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Dr. Cynthia Tracy, MD
Internist

Video profile

Education ?

Medical School Score
The University of Toledo *
  • Currently 2 of 4 apples
Residency
Georgetown Univ Hosp (1982) *
Cardiovascular Disease
Fellowship
Georgetwon Univ. Medical Center (1984) *
Cardiology
* This information was reported to Vitals by the doctor or doctor's office.

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Cardiac Arrhythmias
Castle Connolly's Top Doctors™ (2012 - 2013)
Patients' Choice Award (2010 - 2011, 2013 - 2014)
Compassionate Doctor Recognition (2010, 2012 - 2013)
Associations
American Board of Internal Medicine
American College of Cardiology
Heart Rhythm Society

Affiliations ?

Dr. Tracy is affiliated with 1 hospitals.

Hospital Affilations

Score

Rankings

  • George Washington Univ Hospital
    Cardiology
    901 23rd St NW, Washington, DC 20037
    • Currently 1 of 4 crosses
  • Publications & Research

    Dr. Tracy has contributed to 69 publications.
    Title Interpretation of Remotely Downloaded Pocket-size Cardiac Ultrasound Images on a Web-enabled Smartphone: Validation Against Workstation Evaluation.
    Date April 2012
    Journal Journal of the American Society of Echocardiography : Official Publication of the American Society of Echocardiography
    Excerpt

    Pocket-size ultrasound has increased echocardiographic portability, but expert point-of-care interpretation may not be readily available. The aim of this study was to test the hypothesis that remote interpretation on a smartphone with dedicated medical imaging software can be as accurate as on a workstation.

    Title 2011 Accf/aha/hrs Focused Update on the Management of Patients with Atrial Fibrillation (updating the 2006 Guideline): a Report of the American College of Cardiology Foundation/american Heart Association Task Force on Practice Guidelines.
    Date January 2011
    Journal Circulation
    Title Accf/aha 2009 Expert Consensus Document on Pulmonary Hypertension: a Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: Developed in Collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association.
    Date June 2009
    Journal Circulation
    Title Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management Endorsed by the Heart Rhythm Society.
    Date January 2008
    Journal Journal of the American College of Cardiology
    Title Sustained Ventricular Tachycardia in Apical Hypertrophic Cardiomyopathy, Midcavitary Obstruction, and Apical Aneurysm.
    Date October 2007
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    The prevalence of hypertrophic cardiomyopathy is estimated at 1:500 in the general population. Of these patients, approximately 1% develops midcavitary obstruction and subsequent apical aneurysm. We present a brief review of the literature on apical hypertrophic cardiomyopathy (HCM) using a rare case-based example. The etiology for apical aneurysm development is unclear but is thought to extend from apical fibrosis and necrosis secondary to subendocardial ischemia. The lifetime risk of cardiovascular death in patients with HCM is 2%. However, the risk may be higher in patients with apical aneurysms. Definitive therapy involves implantation of an automatic implantable cardioverter defibrillator, since medical therapy has variable success.

    Title Potential Energy Surfaces for Small Alcohol Dimers. Ii. Propanol, Isopropanol, T-butanol, and Sec-butanol.
    Date September 2007
    Journal The Journal of Chemical Physics
    Excerpt

    Potential energy landscapes for homogeneous dimers of propanol, isopropanol, tert-butanol, and sec-butanol were obtained using 735 counterpoise-corrected energies at the MP2/6-311+G(2df,2pd) level. The landscapes were sampled at 15 dimer separation distances for different relative monomer geometries, or routes, given in terms of the yaw, pitch, and roll of one monomer relative to the other and the spherical angles between the two monomer centers (taken as the C atom attached to the O). The resultant individual energy surfaces and their complex topographies were also regressed using a site-site pair potential model using a modified Morse potential that provides a mathematically simple representation of the landscapes suitable for use in molecular simulations. Generalized Morse parameters were also obtained for this model from a composite regression of these energy landscapes and those previously reported for methanol and ethanol. The quality of fit for all these energy landscapes suggests that these site parameters have transferability for possible use on other alcohols.

    Title Potential Energy Surfaces for Small Alcohol Dimers I: Methanol and Ethanol.
    Date August 2007
    Journal The Journal of Chemical Physics
    Excerpt

    Potential energy landscapes for homogeneous dimers of methanol and ethanol were calculated using counterpoise (CP) corrected energies at the MP26-311+G(2df,2pd) level. The landscapes were sampled at approximately 15 dimer separation distances for different relative monomer geometries, or routes, given in terms of a relative monomer yaw, pitch, and roll and the spherical angles between the monomer centers (taken as the C atom attached to the O). The 19 different routes studied for methanol and the 22 routes examined for ethanol include 607 CP corrected energies. Both landscapes can be adequately represented by site-site, pairwise-additive models, suitable for use in molecular simulations. A modified Morse potential is used for the individual pair interactions either with or without point charges to represent the monomer charge distribution. A slightly better representation of the methanol landscape is obtained using point charges, while the potential energy landscape of ethanol is slightly better without point charges. This latter representation may be computationally advantageous for molecular simulations because it avoids difficulties associated with long-range effects of point-charge-type models.

