bluuebunny/crossref_metadata_2025 huggingface dataset:
The Initial Attack of Acute Rheumatic Fever During Childhood in North India
Authors: SANYAL SHYAMAL K. , THAPAR MOHINDER K. , AHMED SYED H. , HOOJA VIJAYA , TEWARI PROMILA
Published: June 2012

A prospective study was done to determine the clinical profile of first attacks of acute rheumatic fever in children in North India. Unlike other reports, the clinical profile described here closely resembles the spectrum prevalent in the West. Arthritis, the most common manifestation, was seen in 66.6% of the 102 patients, chorea in 20.7%, and carditis in 33.7%. Carditis was considered mild in 22 patients and severe in 12; a persistent elevation of sleeping pulse rate and mitral regurgitation was noted in each case. Patients with severe carditis also had significant cardiomegaly and apical mid-diastolic murmur. Two patients with severe carditis developed congestive heart failure; one of them had pericarditis as well. Murmur of aortic origin was not noted in this series. One patient with severe carditis died from the disease. Erythema marginatum was noted in two, both of whom had severe carditis. There were two instances of subcutaneous nodules, one with and one without carditis. The close similarity of these results with those in the West is attributed to the prospective design of the study, analysis of first attacks only and survey of a general pediatric population for all manifestations suggestive of the disease.
Role of the Vagus Nerves in the Cardiovascular Changes Induced by Coronary Occlusion
Authors: CORR PETER B. , GILLIS RICHARD A.
Published: June 2012

The importance of vagus nerves to the heart rate, contractile force, blood pressure, and incidence of fatal arrhythmias produced by occlusion of the anterior descending branch of the left coronary artery was studied in chloralose-anesthetized cats. Occlusion performed in 20 animals with intact vagus nerves produced significant decreases in heart rate (23 ± 5.3 beats/min), contractile force (23 ± 6.6%), and blood pressure (20 ± 2.7 mm Hg). Time to onset of arrhythmias was 2.6 ± 0.4 minutes and death due to ventricular fibrillation occurred in four of 20 animals. Occlusion performed in 20 animals with bilateral vagotomy and 20 animals with intact vagus nerves but pretreated with atropine did not decrease heart rate and resulted in significantly more deaths. Time to onset of the arrhythmia was significantly less in both cases. Occlusion produced the usual decrease in contractile force and blood pressure. In addition, a delayed (i.e., after sinus rhythm was restored) decrease in blood pressure and contractile force occurred in animals with vagus nerves sectioned. Pacing hearts of animals with intact and functional vagus nerves to rates comparable to those seen in vagotomized and atropinized cats resulted in a mortality rate identical to that seen in controls. On the other hand, time to onset of the arrhythmia was significantly less than controls and equivalent to the onset times of the vagotomized and atropinized groups. These results suggest that 1) efferent vagus nerves mediate sinus bradyeardia that occurs after coronary occlusion, 2) presence of efferent vagus tone
per se
reduces the incidence of death, 3) rate effect of efferent vagal tone increases the time to onset of arrhythmias, and 4) presence of afferent vagal tone counteracts the late decline in arterial pressure and contractile force.
Memorial Service Remarks
Authors: PUDDU VITTORIO
Published: June 2012

Dr. Vittorio Puddu was closely associated with Dr. White for over twenty-five years, beginning when they both were elected members of the First International Council of Cardiology, later to become the International Society of Cardiology, of which Dr. Puddu is the current president. He also serves as director of the Cardiac Department of the Hospitals of Rome, Italy. The following are his remembrances of Dr. White presented at the Memorial Service.
Permanent Pervenous Atrial Pacing From the Coronary Vein
Authors: MOSS ARTHUR J. , RIVERS ROBERT J. , KRAMER DAVID H.
Published: June 2012

This report details our clinical experience during a 12 to 63 month follow-up period in 30 patients with permanent pervenous atrial pacemakers implanted in the coronary vein prior to May 1972. Indications for permanent atrial pacing included 20 patients with symptomatic sinus bradycardia, seven with atrial brady-tachy syndrome refractory to pharmacologic therapy, and three patients with atrial overdrive suppression for intractible ventricular arrhythmias. The average duration of atrial pacing was 29.2 ± 2.4 (
sem
) months, median 24 months. A bipolar electrode was used in 28 patients and a unipolar system in two. The atrial signal was of sufficient amplitude (>1.5 mV) to permit atrial demand pacing when required. The atrial pacing threshold averaged 2.0 ± 0.2 ma initially and increased by less than 1.0 ma at the time of battery replacement 20 months later. Only four of 30 patients (13%) developed pacemaker related problems during the 879 pacing months of this follow-up period. Coronary vein perforation or thrombosis was not observed, and there were no pacemaker related deaths. The coronary vein provides a safe and effective electrode location for long-term permanent pervenous atrial pacing.
Echocardiographic Studies of Stented Fascia Lata Grafts in the Mitral Position
Authors: MARY DAVID A. S. , PAKRASHI BROJESH C. , CATCHPOLE ROGER W. , IONESCU MARIAN I.
Published: June 2012

