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ST-alternans alternans
ischemic heart disease.Our management of the 2 caseswas empirical. Sotalol administration was followed by disappearanceof ventricular arrhvthmias: steroids were administekxl in the first patient becau*nnP histologic evidence of OF-“---_ DVlUUS cellular necrosis at histoloa I, but IlOt in the second. It is impossible to assessthe extent to which treatment contributed to either the remission uu
ST-Alternans
“I
of symptoms or to the absence of
ECL. Apical aneurysms of Chagas’s heart disease.
changes
Br Heart J 1981;46:432-437.
in cardiac
function
and LV
aneurysm size in the short-term follow-up. , c7md.w F Anm,r.rrm. nf,I,.-IPF, m”++le,car-
m.
VI...,.“,
I.
‘Y..A..JL’.Y
“I
L...,
111%
.“...LZ.
diovasc Clin 1912;4:187-217. 2. Kissane RN. Traumatic heart disease: non-penetrating injuries. Circulation 1952;6:421-435. 3. Matthews RV, French WJ, Criley JM. Chest trauma and subvalvular left ventricular aneurysms. Chest 1989;95:474-475. 4. Oliveira JSM, Oliveira JAM, Frederique V, Filho
5. Pinamonti B, Alberti E, Cigalotto A, Dress L, Salvi A, Silvestri F, Camermi F. Echocardiographic findings in myocarditis. Am J Cardiol 1988;62: 285-291. 6. Goodevenous .I, Parry G, Gold RG. Coxsackie 84 viral myocarditis causing ventricular aneurysm. Int J Cardiol 1990;27:122-124. 7. Daly K, Richardson PJ, Olsen EGJ, MorganCapner P, McSorley C, Jackson G, Jewitt DE. Acute myocarditis - role of histological and virological examination in the diagnosis and assessment of immunosuppressive treatment. Br Heart J 1984;51:30-35.
Alternans
taneous and induced myocardial ischemia in experimental animals1y3 Kenneth M. Kessler, MD, E. Joseph Bauerlein, MD, Alan Schob, MD, and in man during exercise,4PrinzEduardo de Marchena, MD, and Robert J. Myerburg, MD metal angina5T6and coronary angioplasty.7’9 Whereas ST-segment T-segment alternans indicates shifts (particularly ST-segment eleFrom the Division of Cardiology, Department nonuniformity of ventricular re vation) are frequent during angioof Medicine, University of Miami School of Medicine, Miami, and the Cardiology Section polarization in time and space,and plasty,lOST-segmentalternans is in(111A), Medical Service, Veterans Affairs consequently correlates with the oc- frequent. We present a patient who Medical Center, 1201N.W. 16Street, Miami, on sequential balloon inflations durFlorida 33125. Manuscript received April 6, currence of ventricular fibrillation 1992;revisedmanuscript receivedand accept- during cardiac ischemia.‘~2ST alter- ing coronary angioplasty demoned June 9.1992. nans has beenobservedduring spon- strated a sequence of ST-segment
S
b
1224
NOVEMBE THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70 1, 1992
shifts recordedby intracoronary electrocardiography, reflecting the unique effects of repeated short episodes of ischemia on the alternans phenomenon. A 59-year-old woman with insulin-dependent diabetes mellitus and known coronary artery disease presented with hypoglycemia and an increased frequency of angina1 episodes. Six months earlier, she underwent percutaneous transluminal coronary angioplasty of the circumflex coronary artery, with satisfactory angiographic and clinical results. Because of the increase in angina frequency, she underwent diagnostic cardiac catheterization that showed normal left ventricular systolicfunction, 30% obstruction of the circumflex coronary artery, and a new 70% obstruction of the mid-left anterior descending coronary artery. Percutaneous transluminal coronary angioplasty of the new narrowing was successfully performed, with a 30% residual stenosis. During the procedure, a continuous intracoronary electrocardiogram was recorded from the tip of the guidewire positioned distal to the stenosis.” The intracoronary electrocardiogram pattern was affected differently on sequential intations (Figure 1). The surface electrocardiogram (3 leads) showed no changes throughout the procedure.