    Title Accf/aha/scai 2007 Update of the Clinical Competence Statement on Cardiac Interventional Procedures: a Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training (writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures).
    Date August 2007
    Journal Journal of the American College of Cardiology
    Title Accf/aha/scai 2007 Update of the Clinical Competence Statement on Cardiac Interventional Procedures: a Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training (writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures).
    Date July 2007
    Journal Circulation
    Title Accf/aha/cdc Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats: the Clinical and Public Health Implications for the Prevention and Control of Cardiovascular Diseases.
    Date May 2007
    Journal Circulation
    Title Accf/aha/cdc Conference Report on Emerging Infectious Diseases and Biological Terrorism Threats: the Clinical and Public Health Implications for the Prevention and Control of Cardiovascular Diseases.
    Date April 2007
    Journal Journal of the American College of Cardiology
    Title Accf/aha 2007 Clinical Expert Consensus Document on Coronary Artery Calcium Scoring by Computed Tomography in Global Cardiovascular Risk Assessment and in Evaluation of Patients with Chest Pain: a Report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (accf/aha Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography).
    Date February 2007
    Journal Circulation
    Title American College of Cardiology/american Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion: a Report of the American College of Cardiology/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training: Developed in Collaboration with the Heart Rhythm Society.
    Date October 2006
    Journal Circulation
    Title American College of Cardiology/american Heart Association 2006 Update of the Clinical Competence Statement on Invasive Electrophysiologystudies,catheterablation,andcardioversion: a Report of the American College of Cardiology/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training Developed in Collaboration with the Heart Rhythm Society.
    Date October 2006
    Journal Journal of the American College of Cardiology
    Title Acc/acp/scai/svmb/svs Clinical Competence Statement on Vascular Medicine and Catheter-based Peripheral Vascular Interventions. A Report of the American College of Cardiology/american Heart Association/american College of Physicians Task Force on Clinical Competence (acc/acp/scai/svmb/svs Writing Committee to Develop a Clinical Competence Statement on Peripheral Vascular Disease).
    Date August 2006
    Journal Vascular Medicine (london, England)
    Title Use of Ice for Rf Ablation of Af.
    Date May 2006
    Journal Journal of Cardiovascular Electrophysiology
    Title Task Force 6: Training in Specialized Electrophysiology, Cardiac Pacing, and Arrhythmia Management: Endorsed by the Heart Rhythm Society.
    Date April 2006
    Journal Journal of the American College of Cardiology
    Title Accf/aha/aap Recommendations for Training in Pediatric Cardiology. A Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence (acc/aha/aap Writing Committee to Develop Training Recommendations for Pediatric Cardiology).
    Date March 2006
    Journal Circulation
    Title Accf/aha Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance.
    Date February 2006
    Journal Circulation
    Title Accf/aha Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance: a Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training.
    Date August 2005
    Journal Journal of the American College of Cardiology
    Title Integrating Complementary Medicine into Cardiovascular Medicine. A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine).
    Date July 2005
    Journal Journal of the American College of Cardiology
    Title Accf/aha/hrs/scai Clinical Competence Statement on Physician Knowledge to Optimize Patient Safety and Image Quality in Fluoroscopically Guided Invasive Cardiovascular Procedures: a Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training.
    Date July 2005
    Journal Circulation
    Title Atrial Fibrillation Device Therapy Considerations in Design of Clinical Trials.
    Date July 2005
    Journal American Journal of Therapeutics
    Excerpt

    Management of atrial fibrillation is largely driven by the clinical status of the affected patient. Advances in understanding the mechanism of the arrhythmia have led to more aggressive catheter-based approaches to the management of atrial fibrillation. Because atrial fibrillation is a complex disease with multiple possible mechanisms, one approach for all patients is not feasible. Considerations regarding trial design and patient selection are discussed in this paper.

    Title Accf/aha/hrs/scai Clinical Competence Statement on Physician Knowledge to Optimize Patient Safety and Image Quality in Fluoroscopically Guided Invasive Cardiovascular Procedures. A Report of the American College of Cardiology Foundation/american Heart Association/american College of Physicians Task Force on Clinical Competence and Training.
    Date December 2004
    Journal Journal of the American College of Cardiology
    Title Acc/acp/scai/svmb/svs Clinical Competence Statement on Vascular Medicine and Catheter-based Peripheral Vascular Interventions: a Report of the American College of Cardiology/american Heart Association/american College of Physician Task Force on Clinical Competence (acc/acp/scai/svmb/svs Writing Committee to Develop a Clinical Competence Statement on Peripheral Vascular Disease).
    Date September 2004
    Journal Journal of the American College of Cardiology
    Title New-onset Qt Prolongation and Torsades De Pointes Accompanied by Left Ventricular Dysfunction Secondary to Acute Pancreatitis.
    Date December 2003
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    A 70-year-old woman presented with acute pancreatitis and new-onset QT prolongation with subsequent torsades de pointes. Coronary catheterization was performed and was unremarkable. After persistent QT prolongation, despite temporary atrial pacing, a permanent dual chamber cardioverter defibrillator was implanted. In addition to the QT prolongation, significant depression in the left ventricular function was noted. Both resolved once the pancreatitis abated.

    Title Acc/aha Clinical Competence Statement on Echocardiography: a Report of the American College of Cardiology/american Heart Association/american College of Physicians-american Society of Internal Medicine Task Force on Clinical Competence.
    Date September 2003
    Journal Journal of the American Society of Echocardiography : Official Publication of the American Society of Echocardiography
    Title American College of Cardiology/american Heart Association Clinical Competence Statement on Echocardiography: a Report of the American College of Cardiology/american Heart Association/american College of Physicians--american Society of Internal Medicine Task Force on Clinical Competence.
    Date March 2003
    Journal Circulation
    Title Acc/aha Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography: A Report of the Acc/aha/acp-asim Task Force on Clinical Competence (acc/aha Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography) Endorsed by the International Society for Holter and Noninvasive Electrocardiology.
    Date January 2002
    Journal Circulation
    Title Acc/aha Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography. A Report of the Acc/aha/acp-asim Task Force on Clinical Competence (acc/aha Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography).
    Date January 2002
    Journal Journal of the American College of Cardiology
    Title Central Clinical Research Issues in Electrophysiology: Report of the Naspe Committee.
    Date September 2001
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    This article contains the results of an attempt by appointed members of the North American Society of Pacing and Electrophysiology to define the research frontier in electrophysiology and suggest areas of study as an aid in setting the research agenda.

    Title American College of Cardiology/society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards. A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.
    Date July 2001
    Journal Journal of the American College of Cardiology
    Title Clinical Competency Statement: Implantation and Follow-up of Cardioverter Defibrillators.
    Date June 2001
    Journal Journal of Cardiovascular Electrophysiology
    Title An Abdominal Active Can Defibrillator May Facilitate a Successful Generator Change when a Lead Failure is Present.
    Date March 2001
    Journal Europace : European Pacing, Arrhythmias, and Cardiac Electrophysiology : Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology
    Excerpt

    AIMS: Defibrillator generator changes are frequently performed on patients with an implantable cardioverter defibrillator in an abdominal pocket. These patients usually have epicardial patches or older endocardial lead systems. At the time of a defibrillator generator change defibrillation may be unsuccessful as a result of lead failure. We tested the hypothesis that an active can defibrillator implanted in the abdominal pocket could replace a non-functioning endocardial lead or epicardial patch. METHODS AND RESULTS: An abdominal defibrillator generator change was performed in 10 patients, (mean age = 67 +/- 13 years, nine men). Initially, a defibrillation threshold (DFT) was obtained using a passive defibrillator and the chronic endocardial or epicardial lead system. DFTs were then performed using an active can emulator and one chronic lead to simulate endocardial or epicardial lead failure. We tested 30 lead configurations (nine endocardial and 21 epicardial). Although a DFT of 7.3 +/- 4.2 joules was obtained with the intact chronic lead system, the active can emulator and one endocardial or epicardial lead still yielded an acceptable DFT of 19.9 +/- 6.1 joules. In addition, a successful implant (DFT < or = 24 joules) could have been accomplished in 28 of 30 (93%) lead configurations. CONCLUSION: An active can defibrillator in an abdominal pocket may allow for a successful generator change in patients with defibrillator lead malfunction. This would be simpler than abandoning the abdominal implant and moving to a new pectoral device and lead or tunnelling a new endocardial electrode. However, loss of defibrillation capability with a particular complex lead may be a warning of impending loss of other functions (eg. sensing and/or pacing).