Nineteen patients with stented fascia lata grafts in the mitral position were studied by the reflected ultrasound technique. Eleven of these had competent grafts, two had minimal regurgitation and six had severe graft incompetence as judged by ventriculography and during surgery. The diastolic closure rate (E-F speed) of the cusps revealed significant correlation with the effective graft area derived by calculations from cardiac catheterization data (
P
< 0.01), and indicated only mild to moderate stenosis. The exhibited cusp mobility revealed an amplitude which was comparable with and similar to that measured in cusps from freshly prepared fascia lata valves. The demonstrated cusp mobility and E-F speed did not show a statistically significant difference between competent and incompetent grafts (
P
> 0.7 and
P
> 0.4 respectively). Further evidence is presented supporting the role played by the mitral annulus mobility in the production of echocardiographic diastolic movement of the leaflet.
Intraoperative Coronary Collateral Function in Patients With Coronary Occlusive Disease
Authors: GOLDSTEIN ROBERT E. , STINSON EDWARD B. , SCHERER JAMES L. , SENINGEN RONALD P. , GREHL TODD M. , EPSTEIN STEPHEN E.
Published: June 2012

To elucidate the direct influence of nitroglycerin on coronary collateral function in patients and to clarify the relation between angiographic appearance and functional performance of coronary collaterals, we measured retrograde flow and peripheral coronary pressure (PCP) before and after nitroglycerin in patients undergoing saphenous vein bypass. Measurements were made via the distally (but not proximally) attached vein graft while the coronary artery receiving the graft was totally occluded proximal to the site of graft attachment. Nitroglycerin (100 to 150 mcg bolus and 100 mcg/min) was infused into the ascending aorta in 29 patients. Baseline measurements revealed: aortic pressure mean 79 mm Hg, PCP 30 mm Hg, retrograde flow 2.7 ml/min, and collateral resistance 28.5 mm Hg/ml/min. Following nitroglycerin, mean aortic pressure decreased 18% but retrograde flow was not consistently changed; thus collateral resistance fell significantly (average 28%,
P
< 0.05). Similarly, collateral resistance fell (mean 50%) in eight individuals in whom aortic pressure changes were attenuated by altering systemic flow. If calculated as a fraction of aortic pressure, PCP increased 9.9% (
P
< 0.02), a finding consistent with enhanced collateral flow. Our results suggest that nitroglycerin can diminish resistance to collateral flow despite severe multivessel involvement. Comparison of baseline data with preoperative angiography revealed a correlation between the size and extent of coronary collaterals and physiologic evidence of collateral function. Thus, angiographic appearance of coronary collaterals accurately predicts collateral function during bypass surgery.
Sound Pressure Correlates of the Second Heart Sound
Authors: SHAVER JAMES A. , NADOLNY RICHARD A. , O'TOOLE JAMES D. , THOMPSON MARK E. , REDDY P. S. , LEON DONALD F. , CURTISS EDWARD I.
Published: June 2012

The sound pressure correlates of the second heart sound were studied in 22 patients during diagnostic cardiac catheterization. Simultaneous right ventricular and pulmonary artery pressures were recorded with equisensitive catheter-tip micromanometers together with the external phonocardiogram and ECG. In 12 patients having normal pulmonary vascular resistance (group 1), pulmonic closure sound was coincident with the incisura of the pulmonary artery pressure curve which in turn was separated from the right ventricular pressure trace by an interval denoted hangout. The duration of this interval varied (33-89 msec), was independent of pulmonary artery pressure or resistance and was felt to be primarily a reflection of the capacitance of the pulmonary vascular tree. The absolute value of this interval during inspiration was very similar to the splitting interval and, when subtracted from the Q-P
2
interval, the remaining interval (QRV) was almost identical to the Q-A
2
interval, indicating that the actual duration of right and left ventricular systole is nearly equal. Awareness of the existence of the hangout interval and its hemodynamic determinants offers a reasonable mechanism to explain the audible expiratory splitting of the second heart sound found in patients with idiopathic dilatation of the pulmonary artery following atrial septal defect repair and in one additional patient studied with mild valvular pulmonic stenosis. In nine patients with elevated pulmonary vascular resistance approaching systemic levels (group 2), the absolute value of the hangout interval was markedly reduced (15-28 msec) consistent with the decrease in capacitance of the pulmonary vascular bed and the increased pulmonary vascular resistance known to occur in pulmonary hypertension. In those patients where the duration of right and left ventricular systole were nearly equal, narrow splitting of the second heart sound was present. In those patients where selective prolongation of right ventricular systole occurred, the narrow hangout interval persisted, but the splitting interval was prolonged proportionate to the increased duration of right ventricular systole.
Results of Elective Aortocoronary Saphenous Vein Graft Surgery in a Community Hospital
Authors: FORKER ALAN D. , REESE HERBERT E. , WEAVER WALT F. , WILSON CHARLES S. , BUCHMAN ROBERT , CARVETH STEPHEN W.
Published: June 2012

In a community hospital setting, without academic affiliation or house staff coverage, 145 patients had elective saphenous vein graft surgery between January 1970 and January 1973. Patients with good left ventricular function, with or without associated procedures, had an operative mortality of 2.4%. The surgical mortality of patients who had associated procedures was 9.5%. The overall operative mortality was 6.2% with an immediate postoperative myocardial infarction rate of 17%. Results in 38 patients with pre-infarction angina were no different from the group as a whole. The risk of surgery is best categorized by a combination of angiographic severity of coronary artery disease plus severity of left ventricular dysfunction estimated by left ventriculogram.
Simultaneous Measurement of Total and Nutritional Coronary Blood Flow in Dogs
Authors: LEBLANC ADRIAN D. , RILEY RICHARD C. , ROBINSON RALPH G.
Published: June 2012

Significant correlation has been shown between the severity of coronary disease and level of coronary blood flow as measured by the rubidium coincidence technique. Contrary to the commonly expressed view, however, the rubidium coincidence method does not evaluate nutritional flow, but estimates total coronary blood flow (CBF
T
). An equation is derived that does evaluate nutritional flow (CBF
N
), allowing simultaneous measurement of total and nutritional flow.

