bluuebunny/crossref_metadata_2025 huggingface dataset:
Shock: A Semantic Enigma
Authors: RUSHMER ROBERT F. , VAN CITTERS ROBERT L. , FRANKLIN DEAN L. , Baker Donald , Schlegel William , Harding Donald , Watson Nolan , Smith Raymond
Published: June 2012

The first step in analyzing any clinical problem must be the identification and precise definition of the entity. An adequate definition must be based on accurate and quantitative description in terms of crucial variables. Since many of the essential variables can be measured or estimated on patients, shock can be approached in a series of logical steps for each type:

1. A discrete clinical condition currently classified under the term "shock" could be identified.

2. A specific and unique name and definition of this condition could be derived by direct and quantitative measurements of variables such as those represented in figure 1.

3. The initiating factors would become apparent from these measurements.

4. The compensatory reactions that are inadequate should be distinguished from responses that are inappropriate.

5. With this knowledge at hand, a suitable model of the circulatory disturbance could be evolved and validated by quantitative measurements in experimental analysis.

6. Appropriate therapy of the defined condition could then be based on knowledge of the nature of the basic disturbance. Obviously, treatment that would effectively correct the fundamental defect from extravasation or anaphylaxis might be dangerous if applied to a patient with myocardial infarction.

7. The terminal events in fatal shock-like states can be regarded as a group of potential vicious circles that may have no obvious connection with the original cause of the systemic arterial hypotension. Effective therapy during the final stages of circulatory deterioration requires a great deal more knowledge regarding the various mechanisms of circulatory collapse than we now possess.
Further Electrocardiographic Observations on Direct Epicardial Potentials in Congenital Heart Lesions
Authors: WASSERBURGER R. H. , YOUNG W. P. , SIEBECKER K. , HAWKINS L. K. , BAMFORTH B. , KING J. T.
Published: June 2012

Epicardial electromotive potentials have been recorded at the time of open thoracotomy on 130 patients, 124 having congenital heart disease.

These data confirm characteristic epicardial potentials with right ventricular preponderance, incomplete right bundle-branch block, and complete right bundle-branch block, as well as with normal rS and rSr' complexes, as identified in the right precordial leads of unipolar electrocardiograms.

The major differential feature between right ventricular preponderance and incomplete right bundle-branch block is a critical difference in onset of depolarization of the free wall of the right ventricle. This measurement, AB of figure 1, is 0.02 second with right ventricular preponderance and 0.03 second or greater with incomplete right bundle-branch block.

Although rR' or rsR' right precordial QRS complexes are identified with both right ventricular preponderance and incomplete right bundle-branch block, the broad left ventricular S wave of the incomplete right bundle-branch block aids in differentiating them on the conventional electrocardiogram.

A tall predominant late R wave in aV
R
, arising from the R' component of the rR' potential of the hypertrophied right ventricular outflow tract, serves to denote an advanced degree of right ventricular hypertrophy, whether the classic pattern of right ventricular preponderance or an incomplete right bundle-branch block associated with right ventricular preponderance presents on the routine electrocardiogram.

The apparent slurred or pure R waves, the Rs and qR right precordial QRS complexes, seen with instances of right ventricular preponderance or incomplete right bundle-branch block, are actually rR' or rsR' complexes. Additional exploratory right anterior chest leads will invariably bring out the initial septal r wave component.

The rR' or rsR' potentials of right ventricular preponderance or right bundle-branch block arise from a relatively selective site of the high medial outflow tract of the right ventricle.
Proteolysis, Fibrinolysis, and Coagulation
Authors: ALEXANDER BENJAMIN , PECHET LIBERTO , KLIMAN ALLAN
Published: June 2012

The fibrinolytic mechanism, one of the blood protease systems, constitutes a fourth phase of clotting, which contributes to maintenance of coagulation in delicate balance.

"Shwartzman"-induced in vivo coagulation, combined with fibrinolysin, produces profound clotting defects with severe hemostatic failure, in contrast to the relative innocuousness of either alone.

The same defects are obtainable in vitro. The thrombin-fibrinogen interaction is blocked, simulating the in vivo "afiibrinogenemia." These observations are pertinent to thrombolytic therapy invoked for conditions where intravascular clotting may be occurring.

Fibrinogen clottability is also blocked by trypsin. Apparently, fibrinolysin, thrombin, and trypsin are competitive for fibrinogen.

Trypsin, as, well as other proteases, markedly activates factors II, VII, and X, resembling the action of thromboplastin. In contrast, fibrinolysin and thrombin are inert on these clotting factors, whereas on factor V they first activate and then destroy it. This explains why factor V depression is observed in thrombolytic therapy.

The activating effect of trypsin on factors II, VII, and X precludes its use in thrombolytic therapy, and also draws attention to the tryptase-antitryptase equilibrium in normal and certain thrombotic states.