    Title American College of Cardiology/american Heart Association Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. A Report of the American College of Cardiology/american Heart Association/american College of Physicians--american Society of Internal Medicine Task Force on Clinical Competence.
    Date January 2001
    Journal Journal of the American College of Cardiology
    Title American College of Cardiology/american Heart Association Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion: A Report of the American College of Cardiology/american Heart Association/american College of Physicians-american Society of Internal Medicine Task Force on Clinical Competence.
    Date November 2000
    Journal Circulation
    Title American College of Cardiology/american Heart Association Clinical Competence Statement on Stress Testing. A Report of the American College of Cardiology/american Heart Association/american College of Physicians-american Society of Internal Medicine Task Force on Clinical Competence.
    Date October 2000
    Journal Circulation
    Title American College of Cardiology/american Heart Association Clinical Competence Statement on Stress Testing: a Report of the American College of Cardiology/american Heart Association/american College of Physicians--american Society of Internal Medicine Task Force on Clinical Competence.
    Date October 2000
    Journal Journal of the American College of Cardiology
    Title Acc/aha Guidelines for Ambulatory Electrocardiography. A Report of the American College of Cardiology/american Heart Association Task Force on Practice Guidelines (committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in Collaboration with the North American Society for Pacing and Electrophysiology.
    Date September 1999
    Journal Journal of the American College of Cardiology
    Title Acc/aha Guidelines for Ambulatory Electrocardiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/american Heart Association Task Force on Practice Guidelines (committee to Revise the Guidelines for Ambulatory Electrocardiography).
    Date September 1999
    Journal Circulation
    Title Alterations in Heart Rate Following Radiofrequency Ablation in the Treatment of Reentrant Supraventricular Arrhythmias: Relation to Alterations in Autonomic Tone.
    Date January 1999
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    To determine the relation between the creation of endocardial lesions and alterations in autonomic tone, we analyzed heart rate variability in patients undergoing radiofrequency catheter ablation for symptomatic supraventricular tachycardia. Elevated heart rates are frequently noted after radiofrequency catheter ablation for supraventricular arrhythmias. It has been postulated that this elevation may be secondary to alterations in cardiac autonomic tone. Since heart rate variability is a measure of autonomic nervous system activity, we used this technique to examine the heart rate elevation and to characterize postablation autonomic changes. Thirty-eight patients undergoing 44 radiofrequency catheter ablation procedures were included in the study. Total arrhythmic substrates treated included 34 accessory pathways and 13 AV nodes with dual physiology. Twenty-four hour ambulatory electrocardiographic recordings were obtained in a drug-free state prior to, ablation early postablation, and late postablation. Spectral and nonspectral analyses of heart rate variability were performed. Subgroup analyses were also done on specific cohorts. Subgroups included patients undergoing accessory pathway ablations, AV node modifications, and ablation of septal and nonseptal targets. To determine whether the amount of tissue damage was related to changes in heart rate variability, we analyzed the relation between the total energy delivered to the endocardium and the peak change in creatine kinase and heart rate variability. In this population, a significant transient increase in heart rate was noted following radiofrequency ablation. All time and frequency domain parameters of heart rate variability showed significant reversible decreases. These changes were independent of target site and arrhythmia substrate. There was no correlation noted between the changes in heart rate variability and either the total amount of energy applied to the endocardium or the change in creatine kinase. Increased heart rates and decreased heart rate variability occur following radiofrequency catheter ablation for supraventricular tachycardia. Clinically, the predominant effect is that of decreased parasympathetic tone. Since these transient changes are independent of arrhythmic substrate or ablation site in the atria, a rich parasympathetic innervation of the heart is proposed.

    Title Successful Ablation of a Nonreentrant Dual Atrioventricular Nodal Tachycardia.
    Date January 1999
    Journal Journal of Interventional Cardiac Electrophysiology : an International Journal of Arrhythmias and Pacing
    Excerpt

    Selective radiofrequency catheter ablation of the slow pathway of the AV node has become the treatment of choice for AV nodal reentrant tachycardia. We describe a case of a nonreentrant AV nodal tachycardia and its successful treatment by slow pathway ablation.

    Title Qt Prolongation and Near Fatal Cardiac Arrhythmia After Intravenous Tacrolimus Administration: a Case Report.
    Date October 1998
    Journal Transplantation
    Excerpt

    BACKGROUND: The use of immunosuppressant agents is mandatory in the long-term management of transplant recipients. Herein, we report a case of near fatal cardiac arrhythmia related to the use of intravenous tacrolimus in a 35-year-old woman undergoing renal transplantation. METHODS: The patient had no previous history of cardiac disease, but an initial electrocardiogram demonstrated slightly prolonged QT and QTc intervals and normal sinus rhythm. Postsurgical immunosuppression included intravenous tacrolimus and methylprednisolone. During intravenous tacrolimus infusion, marked QT prolongation occurred. The patient suffered recurrent runs of torsade de pointes, refractory to aggressive medical management and requiring numerous defibrillations. Rapid atrial pacing eventually controlled the arrhythmia. RESULTS: We note not only a temporal association, but also a direct linear relationship, between this arrhythmia and blood tacrolimus levels. CONCLUSION: We believe this case presents a little recognized hazard associated with the use of intravenous tacrolimus and points to the need for careful predrug screening for QT prolongation. Tacrolimus has been shown to effect intracellular calcium and to prolong the action potential duration experimentally. This suggests that an increase in the intracellular calcium may underlie torsades de pointes associated with intravenous tacrolimus.

