1706 Brief Communications 3. 4. 5. 2. Baerman JM. Hoean L. Swirvn S. Dianhramnatic hernia nro- ducing symptoms-and signs of a left atria1 mass. AM HEART J 1988;116:198-200. D’Cruz IA, Hoffman PK, Ewald FW. Echocardiography of posterior mediastinal masses encroaching on the left atrium. Echocardiography 1989;6:485-96. Percy RF, Conetta DA, Miller AB. Esophageal compression of the heart presenting as an extracardiac mass on echocardio- graphy. Chest 1984;85:826-8. Hoit BD, Eppert D. Presbyesophagus masquerading as an ex- tracardiac mass on echocardiography. AM HEART J 1989; 118:419-21. Daffner RH, Halber MD, Postletwait RW, Korobkin M, Th- ompson WM. CT of the esophagus. II. Carcinoma. AJR 1979;133:1051-5. Moss AA, Schnyder P, Thoeni RF, Margulis AR. Esophageal carcinoma: pretherapy staging by computed tomography. AJR 1981;136:1051-6. Picus D, Balfe DM, Koehler RE, Roper CL, Owen JW. Com- puted tomography in the staging of esophageal carcinoma. Radiology 1983;146:433-8. Quint LE, Glazer GM, Orringer MB, Gross BH. Esophageal carcinoma: CT findings. Radiology 1985;155:171-5. 6. 7. 8. 9. Congenital complete heart block in a neonate Anita Saxena,DM, Atul Mathur, DM, Krishna S. Iyer, MCh, and Kewal K. Talwar, DM. New Delhi, India Congenital complete heart block is a rare disorder with an incidence between 1 in 15,000 and 1 in 20,000live births1 It may be isolated or associated with congenital heart dis- ease.A permanent pacemaker is rarely required in the newborn with isolated complete heart block. We report a case of congenital complete heart block diagnosed at birth that had an unusual presentation. RP, a product of a lower segmentcesarean section, was referred to this hospital at 8 hours of agebecause of a slow heart rate. The baby weighed 3 kg and was mildly jaun- diced; there wasno cyanosis or respiratory distress. Exam- ination of the cardiovascular systemrevealed normal heart sounds and absence of any murmur. The liver was palpa- ble 2 cm below the right costal margin. The electrocardio- gram revealed complete atrioventricular dissociation,with an atria1 rate of 140beats/min and a ventricular rate of 35 to 40 beats/min. The QRS complex was wide, being 0.09 second in duration and the corrected QT, interval was 0.46 second (Fig. 1). There was no increase in the ventricular rate on the infant’s crying or when the infant was given in- travenous atropine. The chest x-ray film showed a normal situs with a cardiothoracic ratio of 50% and normal pulmonary vascularity. Echocardiography revealed vis- From the Cardiothoracic Centre, All India Institute of Medical Sciences. Reprint requests: Dr. Kewal K. Talwar, Department of Cardiology, Car- diothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. 4/4/36480 June 1992 American Heart Journal ceroatrial, atrioventricular, and ventriculoarterial concor- dancewith no intracardiac defect. The left ventricular di- mensions and contractility were normal. The baby was kept under observation in the intensive care unit. Thirty-six hours after birth, the patient had three episodes of non- sustained polymorphic ventricular tachycardia lasting 12 to 16 beats. The fourth episode of ventricular tachycardia lasted more than 20 seconds and required thump cardio- version to return the heart to basal rhythm. At this time the ventricular rate also showeda fall to 28 to 30 beats/min. Emergencypacing wastherefore planned. After unsuccess- ful femoral vein puncture, a 5F bipolar temporary pacing catheter wasintroduced via the umblical vein and through the inferior vena cava and right atrium. The catheter tip was positioned at the right ventricular apex. The pacing rate was set arbitrarily at 100 beats/min. There were no further episodes of ventricular tachyarrhythmia. The mother had no clinical or serologic evidence of any connec- tive tissue disease. Anti-R0 antibodies and antiviral anti- bodies (done for cytomegalovirus and enterovirus) were absent in the baby’s serum.The implantation of a perma- nent pacemakerwasdelayed sincethe baby developedhy- perbilirubinemia (mainly conjugated). To keep the ante- rior abdominal wall cleanfor subsequent permanent pace- maker implantation, the pacingcatheter from the umblical vein was replaced through the right femoral vein. Perma- nent pacemaker implantation was performed on the sev- enteenth day of life. The diaphragmatic surface of the left ventricle wasexposed through a 5 cm long vertical incision centered over the xiphisternum and dividing the sternal attachment of the diaphragm. A 25 cm screw-in epicardial pacing lead (CPI-4316, Cardiac Pacemakers, Inc., St. Paul, Minn.) was affixed to the diaphragmatic surface of the left ventricle. The generator (Vista-445) was implanted in a pocket created posterior to the anterior rectus sheath and anterior to the rectums. Congenitalcomplete heart block resultsfrom a breachof continuity of the atrioventricular conduction systemacross the fibrous atrioventricular anulus.2Congenital complete heart block in the absence of structural heart disease has been considered a relatively benign disorder requiring pacemaker implantation, usually during adolescence or adulthood.‘, 3In a review of 43 patients,4 only 32?A became symptomatic during a follow-up ranging between 1 day and 30 years (mean 12.2 t 10 years). Only one newborn with a narrow QRS escape rhythm at the rate of 50 beats/min un- derwent temporary transvenous pacing because of severe congestive heart failure at birth. That patient, however, died during the procedure because of cardiac perforation. In our case,on the contrary, congestive heart failure was not the indication for pacing. In none of the previously re- ported series had a high-grade ventricular ectopy been re- ported so early in life as in the present case.Our caseis therefore very unusual in having developed nonsustained ventricular tachycardia in the absence of any feature sug- gestive of myocarditis. Since these episodes of ventricular tachyarrhythmia resolved after pacemaker insertion, bradycardia can be implicated in the causationof this ven- tricular irritability. We conclude that congenital complete