The extraction ratio of the total body (ER
TB
) relative to the extraction ratio of the heart (ER
C
) was measured in a total of 21 dogs by employing the relative uptake of labeled microspheres and diffusible ions,
86
Rb and
131
Cs.

CBF
T
, measured with a bolus injection of
86
Rb or
131
Cs, was compared with total flow measured by the microsphere technique in dogs, with and without drug administration (norepinephrine, isoproterenol, nitroglycerin). These studies showed that while rubidium gives accurate mean values of total flow (4% mean difference,
r
= 0.92) individual estimates may be in error by as much as ± 42%. It was found, however, that isotopes of cesium are not suitable for measuring either total or nutritional coronary blood flow by the methods described in this paper.

Comparison of CBF
N
with CBF
T
showed that not only was CBF
N
significantly less than CBF
T
, but the percentage increase in CBF
N
was significantly less than that of CBF
T
after norepinephrine or isoproterenol administration.
Insulin, Free Fatty Acids, and Glucose Response to Intravenous Glucagon Following Myocardial Infarction
Authors: GUPTA P. R. , SINHA M. K. , DASH R. J. , WAHI P. L. , RASTOGI G. K.
Published: June 2012

The response of plasma immunoreactive insulin (IRI), free fatty acids (FFA), and blood glucose to intravenous (I.V.) glucagon is evaluated in ten healthy subjects and in 22 patients following acute myocardial infarction (MI). Heparinized venous blood samples were drawn from patients and subjects in the fasting state and 2, 5, 15, 30, 60, 90, and 120 min after 1 mg I.V. glucagon. Healthy subjects showed a significant increase in insulin (peak at 5 min) and blood glucose (peak 15 min), and a persistent fall in FFA (nadir 90 min). In patients in the first week after suffering an acute MI, there was a significant elevation in fasting blood glucose whereas fasting insulin was low and FFA, normal. After glucagon administration, there was a pronounced rise in insulin and a significant rise in glucose and FFA. Six weeks after the acute MI, the mean fasting blood glucose reading showed a fall whereas insulin rose to normal range. Glucagon elicited a rise in insulin, glucose, and FFA. These results suggest that after MI the insulin resistance is a stronger influence than failure of insulin secretion. The relevance of these results in relation to use of glucagon in large doses in cardiogenic shock of MI is discussed.
Acute Rejection in the Long-Term Cardiac Transplant Survivor
Authors: GRAHAM ANTHONY F. , RIDER ALAN K. , CAVES PHILIP K. , STINSON EDWARD B. , HARRISON DONALD C. , SHUMWAY NORMAN E. , SCHROEDER JOHN S.
Published: June 2012

Thirty-two of 59 patients undergoing cardiac transplantation at Stanford University Medical Center since January, 1968, have survived longer than three months. In 19 of these long-term survivors 47 episodes of late acute rejection occurred. In the first two months post-transplantation the incidence of acute rejection is one episode per 20.5 patient days, but between four and 12 months post-transplantation decreases to one episode per 200 patient days. Late acute rejection episodes are usually clinically mild and can be detected by electrocardiographic changes, evidence of mild graft dysfunction and characteristic histologic changes in tissue obtained by transvenous endomyocardial biopsy. Out-patient treatment with increased oral prednisone has successfully reversed 70% of these late acute rejection episodes, with the other 30% requiring more aggressive therapy. Late acute rejection or complications related to its treatment have contributed to the death of three long-term survivors and has been implicated as a causative factor in the development of graft coronary atherosclerosis in six patients in the earlier part of our series. However, the occurrence of acute rejection in the long-term cardiac transplant patient does not preclude good graft function and patient survival in the majority of patients.
Echocardiographic Features of Endocardial Cushion Defects
Authors: WILLIAMS ROBERTA G. , RUDD MICHAEL
Published: June 2012

The echocardiographic features of endocardial cushion defects were defined in 28 patients. Two basic characteristics, common to both complete and incomplete forms of endocardial cushion defects, were found. First, the mitral valve excursion was not seen best in the usual location as defined by intraventricular landmarks. Secondly, the mitral valve echoes in cases where there are dense attachments of the mitral leaflet to the crest of the interventricular septum may be traced to the rightward and anterior border of the left ventricular outflow tract. This is the echocardiographic representation of the characteristic "goose-neck" deformity seen angiographically.