ST altemans has been reported only rarely on the surface electrocardiogram during angioplasty, particularly during prolonged inflations.7-9 The current findings were observed by intracoronary electrocardiogram. Intracoronary electrocardiogram is
known to be more sensitivethan are conditioning on a marker of ventricusurfacerecordings,” and altemans is lar fibrillation. known to be a localized phenomenon in someca~es.~~ However, the rarity 1. Konta T, Ikeda K, Yamaki M, Nakamura K, of ST altemans is suggestedby the Honma K, Kubota I, Yasui S. Significanceof diirfact that no caseswere observedin dant ST altemansin ventricular tibrillation. Circulo25 patients studied by intracoronary lion 1990;82:2185-2189. EA. RcsenbaumDS, Bhasin R, Cohen electrocardiogram during angio- 2.RJ.Raeder Alternating morphology of the QRST complex plasty by Friedman et ali] or in 50 preceding suddendeath. N Engl J Med 1992326: others studied in our laboratory. The 271-272. Hellerstein HK, Liebow I. Electrical alternation in unique aspect of the current case is 3. experimentalcoronary artery occlusion.Am J Physthe sequential finding of alternation iol 1950;160:366-374. Wayne VS. Bishop RL, Spcdick DH. Exercise of ST-segmentelevation and depres- 4. induced ST segment alternans. Chesl 1963;83: sion with alternans during subse- 824-825. quent ischemic episodes.During dis- S. Kleinfeld MJ, Rozanski JJ. Altemans of the ST in Primmetal’s angina. Circulolion 1977; crete repeatedepisodesof ischemia,a segment 55574-577. shift from ST-segment elevation to 6. Williams RR, Wagner GS, Peter RH. ST-segdepression (with or without alter- merit altemans in Prinzmetal’s angina. Ann Intern Med 1974;81:51-54. nans) has not been observedto our 7. Joyal M, Feldman RL, Pepine CJ. ST-segment knowlcdge,9J0 although a change altemans during percutaneous transluminal corn nary angioplasty. Am J Cardiol 1984;54:915-916. from ST-segment depressionto ele- 8. Gilchrist IC. Prevalenceand significance of STvation may rarely be seenduring 1 segmentaltemansduring coronary angioplasty. Am ischemicepisode.13There wasno evi- J Cardiol 1991;68:1534-1535. ShahDC, RamachandranP, SubramanyanK. ST dence of instability of the record- 9. segmentaltemansduring percutaneoustransluminal ing mechanism to account for the coronary angioplasty. Indian Heart J 1991;43: changes,and no changesin QRS am- 121-122. 10. Jain A, GetteaL. Patternsof ST-segmentchange plitude or vector accompanying the during acute no-flow myocardial ischemiaproduced ST alterations. Whereasthe mecha- by balloon occlusion during angioplasty of the left descendingcoronary artery. Am J Cardiol nism of ST-segment altemans may anterior 1991:67:305-1n7. berelated to variations in calcium ion 11. FriedmanPL, ShookTL, KirshenbaumJM, Selflux,*JOwe can only speculateon the wyn AP, Ganz P. Value of intracoronary electrocardiogram to monitor myocardiil ischemiaduring permechanism of the ST-altemans “al- cutaneous transluminal coronary angioplasty.Circutemans” in this patient. We postulate lation 1986~74330-339. that ischemic preconditioning14 of 12 Sutton @MI, Taggart P, Lab M, Runnalls ME, W, TreasureT. Altemans of epicardial repothe myocardium during the seriesof O’Brien larization as a localized phenomenonin man. Eur percutaneoustransluminal coronary Heart J 1991;12:70-78. 13. Wagner NB, Elias WJ, Kmcoff MW, &villa angioplasty inflations changed the DC, JacksonYR, Kent KK, Wagner GS. Transient expression of &hernia from trans- electrocardiographicchangesof electivecoronary anmural to subendocardialinjury with gioplasty compared with evolutionary changes of acute myocardial infarction observed altemans, to no demonstrableische- subequent with continuous three-lead monitoring. Am J Carmia during the initial short inflation dial 1990;66:150!-1512. or the final inflation. Therefore, this 14. Murry CE, JenningsRB, Remer KA. Precondiwith ischcmia:a delay of lethal cell injury in casemay demonstratethe sequential tioning ischemic myocardium. Circulation 1986;74: effects of myocardial ischemic pre- 1124-1136.
