Tricuspid regurgitation (TR) is commonly encountered in the management of patients with a variety of cardiovascular diseases. Primary TR is the result of structural abnormalities of the valve or ...chordal attachments whereas functional TR results from alterations in right ventricular (RV) or right atrial (RA) size, shape or function. The vast majority of TR cases seen in practice are functional in nature and usually results from left-sided heart disease (e.g., mitral valve disease, left ventricular (LV) systolic dysfunction) and/or pulmonary vascular disease, though it also manifests in the presence of isolated chronic atrial fibrillation (AF). The relationships among the tricuspid leaflets, annulus, chordal attachments and papillary muscles are critical to normal valve function. Disruption of these interactions through annular dilation and apical displacement of the papillary muscles underlies the pathophysiology of functional TR. Two-dimensional transthoracic echocardiography (2D-TTE) is the primary modality used to assess TR. In situations where 2D-TEE is limited, 3D-TTE and transesophageal echocardiography (TEE), multidetector computed tomography (CT) and cardiac magnetic resonance imaging (MRI) can provide additional information. Classification schemes have been proposed that focus not only on the severity of TR, but also on annular dilation and the mode of leaflet coaptation. Despite often being referred to as the "forgotten valve," there is increasing evidence that functional TR is prognostically significant and may warrant intervention. Appropriate patient selection for and timing of intervention are important clinical tasks that require a comprehensive understanding of the pathophysiology and natural history of functional TR.
Arrhythmias are common after cardiac surgery and are associated with hemodynamic compromise, stroke, and prolonged hospitalization. Beta blockers prevent atrial fibrillation postoperatively, but ...there are few data regarding the prophylactic use of type I antiarrhythmic agents or the prevention of ventricular arrhythmias. Accordingly, we performed a randomized, double-blind, placebo-controlled study of the effects of oral procainamide on 100 patients undergoing elective coronary artery bypass surgery. Procainamide was received for 4 days; the dosage was adjusted for body weight. Patients receiving procainamide had a significant reduction in atrial fibrillation (16 vs 29 patient-days, p < 0.05) and ventricular tachycardia (2% vs 20%, p < 0.01). However, the incidence of atrial fibrillation was not significantly reduced (38% vs 26%). In the group achieving therapeutic serum procainamide levels, there was a reduction in all measured postoperative arrhythmias. No serious cardiac or noncardiac adverse events were noted during procainamide therapy, although there was a significant increase in the incidence of nausea. We conclude that procainamide reduces arrhythmias in the early postoperative period after coronary artery bypass surgery, most prominently in patients who achieve therapeutic serum levels. This was associated with no serious cardiac adverse reactions.
During a retrospective review of 70 consecutive intensive care unit admissions for tricyclic antidepressant (TCA) overdose, we identified 12 patients (17%) who had simultaneously ingested a ...neuroleptic agent. We then compared several clinical and laboratory features of patients who had ingested TCAs alone with those patients who had also taken a neuroleptic drug. The 12 patients in the TCA-neuroleptic group, when compared with patients in the TCA-only group, showed a markedly higher prevalence of first-degree atrioventricular block (p less than 0.001), a significantly higher prevalence of prolongation of the QRS duration (greater than 0.10 sec) (p less than 0.05), and a threefold increase in the prevalence of QTc prolongation (p less than 0.05). Our data indicate that coingestion of neuroleptics and TCAs, when compared with the ingestion of TCA alone, may significantly increase the risk of adverse cardiac consequences. We discuss the possible mechanisms for these electrocardiographic changes as well as their potential implications.
This study sought to determine how noninvasive and invasive cardiologists may differ in the hospital care of patients with acute myocardial infarction.
Scant information exists regarding the effect ...of noninvasive and invasive cardiology subspecialization on invasive cardiac procedural use, cost and outcome in the care of patients with acute myocardial infarction.
This study analyzed a prospective cohort of 292 patients admitted to an urban tertiary care hospital from the emergency room under the care of noninvasive or invasive cardiologists. Clinical characteristics; hospital course, including management, utilization of diagnostic coronary angiography and percutaneous transluminal coronary angioplasty; direct hospital costs; length of hospital stay; and post-hospital discharge follow-up data were collected by a prospective data base instrument.
Despite similar clinical characteristics, extent and severity of coronary artery disease and utilization of diagnostic coronary angiography in the two groups of patients, those under the care of an invasive cardiologist were significantly more likely to undergo coronary angioplasty than those under the care of a noninvasive cardiologist. The direct hospital costs and length of stay of the noninvasive and invasive group patients who underwent coronary angioplasty were similar, although overall the direct hospital costs and length of stay were higher for the invasive than for the noninvasive group patients.
Noninvasive and invasive cardiologists differ in their rate of utilization of coronary angioplasty in similar patients with acute myocardial infarction.
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