Two additional paterns were recognized in patients with complete atrioventricular (A-V) canal. In Pattern I, a large, single, A-V valve was found occupying a central location between the two ventricles. During diastole, the superior segment moved anteriorly into the right ventricle and the inferior segment posteriorly into the left ventricle. In Pattern II, a large single A-V valve moved from the left ventricle in systole into the right ventricle in diastole. This pattern was specific to patients with common A-V valve leaflets.
Coronary Artery Disease in 116 Kindred with Familial Type II Hyperlipoproteinemia
Authors: STONE NEIL J. , LEVY ROBERT I. , FREDRICKSON DONALD S. , VERTER JOEL
Published: June 2012

Analysis of cardiovascular status in adult relatives of 116 kindred affected with familial hyperbetalipoproteinemia (type II hyperlipoproteinemia) was carried out to assess coronary artery disease (CAD) risk in relatives with type II (II) compared to unaffected family members. Over 90% of the 738 living relatives were interviewed by one investigator and 12 lead electrocardiograms were obtained. In these, and in 285 deceased relatives, physician and hospital records were utilized to determine CAD events by standard criteria. This study, the largest of its kind, permitted more precise and extensive determination of the CAD risk accompanying severe hyperbetalipoproteinemia than has heretofore been possible. CAD was diagnosed in 29.5% of II's compared with 10.5% of normal relatives (N) (
P
< .001). The II's and N's did not differ significantly with regard to age distribution, sex, hypertension, smoking habits, or body mass index. According to the Rose questionnaire, angina pectoris was diagnosed in 21.8% of II's and 6.5% of N's (
P
< .001). Documented myocardial infarction occurred in 6% of II's versus 1% of N's (
P
= .002). CAD death or myocardial infarction occurred in 10.1% of II's compared with 1.8% of N's (
P
< .001). The cumulative probability of nonfatal or fatal CAD by age 40 in male II's was 16% (1 in 6); by age 60, the expectation of an event had risen to 52% (1 in 2). Among male N's, the risk of nonfatal or fatal CAD by age 60 was 12.7%, lagging 20 years behind that seen in male II's. In female II's, the risk of nonfatal or fatal CAD by age 60 was 32.8% compared with only 9.1% in female N's.
A Comparison of Transmural and Nontransmural Acute Myocardial Infarction
Authors: MADIAS JOHN E. , CHAHINE ROBERT A. , GORLIN RICHARD , BLACKLOW DANIEL J.
Published: June 2012

The records of one hundred and four patients who had enzyme curves diagnostic for acute myocardial infarction (MI) were analyzed to determine what differences, if any, existed between the clinical course of patients with transmural myocardial infarction (TMI) and patients with nontransmural myocardial infarction (NTMI). The patients were subdivided into the two groups on the basis of accepted electrocardiographic criteria. There were no significant differences in prevalence or type of arrhythmias, occurrence of cardiogenic shock, or mortality in the hospital between the two groups. Enzymes tended to be somewhat lower in those with NTMI than in those with TMI. Clinical congestive heart failure (CHF) occurred more frequently in patients with TMI than in those with NTMI. Therefore, determining by electrocardiographic criteria whether or not a MI is transmural or nontransmural does not make it possible to predict the outcome or pattern of complications in a patient with acute myocardial infarction.
Catheter-Induced Intra-Hisian and Intrafascicular Block During Recording of His Bundle Electrograms
Authors: JACOBSON LESTER B. , SCHEINMAN MELVIN
Published: June 2012

Mechanical injury of the atrioventricular (A-V) node, His bundle, and right bundle branch is a potential complication of His bundle recording. In the presence of left bundle branch block, catheter-induced injury of the right bundle branch may cause prolongation of A-V conduction time or even complete A-V block. Two cases are reported in which catheter-induced transient high grade Mobitz II A-V block, acute reversible prolongation of infranodal conduction time with probable intra-Hisian conduction delay, and persistent (6 hours duration) complete A-V block occurred in patients with left bundle branch block. The observations made indicate that A-V conduction times and the appearance of "split His" potentials may be influenced by the recording catheter itself, and suggest that the operators be prepared to institute immediate right ventricular pacing when His bundle recordings are obtained in patients with left bundle branch block.
Unmasking and Conversion of Gap Phenomenon in the Human Heart
Authors: AKHTAR MASOOD , DAMATO ANTHONY N. , BATSFORD WILLIAM P. , CARACTA ANTONIO R. , VARGAS GUILLERMO , LAU SUN H.
Published: June 2012

Two types of gap phenomena (types I and II ) have been described in human hearts and their electrophysiologic bases have been delineated. In both types of gap phenomena relatively early premature atrial impulses are blocked within some portion of the His-Purkinje system (HPS). By increasing the prematurity of the atrial depolarization, conduction to the ventricles resumes due to delay of the premature impulse with the atrioventricular node (A-VN) (type I gap) or within the proximal HPS (type II gap). Gap phenomena are not observed when the refractory period of the A-VN exceeds that of the HPS. Since atropine decreases refractoriness of the A-V node, its effect on the gap phenomena was studied in nine subjects. After administration of atropine (0.2-0.5 mg i.v.) type I gap was demonstrated in six subjects and type II gap in three subjects. When atropine shortened the functional and effective refractory period (ERP) of the A-V node, premature atrial impulses arrived at the HPS during its ERP. By a similar mechanism, type I gap was converted into type II gap in three subjects following atropine administration. Decreasing the basic atrial drive rate converted type II gap into type I (two subjects) and ultimately abolished both types of gap phenomena in all subjects. These results suggest that the gap penomenon may be functional in nature and may be readily manifested or abolished by varying the refractoriness of the A-V node relative to that of the HPS.
Atrioventricular Conduction in Patients with Incomplete Endocardial Cushion Defect
Authors: GOODMAN DANIEL J. , HARRISON DONALD C. , CANNOM DAVID S.
Published: June 2012

