bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical and Hemodynamic Studies in Patients with Homograft Mitral Valve Replacement
Authors: GRAHAM ANTHONY F. , SCHROEDER JOHN S. , DAILY PAT O. , HARRISON DONALD C.
Published: June 2012

Debate continues regarding the long-term clinical and hemodynamic benefit of homograft replacement of the diseased mitral valve. The results of valve replacement with mitral homografts in the 120 patients who have had operation at the Stanford Medical Center from May 1967 to November 1970 are given. The operative mortality rate has been 5% and the late mortality rate 6%. Anticoagulants were stopped 6 weeks following surgery and there has been only one thromboembolic complication. Ninety percent of the surviving patients are improved clinically. Thirteen of these patients have been restudied 25 to 41 months after receiving homograft mitral valve replacement. Hemodynamic studies showed a 43% decrease in mean left atrial pressure and 42% decrease in mean pulmonary artery pressure with a 10% increase in mean resting cardiac output. Early diastolic gradients between the left atrium and left ventricle averaging 3.0 mm Hg at rest and 6.0 mm Hg during moderate exercise were present. Left ventricular angiography showed a trace of mitral insufficiency in three patients, moderate to severe in three others, and poor contractility in three other patients with normal homograft function. Mitral insufficiency, when present, was thought to result from poor mounting of the homograft on the metal strut rather than primary deterioration of the valve leaflets. These data indicate that fresh homograft replacement of the mitral valve provides good long-term clinical and hemodynamic benefit in most patients.
Role of Parasympathetic Inhibition in the Hyperkinetic Type of Borderline Hypertension
Authors: JULIUS STEVO , PASCUAL ARTURO V. , LONDON RICHARD
Published: June 2012

Eleven patients with borderline hypertension and high cardiac output were compared to 16 paid healthy volunteers. Cardiac output, heart rate, and intraarterial blood pressure were determined at rest, after administration of 0.2 mg/kg of propranolol i.v., and after administration of an additional 0.04 mg/kg of atropine. In four additional patients, response to infusion of isoproterenol before and after administration of 0.2 mg/kg of propranolol i.v. was evaluated. Resting heart rate and cardiac output in patients with borderline hypertension were elevated. After propranolol infusion, the values decreased more in the patients with borderline hypertension, but remained significantly elevated. After atropine administration, the difference in cardiac output and heart rate between the two groups disappeared. Consequently, patients with borderline hypertension and hyperkinetic circulation simultaneously exhibit an increase of sympathetic and a decrease of parasympathetic tone.
Clinical-Physiological Correlations in the Development of Hypertensive Heart Disease
Authors: FROHLICH EDWARD D. , TARAZI ROBERT C. , DUSTAN HARRIET P.
Published: June 2012

In order to understand more precisely the progression of ventricular dysfunction in hypertension prior to development of ventricular failure, 25 normal volunteer subjects and 97 untreated essential hypertensive patients (21 of whom had coronary arteriography and failed to show significant atherosclerosis) were classified into three groups: (I) normal-sized hearts, 54 patients; (II) left atrial enlargement (ECG criteria), 20 patients; and (III) left ventricular enlargement (ECG and chest X-ray criteria), 23 patients. Heart rate was elevated (
P
< 0.001) in all three groups; total peripheral resistance and arterial pressure increased progressively from group I to II to III (
P
< 0.001); cardiac index was reduced only in group III (
P
< 0.001). However, despite normal cardiac index in group II, left ventricular ejection rate was impaired (
P
< 0.01), and tension-time index and pressure-time per beat were greater than in patients with normal-sized hearts (
P
< 0.001). Thus, left atrial enlargement provided the initial evidence of left ventricular dysfunction. Later, when left ventricular hypertrophy became clinically apparent (always associated with left atrial abnormality) further impairment of left ventricular function was evident. Since these hemodynamic changes were observed in patients with normal coronary arteries, presence of left atrial and ventricular enlargement should provide useful criteria for classifying functional impairment in hypertensive heart disease.
Postextrasystolic Ventricular Pressure Responses
Authors: BECK W. , CHESLER E. , SCHRIRE V.
Published: June 2012

The peak postextrasystolic ventricular pressure was examined in tracings obtained during routine catheterization of the right and left ventricles in 252 cases. The invariable response in the apparently "normal" left ventricle was a fall or no change in peak systolic pressure, whereas in the obstructed left ventricle, the failed left ventricle, the severely volume-overloaded left ventricle, and in mitral stenosis the more usual pattern was a rise in postextrasystolic ventricular pressure. On the right side the usual response both in the normal and abnormal was a rise in postextrasystolic pressures. Significant exceptions were found when the right ventricle ejected against the aortic impedance and in constrictive pericarditis.