    Title Catheter Ablation for Patients with Atrial Tachycardia.
    Date January 1998
    Journal Cardiology Clinics
    Excerpt

    Although atrial tachycardias are relatively rare, their poor response to standard therapies, the suboptimal hemodynamic results of complete atrioventricular node ablation and pacer implantation, and their potential for serious hemodynamic effects make management difficult. Although their mechanisms are complex and divergent, catheter ablation has proven to be highly effective in management of atrial tachycardias. This article discusses arrhythmia mechanisms and therapeutic approaches by catheter ablation.

    Title Implantation of a Nonthoracotomy Defibrillator Using a Second Defibrillator Patch in the Abdominal Pocket.
    Date February 1997
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Successful implantation of a biphasic nonthoracotomy implantable cardioverter defibrillator may not be achieved with a conventional system. We describe a successful device implantation using a pectoral and abdominal patch electrode system.

    Title A Second Defibrillator Chest Patch Electrode Will Increase Implantation Rates for Nonthoracotomy Defibrillators.
    Date January 1997
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Nonthoracotomy defibrillator systems can be implanted with a lower morbidity and mortality, compared to epicardial systems. However, implantation may be unsuccessful in up to 15% of patients, using a monophasic waveform. It was the purpose of this study to prospectively examine the efficacy of a second chest patch electrode in a nonthoracotomy defibrillator system. Fourteen patients (mean age 62 +/- 11 years, ejection fraction = 0.29 +/- 0.12) with elevated defibrillation thresholds, defined as > or = 24 J, were studied. The initial lead system consisted of a right ventricular electrode (cathode), a left innominate vein, and subscapular chest patch electrode (anodes). If the initial defibrillation threshold was > or = 24 J, a second chest patch electrode was added. This was placed subcutaneously in the anterior chest (8 cases), or submuscularly in the subscapular space (6 cases). This resulted in a decrease in the system impedance at the defibrillation threshold, from 72.3 +/- 13.3 omega to 52.2 +/- 8.6 omega. Additionally, the defibrillation threshold decreased from > or = 24 J, with a single patch, to 16.6 +/- 2.8 J with two patches. These changes were associated with successful implantation of a nonthoracotomy defibrillator system in all cases. In conclusion, the addition of a second chest patch electrode (using a subscapular approach) will result in lower defibrillation thresholds in patients with high defibrillation thresholds, and will subsequently increase implantation rates for nonthoracotomy defibrillators.

    Title Supraventricular Tachycardia Precipitated by a Peripherally Inserted Central Catheter.
    Date November 1996
    Journal Journal of Electrocardiology
    Excerpt

    Central venous catheters extending into intracardiac chambers can provoke premature atrial and ventricular complexes, which have been reported to initiate supraventricular tachyarrhythmias. These catheters are traditionally placed via the femoral, subclavian, or internal jugular veins. A new alternative to the conventional central catheter for patients requiring access to large veins is the peripherally inserted central (PIC) catheter. Since its proximal end is of small caliber, a PIC catheter can be mistaken for a peripheral intravenous catheter. The distal end, however, usually extends into the superior vena cava and may be erroneously advanced into intracardiac chambers. The authors report a case of a PIC catheter precipitating supraventricular reentrant tachycardia in a previously asymptomatic patient.

    Title Thermistor Guided Radiofrequency Ablation of Atrial Insertion Sites in Patients with Accessory Pathways.
    Date February 1996
    Journal Pacing and Clinical Electrophysiology : Pace
    Excerpt

    Radiofrequency ablation has gained acceptance in the treatment of patients with symptomatic Wolff-Parkinson-White syndrome. The purpose of this study was to characterize the relation between temperature and other electroconductive parameters in patients undergoing atrial insertion accessory pathway ablation utilizing a thermistor equipped catheter. The mean temperature and power at sites of atrial insertion ablation are lower than has been previously associated with creation of radiofrequency lesions in the ventricle. While high cavitary blood flow in the atrium may result in cooling, the thinner atrial tissue may require less energy to achieve adequate heating than ventricular myocardium.

    Title Effect on Coronary Artery Anatomy of Radiofrequency Catheter Ablation of Atrial Insertion Sites of Accessory Pathways.
    Date May 1993
    Journal Journal of the American College of Cardiology
    Excerpt

    OBJECTIVES. The purpose of this study was to analyze the effects of radiofrequency catheter ablation of the atrial insertion site of accessory pathways on the angiographic appearance of coronary arteries. BACKGROUND. Radiofrequency catheter ablation of accessory pathways requires the application of energy to the endocardial surface of the atrioventricular groove adjacent to the major epicardial coronary arteries. A systematic analysis of the effect of radiofrequency ablation on coronary arteries has not previously been demonstrated. METHODS. Seventy consecutive patients with 76 accessory pathways (7 right free wall, 44 left free wall, 12 posteroseptal, 8 anteroseptal and 5 midseptal) were studied. Quantitative coronary angiography was performed before, immediately after and a mean of 69 +/- 42 days after radiofrequency catheter ablation. RESULTS. Coronary artery diameter adjacent to the ablating electrode was 2.6 +/- 0.9 mm before ablation, 2.7 +/- 0.9 mm immediately after ablation and 2.7 +/- 1.0 mm at the time of follow-up study. Angiographic findings were unchanged from baseline in 69 of 70 patients immediately after ablation and in all 70 patients at the time of follow-up study. CONCLUSIONS. Radiofrequency catheter ablation of the atrial insertion site of accessory pathways does not result in short-term angiographic changes in coronary artery anatomy.