The cause of left axis deviation noted on the electrocardiogram (ECG) in patients with ostium primum atrial septal defect has been attributed to two differing mechanisms: left ventricular overload secondary to mitral insufficiency and a congenitally anomalous atrioventricular conduction system. In order to define the conduction characteristics of the atrioventricular conduction system in patients free from the hemodynamic abnormalities of ostium primum atrial septal defect, seven patients with an ostium primum atrial septal defect were studied in the late postoperative period. Each ECG showed persisting left axis deviation with no new conduction abnormalities. Hemodynamic evaluation, including left ventriculography, showed no intra-atrial shunting and only minimal mitral insufficiency in three patients. His bundle recording techniques were utilized to study the atrioventricular conduction system. The P-A interval was normal in four patients (25-45 msec) and prolonged in three (50, 60 and 60 msec), while the A-H interval was normal in all seven patients (60-130 msec). This is compatible with abnormal intra-atrial conduction and normal conduction through the atrioventricular node. The H-V interval was normal in four patients (35-55 msec) and short in three (20, 25, and 25 msec). Atrial pacing produced the normally expected A-H prolongation, P-A and H-V remaining constant. These results and the persisting left axis deviation can be explained on the basis of the known anatomy of the atrioventricular conduction system in patients with ostium primum atrial septal defect. The left axis deviation is most probably related to early activation of the postero-basal left ventricular wall (patients with short H-V) and/or late activation of the antero-lateral left ventricular wall (patients with normal H-V). Hemodynamics are not important in producing these findings.
Maximum Treadmill Exercise Test in Patients with Abnormal Control Electrocardiograms
Authors: LINHART JOSEPH W. , TURNOFF HOWARD B.
Published: June 2012

To determine the validity and safety of exercise induced ST changes (1 mm ischemic depression or further depression in ECG lead V
5
) as an indication of coronary artery disease (CAD) in patients with abnormal control electrocardiograms (ECG), 121 such patients were compared to 57 patients with a normal control ECG. All underwent a maximum graded treadmill exercise test and coronary arteriography. Among those patients with normal control ECGs, there were no false positives and five false negatives (sensitivity-85%, specificity-100%). In 61 patients with abnormal ECG (no drug therapy except nitrates) there were four false positives and nine false negatives (sensitivity-76%, specificity-79%). In this group of patients T waves reverted from negative to positive in four patients with CAD and 10 patients with no CAD, but T inversion during exercise only occurred in those with CAD (6 patients). Three of 12 patients (25%) with ECG evidence of old infarction and four of eight with single vessel disease had false negative tests. In 60 patients with abnormal ECG on drug therapy there were 10 false positives (17%) and 15 false negatives (sensitivity-55%, specificity-63%). Not helpful in differentiation were resting T vs ST changes, induction of arrhythmias or exercise induced chest pain.

The validity of exercise induced ST changes in differentiating CAD is excellent when the control ECG is normal and is only slightly reduced with control ST-T wave abnormalities. When the latter occur in association with cardiovascular drug therapy, other than nitrates, the exercise ECG is of no use in differential diagnosis although still valid and safe for the determination of exercise tolerance.
Discrepancies Between Cineangiographic and Postmortem Findings in Patients with Coronary Artery Disease and Recent Myocardial Revascularization
Authors: GRONDIN CLAUDE M. , DYRDA IHOR , PASTERNAC ANDRÉ , CAMPEAU LUCIEN , BOURASSA MARTIAL G. , LESPÉRANCE JACQUES
Published: June 2012

In 28 consecutive patients who died following coronary artery grafting and within 30 days of a previous coronary cineangiogram, a study was undertaken to compare the findings at autopsy and those at angiography. In five instances, such a comparison could not be made: in one instance, no postmortem examination was obtained, and in four additional cases, the quality of the cineangiographic document (three instances) or the pathological specimen (one instance) did not permit a reliable comparison. In the remaining 23 cases, there were nine specimens in which an appreciable difference (≥ 25%) was noted in the severity of the coronary artery lesions. In four of these nine cases, failure of cineangiography to assess the degree of coronary arterial narrowing led to incomplete myocardial revascularization and contributed, in retrospect, to the surgical failure. Most discrepancies occurred in the left coronary artery system, despite the fact that in all instances, four projections had been obtained of the left coronary artery in the transverse plane. Because of the particular orientation of the initial portion of the left coronary artery and its major divisions, it is recommended that additional projections in the sagittal plane be included to eliminate angiographic superimposition of multiple branches, which often cannot be properly separated in the standard transverse plane.
Taussig-Bing Heart with Mitral Valve Straddling
Authors: KITAMURA NOBUO , TAKAO ATSUYOSHI , ANDO MASAHIKO , IMAI YASUHARU , KONNO SOJI
Published: June 2012