In the intact circulation the outflow impedance and its rate of decline during the compensatory pause would appear to be the major determinant of the postextrasystolic pressure response. There is some evidence that alterations in the extent and time course of ventricular filling may be a factor, but the effects of variations in the degree of postextrasystolic potentiation based on variations in the prematurity of the extrasystole, which can so easily be demonstrated under controlled conditions, appear to be largely obscured except when fixed outflow obstruction is present. The only practical value of this observation may be the ability to recognize an "abnormal" left ventricle when the postextrasystolic beat shows a higher peak ventricular pressure and to recognize a right ventricle in free communication with the aorta when the peak right ventricular postextrasystolic pressure fails to rise. Conversely, a lower peak left ventricular systolic pressure following a premature beat should not be misinterpreted as being due to a failure of postextrasystolic potentiation and augmentation, as it is in fact a normal phenomenon.
Effects of Alcohol on the Electrocardiogram
Authors: SERENY GEORGE
Published: June 2012

The electrocardiograms of 1,000 chronic alcoholic patients were examined and analyzed. Evidence is presented that excessive consumption of alcohol, in the absence of organic heart disease, may produce changes in the electrocardiogram. The predominant abnormalities were sinus tachycardia and nonspecific T-wave changes. These abnormalities were present in the majority of the patients, provided that electrocardiograms were taken while the patients were still intoxicated. It is suggested that the changes are caused by two known effects of alcohol: stimulation of catecholamine secretion from the adrenal medulla and alteration of cell membrane permeability.
The Relationship of Pulmonary Venous Wedge to Pulmonary Arterial Pressures
Authors: RAO P. SYAMASUNDAR , SISSMAN NORMAN J.
Published: June 2012

A comparison of pressure levels and pressure-time relationships in pulmonary artery pressure (PAP) and pulmonary venous wedge pressure (PVWP) tracings was made from cardiac catheterization records of 60 patients, aged 1 day to 16 years. In 50 patients with normal or low PAP's there was close correlation between systolic, diastolic, and mean pressures in the two sites. In all 10 patients with pulmonary hypertension the PVWP's were elevated but were significantly different from corresponding PAP's. The wave contours showed qualitative similarities in most cases, but the duration of the rise in systolic pressure was longer, and the Q-pressure intervals were delayed in the PVWP tracings. Satisfactory PVWP's were obtained in 42 of 67 (63%) consecutive patients approached from the leg. Lack of correlation of pressures from the two sites in the presence of pulmonary hypertension may be attributed, in part, to decreased compliance of the pulmonary arterial system. It is concluded that the PVWP is useful in catheter evaluation of heart disease: when the PVWP is normal it usually reflects accurately the PAP; an elevated PVWP suggests an elevated PAP but cannot be used reliably as an indication of the actual arterial pressure.
Hemodynamic Evaluation of Rate Augmentation Produced by Atrial Pacing and Isoproterenol in the Early Postoperative Phase of Cardiac Valve Surgery
Authors: ARMSTRONG PAUL W. , GOLD HERMAN K. , BUCKLEY MORTIMER J. , WILLERSON JAMES T. , SANDERS CHARLES A.
Published: June 2012

The hemodynamic effects of atrial pacing were evaluated in a group of 19 patients soon after cardiac valve surgery. Atrial pacing at 30 beats/min above the control rate of 88 beats/min produced an increase in cardiac index of 600 ml/min/m
2
.

Isoproterenol was infused into eight of these patients to produce an increment in heart rate identical to that during atrial pacing. In these patients atrial pacing produced an increment in cardiac index of 400 ml/min/m
2
as compared to an increment of 1400 ml/min/m
2
produced by isoproterenol.

It is concluded (1) that atrial pacing is a useful technique for augmenting cardiac index soon after cardiac valve surgery and (2) that isoproterenol provides a greater increment in cardiac index at identical heart rates and the major portion of its effect is directly inotropic.
Control of Intractable Ventricular Tachycardia by Coronary Revascularization
Authors: ECKER ROGER R. , MULLINS CHARLES B. , GRAMMER JOHN C. , REA WILLIAM J. , ATKINS JAMES M.
Published: June 2012

Ventricular tachycardia (VT) is an arrhythmia that has an ischemic origin in up to 74% of cases and results in a 42 to 67% mortality when it is recurrent and paroxysmal. Present therapy is aimed at suppression of the abnormal rhythm but does not alter the prognosis of the underlying ischemic heart disease. A new concept of treatment of VT is introduced that is based on direct coronary revascularization by the aorta to coronary, saphenous vein-bypass technique. The method was successfully applied in a 61-year-old man who developed episodes of VT 2 months after myocardial infarction. Maximal medical therapy in a coronary care unit for 26 days did not abolish the arrhythmia which occurred as frequently as seven times an hour. Coronary angiography and aortocoronary bypass grafting were done when the patient developed electrocardiographic and enzyme evidence of subendocardial myocardial infarction and symptoms of cerebral ischemia. The patient remains free of arrhythmia 1 year later, and his exercise capability is now normal for his age. Follow-up coronary angiography is presented. Coronary revascularization has been shown to abolish angina pectoris. This report demonstrates that aortocoronary bypass grafting can abolish an arrhythmia of ischemic origin. When persistent or recurrent VT fails to respond to all medical therapy, direct coronary revascularization should be considered to control this ischemic arrhythmia.
Real-Time Analysis of Cardiac Catheterization Data Using a Computer System
Authors: HARRISON DONALD C. , RIDGES J. DOUGLAS , SANDERS WILLIAM J. , ALDERMAN EDWIN L. , FANTON JOHN A.
Published: June 2012

A computer system for real-time analysis of hemodynamic data from the cardiac catheterization laboratory has been developed. The system utilizes a small digital computer and is compatible with the analog recording equipment generally used in a catheterization laboratory. Calculated results are transmitted to the laboratory by closed circuit TV and are available to the operator instantaneously during the course of the procedure. A permanent hard-copy report is prepared on a teletypewriter at the termination of the catheterization procedure. Comparisons of pressures and value gradients calculated by the computer and physician demonstrate excellent agreement. By utilizing a small computer and programs generally applicable in any cardiac catheterization laboratory, this system can be exported without costly modifications into many laboratories. Additional personnel are not required for implementation.
Etiology of Right Bundle-Branch Block in Patients Undergoing Total Correction of Tetralogy of Fallot
Authors: GELBAND HENRY , WALDO ALBERT L. , KAISER GERARD A. , BOWMAN FREDERICK O. , MALM JAMES R. , HOFFMAN BRIAN F.
Published: June 2012