    Title Radiofrequency Catheter Ablation of Ectopic Atrial Tachycardia Using Paced Activation Sequence Mapping.
    Date April 1993
    Journal Journal of the American College of Cardiology
    Excerpt

    OBJECTIVES. Although ectopic atrial tachycardia is infrequent, it can be an important clinical challenge. We sought to define an alternative therapeutic approach to this refractory problem. BACKGROUND. Radiofrequency energy catheter ablation has been used to treat a variety of ventricular and supraventricular arrhythmias but has not been proved efficacious in the management of ectopic atrial tachycardia. METHODS. Ten patients (14 to 47 years of age) referred with refractory ectopic atrial tachycardia were studied. Mapping techniques included identification of earliest atrial activation, confirmation of concordance of P wave configuration during spontaneous tachycardia and pacing from the ablation catheter, and paced activation sequence mapping. The paced activation sequence mapping compared the activation sequence at multiple atrial sites during spontaneous tachycardia with that recorded during pacing from the ablation catheter. The catheter was steered to a point where pacing reproduced the spontaneous activation sequence. RESULTS. Foci were right atrial in eight patients and left atrial in two. In 8 of 10 patients, 514 +/- 97 (SE) J and 5.7 +/- 2.3 (SD) J radiofrequency energy applications ablated the ectopic focus. Seven of these eight patients presented with one focus and one had two discrete and stable foci. Ablation was unsuccessful in two patients with multiple foci. No complications occurred. An arrhythmia focus recurred in two patients and one patient underwent successful repeat ablation. The other patient was managed medically. All seven patients with successful ablation are symptom free after 6.5 +/- 3.8 months. CONCLUSIONS. Our preliminary experience suggests that with the use of both paced activation sequence mapping and standard techniques, radiofrequency ablation of ectopic atrial tachycardia may be a safe and effective form of therapy.

    Title Radiofrequency Endocardial Catheter Ablation of Accessory Atrioventricular Pathway Atrial Insertion Sites.
    Date March 1993
    Journal Circulation
    Excerpt

    BACKGROUND. High rates of success using radiofrequency ablation energy have rapidly transformed catheter ablation from an investigational procedure to the nonpharmacological therapy of choice for symptomatic Wolff-Parkinson-White syndrome. Prior studies of radiofrequency accessory pathway ablation were based on a ventricular approach. Risks associated with prolonged arterial catheter manipulation, retrograde left ventricular catheterization, and production of ventricular lesions required for successful ventricular insertion ablation can be avoided using atrial insertion ablation procedures. The purpose of the present study was to define the safety and efficacy of accessory pathway ablation using radiofrequency energy delivered solely to accessory atrioventricular pathway atrial insertion sites. METHODS AND RESULTS. One hundred fourteen patients with accessory pathway-mediated tachycardia underwent attempted radiofrequency current ablation at the accessory pathway atrial insertion site. All catheters were introduced transvenously. Left-sided accessory pathways were approached using transseptal left atrial catheterization techniques. Retrograde localization of the atrial insertion site during reentrant tachycardia was characterized by 40 +/- 15-msec local ventriculoatrial and 79 +/- 17-msec surface QRS to local atrial electrogram intervals. Presumed accessory pathway potentials were present in only 30% of ablation site electrograms. Successful ablation required 6.2 +/- 5.3 radiofrequency energy applications. Cumulative energy dose required for success was 2,341 +/- 2,233 J. There were no complications associated with transseptal catheterization. Energy delivery to accessory pathway atrial insertion sites was associated with non-life-threatening complications in two patients. Recurrent conduction requiring repeat ablation occurred in 10 of 115 (9%) successfully ablated accessory pathways, all within 1 month of the ablation procedure. After 21.2 +/- 4.6 months of follow-up, 108 of 114 (95%) patients are asymptomatic and without evidence of accessory pathway conduction. CONCLUSIONS. The atrial insertion approach to accessory pathway ablation is safe and highly effective. This approach compares favorably with the retrograde ventricular insertion ablation technique. Atrial insertion ablation eliminates the need to produce ventricular lesions and avoids the risks of prolonged arterial catheter manipulation and retrograde left ventricular catheterization.

    Title Catheter Ablation of Hemodynamically Compromising Incessant Atrioventricular Tachycardia.
    Date March 1992
    Journal Journal of Electrocardiology
    Excerpt

    A 27-year-old woman was admitted to the Georgetown University Hospital with refractory hemodynamically compromising incessant atrioventricular tachycardia. A single left-sided accessory pathway was identified and successfully modified acutely. Endocardial delivery of direct current energy provided an extremely effective therapeutic intervention resulting in termination of atrioventricular tachycardia and restoration of stable hemodynamic status. Although a second ablation procedure was necessary to permanently interrupt accessory pathway conduction, the patient has remained free of symptoms without medications for 13 months.

    Title The Signal-averaged Electrocardiogram in Predicting Coronary Artery Disease.
    Date December 1991
    Journal American Heart Journal
    Excerpt

    The ability to noninvasively detect coronary artery disease (CAD) in patients undergoing diagnostic cardiac catheterization was studied using a signal-averaged electrocardiogram. An initial study of 13 patients revealed that a QRS duration greater than or equal to 100 msec, a root mean square voltage in the terminal 40 msec of the QRS less than 50 microV, and a low amplitude signal (LAS) duration greater than 28 msec were suggestive of CAD. These parameters were then used prospectively to examine 40 consecutive patients with chest pain of undetermined etiology referred for cardiac catheterization. Patients with CAD had significantly longer filtered QRS and LAS durations and lower root mean square voltages compared with patients without CAD. The sensitivity, specificity, and positive predictive value of a single parameter ranged from 62% to 76%, 74% to 89%, and 75% to 87%, respectively. Thus the signal-averaged electrocardiogram may be a useful tool in evaluating patients for the presence of CAD.

    Title Evidence That Cocaine Slows Cardiac Conduction by an Action on Both Av Nodal and His-purkinje Tissue in the Dog.
    Date November 1991
    Journal Journal of Electrocardiology
    Excerpt

    The effects of intravenous cocaine (2 mg/kg) were tested on several indices of cardiac electrical activity in sedated dogs. These included sinus rate, PR, AH, and HV intervals; AV nodal effective refractory period (AVNERP); ventricular effective refractory period; QRS duration; and the QT interval. Cocaine induced significant changes in six control animals with an intact-functioning autonomic nervous systems. After pharmacologic autonomic blockade with propranolol plus propantheline, cocaine increased the PR interval (+ 11 +/- 4.0 ms, p less than 0.05), primarily by slowing conduction at the AV nodal level. However, with constant atrial pacing at a rate above the sinus cycle length, prolongation of both the AH and the HV intervals (+ 15 +/- 2.5 and 6.7 +/- 1.7 ms, respectively) occurred. There was also a significant increase in the AVNERP (+ 29 +/- 5.9 ms, p less than 0.05). Consistent with the observed rate-dependent HV prolongation, cocaine decreased the rate of rise of phase 0 of the transmembrane action potential of Purkinje fibers. These data indicate that cocaine impairs cardiac conduction by direct actions on AV nodal and His-Purkinje cells.

