Mankin, Harold T.

Experience with 110 separate periods of transvenous cardiac pacing by means of a catheter-electrode in 91 patients has been reviewed. Indications for the use of the catheter-electrode included (1) complete heart block with and without Adams-Stokes syndrome, (2) other arrhythmias with and without cardiogenic syncope, (3) malfunction of previously implanted permanent pacemaker units, and (4) need for pacing during general surgical procedures in patients with a variety of rhythm disturbances. A case illustrating the combined use of drug therapy and catheter-electrode pacing in controlling paroxysmal ventricular tachycardia is presented. Only six deaths occurred in spite of the serious heart disease in all 91 patients in this series. Two were related to complications of temporary transvenous intracardiac pacing. The major complications associated with the procedure included perforation of the heart, bacteremia, acute myocardial infarction, cephalic vein phlebitis, and ventricular tachyarrhythmia. Minor problems were primarily related to equipment failure or positional difficulties with the catheter-electrode and were usually of no serious consequence.

Calcific emboli were observed in 38 of 62 patients (61 per cent) who died at varying intervals following aortic valvotomy for calcific aortic stenosis. Major coronary embolization occurred in 10 patients (16 per cent) and was considered to be a major cause of death of four patients. Minor coronary embolization occurred in 33 patients (53 per cent) and was not directly implicated as a cause of death in any patient. Calcific emboli occurred to other organs in eight patients (13 per cent). The technics instituted for reducing the incidence of embolization—occlusion of coronary ostia, diligence in detection and removal of any debris, and final aspiration of the left ventricle—appeared to have had a favorable effect.

The problem of spontaneous calcific embolization was investigated at necropsy in 165 patients with calcific aortic stenosis. Minor coronary arteries contained calcific emboli in 18 patients (11 per cent), and major coronary arteries contained calcific emboli in 10 (6 per cent). Examination of the brain, kidney, and eye also disclosed spontaneous calcific emboli. In three instances of major coronary artery embolization, there was evidence of old silent infarction but no associated clinical disorder. Calcific embolization is apparently not rare in cases of calcific aortic stenosis, but this phenomenon does not appear to lead very often to extensive infarction or to clinically obvious disorders.

Calcareous disease of the aortic valve, diagnosed by fairly uniform signs and measurements, has been treated in 14 cases at the Mayo Clinic by an open surgical technic with utilization of extracorporeal circulation. One patient died during the operation and another died after leaving the hospital. Among 7 cases followed 6 to 9 months after operation, definite symptomatic improvement has been shown in 6. This disease is very dangerous, but a small improvement in the size of the valvular orifice can bring important benefits. The open operation is advantageous in avoidance of creating or aggravating insufficiency while relieving stenosis. Presently this operation is advised for patients whose disability is significant or progressing. Severe coexisting coronary artery disease is a contraindication; but associated aortic valvular insufficiency, advanced degrees of disability, and left ventricular failure are not.