The experimental observations help elucidate some clinical and clinicolaboratory findings in acquired "afibrinogenemia" and therapeutically induced "fibrinolytic" states. The retarded thrombin clotting time of the plasma, and reduction in prothrombic activity attributable to fibrinolytic depression of factor V, may be valuable guides to thrombolytic therapy.
Structure of the Plasma Membrane
Authors: STOECKENIUS WALTER
Published: June 2012

Electron micrographs of the cell membrane is compatible with the assumption that it consists of a bimolecular leaflet of lipid coated on both sides with protein.
The Nature and Stability of the Plasma Membrane
Authors: FINEAN J. B.
Published: June 2012

Structural features of plasma membranes have been derived from chemical and structural data on nerve myelin, a multilayered membrane system which is highly favorable for direct study. Molecular constituents of such membranes have been related to electron-density distribution curves derived from x-ray diffraction patterns of myelin in fresh nerve tissue. These curves relate to the variations of electron density through the thickness of the membrane layer, and they indicate significant structural differences between Schwann-cell and glial-cell membranes. Experience with the myelin system has also facilitated discussion of the distribution of molecular constituents within the plane of the membrane and the possibility of variations in this distribution in relation to function.
Ultrastructure and Transport Across Epithelial Membranes
Authors: HOGBEN C. ADRIAN M.
Published: June 2012

For epithelia, all too frequently this or that ultrastructure is spoken of as "absorptive" or "(secretory." Correlation between structure and function must relate to phenomena, such as the apparent active transport of weak electrolytes or water, that are unique for the epithelium. The macroscopic tubule of the gastric mucosa cannot sequester the active transport of hydrochloric acid from the solution bathing the mucosa. In the absence of both intracellular canaliculi and a microvillous border from the amphibian parietal cell, by exclusion, the endoplasmic reticulum or the plasma membrane proper must be considered as possible structures responsible for the sequestration.
An Unusual Complication of Inferior Venacavography
Authors: KOEHLER P. RUBEN , ISARD HAROLD J.
Published: June 2012

During inferior venacavography the tip of the catheter perforated the wall of the common iliac vein and entered the epidural space of the adjacent large lumbosacral trunk. Anatomically it is only at the level of the first sacral segment that the vein and nerve lie in very close proximity. Simultaneous opacification of the venous system and the epidural space resulted. A severe, temporary pain occurred upon the injection of the epidural space. There was no residual neurologic deficit.
The Plasma Membrane, with Notes on the History of Botany
Authors: SMITH HOMER W.
Published: June 2012

The origin of the concept of the plasma membrane is rather ambiguously identified. It antedated Pfeffer and deVries, and, after searching the literature, the writer attributes it to Carl Nägeli (1855), who had been working with algae, fungi, mosses, and unicellular plants. He noted particularly that the surface of discontinuity of the cell is impermeable to pigments contained within the cytoplasm or added to the solution around the cell. He found the protoplasmic surface to be more dense, viscous, and otherwise distinguishable from the cytoplasm, and hence he called the surface layer the
plasma membrane
. From experiments on osmosis he concluded that the plasma membrane endows the cell with its osmotic properties.
Supravalvular Aortic Stenosis in Association with Mental Retardation and a Certain Facial Appearance
Authors: BEUREN A. J. , APITZ J. , HARMJANZ D.
Published: June 2012

Four patients with supravalvular aortic stenosis are reported. In three of these patients a certain facial resemblance was striking, and these three patients were also mentally and physically retarded. The cases are very similar to the four cases recently reported in the literature. Supravalvular aortic stenosis in association with mental retardation and a certain facial appearance may constitute a previously unrecognized clinical syndrome.

A systolic thrill and murmur most pronounced in the first right intercostal space and just below the clavicle, with an empty vascular pedicle on the roentgenogram, may be a clue to the clinical diagnosis of supravalvular aortic stenosis.

Supravalvular aortic stenosis is best demonstrated by left ventriculography. A collateral circulation between the coronary arteries and the internal mammary artery has been shown in one patient.
Mitral Regurgitant Flow and Left Ventricular Function in Patients with Mitral Valve Disease
Authors: JOSE ANTHONY D. , BERNSTEIN L.
Published: June 2012

A direct indicator-dilution principle for measurement of regurgitant flow has been applied in the study of 39 patients with mitral valve disease.

Certain technical modifications in the procedure appear to have abolished the grossly anomalous results encountered previously, enabling a degree of reliance to be placed on the quantitative measurement.

With use of the measurement obtained, together with other hemodynamic data, the functional status of patients with mitral incompetence has been analyzed. The findings confirm that left ventricular failure, not mitral incompetence itself, underlies many of the criteria presently used to determine the severity of the disease, i.e., the presence of symptoms, the clinical and radiologic signs, and abnormalities in arterial dye dilution curves. These criteria are therefore probably not optimal ones on which to base selection of patients for surgical treatment, or to follow its results.
Aldosterone in Cerebral Salt Wasting
Authors: VOGEL JOHN H. K.
Published: June 2012

A metabolic balance study in a patient with cerebral salt wasting is reported. The results suggest that a normal aldosterone mechanism was present in association with inappropriate antidiuretic hormone secretion.
Angina of Micturition
Authors: MORRIS JAMES J. , MCINTOSH HENRY D.
Published: June 2012

A case history of a 46-year-old Negro male was presented with rheumatic aortic insufficiency, angina pectoris, and possible subacute bacterial endocarditis. While hospitalized, the patient developed angina pectoris associated with micturition. This was not accompanied by a change in blood pressure, pulse, or increase in respiratory rate. The striking similarity to a description of a case approximately 300 years ago is pointed out and possible mechanisms of this association of angina and micturition are considered.
Congenital Mitral Stenosis
Authors: DAOUD GEORGES , KAPLAN SAMUEL , PERRIN EUGENE V. , DORST JOHN P. , EDWARDS F. KATHRYN
Published: June 2012