The electrocardiographic (ECG) pattern of right bundle-branch block (RBBB) occurs routinely in patients after open-heart surgery for tetralogy of Fallot (TF). To determine the etiology of the RBBB pattern, 14 patients with TF, seven with ventricular septal defects (VSD), and one with pulmonary stenosis (PS) were studied during and after cardiac surgery. Bipolar electrograms from 10 selected right ventricular epicardial sites were recorded simultaneously with an ECG. Records were obtained before and immediately after vertical right ventriculotomy, after infundibular resection, and after repair of a ventricular septal defect (VSD). The vertical ventriculotomy alone was always associated with significant prolongation of the time of epicardial activation only to the recording sites lateral to the incision with prolongation of the QRS complex by an average of 39 msec, and with the appearance of an RBBB ECG pattern. Infundibular resection and VSD repair were not associated with any changes in the electrophysiologic parameters measured. A retrospective analysis of 251 patients with TF, VSD, and PS revealed a 100% incidence of RBBB pattern in the electrocardiograms of only those who had undergone ventriculotomy. It can be concluded that the RBBB pattern seen postoperatively in patients with TF is due to changes in right ventricular activation secondary to the vertical ventriculotomy.
Clinical, Surgical, and Pathologic Correlation in Patients with Acute Myocardial Infarction and Pump Failure
Authors: BOLOOKI HOOSHANG , LEMBERG LOUIS , GHAHRAMANI ALI , ECONOMIDES CHRIS , CALDWELL THOMAS , JUDE JAMES R. , Boccabella Kathleen
Published: June 2012

A review was made of the entire hospital course of 20 patients aged 44 to 79 years who suddenly developed clinically intractable left-heart pump failure as a result of acute myocardial infarction. They were divided into three groups according to their presenting circulatory state. Thirteen patients were in cardiac arrest (group I), four had cardiogenic shock due to myocardial rupture (group II), and three had severe intractable left-heart failure (group III). Preoperative partial or complete cardiac catheterization was possible in six patients.

Surgical treatment using cardiopulmonary bypass was selectively undertaken as a mode of therapy in 11 of the 20 cases. In 10, the area of infarction was delineated and was resected. Pathologically, the infarcts were from 1 to 14 days old, and in 19 of 20 cases involved the anterior wall. The specimens weighed 25 to 83 g. One patient, who was discharged, had infarctectomy and double coronary vein bypass graft. One patient lived for 3 weeks after infarctectomy and pulmonary embolectomy. Two others survived after surgery for 2 and 36 hours, respectively.

The results of this prospective study suggest that identification of patients possibly amenable to successful treatment of medically irreversible pump failure by surgical means will require earlier recognition of the high-risk group and intensive hemodynamic and radiographic evaluation of the extent of the disease process.
Natural Course of Peripartum Cardiomyopathy
Authors: DEMAKIS JOHN G. , RAHIMTOOLA SHAHBUDIN H. , SUTTON GEORGE C. , MEADOWS W. ROBERT , SZANTO PAUL B. , TOBIN JOHN R. , GUNNAR ROLF M.
Published: June 2012

Twenty-seven patients presented in the puerperium with cardiomegaly, abnormal `ECG, and congestive cardiac failure and were considered to have peripartum cardiomyopathy (PPCM). The incidence of PPCM was significantly higher in women over 30 years of age, in women in their third or subsequent pregnancy, and in the presence of twins or toxemia. Within 6 months, 14 patients had normal sized hearts (group A), and 13 patients maintained cardiomegaly (group B).

The 14 patients in group A have been followed for 3 to 21 years (average 10.7 years). Two have died of unrelated causes. Of the remaining 12, eight are functional class I and four are functional class II. Eight patients had 21 subsequent pregnancies, with no permanent deterioration of cardiac function. Of 13 patients in group B, 11 (85%) have died of congestive cardiac failure. Their average survival was 4.7 years; six of 11 were dead in 3 years. Their clinical course was punctuated by repeated admissions for congestive cardiac failure. Six had pulmonary emboli, one had a systemic embolus, and three of six patients with subsequent pregnancies deteriorated in the puerperium. Of the two surviving patients, one is functional class I and the other is functional class II.

Therefore, in those patients in whom cardiomegaly persisted, the prognosis was poor, and subsequent pregnancies were likely to lead to permanent deterioration. In those in whom the heart size returned to normal the prognosis was excellent.
Mobitz Type II Block without Bundle-Branch Block
Authors: ROSEN KENNETH M. , LOEB HENRY S. , GUNNAR ROLF M. , RAHIMTOOLA SHAHBUDIN H.
Published: June 2012

His bundle (H) electrograms were recorded in three patients with Mobitz type II block and narrow QRS. Block was secondary to digitalis intoxication in one patient. In the second patient, who had first-degree A-V block, type II block occurred with atrial pacing at a slightly increased heart rate. In the third patient, who had corrected transposition of the great vessels, type II block occurred spontaneously. In two additional patients, block simulating type II block was noted. In one, block of single P waves occurred with carotid massage. In the other, Wenckebach periods with small increments in P-R (and P-H) intervals resembled episodes of type II block. In all five patients, block was proximal to H, suggesting the A-V node as the site of block. The conduction defects in these patients were not progressive; none of the patients needed a pacemaker.