CASE REPORTS
1225
ST-Alternans
“I
of symptoms or to the absence of
ECL. Apical aneurysms of Chagas’s heart disease.
changes
Br Heart J 1981;46:432-437.
in cardiac
function
and LV
aneurysm size in the short-term follow-up. , c7md.w F Anm,r.rrm. nf,I,.-IPF, m”++le,car-
m.
VI...,.“,
I.
‘Y..A..JL’.Y
“I
L...,
111%
.“...LZ.
diovasc Clin 1912;4:187-217. 2. Kissane RN. Traumatic heart disease: non-penetrating injuries. Circulation 1952;6:421-435. 3. Matthews RV, French WJ, Criley JM. Chest trauma and subvalvular left ventricular aneurysms. Chest 1989;95:474-475. 4. Oliveira JSM, Oliveira JAM, Frederique V, Filho
5. Pinamonti B, Alberti E, Cigalotto A, Dress L, Salvi A, Silvestri F, Camermi F. Echocardiographic findings in myocarditis. Am J Cardiol 1988;62: 285-291. 6. Goodevenous .I, Parry G, Gold RG. Coxsackie 84 viral myocarditis causing ventricular aneurysm. Int J Cardiol 1990;27:122-124. 7. Daly K, Richardson PJ, Olsen EGJ, MorganCapner P, McSorley C, Jackson G, Jewitt DE. Acute myocarditis - role of histological and virological examination in the diagnosis and assessment of immunosuppressive treatment. Br Heart J 1984;51:30-35.
Alternans
taneous and induced myocardial ischemia in experimental animals1y3 Kenneth M. Kessler, MD, E. Joseph Bauerlein, MD, Alan Schob, MD, and in man during exercise,4PrinzEduardo de Marchena, MD, and Robert J. Myerburg, MD metal angina5T6and coronary angioplasty.7’9 Whereas ST-segment T-segment alternans indicates shifts (particularly ST-segment eleFrom the Division of Cardiology, Department nonuniformity of ventricular re vation) are frequent during angioof Medicine, University of Miami School of Medicine, Miami, and the Cardiology Section polarization in time and space,and plasty,lOST-segmentalternans is in(111A), Medical Service, Veterans Affairs consequently correlates with the oc- frequent. We present a patient who Medical Center, 1201N.W. 16Street, Miami, on sequential balloon inflations durFlorida 33125. Manuscript received April 6, currence of ventricular fibrillation 1992;revisedmanuscript receivedand accept- during cardiac ischemia.‘~2ST alter- ing coronary angioplasty demoned June 9.1992. nans has beenobservedduring spon- strated a sequence of ST-segment
S
b
1224
NOVEMBE THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70 1, 1992
shifts recordedby intracoronary electrocardiography, reflecting the unique effects of repeated short episodes of ischemia on the alternans phenomenon. A 59-year-old woman with insulin-dependent diabetes mellitus and known coronary artery disease presented with hypoglycemia and an increased frequency of angina1 episodes. Six months earlier, she underwent percutaneous transluminal coronary angioplasty of the circumflex coronary artery, with satisfactory angiographic and clinical results. Because of the increase in angina frequency, she underwent diagnostic cardiac catheterization that showed normal left ventricular systolicfunction, 30% obstruction of the circumflex coronary artery, and a new 70% obstruction of the mid-left anterior descending coronary artery. Percutaneous transluminal coronary angioplasty of the new narrowing was successfully performed, with a 30% residual stenosis. During the procedure, a continuous intracoronary electrocardiogram was recorded from the tip of the guidewire positioned distal to the stenosis.” The intracoronary electrocardiogram pattern was affected differently on sequential intations (Figure 1). The surface electrocardiogram (3 leads) showed no changes throughout the procedure.