Seven patients with isolated congenital mitral stenosis are described. In one instance there was an associated coarctation of the aorta. Repeated pulmonic infections, pulmonary edema, and congestive heart failure occurred frequently. The clinical diagnosis is suspected in the presence of an apical diastolic rumbling murmur and left atrial enlargement. Presystolic accentuation of this diastolic murmur, a sharp first heart sound, and an opening snap strengthen the diagnosis. Cardiomegaly and the electrocardiographic finding of right ventricular hypertrophy are common. Pulmonary hypertension and congestive heart failure may obscure the clinical picture of isolated congenital mitral stenosis. In infancy, the presence of tight mitral stenosis is usually associated with a poor prognosis.

The mitral leaflets showed variable degrees of fusion and thickening. The chordae tendineae were shortened and the papillary muscles hypertrophic. Endocardial fibroelastosis was common in the left heart, especially in the atrium.

In infancy and early childhood, the results of the medical and surgical treatment were generally poor. In older children, a better result was obtained and the surgical indications in these instances are not unlike those of rheumatic mitral stenosis.
Ventricular Septal Defect with Aortic Insufficiency
Authors: KECK ERNST W. O. , ONGLEY PATRICK A. , KINCAID OWINGS W. , SWAN H. J. C.
Published: June 2012

Eighteen patients with the combination of ventricular septal defect and aortic insufficiency were studied. Nine also had infundibular pulmonary stenosis. Seventeen were treated by open-heart operations.

The physical findings were those of a typical ventricular defect murmur and thrill together with an aortic insufficiency blow and a wide pulse pressure. A systolic murmur at the upper left sternal border with thrill is strongly suggestive of the additional lesion of infundibular pulmonary stenosis, but the presence or absence of infundibular pulmonary stenosis was indicated most accurately at cardiac catheterization and on inspection at operation. It was not of sufficient severity for signs of additional right ventricular hypertrophy to appear on the electrocardiogram.

Retrograde aortography serves to demonstrate the severity of the aortic regurgitation.

The problem of the surgical correction of these lesions will be the subject of a separate communication.
Bronchoconstriction in the Presence of Pulmonary Embolism
Authors: GUREWICH VICTOR , THOMAS DUNCAN , STEIN MYRON , WESSLER STANFORD
Published: June 2012

In a group of seven patients with pulmonary embolism, evidence of bronchoconstriction was found. Heparin appeared to relieve partially the observed airway obstruction. A possible common mechanism for the initiation of intravascular coagulation and the production of bronchoconstriction was considered. When other causes can be eliminated, the detection of bronchoconstriction may serve as a useful index for the early recognition of pulmonary emboli.
Studies in Serum Lipids
Authors: CROMIE J. B. , THOMSON K. J. , CULLIMORE O. S. , BEACH E. F.
Published: June 2012

Repeated measurements of the fasting and 2-hour postprandial serum lipids (cholesterol, phospholipid, and triglyceride) of "normal" [see table in the PDF file] subjects and subjects with atherosclerotic heart disease when consuming diets of high-, low-, or "normal"-fat content have been made.

Triglyceride levels correlated better with the clinical diagnosis of heart disease than did cholesterol or phospholipid levels. The wide fluctuations in triglyceride levels in the same [see table in the PDF file] subject (normal or atherosclerotic) when on a "normal self-selected" diet and the unexpected findings when a short-term (3-day) period of dietary fat manipulation render the value of random triglyceride levels as an indictator of the presence or likely development of atherosclerotic heart disease of little or no value in the individual subject.
Studies on Digitalis
Authors: KAHLER RICHARD L. , THOMPSON RONALD H. , BUSKIRK ELSWORTH R. , FRYE ROBERT L. , BRAUNWALD EUGENE
Published: June 2012

Three patients with acquired valvular heart disease and cardiac enlargement who were able to perform normal everyday activity without difficulty in the absence of digitalis therapy were exercised while receiving a placebo and again while receiving digoxin. Digoxin administration did not produce a significant change in body weight or in the subjective condition of the individuals. Varying degrees of exercise were performed on a treadmill in a Metabolic Chamber and oxygen consumption was measured cotinuously before, during, and after the period of exercise, utilizing a continuous gas flow paramagnetic oxygen analyzer. The oxygen debt that developed during digoxin administration was compared to that observed during placebo administration.

In all patients the oxygen debt was smaller during the period of digoxin administration, although the external work performed was identical. In the first patient, following a 7-minute walk, the oxygen debt was 53 per cent more and following a 10-minute walk it averaged 40 per cent more while not receiving digoxin than when receiving this drug. In the second subject the oxygen debt following a 7-minute walk was 34 per cent more and following 10-minute walk it averaged 74 per cent more when he was not receiving digoxin than when receiving this drug. In the third subject the oxygen debts were 46 per cent and 41 per cent greater following 10- and 15- minute walks respectively, when she was not receiving digoxin.