Although these mechanisms were identified in patients with narrow QRS complexes, they could occur with bundle-branch block suggesting an erroneous diagnosis of bilateral bundle-branch disease. It is concluded that His bundle recording is helpful in delineating these benign forms of block. The site of block may be a more important determinant of prognosis than the type of block.
Effects of Isometric Exercise on Cardiac Performance
Authors: KIVOWITZ CHARLES , PARMLEY WILLIAM W. , DONOSO ROBERTO , MARCUS HAROLD , GANZ WILLIAM , SWAN H. J. C.
Published: June 2012

Twenty-two patients with heart disease performed a standard isometric exercise, sustained handgrip, during the course of diagnostic cardiac catheterization. During handgrip an increase in mean arterial pressure (average 87 to 104 mm Hg) was noted in all patients. Coronary sinus blood flow and myocardial O
2
consumption increased (average 45%) in all patients so monitored. Systemic vascular resistance increased in 19 patients, in contrast to the response reported in normal volunteers. The relation between left ventricular stroke-work index and LVEDP (left ventricular function curve) during the control state and during the fourth minute of sustained handgrip provided a simple estimate of left ventricular reserve and correlated well with the New York Heart Association functional classification of the patient studied. Patients with good reserve had a rise in stroke-work with little or no change in LVEDP. Patients with poor reserve had a fall in stroke-work together with a substantial rise in LVEDP. It is concluded that the stress imposed by sustained handgrip provides a simple test for the evaluation of left ventricular reserve.
Serum Cardiac Glycoside Assay Based upon Displacement of
3
H-Ouabain from Na-K ATPase
Authors: BROOKER GARY , JELLIFFE ROGER W. , Cochran Victoria , Sauer Sabine
Published: June 2012

An assay of serum digoxin and other cardiac glycosides by displacement of
3
H-ouabain from Na-K ATPase is described. It is rapidly set up by any laboratory with a liquid scintillation counter. It can also assay digitalis leaf, digitoxin, and gitalin (Gitaligin), and has uncovered unsuspected administration of them.

The assay takes less than 1 hour. No quench correction of counts is required. One technician can assay 30 samples/day with results that afternoon. No interfering compounds have been found in over 1,800 assays. It is unaffected by lung scans.

Incidence of toxicity from digoxin is 10%, 25%, and 50% at serum levels of 1.4, 2.0, and 2.9 ng/ml, respectively. Toxic levels of digitalis and digitoxin are usually over 40 ng/ml.

Serum digoxin levels are also highly correlated with computed total-body concentrations of digoxin, obtained from data of dosage, route of administration, and the patient's weight and renal function.

Physicians may now select a serum digoxin level and computed total-body concentration of digoxin which are associated with an incidence of arrhythmias which they feel is reasonable for the urgency of each patient's clinical situation. These selected serum levels are associated with specific loading and maintenance dosage regimens, individualized to that patient's body weight, renal function, and route of digoxin administration.
Metabolic Response during Impending Myocardial Infarction
Authors: OPIE L. H.
Published: June 2012

Both glucose and free fatty acids (FFA) are major fuels for the normally oxygenated heart with the dominant contribution being derived from glucose in the resting, fed state and FFA in the resting, fasted state. In anoxia, all energy must be produced anaerobically from glycogen or glucose. Anoxia by itself accelerates glycolysis, but further increases may follow an increased circulating glucose concentration and the addition of insulin. Even maximal rates of anaerobic glycolysis, achieved at high coronary flow rates, can only sustain the energy needs of the K
+
-arrested heart but not of the working heart. FFA cannot be utilized for energy in anoxia and may accumulate intracellularly as triglyceride or FFA. From these and other animal data have grown the concepts that glucose is "good" for the survival of the ischemic heart, and that FFA is "bad." However, glucose-fatty acid interaction has not been well studied in the infarcting, ischemic myocardium. While a "toxic" effect of FFA has been shown in many experimental models, there are other reports of increased FFA concentrations having no harmful effect or even a beneficial effect on the infarcting myocardium. The possible benefits of administration of glucose (with insulin) to patients with acute myocardial infarction could only be assessed by a controlled therapeutic trial.
Echocardiographic Assessment of the Effects of Surgery and Propranolol on the Dynamics of Outflow Obstruction in Hypertrophic Subaortic Stenosis
Authors: SHAH PRAVIN M. , GRAMIAK RAYMOND , ADELMAN ALLAN G. , WIGLE E. DOUGLAS
Published: June 2012

The long-term effects of surgery (ventriculomyotomy) and oral propranolol therapy were assessed by echocardiographic recordings in 51 studies conducted on 37 patients with hypertrophic subaortic stenosis. The incidence and severity of echocardiographic findings in 19 patients treated with propranolol and in 18 not so treated showed no significant differences. Likewise these findings were unaltered by administration of propranolol in 12 patients who were studied both while they were on the drug and while they were not. In contrast, of 14 patients studied after surgery, only one had persistently abnormal mitral valve motion, two had inconstant abnormality, and 11 had no abnormality at rest. The echocardiographic findings correlated well with independent postoperative hemodynamic assessment. The echocardiographic studies provide a noninvasive objective method for longitudinal evaluation of patients with hypertrophic subaortic stenosis (HSS).
Resting and Exercise Systolic Time Intervals
Authors: MCCONAHAY DAVID R. , MARTIN CARROLL M. , CHEITLIN MELVIN D.
Published: June 2012

Indirect systolic time intervals (STI) corrected for heart rate were compared at rest and immediately following 3 minutes of moderate supine exercise in 33 normal subjects and 32 age- and sex-matched patients with coronary artery disease (CAD). The intervals were correlated with measurements of cardiac index (CI), stroke volume index (SVI), mean pulmonary artery and wedge pressures obtained under identical conditions of rest and exercise, and with resting left ventricular end-diastolic pressure (LVEDP), LV dp/dt, exercise factor, ejection fraction (EF), and extent of CAD.