ST altemans has been reported only rarely on the surface electrocardiogram during angioplasty, particularly during prolonged inflations.7-9 The current findings were observed by intracoronary electrocardiogram. Intracoronary electrocardiogram is
known to be more sensitivethan are conditioning on a marker of ventricusurfacerecordings,” and altemans is lar fibrillation. known to be a localized phenomenon in someca~es.~~ However, the rarity 1. Konta T, Ikeda K, Yamaki M, Nakamura K, of ST altemans is suggestedby the Honma K, Kubota I, Yasui S. Significanceof diirfact that no caseswere observedin dant ST altemansin ventricular tibrillation. Circulo25 patients studied by intracoronary lion 1990;82:2185-2189. EA. RcsenbaumDS, Bhasin R, Cohen electrocardiogram during angio- 2.RJ.Raeder Alternating morphology of the QRST complex plasty by Friedman et ali] or in 50 preceding suddendeath. N Engl J Med 1992326: others studied in our laboratory. The 271-272. Hellerstein HK, Liebow I. Electrical alternation in unique aspect of the current case is 3. experimentalcoronary artery occlusion.Am J Physthe sequential finding of alternation iol 1950;160:366-374. Wayne VS. Bishop RL, Spcdick DH. Exercise of ST-segmentelevation and depres- 4. induced ST segment alternans. Chesl 1963;83: sion with alternans during subse- 824-825. quent ischemic episodes.During dis- S. Kleinfeld MJ, Rozanski JJ. Altemans of the ST in Primmetal’s angina. Circulolion 1977; crete repeatedepisodesof ischemia,a segment 55574-577. shift from ST-segment elevation to 6. Williams RR, Wagner GS, Peter RH. ST-segdepression (with or without alter- merit altemans in Prinzmetal’s angina. Ann Intern Med 1974;81:51-54. nans) has not been observedto our 7. Joyal M, Feldman RL, Pepine CJ. ST-segment knowlcdge,9J0 although a change altemans during percutaneous transluminal corn nary angioplasty. Am J Cardiol 1984;54:915-916. from ST-segment depressionto ele- 8. Gilchrist IC. Prevalenceand significance of STvation may rarely be seenduring 1 segmentaltemansduring coronary angioplasty. Am ischemicepisode.13There wasno evi- J Cardiol 1991;68:1534-1535. ShahDC, RamachandranP, SubramanyanK. ST dence of instability of the record- 9. segmentaltemansduring percutaneoustransluminal ing mechanism to account for the coronary angioplasty. Indian Heart J 1991;43: changes,and no changesin QRS am- 121-122. 10. Jain A, GetteaL. Patternsof ST-segmentchange plitude or vector accompanying the during acute no-flow myocardial ischemiaproduced ST alterations. Whereasthe mecha- by balloon occlusion during angioplasty of the left descendingcoronary artery. Am J Cardiol nism of ST-segment altemans may anterior 1991:67:305-1n7. berelated to variations in calcium ion 11. FriedmanPL, ShookTL, KirshenbaumJM, Selflux,*JOwe can only speculateon the wyn AP, Ganz P. Value of intracoronary electrocardiogram to monitor myocardiil ischemiaduring permechanism of the ST-altemans “al- cutaneous transluminal coronary angioplasty.Circutemans” in this patient. We postulate lation 1986~74330-339. that ischemic preconditioning14 of 12 Sutton @MI, Taggart P, Lab M, Runnalls ME, W, TreasureT. Altemans of epicardial repothe myocardium during the seriesof O’Brien larization as a localized phenomenonin man. Eur percutaneoustransluminal coronary Heart J 1991;12:70-78. 13. Wagner NB, Elias WJ, Kmcoff MW, &villa angioplasty inflations changed the DC, JacksonYR, Kent KK, Wagner GS. Transient expression of &hernia from trans- electrocardiographicchangesof electivecoronary anmural to subendocardialinjury with gioplasty compared with evolutionary changes of acute myocardial infarction observed altemans, to no demonstrableische- subequent with continuous three-lead monitoring. Am J Carmia during the initial short inflation dial 1990;66:150!-1512. or the final inflation. Therefore, this 14. Murry CE, JenningsRB, Remer KA. Precondiwith ischcmia:a delay of lethal cell injury in casemay demonstratethe sequential tioning ischemic myocardium. Circulation 1986;74: effects of myocardial ischemic pre- 1124-1136.
CASE REPORTS
1225