The accumulation of a smaller oxygen debt following exercise while these subjects were receiving digoxin indicates that the functional status of their circulatory system was improved by the drug. It would appear that digitalis administration is beneficial to at least some patients who have cardiac disease and enlarged hearts and some decrease in cardiac reserve without signs or symptoms of heart failure.
Effects of Inhalation of 100 Per Cent Oxygen on the Pulmonary Blood Volume in Patients with Organic Heart Disease
Authors: GLICK GERALD , SCHREINER BERNARD F. , MURPHY GERALD W. , YU PAUL N.
Published: June 2012

The effect of breathing 100 per cent oxygen on the pulmonary blood volume, pulmonary arterial pressure, left atrial pressure, and pulmonary vascular distending pressure was studied during cardiac catheterization in eight patients with organic heart disease. In half of the patients, a significant decrease in pulmonary blood volume was observed. This decline in pulmonary blood volume in the face of a decrease or no change in the pulmonary distending pressure is interpreted as evidence for a passive mechanism of action for 100 per cent oxygen.

The effects of hyperoxia are compared to those of acetylcholine, which works by actively dilating the pulmonary vascular bed.
A Surgical Approach to Ebstein's Disease
Authors: SCOTT III L. P. , DEMPSEY J. J. , TIMMIS H. H. , MCCLENATHAN J. E.
Published: June 2012

Ebstein's disease in a severely cyanotic 7-year-old boy was successfully treated by anastomosing the superior vena cava to the right pulmonary artery.

A discussion of impaired right heart function in Ebstein's disease is presented emphasizing the inefficiency of right atrial contraction as a consequence of the "atrialization" of the right ventricle.

It is our belief that right heart bypass with a superior vena cava to right pulmonary artery anastomosis is the surgical procedure of choice in patients severely ill from Ebstein's disease.
Origin of the Right Pulmonary Artery from the Ascending Aorta
Authors: PORTER DAVID D. , CANENT RAMON V. , SPACH MADISON S. , BAYLIN GEORGE J.
Published: June 2012

A case of aortic origin of the right pulmonary artery has been presented. A venous cineangiocardiogram demonstrated filling of the left side of the heart from the right atrium with subsequent opacification of the aorta and the anomalous right pulmonary artery without initial opacification of the right ventricle and main plus left pulmonary artery. At necropsy there was a fibrous band connecting the main pulmonary artery with the anomalous vessel. The embryologic implications suggest that this case represents atresia of the proximal portion of the right sixth aortic arch.
A Method for the Control of Severe Alterations in Acid-Base Equilibrium
Authors: MOORE DOUGLAS , BERNHARD WILLIAM F.
Published: June 2012

Tris buffer was utilized in the prevention or treatment of profound metabolic acidosis which developed during, and immediately after, extended periods of extracorporeal circulation. In 16 patients (group I), buffer was added to the 24-hour-old heparinized priming blood prior to initiation of bypass, to counteract a low pH and high lactic acid concentration. The success of this therapy was manifested by the stability of all acid-base parameters during and following operation.

In the second group of 11 patients (group II), severe metabolic acidosis developed despite preliminary buffering of the priming blood. Here, the administration of additional buffer successfully restored acid-base equilibrium prior to the termination of perfusion.

The buffer also proved effective in the treatment of two patients who developed severe respiratory acidosis in the immediate postperfusion period, and was instrumental in the resuscitation of a final patient following a prolonged period of cardiac arrest.

It is suggested that tris buffer is a safe, potent agent for use in the prevention and treatment of acidosis from whatever cause.
Electrocardiographic and Biochemical Study in Hemorrhagic Shock in Dogs Treated with Hyperbaric Oxygenation
Authors: COWLEY R. ADAMS , ATTAR SAFUH , ESMOND WILLIAM G. , BLAIR EMIL , HAWTHORNE ILSE
Published: June 2012

A modification of the standard Fine preparation for hemorrhagic shock yielding an 83 per cent mortality rate was developed. Hyperbaric oxygenation (OHP) at 3 atmospheres absolute was found to decrease the mortality rate significantly, to 26 per cent. Electrocardiographic changes induced by OHP were bradycardia and sinus arrhythmia, which were abolished by vagotomy. Tachycardia, depression of the S-T segment, with changes in the configuration of the T wave that indicated myocardial damage, was observed in shock dogs treated with OHP. All changes improved after decompression and reinfusion of shed blood. The improved survival rate is attributed to better oxygenation of the hypoxic tissues [see figure in the PDF file] by the increased physically dissolved oxygen.
Oxygen Uptake of Tissues Following Acidosis During Profound Hypothermia
Authors: PREHATNY JOHN R. , CHING NATHANIEL P. H. , TEMPLETON JOHN Y. , NEALON THOMAS F.
Published: June 2012

Oxygen consumption was measured in experimental dogs, cooled to 15 C., by biventricular bypass and blood-stream cooling. Rendering the animals acidotic by the infusion of dilute HCl did not change the consumption of oxygen.
Experience with Anastomosis of Superior Vena Cava to Pulmonary Artery (Glenn Procedure)
Authors: KEIRLE ALFRED M. , HELMSWORTH JAMES A. , KAPLAN SAMUEL , OGDEN ARTHUR E.
Published: June 2012

Fifteen children with uncorrectable cyanotic heart disease were treated with the Glenn procedure. The hospital mortality was 20 per cent. Total and partial body perfusions were used in two cases to accomplish the anastomosis. The indications for perfusion have been discussed. Modifications in anesthesia were presented to reduce the high incidence of hypotension, bradycardia, and cardiac arrest.
Aortic Replacement
Authors: STARR ALBERT , EDWARDS M. LOWELL , MCCORD COLIN W. , GRISWOLD HERBERT E.
Published: June 2012

A ball-valve prosthesis for aortic replacement has been described which, while it is similar to the mitral ball valve in terms of materials and construction, is quite different in sewing margin and internal geometry. Implantation is greatly facilitated by the flexibility of the prosthesis in terms of external diameter, and by the availability of a full set of varying sizes for obtaining a proper fit. Widening of the aortic root by patch grafting has not been necessary. Long-term survival has been achieved in the dog, and early clinical results are most promising.