    Title Sudden Death During Empiric Amiodarone Therapy in Symptomatic Hypertrophic Cardiomyopathy.
    Date February 1991
    Journal The American Journal of Cardiology
    Excerpt

    Amiodarone is reported to improve symptoms and to prevent sudden death in patients with hypertrophic cardiomyopathy (HC). Amiodarone treatment (loading dose 30 g given over 6 weeks; maintenance dose 400 mg/day) was prospectively evaluated in 50 patients with HC in whom the drug was initiated because of symptoms refractory to conventional drug therapy (calcium antagonists and beta blockers). Twenty-one (42%) patients had ventricular tachycardia (VT) during Holter monitoring. Amiodarone significantly and often markedly improved the patients' New York Heart Association functional class status (from 3.3 to 2.7 at 2 months, p less than 0.001) and treadmill exercise duration (p less than 0.001). Eight patients, however, died (7 suddenly) during a mean follow-up period of 2.2 +/- 1.8 years. Of the 7 sudden deaths, 6 occurred within 5 months of initiation of treatment. The 6-month and 1- and 2-year survival rates were 87, 85 and 80%, respectively. The survival rate of patients with VT was significantly worse than that of patients without VT (61 vs 97% at 2 years; p less than 0.01). Sudden death occurred despite abolition of VT on Holter monitoring. Amiodarone increased left ventricular peak filling rate by radionuclide angiography in 20 of 33 patients (61%) (p less than 0.01). Decrease in peak left ventricular filling rate within 10 days of amiodarone therapy (8 of 33 patients) was associated with subsequent sudden death (p less than 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Beneficial and Detrimental Effects of Lidoflazine in Microvascular Angina.
    Date July 1990
    Journal The American Journal of Cardiology
    Excerpt

    Lidoflazine, a piperazine derivative calcium antagonist, was investigated as therapy in 22 patients with microvascular angina (chest pain, angiographically normal coronary arteries and left ventricle, microvascular constrictor response to pacing after ergonovine administration and limited coronary flow response to dipyridamole). Eighteen of 22 patients reported symptom benefit while taking lidoflazine 360 mg daily. Compared to baseline exercise treadmill testing, lidoflazine resulted in significant improvement in exercise duration (812 +/- 337 vs 628 +/- 357 seconds, p less than 0.01) and time to onset of chest pain (530 +/- 343 vs 348 +/- 246 seconds, p less than 0.01). The 5 patients with ischemic ST-segment changes during baseline testing demonstrated an almost 4-minute delay in ST-segment depression (3 patients) or no ST-segment depression (2 patients) while taking lidoflazine. Repeat invasive study of coronary flow in 11 patients taking lidoflazine demonstrated significantly greater coronary vasodilation at rest, during pacing, during pacing after ergonovine and after dipyridamole administration (all p less than 0.03), compared to the initial drug-free study. During the randomized, placebo-controlled phase of the study with 7-week treatment periods, 9 of 11 patients who completed this phase of the study preferred lidoflazine and all demonstrated improved exercise capacity with lidoflazine compared to placebo. However, 3 patients developed malignant ventricular arrhythmias, and 1 died while taking lidoflazine, resulting in termination of the study. Limited coronary vasodilator response in microvascular angina has a reversible vasoconstrictor component and may be due to elevated systolic calcium levels. Despite the hemodynamic, symptom and exercise benefit, lidoflazine may be unsafe for clinical use because of its propensity to cause potentially fatal ventricular arrhythmias.

    Title Chest Case of the Day. Tetralogy of Fallot with Pulmonary Atresia (pseudotruncus Arteriosus).
    Date June 1990
    Journal Ajr. American Journal of Roentgenology
    Title Factors Determining Whether Cocaine Will Potentiate the Cardiac Effects of Neurally Released Norepinephrine.
    Date March 1990
    Journal The Journal of Pharmacology and Experimental Therapeutics
    Excerpt

    The purpose of the present study was to re-evaluate the effects of cocaine on cardiac responses elicited by sympathetic nerve stimulation. Cats anesthetized with pentobarbital and subjected to spinal cord transection were used. Control heart rate increases were obtained to submaximal stimulation of postganglionic accelerator nerves, before and after i.v. bolus doses of cocaine ranging from 0.0625 to 2.0 mg/kg. Maximal potentiation of heart rate increases elicited by nerve stimulation were observed with 0.25 mg/kg. In precocaine controls, stimulation increased sinus rate by 31 +/- beats/min; 30 sec to 1 min after cocaine (0.25 mg/kg), stimulation increased sinus rate by 55 +/- beats/min. Maximal potentiation (80 +/- 10%) was observed at 30 sec to 1 min after cocaine administration, and was usually over by 45 to 60 min later. Cocaine was repeated twice (0.25 mg/kg i.v.) at hourly intervals and the magnitude of potentiation was only 19 +/- 6 and 24 +/- 4%, respectively, indicating that tachyphylaxis had developed toward cocaine's potentiating effect. Dose-response studies indicated that as little as 0.0625 mg/kg of cocaine can potentiate heart rate increases elicited by sympathetic nerve stimulation. Doubling the dose to 0.125 mg/kg, and again to 0.25 mg/kg, resulted in a linear dose-related increase in the magnitude of potentiation. However, doubling the dose again to 0.5 mg/kg and increasing this dose by 4-fold to 2 mg/kg did not result in additional potentiation. Indeed, there was a significant drop-off in the magnitude of potentiation to nerve stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Electrophysiologic Abnormalities in Patients with Hypertrophic Cardiomyopathy. A Consecutive Analysis in 155 Patients.
    Date December 1989
    Journal Circulation
    Excerpt