Total electromechanical systole (Q-A2
c
) was the same at rest in both normal and CAD groups and did not change with exercise in either group. The CAD group had a significantly longer preejection period PEP
c
), shorter left ventricular ejection time (LVET
c
), and larger PEP/LVET at rest and exercise than the normal group. Both groups responded to exercise with a significant reduction of PEP
c
, prolongation of LVET
c
, and reduction of PEP/LVET. Significant correlations were found between these STI and SVI, CI, LV dp/dt, LVEDP, and EF, which explained the differences in STI between the normal and CAD groups. However, exercise did not improve the sensitivities of the STI in detecting disordered hemodynamics in the patients with CAD. Furthermore, the STI failed to predict reliably hemodynamic abnormalities in the individual patient which were not already clinically obvious.
Eccentric Ventricular Hypertrophy in Familial and Sporadic Instances of 46 XX, XY Turner Phenotype
Authors: EHLERS KATHRYN H. , ENGLE MARY ALLEN , LEVIN AARON R. , DEELY WILLIAM J.
Published: June 2012

This study of individuals with familial and sporadically occurring 46 XX or XY Turner phenotype documented a wide range of right- and left-sided cardiovascular abnormalities and a previously unreported eccentric hypertrophy of the left ventricle.

A mother and five of her seven children had abnormal cardiovascular findings. Five had an abnormal electrocardiogram with frontal ÂQRS of -60° to ±180° and rS or rsr' in V
1
and rS, qrS, or qRS in V
5
. Catheterization demonstrated the following anomalies: coarctation of the aorta in three, valvular aortic stenosis in one, pulmonary valvular insufficiency with atrial septal defect in one, and pulmonary arterial branch stenosis in one child. All six had a similar abnormality of the left ventricle on angiocardiography. During systole and also in diastole the cavity was encroached on in its superolateral and posteroinferior aspects. Septal hypertrophy altered right ventricular contour in two.

A similarly abnormal electrocardiogram and left ventricle were found in four unrelated individuals with the XX, XY Turner phenotype. Three had pulmonary stenosis; in two there was an associated septal defect. The fourth, with no associated cardiac defect, died in heart failure at 5 months of age. At necropsy she had marked eccentric biventricular hypertrophy, chiefly involving the left ventricle so that the chamber was reduced to a slitlike cavity. The hypertrophied septum bulged into the right ventricular outflow tract.

A number of cardiovascular anomalies occur in familial and sporadic instances of this syndrome; eccentric ventricular hypertrophy recognizable by an electrocardiographic abnormality seems to be a distinctive cardiac lesion in the XX, XY Turner phenotype. Except for the unusual and, we believe, characteristic ECG, there was no clinical clue on physical examination or cardiac series of chest roentgenograms to suggest the presence of eccentric left ventricular hypertrophy. We recommend that selective left ventricular angiocardiography be performed when patients with the Turner phenotype undergo diagnostic cardiac catheterization, especially when the frontal ÂQRS is superiorly directed.
Left Pulmonary Artery from Ascending Aorta in Tetralogy of Fallot
Authors: MORGAN JACOB R.
Published: June 2012

Reported is the first surgically corrected case of tetralogy of Fallot with anomalous origin of the left pulmonary artery from the ascending aorta. The diagnosis of origin of the left pulmonary artery from the aorta depends on an aortogram, but clinical hints are increased vascularity in the left lung compared with the right lung and a continuous murmur. In tetralogy of Fallot, when there is late filling of the left pulmonary artery after a right ventricular cineangiogram, anomalous origin of the left pulmonary artery should be suspected and confirmed by an aortogram. Differentiation from complete absence of the left pulmonary artery, which is also often associated with tetralogy of Fallot, is possible by chest roentgenogram.
Left Ventricular Stress and Compliance in Man
Authors: GAASCH WILLIAM H. , BATTLE WILLIAM E. , OBOLER ALLEN A. , BANAS JOHN S. , LEVINE HERBERT J.
Published: June 2012

Left ventricular circumferential end-diastolic stress (Sed), peak systolic stress (Sps), and compliance at end-diastole ([dV/VdP]ed) were estimated in 13 subjects with normal left ventricles (N group), nine subjects with inappropriate hypertrophy (IH group), five with aortic valvular stenosis (AS group), and six with congestive cardiomyopathy (CC group). The product of Sed and (dV/dP)ed was employed as an index of "muscle fiber stretch" and related to systolic indices of ventricular performance. Compliance was significantly less than normal in IH (
P
< 0.001), in AS (
P
< 0.01), and in CC (
P
< 0.001), while end-diastolic volumes were smaller than normal (
P
< 0.05), normal (
P
=
ns
), and larger than normal (
P
< 0.001) in the three groups, respectively. Sed was normal in IH and AS but elevated in CC (
P
< 0.001), while Sps was decreased in IH and normal in AS and CC. "Muscle fiber stretch," however, was substantially less than normal in IH (
P
< 0.001), indicating that the low Sps is due at least in part to short sarcomeres. In CC, despite a markedly elevated preload, "muscle fiber stretch" was normal (
P
=
ns
), while work indices of the ventricle were diminished indicating depressed ventricular function. Thus, the product of Sed and (dV/VdP) ed provides a normalized index of "muscle fiber stretch," which permits one to compare length-tension or length-work relationships in diseased ventricles of varying dimensions and compliance.
Selective Coronary and Left Ventricular Cineangiography during Intraaortic Balloon Pumping for Cardiogenic Shock
Authors: LEINBACH ROBERT C. , DINSMORE ROBERT E. , MUNDTH ELDRED D. , BUCKLEY MORTIMER J. , DUNKMAN W. BRUCE , AUSTEN W. GERALD , SANDERS CHARLES A.
Published: June 2012