While the selection of the ideal aortic valvular replacement must await further experience with all types of prostheses, continued evaluation of the ball valve in the aortic position, in carefully chosen patients, is indicated.
Ventricular Septal Defect with Aortic Valvular Incompetence
Authors: ELLIS F. HENRY , ONGLEY PATRICK A. , KIRKLIN JOHN W.
Published: June 2012

Nineteen patients with ventricular septal defect and severe aortic valvular incompetence have been operated on at the Mayo Clinic. There were two early deaths and two late deaths. The ventricular septal defect was located high and anteriorly in the septum and was often small. Aortic valvular incompetence was due, in most cases, to a deformed, prolapsing right coronary cusp. Mild to moderate degrees of infundibular pulmonary stenosis coexisted in nine patients.

Repair of the ventricular septal defect was readily accomplished in most cases by direct suture, and relief of obstruction to right ventricular outflow was effected, when required, by resection of the crista supraventricularis. Repair of the aortic incompetence was attempted by a variety of means, but the incidence of persistent significant regurgitation was high, except when prosthetic cusp replacement was used.

It is currently our policy to defer operation in children unless there are significant symptoms. When the patient is past the age of about 12 to 14 years, operation is advised under proper circumstances, and it consists generally of suturing of the ventricular septal defect and replacement of the right coronary cusp of the aortic valve.
Effect of Low Molecular Weight Dextran on Red Blood Cell Charge During Clinical Extracorporeal Circulation
Authors: BERNSTEIN EUGENE F. , EMMINGS FRED G. , EVANS ROBERT L. , CASTANEDA ALDO , VARCO RICHARD L.
Published: June 2012

Low molecular weight dextran, when included in the priming mixture of a pump oxygenator for clinical extracorporeal circulation, almost uniformly increased the electric charge of red blood cells. In perfusions in which 5 per cent dextrose and water were used as the priming vehicle, there appeared to be no change in red blood cell charge. The increase in red blood cell electronegativity, associated with the presence of low molecular weight dextran, appeared to decrease red blood cell aggregation and permit improved tissue perfusion.
Renal Hemodynamic Effects of Total Cardiopulmonary Bypass Eliminating Heparinized Blood
Authors: BEALL ARTHUR C. , COOLEY DENTON A. , Smith C. Polk
Published: June 2012

In order to compare the renal hemodynamic effects of using 5 per cent dextrose in distilled water with the effects of using fresh, heparinized blood as the priming agent for extracorporeal circulation, mongrel dogs were subjected to 30 minutes of total cardiopulmonary bypass by each technique. Discrete renal function determinations were performed before and after bypass. In one group, homologous blood was used to prime the pump oxygenator. Renal function in these animals was depressed to approximately two-thirds of control values. In the other group, 5 per cent dextrose in distilled water was used as the priming agent. In these animals, little or no change in renal function was noted following operation, indicating more optimal maintenance of renal function by this technique.
Prevention of Excess Hemolysis During Cardiopulmonary Bypass by the Use of Mannitol
Authors: PORTER GEORGE A. , SUTHERLAND DONALD W. , MCCORD COLIN W. , STARR ALBERT , GRISWOLD HERBERT E. , KIMSEY JEAN
Published: June 2012

Mannitol infusion has significantly decreased plasma hemoglobin build-up rate in mitral and aortic valvular replacement. This occurred before hemoglobin appeared in the urine, and was unrelated to the binding of hemoglobin by haptoglobin. The mechanism by which mannitol decreases the build-up rate of plasma hemoglobin is unknown, but seems to be other than by renal excretion of hemoglobin.
Effects of Right Ventriculotomy upon Activation of the Epicardial Surface of the Canine Right Ventricle
Authors: GENENDER LAWRENCE J. , STUCKEY JACKSON H. , JOMAIN SERGE L. , HOFFMAN BRIAN F.
Published: June 2012

The sequence of activation of the epicardial surface of the right ventricle has been studied before and after right ventriculotomy. Normally, the area of the right ventricle adjacent to the anterior interventricular groove is activated first, the midportion of the wall second, and the area adjacent to the posterior interventricular groove and the anterior basal area are activated last. Activation of the entire epicardial surface of the right ventricle requires 25 to 40 msec.

Right ventriculotomy does not alter the sequence of activation or the time of activation of the right ventricular epicardium if the incision passes medial to the free-running Purkinje fibers or through their arborization on the right, ventricular wall. When the ventriculotomy is made lateral to the arborization of these fibers, activation of that portion of the wall lateral to the incision is delayed, and activation of the entire ventricular surface requires 42 to 52 msec.

