UNLABELLEDOBJECTIVE, DESIGN AND PATIENTS: Between August 1981 and July 1983, 5839 consecutive myocardial infarction patients were hospitalized in 13 coronary care units in Israel. The present study examines 10 year survival among 4037 consecutive patients with a first myocardial infarction with either Q or non-Q waves. Demographic and medical data were collected from hospital records, and 1 year clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean 10 years of follow-up).RESULTSFive hundred and eighty patients (14%) had first myocardial infarctions of the non-Q wave type and 3457 of the Q wave type. Hospital mortality was significantly higher in patients with a Q wave (10%) than those with a non-Q wave myocardial infarction (7%) (P < 0.05). One year post-discharge, non-fatal reinfarction and mortality rates were comparable in patients with Q wave (4% and 7%) and non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates were equally high in patients with a non-Q wave (26% and 44%) as in those with a first episode of a Q wave myocardial infarction (22% and 40% respectively).CONCLUSIONSPatients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but the advantage did not persist after discharge. Patients with a non-Q wave infarction deserve particular attention as their post-discharge mortality risk is similar to counterparts with a first Q wave myocardial infarction.

The purpose of this study was to assess the predictive value of admission heart rate (HR) for in-hospital and 1 year post-discharge mortality in a large cohort of patients hospitalized for acute myocardial infarction (MI). Data were derived from the SPRINT-2 secondary prevention study population, and included 1044 patients (aged 50-79), hospitalized in 14 coronary care units in Israel with acute MI in the years 1985-1986, before the beginning of thrombolytic therapy in acute MI. Demographic, historical and medical data were collected for each patient. All deaths during initial hospitalization and 1 year post-discharge were recorded. In-hospital mortality was 5.2% for 294 patients with HR < 70 beats/min, 9.5% for 532 patients with HR 70-89 beats/min, and 15.1% for 323 patients with HR > or = 90 beats/min (p < 0.01). One year post-discharge mortality was 4.3% for patients with HR < 70 beats/min, 8.7% for patients with HR 70-80 beats/min and 11.8% for patients with HR > or = 90 beats/min (p < 0.01). An increasing trend of mortality with higher HR was confined to patients with mild CHF (p = 0.02) and likely to patients with absent CHF (p = 0.06), but this post hoc observation requires confirmation in larger groups. The combination of high admission HR (> or = 90 beats/min) and a systolic blood pressure < 120 mmHg was a powerful predictor of in-hospital mortality. Multivariate analysis showed that admission HR was an independent risk factor for in-hospital and 1 year post-discharge mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Independent clinical factors predicting reinfarction in the Ist year following an initial myocardial infarction were identified among 900 women and 2,795 men. Women were older (65.8 vs. 59.3 years; p < 0.001) but tended to suffer from reinfarction at a rate similar to that of men (6.9 vs. 5.6%, p = 0.17). Cumulative 1-month, 1- and 5.5-year all-cause mortality following the first infarction was higher among women who sustained reinfarction (43, 52 and 74%, respectively) than among men (29, 30 and 51%, respectively, p < 0.01 for each). Independent clinical predictors for recurrent myocardial infarction among women were (adjusted relative odds): peripheral vascular disease (3.2), postinfarction angina (2.3), diabetes mellitus (2.2), radiographic evidence of cardiomegaly (1.9), anterior location of the first infarction (2.0), congestive heart failure (1.8), prior angina (1.6) and age (10 years) increment (1.2). Predictive variables for men were: anterior infarct location (1.7), peripheral vascular disease (1.6), prior stroke (1.5), prior angina (1.4), systemic hypertension (1.3) and age (10 years) increment (1.1). Our data indicate (a) different cardiac risk factors for reinfarction among men and women after a first myocardial infarction, and (b) a prognostic advantage for men over women following reinfarction.