Eleven patients underwent selective coronary and left ventricular cineangiography during intraaortic balloon pumping for acute myocardial infarction and cardiogenic shock. Studies were performed when the clinical and hemodynamic trend predicted in-hospital death. Angiograms were reviewed by dividing the left ventricle into six segments, each with its characteristic coronary perfusion. No patient with avascular and akinetic segments survived with or without surgery. One patient with residual perfusion of all segments showed massive necrosis at operation that eventually led to his death. In four patients the findings of residual contraction and perfusion of most segments suggested reversible ventricular dysfunction. Three of these underwent coronary surgery with two excellent survivors.
Long-Term Follow-up Study of Survival and Recurrence Rates following Myocardial Infarction in Exercising and Control Subjects
Authors: RECHNITZER PETER A. , PICKARD H. A. , PAIVIO ALLAN U. , YUHASZ MICHAEL S. , CUNNINGHAM DAVID
Published: June 2012

Male subjects (N = 68), under age 51 years, with previous myocardial infarction, who participated in a program of graduated exercises over a 7-year period (1964-71), have been compared with a control group (N = 131) for incidence of nonfatal recurrence and cardiac death. The controls fulfilled the criteria to enter the exercise program, but did not. Of the 68 exercising subjects, 66 were traced in January 1971. Two (3.0%) had had a nonfatal recurrence. Of the 131 control subjects, only 117 gave valid information concerning possible recurrence. Thirteen (11.1%) had suffered a nonfatal recurrence (
P
< 0.10). The incidence of cardiac death (7.6%) was significantly lower (
P
< 0.05) in the exercising subjects than in the 127 control subjects (four of the 131 could not be traced).

In 1969 a separate comparison of recurrence and survival over a 5-year period was made between 77 exercising subjects who had remained in the program for a minimum of 3 months and 127 control subjects in Toronto. One (1.3%) of the exercising subjects had had a nonfatal recurrence, and 31 (27.9%) of 111 Toronto control subjects (16 others were alive but information on recurrence was lacking) gave a history of nonfatal recurrence (
P
< 0.001). There were three (3.9%) deaths in the exercise group and 15 (11.8%) deaths in the Toronto control group (
P
< 0.10).

Variables affecting prognosis, but not included in the study, were blood pressure, prior angina, and current angina. Although results of this investigation suggest that an exercise program in a selected group may favorably affect prognosis following recovery from myocardial infarction, they should be interpreted cautiously. One or more variables not related to the exercise program per se may have been operative in producing the apparent benefit.
Influence of Nitroglycerin on Myocardial Metabolism and Hemodynamics during Angina Induced by Atrial Pacing
Authors: CHIONG MIGUEL A. , WEST ROXROY O. , PARKER JOHN O.
Published: June 2012

Myocardial lactate extraction, arterial-coronary sinus difference (A-CS) of potassium (K
+
), hemodynamics, and S-T segments were studied in 15 patients with coronary artery disease who developed angina during atrial pacing. The study consisted of the following periods: control (C
1
), pacing (P
1
), recovery (C
2
), control after nitroglycerin (C
GTN
), second pacing (P
2
), and recovery. During C
1
, mean lactate extraction, S-T segments, and left ventricular end-diastolic pressure (LVEDP) were normal, and there was no myocardial K
+
loss. During P
1
the mean lactate production was –12.0%, mean K
+
loss –0.26 mEq/liter, and mean S-T segment depression 1.97 mm, while the average LVEDP remained unchanged, increasing when pacing was discontinued to a mean value of 23.3 mm Hg. These values returned to control levels by the time GTN was administered. After GTN there were significant decreases in mean cardiac index, LVEDP, brachial artery pressure, and left ventricular stroke work. During P
2
, eight subjects had no pain, five experienced less severe angina, mean lactate production and K
+
loss were abolished, S-T segments became less depressed (0.8 mm), and mean LVEDP decreased during pacing, rising only to 11.4 mm Hg when pacing was discontinued. Myocardial lactate production reverted to extraction in two patients and decreased in another two, whereas seven patients showed a decreased K
+
loss or uptake. It is concluded that GTN may prevent or reduce pacing-induced angina, as well as improve the electrocardiogram and hemodynamics, and in some patients decrease myocardial anaerobiosis.
Site of Heart Block as Defined by His Bundle Recording
Authors: ROSEN KENNETH M. , RAHIMTOOLA SHAHBUDIN H. , GUNNAR ROLF M. , LEV MAURICE
Published: June 2012

His bundle electrograms were recorded in three patients with heart block who subsequently died. Serial sections of the conduction system were performed. Two patients had complete block distal to H with wide QRS and P-H intervals of 135 and 100 msec, respectively (normal 80-140 msec). Postmortem (PM) revealed relatively insignificant A-V nodal lesions and major destructive lesions of both bundle branches. The third patient had block proximal to H with left bundle-branch block and H-V prolongation. PM revealed amyloidosis of the A-V nodal approaches and fatty infiltration of the A-V node and His bundle. There were also fibroelastic lesions, with total disruption of the left and moderate involvement of the right bundle branch.