There is no electrocardiographic evidence of bundle-branch block, complete or partial, following right ventriculotomy, regardless of the location of the incision.
Aortico-Left Ventricular Tunnel
Authors: LEVY MORRIS J. , LILLEHEI C. WALTON , ANDERSON RAY C. , AMPLATZ KURT , EDWARDS JESSE E.
Published: June 2012

To be distinguished from aneurysm of an aortic sinus (Valsalva) is the rare condition in which an abnormal channel begins in the ascending aorta (above the right coronary artery), bypasses the aortic valve, and leads through the ventricular septum into the left ventricular cavity. This entity, which has not previously been diagnosed during life, to our knowledge, is herein named aortico-left ventricular tunnel.

The cases of three patients (aged 3, 5, and 10 years) with this rare condition are described. The clinical, electrocardiographic, and radiological features were similar in each case and resembled those in aortic valvular insufficiency.

The diagnosis may be established clinically through selective aortography. This reveals that the origin of the abnormal communication lies in the anterior wall of the ascending aorta above the levels of the coronary arterial origins. The abnormal communication leads to the left ventricle. The condition is distinguished from aortic sinus aneurysm by its origin above the level of the aortic sinuses.

Identical anatomical findings and the presence of abnormal physical findings since infancy in each of the three patients suggest that this peculiar condition is a congenital malformation.
Successful Surgical Correction of Supravalvular Aortic Stenosis
Authors: DEBAKEY MICHAEL E. , BEALL ARTHUR C.
Published: June 2012

Stenotic lesions in the aortic valve region may be acquired or congenital, and may be valvular, subvalvular, or supravalvular in location. As more of these patients are offered the benefits of surgical correction, cases of supravalvular aortic stenosis are being reported with increasing frequency. At least seven previous cases have been corrected successfully and another is reported.

The diagnosis of supravalvular aortic stenosis usually cannot be made on clinical grounds alone. Definitive diagnostic technics are available, however, and allowed accurate delineation of the lesion in the case reported. Surgical correction consists of enlarging the aortic lumen in the area of supravalvular constriction. This usually is possible by longitudinal aortotomy through the area of constriction followed by patch angioplasty, as employed in this case in conjunction with modified endarterectomy. In most instances of supravalvular aortic stenosis, the valve itself is perfectly normal, and total correction is possible if the correct diagnosis is made.
Analogy of Electronic Pacemaker and Ventricular Parasystole with Observations on Refractory Period, Supernormal Phase, and Synchronization
Authors: BURCHELL HOWARD B.
Published: June 2012

The artificial pacemaker has been compared to a physiologic ventricular parasystolic focus. In hearts being driven by a pacemaker, in the absence of atrioventricular (AV) block, capture (interference) phenomena are constantly seen. While variations in QRS complexes have been observed when the external pacemaker stimulus occurs early in the T-wave period of a sinus conducted beat, no sequence of aberrant beats has been observed. One patient showed occasional sinus beats interpolated between ventricular beats arising from the artificial pacemaker, and these occurred at a very narrow time band suggesting that AV conduction was permitted by phenomenon of a supernormal phase. At a later date this patient showed also
retrograde
conduction believed related to a supernormal phase during recovery of junctional tissue penetrated by an impulse entering from above, though the impulse itself was blocked.

Records of two patients are used to illustrate grossly aberrant QRS complexes produced by the stimulus of the electric pacemaker when this fell in the semirefractory period. Noteworthy was the presence of a latent period before potentials of the propagated impulse were recorded, there being evident stimulus-to-QRS delays. The situation wherein the rhythm is most chaotic is that where AV block is absent, the sinus rate is fast, and the electric pacemaker rate is relatively slow. In two patients, retrograde activation of the atria occurred as a stable mechanism. In one patient, nodal rhythm of the RP type occurred, and sequences of the records suggested that the AV node might have become synchronized with the extrinsic pacemaker cycle. In this last instance three independent centers of effective impulse formation coexisted, the sinus node, AV node, and stimulating electrodes of the electronic pacemaker.

A marked increase in the refractory period of the ventricle, as measured by its response to the set stimulus of the electric pacemaker delivered at varying instants with respect to the sinus mechanism, occurred in one case within a few days. The possibility that reserpine therapy contributed to this change is possible but has not been established, for the effective refractory period, as measured, later remained constant over a period of many weeks.
Aortoplasty in Infants with Coarctation
Authors: KING HAROLD , WALDHAUSEN JOHN A.
Published: June 2012

Seven severely ill patients under the age of 6 months with coarctation of the aorta were treated by the new operative method of aorto-plasty. Six survived and were improved. The operative technic consists of a longitudinal incision, excision of the intimal diaphragm, and transverse closure of the aorta. The aortic obstruction can be quickly and completely relieved. Since the suture line extends for only [see figure in the PDF file] about one half of the vessel circumference, growth of the aorta at that site may prove to be more normal than that following resection and end-to-end anastomosis. It is our impression that the technical simplicity of this new technic will extend the usefulness and lower the mortality of surgical correction of coarctation of the aorta in infancy.
Recognition and Surgical Repair of Superior Mesenteric Arteriovenous Fistula
Authors: SUMNER ROBERT G. , KISTLER PHILIP C. , BARRY WILLIAM F. , McINTOSH HENRY D.
Published: June 2012