Seven autopsied cases of the Taussig-Bing Heart diagnosed at the Heart Institute of Japan were reexamined for this report. Three cases had been correctly classified according to the original description of the Taussig-Bing Heart. The remaining four cases provided examples of a rare variation of this malformation. Characteristic features included the following: the mitral valve straddled the ventricular septum in all cases; the chordae of the anterior leaflet crossed over the septum into the right ventricle through a large subpulmonary ventricular septal defect; and an abnormal muscle ridge, extending from the caudal part of the parietal band, covered the right ventricular side of the ventricular septal defect. Although these four cases differ anatomically from the original Taussig-Bing Heart, their hemodynamics are similar. We have called this anomaly the Taussig-Bing Heart with mitral valve straddling.
Echocardiographic Manifestation of Right Sinus of Valsalva Aneurysm
Authors: ROTHBAUM DONALD A. , DILLON JAMES C. , CHANG SONIA , FEIGENBAUM HARVEY
Published: June 2012

This case report describes the distinctive echocardiographic pattern in a patient with a congenital right sinus of Valsalva aneurysm. The echocardiogram demonstrated an abnormal structure extending from the aortic root into the left ventricular chamber adjacent to the interventricular septum. The structure showed diastolic motion away from the septum and systolic motion toward the septum. This movement was consistent with cineangiographic filling of the aneurysm during diastole and emptying during systole. After operative closure of the aneurysm, the echocardiogram showed dense thickening along the aortic root and contiguous interventricular septum, probably representing thrombosis and fibrosis within the obliterated aneurysmal sac; but no abnormal movement of the structure was present.
De Subitaneis Mortibus
Authors: JAMES THOMAS N. , HACKEL DONALD B. , MARSHALL THOMAS K.
Published: June 2012

Two cases of sudden death are described, a boy of 16 and a woman of 34. Both had marked narrowing of the atrioventricular (A-V) node artery and fibrosis in the His bundle. Whereas he had been known to have complete heart block for several years, she was thought to be in excellent health until her sudden unexpected death. The degree of fibrosis in his His bundle was so extensive that one can doubt any effective transmission of a sinus impulse. Her His bundle was much less involved, but this may have been the consequence of her death during an initial mal-function of this crucial region of the heart, whereas prolonged survival of the boy (by electronic pacing) permitted a final view of the later histological consequences of the same initial arterial lesion. Both also had a mild degree of myocarditis and narrowing of a few other small coronary arteries (the large ones were normal). The possible functional inter-relationship of these factors is discussed.
Pulmonary Varix
Authors: DAVIA JAMES E. , GOLDEN MICHAEL S. , PRICE HERMAN L. , HASTINGS JAMES E. , CHEITLIN MELVIN D.
Published: June 2012

Pulmonary varix is a rare lesion consisting of aneurysmal dilatation of a pulmonary vein. Its radiologic appearance may be indistinguishable from a neoplasm, granuloma, or pulmonary arteriovenous fistula. Pulmonary angiography with follow-up through the venous phase is the only method of diagnosis. Reported herein is an illustrative case.
Erratum
Authors: LOWN BERNARD
Published: June 2012

Dr. L. S. Gettes has alerted me of the fact that three figures appearing in our review article devoted to the subject of ventricular tachycardia (Circulation
47:
1364, 1973) appear to be adaptations of figures which he had published earlier (Am J Cardiol
28:
526, 1971). These figures (in our article Nos. 1, 7 and 8) were diagramatic simplifications of certain electrophysiologic concepts.

One might rationalize that these figures were based on what is now a commonly held viewpoint and furthermore, that they do not represent anyone's painfully acquired data. Of course, such attempts at justification are mere frivolous sophistry. It is best to hasten and apologize to Dr. Gettes for inexcusable oversights which were exclusively my fault. If there is any comfort to be gained from this transgression, perhaps it resides in the realization that next to promulgation of truth, there is some virtue in the public recantation of error.
Intraventricular Conduction Delay as a Determinant of Atrial Echo Beats
Authors: VARGHESE P. JACOB , DAMATO ANTHONY N. , CARACTA ANTONIO R. , GALLAGHER JOHN J. , JOSEPHSON MARK E. , LAU SUN H.
Published: June 2012

Re-entry within the atrioventricular (A-V) node is a common cause of atrial echo beats and paroxysmal atrial tachycardia. This report deals with observations made in four patients in whom the determining factor for atrial echo beats appeared to be a critical conduction delay occurring within the His-Purkinje system and not within the A-V node. The evidence in support of this conclusion is as follows: 1) at a constant A-V nodal delay, echo beats only occurred when a critical His-Purkinje delay was reached; 2) in the presence of different intraventricular conduction times, atrial echoes were dependent on a requisite His-Purkinje conduction delay; 3) at variable A-V nodal conduction times, echo beats appeared only when a requisite delay in His-Purkinje conduction developed; 4) at a constant premature coupling interval atrial echo beats could be abolished when refractoriness within the His-Purkinje system was decreased by decreasing the cycle length of the basic drive; and 5) at constant A-V nodal conduction times, a reciprocal relationship existed between the magnitude of the His-Purkinje delay and the "echo interval" defined as the interval between the onset of ventricular depolarization and the echo beat.
The Gap Phenomena During Retrograde Conduction in Man
Authors: AKHTAR MASOOD , DAMATO ANTHONY N. , CARACTA ANTONIO R. , BATSFORD WILLIAM P. , LAU SUN H.
Published: June 2012

