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4 17
Fig. 3.
VVI bradycardia support systemworking after automatic defibrillator.
Top
Device sensing.
Mid-
dle,
Intracavitary electrogram.
Bottom,
Surface electrocardiogram.
D,
Defibrillation.
pacemaker unction wasnormal, and no ventricular tachy-
cardia was observed on Holter monitoring.
A multiprogrammable telemetric implantable automatic
defibrillator with a multiprogrammable VVI bradycardia
support system Telectronics Guardian, model4201,Telec-
tronics, Inc., Englewood, Colo.) was implanted and the
original VVI pacemakerwas explanted. The defibrillation
threshold was 18 oules. The device wasprogrammedwith
an initial energy of 28 joules (650 V, 8 msec) (safety
margin = 10 joules). The tachycardia detection interval
was 320 msec (Fig. 2) and after defibrillation, the VVI
bradycardia support systemcould be observed Fig. 3). One
month after implant, ventricular fibrillation was nduced
and automatic defibrillation wassuccessful. he patient is
doing well 4 months after implant. No dischargehasbeen
registeredand the bradycardia support of the defibrillator
is working as a VVI pacemaker.
This is the first report of an automatic implantable de-
fibrillator in Chagasdisease.Becausebifascicular or total
atrioventricular block are present in almost 50 of cha-
gasic patients who present with sustained ventricular
arrhythmias, automatic defibrillators with pacemaker
function will probably be very useful in selectedcasesof
chronic Chagasicmyocarditis.
REFERENCES
1. Mirowski M. The automatic mplantable ardioverter-de-
fibrillator. An overview.J Am Co11 ardiol
985;6:461-6.
2. PrataA. Natural historyof chagasicardiomyopathy.n: Pan
AmericanHealthOrganization, d.American rypanossomia-
sis esearch.Washington,C: Pan American Health Organi-
zation 1975:191.
3. Lopes ER Chapadeiro E. Morte subita em ara endemica de
doenca e Chagas. ev Sot BrasMed Trop 1983;16:79-83.
4. Mendoza , Camardo , Moleiro F, Castellanos, MedinaV,
Gomez J Acquatella H Casal H Tortoledo F Puigbo J. Sus-
tained ventricular tachycardia in chronic chagas ic myocardi-
tis: electrophysiologic and pharmacologic characteristics. Am
J Cardiol 1986;57:423-7.
Percutaneous double balloon valvuloplasty
for severe tricuspid stenosis
Irvin F. Goldenberg, MD, Wes Pedersen,MD,
Jeanne Olson, RDMS, JamesD. Madison, MD,
Michael R. Mooney, MD, and Fredarick L. Gobel, MD.
Minneapolis, Minn.
Balloon valvuloplasty hasemergedasan alternative treat-
ment to surgicalvalvotomy for somepatients with congen-
ital or acquired pulmonic, aortic, or mitral stenosis.1-4x-
perience with balloon valvuloplasty for the treatment of
tricuspid stenosis,however, hasbeen imited.5 We present
a caseof tricuspid balloon valvuloplasty in a patient with
rheumatic mitral, aortic, and tricuspid stenosis.
A 40-year-old womanpresentedwith complaints of pro-
gressively increasing fatigue and minimal dyspnea on
exertion. Clinical examination revealed jugular venous
distention and a diastolic rumble that increased with
inspiration, consistent with tricuspid stenosis.On exami-
nation this patient alsohad a diastolic rumble and opening
snap at the left sternal border, consistent with mitral
stenosis;a blowing diastolic murmur, consistent with aor-
tic insufficiency; and a grade II/VI systolic ejection mur-
mur. A chest roentgenogram evealed cardiomegaly, but
there were no signsof pulmonary congestion.An electro-
cardiogram revealed atria1 fibrillation with a frontal plane
QRS axis of +30 degrees.Doppler echocardiography ex-
amination revealed severe tricuspid valve stenosis,mild
mitral valve stenosis,and minimal aortic valve stenosis.
Doppler examination also showedmoderate tricuspid in-
From the Minneapolis Heart Institute.
Reprint requests: Irvin F. Goldenberg MD Minneapolis Heart Institute
920 E. 28th St. Suite 160 Minneapolis MN 55407.
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4 1a Brief Communications
I
PRE TRICUSPID VALVlJLOPL 4STY
I
August 1989
American Heart Journal
RV
Tricuspid Valve Gradient
2
= I
Tricuspid Valve Area 1.64 cm2
c< rdiac Output
I
1
3.05 L/min
Fig. 1.
Simultaneous right atria1 (RA) and right ventricular (RV) pressure recordings before (top panel)
and after (bottom panel) tricuspid valve balloon valvu loplasty. Following balloon valvu loplasty there is a
marked reduction in the transtricuspid valve gradient.
suffic iency and minimal mitral and aortic insuff iciency.
Cardiac catheterization confirmed these findings. Because
her prominent lesion was tricuspid stenosis and her pre-
dominant sympt om was fatigue, we elected to perform
percutaneous balloon valvuloplasty of the tricuspid valve.
