1666

Letters

to the Editor

American

December 1992 Heart Journal

means of intravascular countertraction, 9% were removed except for the electrode, and only 1 S’urequired a limited surgical approach with countertraction or a ventriculotomy. We were able to remove all of the leads. Myers et al.’ are correct in stating that training in this new technique is advisable and because of potentially lifethreatening complications, surgical backup is mandatory. The procedure is not simple, but it is safe, effective, and transferrable. We have succeeded where others have failed. 945 Arthur

Charles L. Byrd, MD Godfrey Rd., Suite 202 Miami Beach, FL 3.3140

REFERENCE

1. Myers MR, Parsonnet V, Bernstein AD. Extraction of implanted transvenous pacing leads: a review of a persistent clinical problem. AM HEART J 1991;121:881-8. 4/a/41626

REPLY To the Editor:

Dr. Byrd’s comments are based largely on results that he and his colleagues have published (in at least seven papers and abstracts) during the 19 months between the submission of our manuscript and the receipt of his letter. During that time we have also studied our own results with lead extraction in more detail (to be published) and have found that in 36 leads extracted from 25 patients, simple manual traction and the use of the Byrd extractor were about equally successful. In fact, the failure rate for both techniques was approximately 35 o/o.The problem with Dr. Byrd’s appraisal of his own technique is that he has not compared the extractor method with manual traction alone. We attempt manual traction first. If this does not succeed, which is the case in about one third of the trials, we then use the extractor as he has described, eventually using the Cook approach for the existing lead or the retrograde approach through the femoral vein. Therefore there has not yet been a thorough objective appraisal of the extractor technique, although there is no question that this method does make it possible to remove many leads that could not be removed by manual traction alone. The distressing issue with regard to the extractor experience has been the incidence of rather serious complications, at least in our hands. In the 10 cases in which it was used, there were two instances of cardiac tamponade, both of which required immediate thoracotomy. For this reason we recommend that these procedures be done in a facility where immediate thoracotomy can be performed and that the patient be prepped and draped accordingly beforehand. Victor Parsonnet, MD Newark Beth Israel Medical Center 201 Lyons Ave. at Osborne Terrace Newark, NJ 07112 4/6/41827

HEPARIN FOR LEFT VENTRICULAR

THROMBUS

To the Editor:

The resolving of a large left ventricular thrombus in a patient with dilated cardiomyopathy by conventional anticoagulation has

Fig. 1. Apical two-dimensional echocardiogram showing pedunculated thrombus from endocardial surface of apex of left ventricle. Top, Amplified view.

been described in the JOURNAL.~Resolution of the thrombus was achieved by means of standard anticoagulation within 3 weeks. We agree that it cannot be determined how soon a thrombus is resolved after anticoagulant therapy is begun. We recently resolved a large and pedunculated thrombus in the left ventricle by means of intravenous heparin and oral acenocoumarol in a patient with an inferior myocardial infarction. The thrombus d&appeared within 13 days after anticoagulant therapy was begun (Figs. 1 and 2). The thrombolysis may have been produced by the lytic effect of heparin. Thrombi frequently form after anterior transmural myocardial infarction and in patients with dilated cardiomyopathy. Anticoagulant therapy is currently indicated in dilated cardiomyopathy, whereas controversy exists regarding the prevention of embolic episodes in patients with thrombus after myocardial infarction.3 In our patient we decided to carry out anticoagulation because of the pedunculated nature and mobility of the thrombus. Jesus Peteiro, MD Perez Gomez, MD Servicio de Cardiologia Hospital Juan Canalejo Puseo de Ronda 5-4” izda A Coruiia 15011 Spain

Volume Number

124 6

Fig. 2. Second two-dimensional echocardiogram 13 days later showing complete disappearance of thrombus.

REFERENCES

1. Butman SM. Rapid resolution of a massive left ventricular thrombus by usual systemic anticoagulation. AM HEARTJ

1991;122:864-6.