Ventricular refractory period studies were performed in 12 consecutive and unselected patients using the ventricular extrastimulus method (V
2
) at basic ventricular cycle lengths (V
1
V
1
). In six of 12 patients two types of retrograde gaps occurred. At relatively long V
1
V
2
intervals, ventriculo-atrial (V-A) conduction failed and then resumed at shorter V
1
V
2
intervals. The initial sites of retrograde block were the A-V node in two patients and the His-Purkinje system in four patients. In both groups, resumption of V-A conduction at shorter V
1
V
2
intervals occurred because of retrograde delay within the His-Purkinje system. Retrograde gaps differ from previously described antegrade gaps in A-V conduction: The site of initial block in A-V gaps is the His-Purkinje system and resumption of A-V conduction occurs at shorter A
1
A
2
intervals because of proximal delay in the A-V node (type I) or delay in the proximal His-Purkinje system (type II). In V-A gaps the site of initial block may be either the A-V node or the His-Purkinje system and resumption of V-A conduction always occurs due to delay within the distal His-Purkinje system. A common feature of both A-V and V-A gaps is the fact that delay of the more premature impulses allows time for previously refractory areas to recover excitability and both can be functional in nature. Only one of the 12 patients had both A-V and V-A gaps in conduction. Retrograde gaps in V-A conduction are more commonly observed than A-V gaps.
Vectorcardiographic Criteria for the Diagnosis of Inferior Myocardial Infarction
Authors: STARR JOHN W. , WAGNER GALEN S. , BEHAR VICTOR S. , WALSTON ABE , GREENFIELD JOSEPH C.
Published: June 2012

Vectorcardiograms (VCG) from two patient groups were analyzed to develop and test quantitative criteria for the diagnosis of inferior myocardial infarction. The first group (219 patients) consisted of four subgroups and was used to develop the criteria. Patients were placed in the normal and infarct subgroups by clinical descriptors including history, course in the coronary care unit, and cardiac catheterization findings. The criteria which were found to give the fewest false positive results with acceptable sensitivity were as follows:

In the frontal plane, generally clockwise early superior QRS forces must be present, i.e., forces which are initially either a) superior (rightward or leftward) or b) inferior and completely rightward for not more than 10 msec prior to becoming superior, and which subsequently cross the X axis to the left of the 0 point (or less commonly, the entire efferent limb remaining superior to the X axis). One of the following conditions must also be present: 1) Time from the 0 point to leftward X intercept of at least 25 msec and distance from the 0 point to leftward X intercept of at least 0.30 mV; 2) A maximal frontal plane QRS vector less than 15°; 3) A maximal superior deviation of at least 0.1 mV and a ratio of maximal superior deviation to maximal inferior deviation of at least 1:5.

The performance of these proposed criteria were then tested prospectively using a second group (255 patients) which was similar to the criteria group. The proposed criteria were found to be statistically superior to both ECG Q wave criteria and to the VCG initial force criteria of Young and Williams.
2
The incidence of false positive diagnosis in the test group was less than 3%.
Cardiac Responses to Isometric Exercise
Authors: QUARRY VERONICA M. , SPODICK DAVID H.
Published: June 2012

The time course of cardiocirculatory responses to different levels of isometric handgrip (IHG) in sitting position were studied noninvasively in normal males and compared to supine IHG results in the same subjects.
Control Comparisons.
Resting postural differences were as expected: sitting heart rates (HR), pre-ejection phase (PEP) and PEP/LVET were higher while left ventricular ejection time (LVET) and ejection time index (ETI) were lower than those supine (P < 0.05 to P < 0.001). The following trends, while not statistically significant, were also noted: systolic and diastolic blood pressure were lower while pressure-rate product (PRP), the interval from appearance of the Q wave to the first major "mitral" component of the first heart sound (Q-I
M
), and isovolumic contraction time (IVCT) tended to be higher than those supine.
Isometric Exercise.
The supine IHG results are consistent with data reported in the literature. During sitting IHG at 15% maximum voluntary contraction (MVC) there was no statistical change in any parameter measured. At 30%, 50%, and 100% MVC there were increases in HR, systolic and diastolic pressures, and PRP. At 30% MVC, Q-I
M
and pulse transmission time (PTT) decreased, ETI increased and IVCT, PEP, LVET, and PEP/LVET did not change significantly. At 50% MCV, Q-I
M
, IVCT, PEP, LVET, PEP/LVET and PTT shortened while ETI increased. At 100% MCV, Q-I
M
, IVCT, PEP, and LVET shortened but no significant changes occurred in PEP/LVET or ETI.

When sitting IHG was compared to supine IHG the end points of exercise yielded statistically similar values for systolic and diastolic pressures, PRP, Q-I
M
, IVCT, PEP, and PTT. LVET and ETI were consistently lower (
P
< 0.02) while HR and PEP/LVET were higher for sitting vs supine IHG. Standard errors were smaller supine, a finding that indicates greater homogeneity of response in this posture and probably explains why some changes in cardiac parameters at lower levels of IHG reached statistical significance in the supine but not the sitting position.

The changes in systolic intervals are consistent with the increased contractility resulting from IHG. Lack of uniform decreases in PEP/LVET with higher levels of IHG, however, were believed to reflect decreased myocardial adaptability to higher pressure (vs volume) loads. Decreases in pulse transmission time appeared to be influenced by diastolic pressure increases which were directly related to the levels of IHG.

