SUMMARY To assess the prognostic importance of resting left ventricular function in survivors of acute myocardial infarction with pulmonary edema, we retrospectively identified 39 consecutive patients who presented with acute pulmonary edema and myocardial infarction. Sixteen patients had radionuclide ejection fractions 10 2 days postinfarction of > 0.45 (group A, mean 0.55 0.06), and 23 patients had ejection fractions S 0.45 (group B, 0.32 + 0.06). There were no significant differences between the two groups for age or sex, but group A patients had a significantly greater incidence of first myocardial infarction predominantly inferior in location. The calculated stroke work index during the acute event was significantly greater in group A than in group B (33.4 + 2.4 vs 23.4 + 2.0) (p < 0.05). During a follow-up of 9 3 months, mortality was not significantly different between the two groups: Four (25%) died in group A and seven (30%) died in group B. In addition, eight patients (50%) in group A were hospitalized for recurrent angina, new myocardial infarction or recurrent pulmonary edema, compared with 11 (48%) in group B (NS). Three deaths in group A were preceded by infarction of the anterior wall of the left ventricle, confirmed at autopsy, and two nonfatal infarctions were anterior by electrocardiography. Four patients in group A had coronary arteriography performed during the follow-up period because of unstable angina, and all had significant (Dr 70% stenosis) three-vessel disease and two had left main coronary artery disease. Therefore, the predischarge ejection fraction did not predict prognosis for this group of patients.Patients with acute pulmonary edema in the course of myocardial infarction form a high-risk group despite good resting left ventricular function at discharge. They have a significant incidence of recurrent myocardial infarction and death and, because they have good residual left ventricular function, are excellent candidates for surgical intervention.THE EARLY and late prognoses for acute myocardial infarction are adversely affected by the occurrence of left ventricular failure. 1-3 The manifestation of acute pulmonary edema is particularly lethal.' 4, 10 Presumably, pulmonary edema reflects the severity and extent of acute and chronic abnormalities in left ventricular contraction. Thus, pulmonary edema is more common in patients with a history of infarction and in patients with large initial infarctions, which are usually anterior wall infarctions. It is not surprising that in a study by Schelbert et al.,14 measuring radionuclide ejection fractions after myocardial infarction, patients with pulmonary edema had severely depressed ejection fractions and no patient had a normal ejection fraction (> 0.52).Since January 1980, we have routinely obtained a predischarge radionuclide angiocardiogram for all survivors of acute myocardial infarction. It became apparent that certain patients who had manifested pulmonary edema had an unexpectedly normal or only mildly depressed ejection fraction at...

The ability to record noninvasively tbe intracardiac electrogram has potential advantages in the follow-up of paced patients. This case report illustrates one use of this feature in the evaluation of pauses in paced rhythm. Case ReportA 53-year-old woman had left bundle branch block, Type II second degree atrioventricular block, anda ventricular rate of 30 per min. A pacing system was implanted, which consisted of a bipolar porous-tipped tined electrode catheter connected to an interrogable multiprogrammable VVI pulse generator, which has the capability of radiofreciuency transmission of the electropram to the programmer.* The pulse generator parameters programmed at the end ofthe implant procedure were: rate -65 pulses per minute (923 ms automatic interval); pulse width -0.50 ms, sensitivity-1.5 mV; hysteresis interval-0.00 s; and refractory period -325 ms [in this model pulse generator, the refractory period after a paced complex is 16 ms longer than that after a sensed spontaneous complex).Immediately upon return to the tloronary Care Unit, pauses in paced rhythm were noted, along with apparent failure to sense(Flg.

SUMMARY Paroxysmal supraventricular tachycardia (PSVT) is associated with altered hemodynamics. We describe the echocardiographic features of myocardial dysfunction during a prolonged episode of PSVT in an 1 1-year-old male. The abnormality of the phases of cardiac activity presented as a markedly prolonged left ventricular systole (320 msec) and isovolumic relaxation phase (220 msec) and a shortened and delayed diastolic filling period (140 msec). These abnormalities reverted to normal immediately after spontaneous conversion to sinus rhythm. Propranolol, which was used to prevent PSVT in this child, may have been involved in the mechanism of the altered mechanical events.ALTERED HEMODYNAMICS during paroxysmal supraventricular tachycardia (PSVT) have been described.'-" The proposed mechanisms for these hemodynamic alterations include a decreased diastolic filling period, atrioventricular (AV) valve regurgitation and changes in the timing of AV contraction relationships. ' We describe a new mechanism for altered hemodynamics in a patient with AV reentrant PSVT. An alteration of the normal cardiac mechanical events caused the ventricular dysfunction. Case ReportAn 11-year-old black male was admitted to the emergency room with a complaint of fatigue and dull, aching chest pain of 36 hours duration. He had a history of recurrent episodes of PSVT. Four years before admission he underwent cardiac catheterization and electrophysiologic studies. The tachycardia was found to be AV reentrant PSVT, with retrograde conduction via a concealed left lateral Kent bundle.' Left-and right-heart pressures and oxygen saturations were normal.Current medications included propranolol, 200 mg/day, and digoxin, 0.25 mg/day. The blood pressure was 130/80 mm Hg and the pulse rate was 90 beats/min. On cardiac examination the only abnormal finding was an intermittent third heart sound. The apical rate was also 90 beats/min. A 12-lead ECG showed a supraventricular tachycardia at a rate of 180 beats/min and minor nonspecific ST-T-wave changes ( fig. 1).The patient was transferred to the noninvasive From the Sections