2. Kyrle KA, Korninger C, Gossinger H, Glogar D, Lechner K, Niessner H, Pabinger I. Prevention of arterial and pulmonary embolism by oral anticoagulants in patients with dilated cardiomyopathy. Thromb Haemost 1985;54:521-3. 3. Halperin JL, Petersen P. Thrombosis in the cardiac chambers: ventricular dysfunction and atria1 fibrillation. In: Fuster V, Verstraete M, eds. Thrombosis in cardiovascular disorders. Philadelphia: WB Saunders, 1992;165-87. 4l8141828

AMBULATORY BLOOD PRESSURE AND POSTPRANDIAL HYPOTENSION To the Editor:

The recent introduction of a noninvasive ambulatory blood pressure (BP) monitoring technique has provided a great deal of information concerning changes in BP along with various types of physical behavior. Changes in BP in relation to ingestion of meals is representative of them. Patients with autonomic dysfunction

Letters to the Editor

1669

often become hypotensive after eating (postprandial hypotension [PPH]), and this PPH usually lasts for 2 or 3 hours. Therefore noninvasive ambulatory BP monitoring is convenient for detecting a BP reduction after meals. Inasmuch as the frequency of PPH has yet to be determined, we monitored the circadian pattern of BP with special reference to prandial behavior. The purpose of this report was to introduce our experience in treating PPH with caffeine and a somatostatin analogue. Ambulatory BP was monitored in 100 clinically healthy volunteers (55 subjects aged 21 to 40 years; 45 subjects aged 41 to 60 years), 50 patients with hypertension (aged 41 to 60 years), 22 patients with diabetes (aged 47 to 74 years), and 15 patients with Parkinson’s disease (aged 45 to 75 years). Measurements of systolic and diastolic BP and heart rate (HR) were obtained at 15-minute intervals over 48 hours with an ambulatory monitor (ABPM-630, Colin Medical Instruments Inc., Komaki, Japan). This instrument provides both oscillometric and auscultatory measurements. The accuracy of this device has been validated previously.‘-” It is small (16.5 x 3.6 X 8.9 cm), lightweight (830 gm), and nearly silent; hence it is less sleep disturbing. Carbon dioxide cartridges are required to inflate the cuff. Data and events (four event markers are provided by the instrument) are recorded in a solid-state memory, which holds more than 600 sets of data and can be connected to an analyzer (AS-loo) for transfer of data to a personal computer for analysis. PPH was defined in this study as a decrease in systolic BP of more than 20 mm Hg within 3 hours after a meal was eaten. When PPH was observed at least once among the six meal times during the 48hour monitoring period, those subjects were defined as having PPH. In the patients selectively found to have PPH, it was confirmed by a 75 gm oral glucose tolerance test (OGTT). That is, all medication was withheld for 1 day before the study, and there was no oral intake of fluid after midnight. BP and HR were monitored every 5 minutes for at least 3 hours after oral administration of 75 gm of glucose in 225 ml of water. Blood samples were drawn for analysis of glucose and insulin levels at 0, 30, 60, and 120 minutes after the oral administration of glucose. Blood glucose and plasma insulin levels were measured by the Glu-DH method and radioimmunoassay, respectively. In three patients with Parkinson’s disease who had PPH, 250 mg of caffeine was administered orally with 100 ml of water 30 minutes before the 75 gm OGTT. In one of the three patients with Parkinson’s disease, the effect of somatostatin on PPH was also examined. A low dose of a long-acting somatostatin analogue @MS-201-995, 0.4 pg/kg, Sandoz, Inc., East Hanover, N.J.) was administered subcutaneously 30 minutes before the same 75 gm OGTT. An example of a 48-hour BP profile in a patient with PPH is shown in Fig. 1. PPH appears repeatedly after meals are eaten. It should be noted that PPH was observed even in clinically healthy subjects-that is, in 8 of 55 subjects (14.5%) aged 21 to 40 years and 13 of 45 (28.9%) aged 41 to 60 years. Among subjects with hypertension or diabetes, PPH was observed in 18 of 50 (36.0:;) and in 6 of 22 (27.2%), respectively. PPH was most frequently observed in patients with Parkinson’s disease-10 of 15 (66.7 7;). The postprandial decrease in systolic BP in these patients was more than 30 mm Hg and lasted several hours. One patient with Parkinson’s disease, in whom PPH was confirmed by the 75 gm OGTT, had a decrease in systolic BP up to 60 mm Hg, which lasted for more than 3 hours (Fig. 2). Diastolic BP also decreased along with systolic BP, but the HR did not change significantly. In three patients with such marked PPH, the effect of caffeine was examined. As a result, PPH improved in all of them but was not completely resolved (Fig. 2, Lower panel). PPH was prevented in a patient with Parkinson’s disease not only by pretreatment with caffeine (Fig. 3, Middle panel) but also with a low dose of a long-

Heparin for left ventricular thrombus.

1666 Letters to the Editor American December 1992 Heart Journal means of intravascular countertraction, 9% were removed except for the electrode,...
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