The aim of this study was to determine the incidence and impact of right and left bundle branch block on the in-hospital, 5-year and 10-year mortality of patients with acute inferior Q wave myocardial infarction. A retrospective analysis of clinical characteristics hospital, 1-, 5-, and 10-year mortality of 2215 consecutive patients with acute inferior Q wave myocardial infarction hospitalized in 13 coronary care units in Israel was performed.Bundle branch block during acute Q wave inferior wall myocardial infarction was present in 108 patients (4.9%), 85 of whom had right and 23 left bundle branch block. Patients with bundle branch block had more in-hospital complications than those without, irrespective of the sire and time of appearance of the block In addition, atrial fibrillation (19%), complete atrioventricular block (21%) and congestive heart failure (45%) appeared more frequently in patients with, than in those without, bundle branch block (11%, 9% and 31%, respectively), and in-hospital and 5-year mortality were higher in patients with the block (22%, 33%) than in those without it (13% and 23%, respectively).Bundle branch block emerged as an independent predictor of death only among patients with new right bundle branch block, and right bundle branch block emerged as an independent predictor for the development of complete atrioventricular block (odds ratio 2.13; 90% confidence interval 1.39-3.28). However, hospital mortality among patients with inferior myocardial infarction and complete atrioventricular block was virtually independent of bundle branch block (39% with vs 36% without bundle branch block, respectively).Patients with inferior Q wave myocardial infarction and bundle branch block comprise a high risk subgroup of patients with a complicated hospital course and increased hospital and long-term mortality.

The incidence of complete heart block (CHB) among 2,560 consecutive patients with acute anterior wall myocardial infarction (MI) was 4% (n = 102). These patients were older, had previous infarction and angina more often, and exhibited a higher rate of in-hospital complications than counterparts without CHB. In-hospital as well as 1- and 10-year post-discharge mortality was significantly higher among patients with CHB (75, 31 and 81%) in comparison to counterparts without block (19, 11 and 48%, respectively; p = 0.001 for each). After adjustment for multiple variables, CHB emerged as an independent predictor of in-hospital death (relative odds 5.7, 95% confidence interval: 3.1-10.4) but not for subsequent mortality. In view of the very high mortality among patients with anterior acute MI exhibiting CHB, high priority should be given to extensive monitoring and aggressive treatment of these patients.

PURPOSE:Patients with large myocardial infarction (MI) presenting with clinical signs of heart failure are at increased risk for subsequent development of cardiogenic shock and death. Little is known, however, about the development of cardiogenic shock among patients with acute MI presenting without clinical signs of heart failure. The aim of the present study was to examine the incidence, predictors for occurrence, and outcome of in-hospital development of cardiogenic shock among patients with acute MI without heart failure on admission.PATIENTS AND METHODS:Clinical data of 5,839 consecutive patients hospitalized with acute MI were analyzed.RESULTS:Of 3,465 (59%) patients without heart failure on admission (Killip class I), 89 (2.6%) developed cardiogenic shock during their hospital stay. This represented 24% of all cases of in-hospital cardiogenic shock in the entire group. Cardiogenic shock developed more than 24 hours after admission in 66% of cases. All but three patients with cardiogenic shock died whereas a 5% in-hospital mortality was found among patients without cardiogenic shock. Independent predictors for in-hospital shock were age (for a 10-year increment, adjusted relative odds [RO] = 2.45, 90% confidence interval [CI] = 1.50 to 4.02); female gender (RO = 1.51, 90% CI = 0.91 to 2.50); history of angina (RO = 2.64, 90% CI = 1.36 to 3.76); history of stroke (RO = 2.12, 90% CI = 1.26 to 6.35); peripheral vascular disease (RO = 1.99, 90% CI = 0.95 to 4.18); peak lactate dehydrogenase (LDH) greater than four times the normal (RO = 3.16, 90% CI = 1.79 to 5.57); and hyperglycemia on admission (RO = 3.52, 90% CI = 2.13 to 5.84). Patients with six risk factors (excluding LDH values) had an estimated probability of 35% for developing in-hospital cardiogenic shock.CONCLUSIONS:(1) A significant proportion of MI patients who developed cardiogenic shock during hospitalization were free of heart failure on admission. (2) Our study identified several risk factors facilitating early identification of subgroups at risk for cardiogenic shock within otherwise low-risk patients.