    Electrophysiologic studies (EPS) were performed in 155 patients with hypertrophic cardiomyopathy (HCM). Indications for EPS were cardiac arrest in 22 patients, syncope in 55 patients, presyncope in 37 patients, asymptomatic ventricular tachycardia (VT) in 24 patients, palpitations in 10 patients, and a strong family history of sudden cardiac death in seven patients. Thirty-five (23%) patients had significant resting left ventricular outflow tract obstruction. Electrophysiologic abnormalities were present in 126 (81%) patients. A high prevalence of abnormal sinus-node function (66%) and His-Purkinje (HV) conduction (30%) was noted. The most commonly induced supraventricular arrhythmias were atrial reentrant tachycardia and atrial fibrillation (10% and 11% of patients, respectively). Accessory atrioventricular pathways were present in seven (5%) patients. Programmed ventricular stimulation (PVS) induced nonsustained ventricular tachycardia in 22 (14%) patients and sustained ventricular arrhythmia in 66 (43%) patients. Sustained ventricular arrhythmia was polymorphic VT in 48 (73%) patients, monomorphic VT in 16 (24%) patients, and ventricular fibrillation in two (3%) patients. Induction was with two premature stimuli in 19 (29%) patients and three premature stimuli in 47 (71%) patients. Of 17 cardiac arrest survivors with sustained ventricular arrhythmia, 16 (94%) patients required three premature stimuli for arrhythmia induction. Sustained ventricular arrhythmia was induced at a right ventricular site in 51 (77%) patients and at a left ventricular site in 15 (23%) patients. Univariate analysis showed a significant (p less than 0.05) association between inducibility of sustained ventricular arrhythmia and VT on Holter in patients with a history of cardiac arrest or syncope but not in patients with presyncope or asymptomatic patients. Multivariate logistic regression analysis revealed that the following were significantly associated with inducibility of sustained ventricular arrhythmia: clinical presentation (cardiac arrest more than syncope more than presyncope more than asymptomatic patients, p = 0.0002; chronic or inducible atrial fibrillation, p = 0.002; and male gender, p = 0.04). In contrast, there was no clinical correlate of induced nonsustained VT.(ABSTRACT TRUNCATED AT 400 WORDS)

    Title Enhanced Regional Left Ventricular Function After Distant Coronary Bypass by Means of Improved Collateral Blood Flow.
    Date August 1989
    Journal Journal of the American College of Cardiology
    Excerpt

    To determine whether coronary artery bypass surgery can improve function in left ventricular regions not amenable to direct revascularization, 24 patients with multivessel coronary artery disease were studied by radionuclide angiography and coronary arteriography before and 6 months after coronary artery bypass surgery. All had proximal stenosis of the left circumflex artery or a major obtuse marginal branch. Left ventricular regional function was assessed by dividing the left ventricular region of interest into 20 sectors; the 8 sectors corresponding to the posterolateral free wall were used to assess function in the left circumflex artery distribution. Change in function in the left anterior descending territory was not analyzed because of the non-specific septal hypokinesia that develops postoperatively. For the total group, coronary artery bypass surgery significantly increased both global left ventricular ejection fraction during exercise (43 +/- 13% to 50 +/- 14%, p less than 0.001) and the change in ejection fraction from rest to exercise (-7 +/- 10% to 0 +/- 6%, p less than 0.001). Such improvement was observed in 9 of 10 patients with all stenoses bypassed, and to an equivalent degree in 9 of 10 patients in whom the left circumflex artery either could not be bypassed or the bypass graft was occluded (but bypass grafts to other coronary arteries were patent). Similarly, regional ejection fraction in posterolateral segments during exercise also increased comparably after operation in patients with a patent (from 57 +/- 18% to 70 +/- 19%, p less than 0.001) or nonpatent (from 51 +/- 14% to 68 +/- 14%, p less than 0.001) left circumflex graft.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title The Effect of Coronary Artery Bypass Grafting on Left Ventricular Systolic Function at Rest: Evidence for Preoperative Subclinical Myocardial Ischemia.
    Date June 1988
    Journal The American Journal of Cardiology
    Excerpt

    Successful coronary artery bypass grafting (CABG) improves exercise-induced left ventricular (LV) dysfunction in patients with coronary artery disease (CAD), but its potential for improving resting LV function remains controversial. To assess the influence of CABG on LV function at rest, 31 CAD patients without previous myocardial infarction were studied before and 6 months after CABG by radionuclide angiography after all cardiac medicines were withdrawn. No patient had angina or ischemic electrocardiographic changes at rest. In 27 patients with patent bypass grafts, CABG significantly increased LV ejection fraction during exercise (47 +/- 11% before to 63 +/- 9% after operation, p less than 0.001), indicating reduction in exercise-induced LV ischemia. Moreover, LV ejection fraction at rest also increased (55 +/- 9 to 60 +/- 8%, p less than 0.001), with 20 of 27 patients manifesting an increase compared with preoperative values. Eleven of these 20 patients had apparently normal LV function at rest (ejection fraction and regional wall motion) before CABG. LV regional ejection fraction was computed by dividing the LV region of interest into 20 sectors. Regional analysis indicated that improved ejection fraction at rest after CABG occurred in regions developing ischemia during exercise before CABG. In 4 patients with occluded grafts, the ejection fraction at rest was unchanged by CABG globally (59 +/- 8 to 58 +/- 9%, difference not significant) and regionally. Thus, LV global and regional function at rest improved after successful CABG, even in patients with normal global LV ejection fraction and no visually detectable wall motion abnormality before surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Differences in Coronary Flow and Myocardial Metabolism at Rest and During Pacing Between Patients with Obstructive and Patients with Nonobstructive Hypertrophic Cardiomyopathy.
    Date August 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    Fifty patients with hypertrophic cardiomyopathy underwent invasive study of coronary and myocardial hemodynamics in the basal state and during the stress of pacing. The 23 patients with basal obstruction (average left ventricular outflow gradient, 77 +/- 33 mm Hg; left ventricular systolic pressure, 196 +/- 33 mm Hg, mean +/- 1 SD) had significantly lower coronary resistance (0.85 +/- 0.18 versus 1.32 +/- 0.44 mm Hg X min/ml, p less than 0.001) and higher basal coronary flow (106 +/- 20 versus 80 +/- 25 ml/min, p less than 0.001) in the anterior left ventricle, associated with higher regional myocardial oxygen consumption (12.4 +/- 3.6 versus 8.9 +/- 3.3 ml oxygen/min, p less than 0.001) compared with the 27 patients without obstruction (mean left ventricular systolic pressure 134 +/- 18 mm Hg, p less than 0.001). Myocardial oxygen consumption and coronary blood flow were also significantly higher at paced heart rates of 100 and 130 beats/min (the anginal threshold for 41 of the 50 patients) in patients with obstruction compared with those without. In patients with obstruction, transmural coronary flow reserve was exhausted at a heart rate of 130 beats/min; higher heart rates resulted in more severe metabolic evidence of ischemia with all patients experiencing chest pain, associated with an actual increase in coronary resistance. Patients without obstruction also demonstrated evidence of ischemia at heart rates of 130 and 150 beats/min, with 25 of 27 patients experiencing chest pain. In this group, myocardial ischemia occurred at significantly lower coronary flow, higher coronary resistance and lower myocardial oxygen consumption, suggesting more severely impaired flow delivery in this group compared with those with obstruction. Abnormalities in myocardial oxygen extraction and marked elevation in filling pressures during stress were noted in both groups. Thus, obstruction to left ventricular outflow is associated with high left ventricular systolic pressure and oxygen consumption and therefore has important pathogenetic importance to the precipitation of ischemia in patients with hypertrophic cardiomyopathy. Patients without obstruction may have greater impairment in coronary flow delivery during stress.