The first patient also had sinus pauses as well as delay between what was felt to be posterior internodal tract depolarization and the P wave. PM also revealed arteriolosclerosis, mononuclear cell infiltration, and fibroelastosis of the SA nodal approaches.

Block distal to H appeared to reflect total disruption of both bundle branches. Normal P-H intervals appeared to correlate with relatively insignificant A-V nodal lesions. Block proximal to H with bundle-branch block and H-V prolongation reflected multiple conduction lesions. SA block appeared to reflect involvement of the SA nodal approaches.
Abnormalities of Ventricular Motion Induced by Atrial Pacing in Coronary Artery Disease
Authors: PASTERNAC ANDRE , GORLIN RICHARD , SONNENBLICK EDMUND H. , HAFT JACOB I. , KEMP HARVEY G.
Published: June 2012

In order to study left ventricular performance and motion under ischemic stress, incremental atrial pacing was performed in 10 patients with angiographically proven coronary artery disease until angina pectoris or segmental S-T depression appeared. Single-plane left ventricular cineangiograms were obtained in both the resting and the transiently ischemic state induced by pacing.

Abnormal motion appeared with pacing in two of three patients with normal contraction at rest; in one of them, gross dyskinesis of the cardiac apex was noted. Seven patients had abnormal contraction at rest; six showed an increase in either the severity or the topographic distribution of abnormality, while one showed no change.

Left ventricular end-diastolic pressure and cardiac index were not altered significantly despite changes in the pattern of contraction. Left ventricular end-diastolic volume decreased irrespective of the development of asynergy, but ejection fraction decreased markedly in those patients in whom asynergy was induced de novo or increased.

Thus left ventriculography during pacing-induced ischemia may reveal segmental or generalized abnormalities of contraction not necessarily reflected in the usual hemodynamic parameters of function. Moreover, asynergy induced by pacing is associated with a decreased ejection fraction.
Percutaneous Myocardial Biopsy of the Left Ventricle
Authors: SHIREY EARL K. , HAWK WILLIAM A. , MUKERJI DEVOBROTO , EFFLER DONALD B.
Published: June 2012

A thin-walled Silverman needle has been used for 254 percutaneous punch biopsies of the left ventricle in 198 patients with closed chests at the Cleveland Clinic. The technic is described. The biopsy specimens were adequate for diagnosis in 192 patients. In all but three patients (who had lupus erythematosus, scleroderma, and chronic glomerulonephritis with congestive heart failure) cardiac catheterization and selective cardioangiographic studies were performed. There was angiographic evidence of primary myocardial disease, coronary atherosclerosis, or both, or rheumatic valvular disease in 175 patients. Cardiac catheterization and angiographic studies demonstrated no evidence of organic heart disease in 20 patients.

Cardiac tamponade was a complication of myocardial biopsy in eight patients. Post-pericardiotomy syndrome occurred in four patients and ventricular fibrillation in one patient.

Myocardium with no pathologic diagnosis and interstitial fibrosis or myocardial hypertrophy or both were the light microscopic findings in 165 patients. Representative sections of the biopsy in 27 patients demonstrated small-vessel disease, basophilic degeneration, focal interstitial myocarditis, amyloidosis, Aschoff's nodules, or vacuolar degeneration. The current experience suggests that myocardial biopsy combined with selective cardioangiography is of experimental value, improves the accuracy of diagnosis, and plays a role in the management of some patients.
Analysis of Left Ventricular Wall Motion by Reflected Ultrasound
Authors: MCDONALD IAN G. , FEIGENBAUM HARVEY , CHANG SONIA
Published: June 2012

Ultrasound echocardiograms from the septal and posterior left ventricular walls were displayed with a simultaneously recorded electrocardiogram, phonocardiogram, and indirect carotid pulse. These echoes differed in both amplitude and waveform. The contour of the posterior wall echo resembled an inverted ventricular volume curve, while the septal echo was of smaller amplitude and had a characteristic notched appearance. Most of the movement of the left ventricular walls relative to the ultrasound transducer was attributable to systolic contraction and diastolic expansion of the cavity. However, superimposed on this motion due to change in cavity size was movement of the left ventricle as a whole, first anteriorly toward the ultrasound transducer during late systole then posteriorly away from it at the beginning of left ventricular relaxation. These movements added to the amplitude of posterior wall motion but subtracted from the motion of the septum and were responsible for the notch in the waveform of this echo. Attachment superiorly to the aortic root might also have limited septal motion which was less near the base than nearer the apex of the left ventricle.

