDIOGRAPHY AND ELECTROPHYSIOLOGY-II 2:oo to 5:30 TYPE AND PROGNOSIS OF INTRAHISIAN BLOCKS IN PATIENTS WITH ISCHEMIC HEART DISEASE. H.C. Cohen, M. Ali, I.A. D'Cruz. Cardiovascular Institute, Michael Reese Hospital, Chicago, Illinois. The prognosis and spectrum of intrahisian block in patients with ischemic heart disease were evaluated based on His bundle recordings during atria1 pacing and on serial ECGs. Fifteen of 130 patients (11.5%) with bundle branch block (BBB) or AV block were found to have intrahisian blocks (IHB). IHB could be divided into three groups: (1) proximal His bundle (HB) block, including type II 2:1, and u:l; (2) mid HB block, including narrowly split H, widely split H (H-H 380 msec), splintered type H, type I, 2:1, 3:1, and alternate beat 2:l; (3) distal HB block, including 221, 3:l with 4:3 A-H block, and type II. Both unidirectional and bidirectional blocks were observed, and IHB in all 3 groups were either bradycardia or tachycardia dependent. Type I block was rare (1 patient). "Classical" type II block in which sudden HB block occurred was seen in only 1 of 15 patients and was bradycardia-dependent. The most common types of IHB were fixed-ratio blocks of 2:1, 3:1, or 4:l. Four of 5 patients with IHB but without BBB developed complete AV block within 3 months, whereas only 2 of 10 patients with IHB with BBB followed a similar course in 3 years. Thus, more thanlO% of patients with ischemic heart disease and AV block have IHB. These blocks are likely to be 2:1, 3:1, or 4:l. In this study rapid progression to complete AV block was common in patients with IHB but without BBB.
SIGNIFICANCE OF CHRONIC BIFASICULAR BLOCK WITHOUT APPARENT ORGANIC HEART DISEASE Ramesh Dhingra, MD, FACC; S. Sridhar, MD; Richard Kehoe, MD; Pablo Denes, MD. FACC; Delon Wu, MD, FACC; Fernando Amat-y-Leon, MD, FACC; Christopher Wyndham, MD; Kenneth Rosen, MD, FACC; University of Illinois, Chicago, Ill. The significance of chronic bifasicular block (BFB) without apparent organic heart disease is unknown. In this study, we report our experience in patients (pts) with "primary bffasicular block" (PBFB), as defined by the presence of chronic BFB, no historical or physical evidence of organic heart disease, and normal radiographic heart size. Out of 518 pts in our BFB clinic, 84 have been classified as having PBFB. These 84 pts were detected, studied and followed between l/70 and 9/77. The group consisted of 74 pts with right bundle branch block (BBB) with left or right axis deviation, ei@ with left BBB and two with alternating BBB. There were 69 sales and 15 females with age8 from 19 to 93 years (mean+ SD, 612 18.8). Initial electrophysiological study revealed A-H interval8 of 55 to 188 msec (mean 962 27.2). H-V intervals ranged from 24 to 100 msec (mean 50 + 13.8). with prolonged (>55 msec) H-V in 18 pts (21%). Pts ware prospectively followed for 26 to 2210 days (mean 888 + 563). A-V block developed in three pts (4%). on days 6, 974 and 1453 respectively. In all three, site of block was distal to H (two spontaneous and one secondary to hyperkalcruia). Twenty-two pts died (26'0, nine (10% of total) due to cardiovascular causes (six sudden). In conclusion, PBF8 was associated with a 21% incidence of trifasicular disease , and a small but definite risk of trifasicular A-V block. The relatively high cardiovascular mrtality suggests that PBF8 as defined above, is sometimes associated with clinically significant organic heart disease.
Volume 41