    Title Determinants of Ventricular Arrhythmias in Mildly Symptomatic Patients with Coronary Artery Disease and Influence of Inducible Left Ventricular Dysfunction on Arrhythmia Frequency.
    Date March 1987
    Journal Journal of the American College of Cardiology
    Excerpt

    To determine the relation among ventricular arrhythmias, prognostic factors and reversible ischemia in coronary artery disease, 131 drug-free, minimally symptomatic patients were studied by radionuclide angiography and 24 hour Holter electrocardiographic monitoring. High grade ventricular arrhythmias (couplets, salvos of premature ventricular complexes and R on T phenomenon) were observed in 33 patients (25%) and were related to lower rest and exercise ejection fraction, greater number of stenotic coronary arteries and higher prevalence of regional wall motion abnormalities at rest (all p less than or equal to 0.1). Among patients with subnormal rest ejection fraction, high grade arrhythmias occurred with greater prevalence in those with reversible left ventricular dysfunction (reduction in ejection fraction) during exercise compared with those with a normal ejection fraction response (59 versus 23%, p less than 0.05), a relation observed principally in patients with multivessel disease. These data indicate that in minimally symptomatic patients with coronary artery disease, arrhythmias are related to both extent of disease and severity of regional and global ventricular dysfunction and are most prevalent in patients with ventricular dysfunction and evidence of inducible ischemia, factors indicating poor long-term prognosis during medical therapy.

    Title Valve Replacement in Narrow Aortic Roots: Serial Hemodynamics and Long-term Clinical Outcome.
    Date December 1986
    Journal The Annals of Thoracic Surgery
    Excerpt

    No long-term data are available that correlate clinical outcome with serial hemodynamic studies for small-diameter (17-mm or 19-mm) aortic prostheses implanted without enlargement of the annulus. After insertion of these valves without annuloplasty, 52 patients underwent resting catheterization and were followed up at the Surgery Clinic of the National Heart, Lung, and Blood Institute for 295 patient-years (mean, 5.7 years per patient). At similar flow rates, peak systolic gradients across 17-mm Björk-Shiley aortic prostheses (N = 6) tended to exceed those of the 19-mm Björk-Shiley model (N = 38); these gradients averaged 30 +/- 6 mm Hg (mean +/- standard error of the mean) and 20 +/- 2 mm Hg, respectively (p = .053). Those patients with 19-mm Hancock (N = 4) and St. Jude Medical valves (N = 4) were studied, and the lowest prosthetic gradients were found with the St. Jude Medical prosthesis (mean, 3 +/- 2 mm Hg). Aortic gradient was independent of flow for 17-mm but not for 19-mm Björk-Shiley valves. There was no difference in calculated effective orifice area with respect to valve size. Effective orifice area and prosthetic gradients were stable during intervals of 2 to 12 years in 10 patients who underwent additional catheterizations. No association was found between prosthetic gradients, flows, or calculated orifice areas and early or late functional class. Actuarial survival was 86 +/- 5% at 5 years, 83 +/- 5% at 8 years, 71 +/- 9% at 10 years, and 60 +/- 12% at 12 years of complete follow-up. It is concluded that small aortic prostheses provide acceptable palliation for long periods and that resting hemodynamic studies have a limited predictive value for long-term prognosis.

    Title Sudden Death and Hypertrophic Cardiomyopathy.
    Date December 1985
    Journal American Heart Journal
    Title The Modern Management of Minimally Symptomatic Atrial Fibrillation in the Post-affirm Era.
    Date
    Journal Current Treatment Options in Cardiovascular Medicine
    Excerpt

    Atrial fibrillation is the most common cardiac arrhythmia and presents a unique management challenge for the physician. Given the variability of clinical presentation as well as the variability of clinical sequelae, no single approach meets all patients' needs. This challenging arrhythmia has recently been reviewed in the American College of Cardiology/American Heart Association/European Society of Cardiology guidelines. This comprehensive document goes a long way toward organizing clinical treatment approaches. However, new information gathered in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial further helps the clinician with clinical assessment. Together, these major documents are invaluable to the clinician and provide a rational basis on which to make clinical decisions.

    Title Primary Care Physicians' Evaluation and Treatment of Depression: Results of an Experimental Study Using Video Vignettes.
    Date
    Journal Medical Care Research and Review : Mcrr
    Excerpt

    Little is known about how patient and primary care physician characteristics are associated with quality of depression care. The authors conducted structured interviews of 404 randomly selected primary care physicians after their interaction with CD-ROM vignettes of actors portraying depressed patients. Vignettes varied along the dimensions of medical comorbidity, attributions regarding the cause of depression, style, race/ethnicity, and gender. Results show that physicians showed wide variation in treatment decisions; for example, most did not inquire about suicidal ideation, and most did not state that they would inform the patient that there can be a delay before an antidepressant is therapeutic. Several physician characteristics were significantly associated with management decisions. Notably, physician age was inversely correlated with a number of quality-of-care measures. In conclusion, quality of care varies among primary care physicians and appears to be associated with physician characteristics to a greater extent than patient characteristics.

    Title 2011 Accf/aha/hrs Focused Update on the Management of Patients with Atrial Fibrillation (updating the 2006 Guideline): a Report of the American College of Cardiology Foundation/american Heart Association Task Force on Practice Guidelines.
    Date
    Journal Journal of the American College of Cardiology
    Title 2011 Accf/aha/hrs Focused Update on the Management of Patients with Atrial Fibrillation (updating the 2006 Guideline): a Report of the American College of Cardiology Foundation/american Heart Association Task Force on Practice Guidelines.
    Date
    Journal Heart Rhythm : the Official Journal of the Heart Rhythm Society

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