The aim of the study was to assess the relationship between paroxysmal atrial fibrillation during acute myocardial infarction and the long-term prognosis of patients after acute myocardial infarction. The incidence of paroxysmal atrial fibrillation among 5803 consecutive hospitalized patients was 9.9% (557/5803). Incidence rose with increasing age (less than or equal to 59 years, 4.2%), (60-69 years, 10.5%), (greater than or equal to 70 years, 16.0%) and was slightly (but not significantly) higher in women (11.0%) than in men (9.6%). The presence of congestive heart failure and mean age represented two major discriminants between patients with paroxysmal atrial fibrillation (70% and 68.6 years) in comparison with their counterparts (35% and 62.3% years). Hospital mortality was significantly higher (25.5%) in patients with paroxysmal atrial fibrillation than in those without (16.2%). However, the effect of paroxysmal atrial fibrillation disappeared when other factors influencing the short term prognosis (i.e. heart failure) were taken into account by a multivariate logistic regression analysis. The covariate adjusted relative odds of in-hospital mortality then fell to 0.82. The 1- and 5-year mortality rates were 18.6% and 43.3% in patients with paroxysmal atrial fibrillation as compared to 8.2% and 25.4% (P less than 0.001), respectively, in patients free of paroxysmal atrial fibrillation. Using a proportional hazards analysis of mortality through the first quarter of 1988 (average follow-up time, 5.5 years) the net risk of dying among patients with paroxysmal atrial fibrillation complicating the acute myocardial infarction is estimated at 1.28 (90% confidence interval, 1.12-1.46) relative to counterparts free of the complication.(ABSTRACT TRUNCATED AT 250 WORDS)

This study reports on a predominantly noninvasive management program for neonatal transposition of the great arteries [TGA] incorporating balloon atrial septostomy [BAS] under echocardiographic control. BAS was performed in 25 consecutive patients presenting with TGA between April 1988 and April 1990. Structural and coronary anatomy was evaluated echocardiographically with angiographic supplementation only when additional data were required. This information was correlated, where possible, with direct anatomic findings and subsequent course. BAS was performed through the umbilicus in 17 patients (85% of patients in whom this approach was attempted). Thirteen patients did not require ventilation during BAS. There were minimal complications and satisfactory septostomies in all cases. Coronary anatomy was correctly predicted in all patients where anatomic correlation was available. Without invasive investigation 9 patients underwent neonatal arterial switch procedures and 2 underwent palliative procedures. BAS under echocardiographic control proved safe, effective, minimally traumatic and mostly possible via the umbilical vein. The umbilical vein, where patent, permitted rapid safe access for BAS. Echocardiographic diagnosis of the coronary artery, and structural and functional anatomy was reliable and allowed minimally invasive preoperative management in many patients.

We have in our records 11 patients with situs ambiguus and left isomerism (polysplenia). Ten had an interruption of the inferior vena cava (IVC) with azygos continuation; in eight cases the continuation was to the left superior vena cava (LSVC), in one case to the right superior vena cava (RSVC) and in one case to both the LSVC and RSVC. Two patients underwent surgical correction by a baffle procedure of the functioning single atrium. The angiographic confirmation of the azygos system anatomy is important in planning the surgical correction of patients with left isomerism. Clinically, given the same heart defects with normal pressures, the right-sided drainage is probably more favorable, producing less peripheral desaturation.

Three patients are described who had situs ambiguus and left isomerism (polysplenia syndrome) and advanced atrioventricuiar block. One presented with a complex bradyarrhythmia with Wenckebach block. The other two had congenital atrioventricular block with a narrow QRS at a ventricular rate of 80 per minute, an atrial rate of 150′ per minute, and both had a P wave axis directed superiorly and to the right in one, and superiorly to the left in the other. This ECG pattern was not observed in more than 400 adult patients with complete A‐V block treated in our service. It is our opinion that in infants and children with heart disease the presence of complete A‐V block with narrow QRS and an unusual P waves axis directed superiorly is strongly suggestive of left isomerism. The incidence rate of complete A‐V block in left isomerism is nearly twenty percent of the cases described.