Once resting postural differences are accounted for, however, the effect of posture on IHG is not very great and certainly does not present the disparity which exists between sitting and supine rhythmic exercise. Most responses were directly related to the level of exertion, with greater changes occurring at the higher levels of IHG. For noninvasive studies, 50% or 100% MVC are the recommended levels of exertion since significant cardiocirculatory responses are greater than at 15% and 30% MVC and occur within one minute.
Myocardial Blood Flow and Oxygen Consumption in Man Early After Valve Replacement
Authors: WISHEART JAMES D. , ARCHIE JOSEPH P. , KIRKLIN JOHN W. , TRACY WILLIAM G.
Published: June 2012

Twenty-one patients without demonstrable coronary artery disease have been studied in the first 48 hours after aortic or mitral valve replacement to determine the possible contribution of abnormalities of left ventricular myocardial blood flow and oxygen consumption to the impaired cardiac performance which is sometimes evident in such patients. In the 14 patients making an uneventful recovery (group A), the mean value for left ventricular coronary blood flow (Kety-Schmidt method) in each study period was between 105.9 and 111.2 ml·min
–1
·100 g
–1
, and myocardial oxygen consumption between 11.1 and 12.7 ml·min
–1
·100 g
–1
, both being higher than in normal resting man. Oxygen extraction was 59 to 69%, and coronary sinus oxygen tension 23 to 29 mm Hg. Lactate extraction was normal. Five patients (group B) required pharmacologic support because of low cardiac output; all had undergone mitral valve replacement. In them, left ventricular coronary blood flow and oxygen consumption were the same as in group A; however, oxygen extraction was greater (68 to 79%), coronary sinus oxygen tension lower (22 to 24 mm Hg) and lactate extraction lower. Patients in group A who underwent mitral replacement (N = 4) had systemic and coronary hemodynamics and metabolism that were as satisfactory as those undergoing aortic replacement, except that left atrial pressure was higher in the first study period. When heart rate was increased from 100 to 128 beats/minute by pacing in five patients in group A, and in two additional patients, myocardial oxygen consumption increased significantly, but in four patients coronary blood flow failed to increase, oxygen extraction increased, and coronary sinus oxygen levels decreased. We conclude that in patients such as those we studied, low cardiac output postoperatively is not the result of low total left ventricular coronary blood flow or myocardial oxygen supply, but may occur in some of these patients at this time from low or absent coronary reserve and added stresses such as those from tachycardia may be met only with the potentially detrimental mechanism of increasing oxygen extraction and reducing coronary venous and myocardial oxygen levels.
Single Ventricle with Transposition
Authors: MARÍN-GARCÍA JOSÉ , TANDON RAJENDRA , MOLLER JAMES H. , EDWARDS JESSE E.
Published: June 2012

Fifty-seven cases of single (common) ventricle with transposition of the great vessels are reviewed. The diagnosis had been confirmed by necropsy in 25 and by angiocardiography in 32 cases.

Single (common) ventricle is defined as that condition in which both atrioventricular valves separately enter a single ventricular cavity. According to this definition, cases presenting with common atrioventricular valve, atresia of one atrioventricular valve, or straddling valves have been excluded. Two structural types of common ventricle are identified: the left ventricular type and the primitive type of single ventricle. The former showed anatomic features similar to a left ventricle, whereas in the latter, features characteristic of a left ventricle were not present. The latter was considered a more primitive condition than the former.

A classification based upon the type of single ventricle and its outflow tract and upon the relationship of the great vessels is presented. Of the 25 cases of single ventricle with transposition studied pathologically, 21 were of the left ventricular type and four of the primitive type. Of the four cases with double conus three were among the four examples of primitive ventricle. Among the 21 cases with a single conus, the type of transposition was about equally divided between the
d
-type (ten cases) and the
l
-type (11 cases).

Pulmonary stenosis or atresia was observed in seven of the 21 cases with a single conus and in one of the four cases with double conus.

In the clinical cases, only angiocardiography could establish the diagnosis and delineate the different types of great vessel-ventricular relationships.
Ineffectiveness of Glucose, Potassium, and Insulin Infusion During Pacing Stress in Chronic Ischemic Heart Disease
Authors: LESCH MICHAEL , TEICHHOLZ LOUIS E. , SOELDNER J. STUART , GORLIN RICHARD
Published: June 2012

Eight patients with coronary artery disease and positive exercise electrocardiograms undergoing cardiac catheterization were subjected to periods of atrial pacing-induced tachycardia at identical rates, before and during a glucose, potassium, and insulin (GKI) infusion. Steady state elevation of glucose and insulin was obtained prior to repeating the atrial pacing test in the GKI state. With each patient serving as his own control, five developed augmented clinical signs of acute ischemia during the paced GKI state, two no change, and one subjective improvement. Left ventricular end-diastolic pressure (LVEDP) was elevated in all patients (1-8 mm Hg) at rest during GKI infusion as compared to the rest control state. LVEDP during pacing was greater during the GKI paced state as compared to the control paced state in three of the eight patients whereas after pacing LVEDP was higher in four of eight patients during GKI. ST-segment depression was less during pacing in the GKI as compared to control state in four patients. A decrease in ST-segment depression was noted in two patients after pacing in the GKI state as compared to this measure after pacing in the control state. Augmented myocardial glucose uptake was demonstrated in the paced GKI state but lactate analysis failed to demonstrate a stoichiometric relationship between enhanced glucose uptake and lactate production.

It is concluded that tolerance to ischemia is not extended and in the majority of cases may be adversely affected by GKI.