A patient is described with a traumatic arteriovenous shunt from the superior mesenteric artery to the superior mesenteric vein. The patient had no symptoms referable to this fistula 3 months after a gunshot wound to the abdomen. The diagnostic feature was a continuous bruit in the supraumbilical area. The radiographic technics used in determining the nature of this patient's fistula are described. This is the first reported case of a traumatic superior mesenteric arteriovenous fistula suspected clinically, demonstrated radiographically, and successfully repaired surgically. Although experience with such fistulas is limited, the fatal outcome of the only other case in the literature (not recognized ante mortem) indicates the need for careful auscultation over all abdominal surgical incisions and sites of trauma at regular intervals.
The George E. Brown Memorial Lecture
Authors: GREGG DONALD E.
Published: June 2012

The results presented are just the beginning of an attempt to study the reactions of the left coronary circulation in the unanesthetized dog to natural stresses of everyday life. They indicate in mild to moderate treadmill exercise, with little change in stroke cardiac output, that the flow and oxygen usage per heart beat does not greatly increase, so that the coronary circulation appears to be largely limited or monitored by the heart rate. During excitement and cardiac sympathetic nerve stimulation, the left coronary vascular bed undergoes massive dilatation, so that the left ventricle is able to increase its coronary circulation as the result of the combined effect of an increased number of heart beats and a greatly increased flow and oxygen usage per heart beat, the latter occurring despite a marked reduction in the duration of systole and of the cardiac cycle, and very little change in the pressure developed by the left ventricle. Although the left ventricular contraction imposes a large myocardial impediment to coronary flow, it permits a very sizable and variable contribution to systolic flow and to left coronary flow. In the resting dog, the left coronary inflow in systole generally approximates 15 to 60 per cent of that during diastole, and under different stress conditions, such as exercise, excitement, drug injections and irreversible hemorrhagic shock, both the systolic and diastolic flow per heart beat can increase by 300 to 400 per cent, the ratio between them remaining the same, or, at times, the volume of systolic flow can equal or exceed the diastolic flow. Evidence has been presented to show that much of this systolic flow represents intramural flow. These findings will, I believe, cause some recasting of our present views concerning the regulation of the coronary circulation.
Termination of Supraventricular Tachycardia Complicating the Wolff-Parkinson-White Syndrome with External Countershock
Authors: KNOEBEL SUZANNE B. , KING HAROLD , FISCH CHARLES
Published: June 2012

A case that demonstrates the feasibility of using external electric countershock for termination of paroxysmal supraventricular tachycardia complicating the Wolff-Parkin-son-White syndrome is presented.

The occurrence of fusion complexes between impulses originating in the sinoatrial and atrioventricular nodes was observed.
A Longitudinal Study of Coronary Heart Disease
Authors: PAUL OGLESBY , LEPPER MARK H. , PHELAN WILLIAM H. , DUPERTUIS G. WESLEY , MACMILLAN ANNE , MCKEAN HARLLEY , PARK HEEBOK
Published: June 2012

Certain of the data accumulated over the course of more than 4 years in a prospective study of coronary heart disease being carried on in an industrial population have been presented.

In a base population of 1,989 men, 88 cases of coronary heart disease have developed: angina pectoris, 47 men; myocardial infarction, 28 men; death from coronary, disease, 13 men. This approximates one case per 100 men per year.

The development of clinical coronary heart disease has shown an association with early age of death of father, history of "noncardiac" chest discomfort, history of chronic cough, history of shortness of breath, history of peptic ulcer, presence of increased skinfold thickness, elevated blood pressure, AV nicking in the fundi, elevated blood cholesterol, ST and T abnormalities in the electrocardiogram, and use of cigarettes and coffee.

No relation was encountered between body weight, mean blood sugar levels, lipoprotein lipase levels, or diet (other than coffee), and the development of coronary heart disease. Similarly, there was no association with job type and no certain relation to physical activity off the job.
Location of Coronary Arterial Occlusions and Their Relation to the Arterial Pattern
Authors: PITT BERTRAM , M. ZOLL PAUL , L. BLUMGART HERRMAN , G. FREIMAN DAVID
Published: June 2012

The present study shows that the coronary artery pattern is not related to the prognosis after infarction nor can it be correlated with the incidence of occlusion or with the severity of atherosclerosis. This analysis re-emphasizes the severity of the occlusive process in patients with angina pectoris and, conversely, the relatively large percentage of patients having coronary occlusion who had either congestive heart failure or who were asymptomatic.

The proper selection of patients for coronary artery surgery requires accurate angiography. The occurrence of multiple occlusions in a large number of cases points to certain difficulties in the interpretation of the coronary angiogram and also indicates the extremely limited role endarterectomy may be expected to play in the therapy of angina pectoris. Until such a time as the operative mortality and secondary failure rate, due to restenosis, can be reduced through new surgical technics, coronary endarterectomy should be considered an experimental procedure to be investigated vigorously in the laboratory but not to be applied for therapeutic purposes in man.
Anatomy of the Atrioventricular Conduction System in Ventricular Septal Defect
Authors: TITUS JACK L. , DAUGHERTY GUY W. , EDWARDS JESSE E.
Published: June 2012

The major parts of the atrioventricular conduction system of the human heart were traced in 21 instances of ventricular septal defect: 19 were examples of variously located uncomplicated ventricular septal defects and two of the tetralogy of Fallot.