The internal left ventricular dimension measured by ultrasound was standardized by using the mitral valve as a landmark and by recording the motion of the left side of the interventricular septum and endocardial surface of the posterior left ventricular wall simultaneously. This measurement was reproducible. In normal subjects, the ultrasonic dimension measured 4.40 ± 0.28 cm at the beginning of systole and shortened by 35.5 ± 3.9% at a rate of 1.22 ± 0.31 lengths/sec. By contrast, the average figures for six patients with primary myocardial disease were 6.96 ± 0.43 cm, 14.9 ± 4.2%, and 0.64 ± 0.11 lengths/sec. Calculation of such indices of left ventricular size and of rate and extent of myocardial shortening should be useful in the detection of impaired myocardial function and in following its progress.
Effects of Digitalis on Myocardial Ionic Exchange
Authors: LANGER G. A.
Published: June 2012

Prior to consideration of the effects of digitalis compounds on ionic exchange the basic mechanisms of active Na
+
and K
+
transport are discussed. It is generally accepted that digitalis is a specific inhibitor of the Na
+
-K
+
activated ATPase located primarily in the sarcolemmal membrane. Present evidence supports the concept that positive inotropic effects of digitalis are not seen unless evidence of inhibition of the enzyme and, therefore, of the "Na pump" leads to a small increase of intracellular Na
+
. This leads to augmented activity of a Na
+
transport system which is coupled, not to K
+
, but to Ca
+ +
. Evidence for the existence of Na
+
-Ca
+ +
coupling at excitable membranes is accumulating, and this is reviewed. The possibility that administration of digitalis, through its inhibition of the Na
+
-K
+
coupled system produces an increase in Na
+
- Ca
+ +
coupled transport and thereby an increase of influx of Ca
+ +
to the myofilaments is discussed and is presented as a possible basis for the mechanism of digitalis action. The toxic electrophysiologic effects of digitalis are discussed in terms of the effects on K
+
exchange induced by the drug.
Echocardiography in the Diagnosis of Congenital Mitral Stenosis and in Evaluation of the Results of Mitral Valvotomy
Authors: LUNDSTRÖM NILS-RUNE
Published: June 2012

Seven patients with congenital mitral stenosis have been investigated with echocardiography using reflected ultrasound. In all cases the mitral stenosis was combined with other cardiovascular malformations. The results are compared with those obtained at clinical investigation, cardiac catheterization, and operation and/or autopsy. It is concluded that the method is of definite value in diagnosing congenital mitral stenosis, even when this is combined with other cardiovascular malformations. The method is also found to be of value in assessing the severity of mitral stenosis.

Three patients have been investigated after mitral valvotomy. It is concluded that the findings at echocardiographic examination agree quite well with the clinical findings and with the results of postoperative cardiac catheterization in the evaluation of the result of mitral valvotomy.
Effect of Lidocaine on the Ventricular Fibrillation Threshold in the Dog during Acute Ischemia and Premature Ventricular Contractions
Authors: SPEAR JOSEPH F. , MOORE E. NEIL , GERSTENBLITH GAIRY
Published: June 2012

The effect of lidocaine on the ventricular fibrillation threshold was investigated in the anesthetized open-chest dog during paced supraventricular rhythm, during acute ligation of the anterior descending coronary artery, and during premature ventricular contractions. The minimum current (in milliamperes) required to induce ventricular fibrillation was determined by passing a train (100 Hz) of 10-14 constant-current pulses through ventricular epicardial electrodes during the vulnerable period of the cardiac cycle. Lidocaine was administered intravenously either as a sudden injection or as a "loading" injection followed by a constant infusion. Following a single injection of 0.7 mg/kg the blood lidocaine decreased to half its original arterial concentration in 9 min. After the termination of a 50-60-min constant drip of 70 µg/kg/min which was preceded by a loading injection of 2 mg/kg, the blood lidocaine concentration fell to 50% of its original value in 31 min. Lidocaine at therapeutic blood levels (1.2-5.5 µg/ml) increased the fibrillation threshold during paced supraventricular rhythm and reversed the fall in fibrillation threshold accompanying acute myocardial ischemia and premature ventricular contractions. The present studies quantify the ability of lidocaine to reduce the vulnerability of the heart to fibrillation during supraventricular rhythm, acute ischemia, and premature ventricular beats and provide information concerning the metabolism of lidocaine in the anesthetized dog.
Left Heart Function in Children with Tetralogy of Fallot before and after Palliative or Corrective Surgery
Authors: JARMAKANI JAY M. M. , GRAHAM THOMAS P. , CANENT RAMON V. , JEWETT PAUL H.
Published: June 2012

Left heart volume and left ventricular mass (LV mass) were calculated from biplane cineangiocardiograms in 58 tetralogy of Fallot (TF) patients preoperatively, in 31 patients after shunt procedure, and in 24 patients after complete correction. Preoperatively, the LV end-diastolic volume and left atrial maximal volume (LA
max
) were normal in cyanotic infants less than 2.0 years old and in acyanotic patients more than 2.0 years old. These variables, however, were less than normal in cyanotic children > 2.0 years old. Left ventricular ejection fraction (LVEF) and LV systolic index (LVSI) were both less than normal in all groups preoperatively. LV mass was normal preoperatively. After successful shunt procedure, there was a significant increase (
P
< 0.01) in LVEDV, LVSI, LA
max
, and LV mass. The LVEF, however, remained less than normal. After successful corrective surgery, the total group showed a significant increase (
P
< 0.01) in LVEDV, LVSI, LA
max
,and LV mass as compared with preoperative values. Furthermore, the LVEDV was slightly but significantly higher than normal and the LV ejection fraction remained significantly depressed from normal. There was an inverse correlation between LVEDV or LVSI, expressed as a percent of normal, and hemoglobin concentration but not with the net left-to-right shunt or aortic saturation.

The decreased LV ejection fraction in cyanotic tetralogy patients in the presence of decreased peak LV pressure (decreased afterload) as well as the decreased LVEF after shunt procedure or complete correction (increased preload) suggests that LV function is depressed in tetralogy patients and remains depressed despite corrective surgery.