After informed, written consent was obtained, the pa-
tient was premeditated with 10 mg of diazepam. Aortic
pressure was monitored by placing a 5F catheter in the de-
scending aorta from the lef t femoral artery. Using the right
and lef t femoral veins, a 7F Swan-Ganz catheter (Baxter
Healthcare Corp., Edwards Division, Santa Ana, Calif. )
was placed in the right atrium and right ventricle . Trans-
tricuspid mean and end-diastolic pressure gradients, car-
diac output, and tricuspid valve area (Gorlin formula) were
calculated before and after tricuspid valvu loplasty. A right
ventriculogram was performed with a 7F Berman catheter
(Arrow, Reading, Pa.) before and after balloon valvulo-
plasty. After obtaining initial baseline hemodynamic mea-
surements, a 14F introducer was placed into both femoral
veins. Using a 7F Berman balloon wedge catheter, an
0.038-inch Teflon-coated exchange guide wire (250 cm
long) was advanced into the main pulmonary artery f rom
each femoral vein. A Mansfield 20 mm
x
3 cm balloon
catheter (Mansfield Scientific Inc. , Mansfield, Mass.) was
threaded over each guide wire and the balloons were posi-
tioned across the tricuspid valve. The first three inflations
were performed with only one balloon across the valv e. The
next eight inflations had both balloons across the valve.
The balloons were inflated to a maximum of 4 atm. The
mean transvalvu lar gradient decreased from 7 to 2 mm Hg
and the transtricuspid end-diastolic gradient decreased
from 5 to 0 mm Hg (Fig. 1). Tricuspid valv e area increased
from 0.82 to 1.64 cm2. Tricuspid insuffic iency that was
moderate initially did not change. The patients functional
status improved immediately following valvuloplasty, from
New York Heart Association class III to New York Heart
Association class II. The patient was discharged 48 hours
after admission. During a 3-month follow-up period, the
patients clinical improvement persisted.
Prior studies have shown that percutaneous balloon val-
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Volume 118
Number 2
Brief Communications
4 19
vuloplasty offers a promising alternative to surgical val-
votomy in somepatients with pulmonic, aortic, and mitral
stenosis.le4 his casedemonstrates hat tricuspid stenosis
can also espond o this treatment modality. The improve-
ment in tricuspid valve area and symptoms n our patient
are similar to those reported after tricuspid valve
commissurotomy.6n our case,however, improvement
was
obtained without the morbidity and cost of surgery. Al-
though we have demonstrated he feasibility of percutane-
ous balloon valvuloplasty for the treatment of severe
tricuspid stenosis,additional investigation will be needed
to assesshe long-term efficacy of this new therapeutic
modality.
REFERENCES
1.
2.
3.
4.
5.
6.
Kan JS, White RI, Mitchell SE, Gardner TJ. Percutaneous
balloon valvu loplasty: a new method fo r treating congenital
pulmonary valve stenosis. N Engl J Med 1982;307:540-2.
Waldman JD,
Schoen
J, Fitzpatrick SE, Mathewson JW,
George L, Lambert JJ. Balloon dilatation of stenotic porcine
pulmonary valves. Clin Res 1987;35:204A.
Cribier A, Savin T, Berland J, et al. Percutaneous translumi-
nal balloon valvu loplasty of adult aortic stenosis: report of 92
cases. J Am Co11 Cardiol 1987;9:381-6.
Kveselis DA, Rocchini AP, Beekman R, et al. Balloon angio-
plasty for congenital and rheumatic mitral stenosis. Am J
Cardiol 1986,57:348-50.
Ribeiro PA, Zaibag MA, Kasab SA, Idris M, Halim M, Abdul-
lah M, Shahed M. Percutaneous double balloon valvotomy for
rheumatic tricuspid stenosios. Am J Cardiol 198&61:660-l.
Trace HD, Bailey CP, Wendhos MH. Tricuspid valve com-
missurotomy with a one-year follow up.
AM HEART J 1954;
47:613-17.
Presbyesophagus masquerading as an
extracardiac mass on echocardiography
Brian D. Hoit, MD, and Dave Eppert, RDMS.
Cincinnati, Ohio
Two-dimensional echocardiography has proven useful for
the detection of mediastinal masses.Although the esoph-
aguscourses hrough the posterior mediastinum with an
intimate spatial relationship to the heart, cardiac compres-
sion due to esophageal isease s infrequently reported.2p
In this report, we describe a case n which an asymptom-
atic, functional disorder of esophagealmotility presented
as an extracardiac masson two-dimensional echocardio-
wvb.
A 75-year-old man was admitted to University of Cin-
cinnati Hospital with a history of lethargy and fatigue.
There was no dysphagia or prior symptoms of upper gas-
trointestinal disease.On physical examination the patient
From the University of Cincinnati Medical Center Division of Cardiology.
Reprint requests: Brian D. Hoit MD University of Cincinnati Medical
Center D ivision of Cardiology 231 Bethesda Ave. M.L. 542 Cincinnati OH
45267.
Fig. 1. Left parasternal long-axis
(upper panel)
and
apical four-chamber
(lower panel)
two-dimensional
echocardiogram.A large, echogenicmass M) compresses
the posterior wall of the left atrium.
wasconfused.The vital signsand ugular venouspressure
were normal. The lungswere clear. The heart soundswere
normal and there was a 2/6 late systolic ejection murmur
at the lower left sternal border. The abdomen was dis-
tended, and the prostate wasenlarged.There wasbilateral
lower extremity edema. An anteroposterior chest radio-
gram wasnormal. Electrocardiogram revealed evidence of
an anteroseptal myocardial infarction of undetermined
age. Abdominal distension was relieved by insertion of a
Foley catheter, which drained 1800 cc of urine. The
patients mental status improved, and an echocardiogram
wasperformed to evaluate the systolic murmur.
Two-dimensional echocardiography (Fig. 1) revealed a
large masscompressing he posterior border of the left
atrium. A color Doppler study revealed a late systolic et of
mitral regurgitation that wasdeflected towards the lateral
wall of the left atrium by the mass.A computed tomogra-
phy (CT) scanof the chest evealeda distended, luid-filled
esophagusrom the esophagogastricunction to the upper
esophageal phincter. The remainder of the mediastinum
was
normal. An air-fluid level with a very poor stripping