A significant number of patients (pts) with sick sinus syndrome (SSS) treated with implanted ventricular pacemakers (PM), develop consequently chronic atrial fibrillation (AF) which terminates their clinical syndrome. In these pts, termination of permanent pacing (PP) may be considered. Among a group of 100 pts with SSS, treated with implanted PMs, 27 pts (27%) developed chronic AF following implantation. Of this group, long-term PP was terminated in 10 pts. In 2 pts pacing was ceased unexpectedly as a result of PM or electrode malfunction. In 8 pts it was terminated intentionally as batteries exhausted and were not replaced. All 10 pts were asymptomatic when pacing was discontinued and have been followed closely since; their ages ranged from 53 to 80 years (mean 70) and the duration of PP before termination ranged between 12 to 76 months (mean 46). Follow-up period since termination of pacing ranged from 12 to 40 months (mean 30). In 5 pts PP had to be reinstituted (by replacing the PM): 3 became asymptomatic due to AF with slow ventricular rate and 2 had symptomatic recurrences of sinus of junctional bradycardia. The other 5 pts remained well and asymptomatic without PP. In conclusion, in some paced SSS pts who developed chronic AF, termination of PP is possible as AF is stable and the ventricular rate is adequate but in some, slow ventricular rate or unstable AF indicates the continuation of pacing.

The reuse of previously implanted pulse generators (PG) has been an accepted practice in Israel. This survey summarizes the long-term follow-up of 132 pts in whom reused PGs were implanted during the years 1976-1982 in 2 of the main medical centers in Israel. Sixty-four PGs were removed post-mortem and 68 from living pts who required reoperation for pouch or electrode problems. The preparation of the units included verifying normal function using a pacemaker (PM) analyzer, thorough cleansing and gas sterilization. During the yrs 1976-1979, the used PGs were implanted only in pts who were over the age of 75 or who suffered from chronic diseases and had predicted short life span, but since 1980 they were used also in younger pts without additional diseases. These reimplanted PGs have been in use for mean period of 18 mos per pt (range: 6 mos to 40 mos) and have contributed until now 2239 mos of pacing. Forty-six PGs are still functioning and 39 have been replaced (mostly the mercury cell units). Forty-two pts died during the follow-up and 5 were lost to follow-up. None of the deaths have been attributed to PG malfunction. In 2 cases pouch infection developed following implantation. No systemic infections, immunological reactions or hepatitis resulted from this procedure.

A 6-day-old baby with a single arterial trunk arising from the aortic arch is reported. The baby had coarctation of aorta with patent ductus arteriosus and ostium primum atrial septal defect. A review of the literature in English reveals no other case reported of an infant with this association of anomlies.

Two young females, who had implanted pacemakers, and experienced an uneventful course of pregnancy and delivery are described. We suggest the chest wall under the breasts as the site of choice for the implanted unit in young females who might expect pregnancy. If this site is used, any restriction of the skin above the unit should be prevented as the abdomen and breasts increase in size. The problem of a fixed heart rate during the period of an increasing work load on the heart in pregnancy is discussed, and the use in these patients of an adjustable-rate pulse-generators is suggested.

Lobar emphysema is an uncommon cause of respiratory distress in infancy. Congenital heart disease is seen in about 20% of the patients with infantile (congenital) lobar emphysema. We described six infants with lobar emphysema. In three of them a congenital heart disease was demonstrated by cardiac catheterization and cineangiography; two had a tetralogy of Fallot with right aortic arch and the third infant a ventricular septal defect. The pulmonary angiography showed stretching of the arteries with very poor filling of the peripheral arteries and a characteristic smaller pulmonary vein in the affected lobe. In all the six patients the pulmonary artery pressure was normal. All the patients underwent lobectomy with good results. We feel that a preoperative cardiac catheterization and cineangiography is of value in this very sick group of infants.