In the presence of a ventricular septal defect, the conduction system was found to have a normal course, except when the ventricular septal defect lay in a position normally occupied by the conduction system. In each specimen with a defect posterior and inferior to the crista supraventricularis, the conduction system occupied a position posterior and inferior to the defect. In no instance did the conduction system occupy a position superior to a defect of this type. Defects located in the posterobasal portion of the muscular part of the ventricular septum sometimes were posterior to the main parts of the conduction system, so that the conduction tissue was related to the anterior edge of the defect. No example of a defect lying superior to the crista supraventricularis was studied. In our two examples of tetralogy of Fallot, the position of the conduction system was essentially similar to that occurring in the usual variety of ventricular septal defect, that is, posterior and inferior to the crista supraventricularis.
Auscultatory and Phonocardiographic Findings in Ventricular Septal Defect
Authors: HOLLMAN ARTHUR , MORGAN J. J. , GOODWIN J. F. , FIELDS H.
Published: June 2012

The phonocardiogram was studied in 93 patients whose ventricular septal defect was completely closed at open-heart surgery. The chief aim was to correlate the phonocardiographic findings with the presence and extent of pulmonary vascular disease, as measured by the postoperative pulmonary artery pressure.

The systolic murmur of the ventricular septal defect proved to be an excellent guide to the severity of pulmonary vascular disease. With a pansystolic murmur there was rarely severe pulmonary vascular disease, but with a short ejection murmur moderate or severe pulmonary vascular disease was always present.

The systolic thrill was weak or absent in 26 patients, and 80 per cent of these had an anatomic complication or severe pulmonary hypertension.

The mitral diastolic murmur was not a good guide to the severity of pulmonary vascular disease.

An associated patent ductus arteriosus gave rise to an early diastolic murmur, never to a continuous murmur, and on auscultatory grounds it could not reliably be distinguished from pulmonary or aortic incompetence.

The degree of splitting and the intensity of the second heart sound correlated well with the presence and severity of pulmonary vascular disease.

Pulmonary stenosis produced characteristic auscultatory features.

A pulmonary ejection click usually indicated the presence of moderate or severe pulmonary vascular disease.
Calcific Embolization Associated with Valvotomy for Calcific Aortic Stenosis
Authors: HOLLEY KEITH E. , BAHN ROBERT C. , MCGOON DWIGHT C. , MANKIN HAROLD T.
Published: June 2012

Calcific emboli were observed in 38 of 62 patients (61 per cent) who died at varying intervals following aortic valvotomy for calcific aortic stenosis. Major coronary embolization occurred in 10 patients (16 per cent) and was considered to be a major cause of death of four patients. Minor coronary embolization occurred in 33 patients (53 per cent) and was not directly implicated as a cause of death in any patient. Calcific emboli occurred to other organs in eight patients (13 per cent). The technics instituted for reducing the incidence of embolization—occlusion of coronary ostia, diligence in detection and removal of any debris, and final aspiration of the left ventricle—appeared to have had a favorable effect.
Clinical Evaluation of Diazoxide
Authors: FINNERTY FRANK A. , KAKAVIATOS NIKOS , TUCKMAN JOHN , MAGILL JOHN
Published: June 2012

Forty-six hypertensive patients have received diazoxide intravenously. Three hundred milligrams (one ampule) administered rapidly undiluted resulted in a 27 per cent average reduction in mean arterial pressure in 1 to 2 minutes. During the next 3 to 5 minutes the arterial pressure increased gradually to a 15 per cent average reduction as compared to the control. The average duration of diazoxide in these patients was 4.7 ± 1.7 hours. No signs of postural hypotension, cerebral ischemia, or collapse were noted. At the peak of hypotensive action there was a 41 per cent average reduction in total peripheral resistance.

Repeated doses of diazoxide in both nonpregnant patients with acute hypertension and pregnant patients with toxemia adequately controlled the arterial pressure and were not associatetd with the development of drug resistance. The standard dosage of 300 mg. (one ampule), the immediate onset of action and the moderately long duration of action, the maintenance of cardiac output, the lack of significant side effects, and the fact that it can be administered repeatedly without the development of drug resistance make diazoxide administered intravenously the ideal therapy for acute hypertension.
Left Ventricular Angiocardiography by Transseptal Puncture of the Left Atrium
Authors: BEUREN A. J. , APITZ J.
Published: June 2012

Experiences with 90 left heart angiocardiograms in 170 patients with transseptal left heart catheterizations are discussed. Selective left heart angiocardiograms of patients with aortopulmonary septal defect, patent ductus arteriosus, coarctation of the aorta, different types of ventricular septal defect, and isolated congenital mitral regurgitation are discussed. Examples of valvular, supravalvular, organic subvalvular, and functional hypertrophic subaortic stenosis are shown. The method is also suitable for the demonstration of endocardial fibroelastosis, truncus arteriosus, and hypoplasia of the aorta.
Basilar Artery Insufficiency Secondary to Obstruction of Left Subclavian Artery
Authors: SPROUL GORDON
Published: June 2012

Two cases are presented of basilar artery insufficiency with reversal of flow in the left vertebral artery secondary to obstruction of the subclavian artery at its origin. The symptoms have been relieved by restoration of pressure in the subclavian artery. The hemodynamics are reviewed, and the value of arteriography in cerebral vascular insufficiency is supported.