bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic Significance of Ventricular Ectopic Beats with Respect to Sudden Death in the Late Postinfarction Period
Authors: KOTLER MORRIS N. , TABATZNIK BERNARD , MOWER MORTON M. , TOMINAGA SUKETAMI
Published: June 2012

The role of ventricular dysrhythmias as determinants of sudden coronary death (SCD) was studied prospectively in 160 male survivors of myocardial infarction, all under 65 years of age and in New York Heart Association (NYHA) functional class I or II. Twelve-hour electrocardiographic recordings were taken in all patients at serial intervals and analyzed for frequency and type of ventricular ectopic beat (VEB). Eighty percent showed VEB's on at least one tape recording. There have been 14 SCD's in a follow-up period ranging between 30 and 54 months, 12 in 87 patients (13.8%) with significant VEB's (frequent, unifocal, multifocal, paired or coupled, and ventricular tachycardia), and only two in 66 patients (3%) with absent or infrequent VEB's (
P
< 0.02).

Although the number of patients in this study is small, the results show that all complex VEB forms together were associated with an excess risk of SCD, notwithstanding the absence of SCD in 27 patients with ventricular parasystole. It is suggested that the differential association with SCD between ventricular extrasystoles and parasystole in the late postinfarction period may have bearing on the mechanism of ventricular fibrillation and SCD.
Natural History of Cardiac Arrhythmias and their Prevention with Quinidine in Patients with Acute Coronary Insufficiency
Authors: BLOOMFIELD SAUL S. , ROMHILT DONALD W. , CHOU TE-CHUAN , FOWLER NOBLE O.
Published: June 2012

In a prospective controlled clinical trial the natural history of cardiac arrhythmias and their prevention with prophylactic quinidine therapy were studied in 23 patients with acute coronary insufficiency without myocardial infarction. After a loading procedure, 300 mg of quinidine sulfate or placebo was administered orally every 6 hours for up to 5 days under balanced, random, double-blind conditions. An automated arrhythmia detection system was used to quantify arrhythmias from stored continuous electrocardiographic tape recordings.

The frequency of ventricular and supraventricular arrhythmias tended to increase progressively on each successive day of study in placebo-treated patients. By contrast, in quinidine-treated patients all arrhythmias were quantitatively lower on each day of therapy and did not show a tendency toward progressive daily increases. In the placebo group there was an average of 140 premature ventricular contractions (PVC's) per day on the first day which increased to 600 PVC's per day by the fifth day, whereas with quinidine there was an average of 40 PVC's per day or less throughout the 5 days of study (
P
< 0.01). The daily increase in ventricular arrhythmias in placebo-treated patients with acute coronary insufficiency during the 5 days is in contrast to the natural history of patients with documented myocardial infarction who have a marked daily decrease in the frequency of ventricular arrhythmias during the first 5 days. Significant arrhythmia suppression with quinidine was present when mean blood quinidine concentration reached a steady state above 4 mg/liter at the end of the first day of therapy. Adverse reactions to quinidine were not observed. On the basis of these data, quinidine sulfate given prophylactically at a dosage producing modest blood concentrations appeared to be both effective and safe for the prevention of ventricular and supraventricular arrhythmias that occurred during the first 5 days after an episode of acute coronary insufficiency without infarction.
Blood Lidocaine Levels and Kinetics following High-Dose Intramuscular Administration
Authors: ZENER JULIAN C. , KERBER RICHARD E. , SPIVACK ALFRED P. , HARRISON DONALD C.
Published: June 2012

In order to evaluate further the potential benefit of prophylactic intramuscular lidocaine administration in coronary artery disease, 24 patients with suspected acute myocardial infarction were given an intramuscular injection of lidocaine (10% solution) in the deltoid and gluteal muscles on consecutive days. Twelve patients received an intermediate dose (4 mg/kg), and 12 received a high dose (6 mg/kg) of lidocaine, and blood lidocaine levels were measured over a 4-hour study period.

Intradeltoid injection produced higher blood lidocaine levels and more rapid development of peak blood levels than did intragluteal injection. Administration of high-dose lidocaine (average dose 450 mg) into the deltoid muscle produced the ideal combination of rapid peak blood levels (6.5 µg/ml ± 2.1 SEM at 5 min) and persistence of therapeutic levels (>1.5 µg/ml) for over 2 hours. Although drowsiness, paresthesias, slurred speech, and tinnitus occurred in seven of the 12 patients in the high-dose group, no major neurotoxicity, such as grand mal seizures, were observed, nor was there evidence of hypotension or increase in atrioventricular block. Prophylactic administration of high-dose 10% lidocaine into the deltoid muscle appears to have potential for reducing the early mortality following acute myocardial infarction.
Progress Study of 590 Consecutive Nonsurgical Cases of Coronary Disease Followed 5-9 Years
Authors: BRUSCHKE ALBERT V. G. , PROUDFIT WILLIAM L. , SONES F. MASON
Published: June 2012

The clinical progress was studied in a series of 590 consecutive nonsurgical patients with coronary disease documented by selective coronary arteriography. All had 50% or more obstruction in at least one major artery. Patients who were operated on within 5 years were excluded. Observations of the survivors ranged from 5 to 9 years. During the total observation period 263 patients died; only 19 deaths were not due to coronary disease. The 5-year cardiac mortality rate was 34.4% for the entire population, 14.6% for patients with one-vessel involvement, 37.8% for patients with two-vessel involvement, 53.8% for patients with three-vessel involvement, and 56.8% for those with at least 50% narrowing of the left main coronary artery. In patients with single-vessel disease the presence or absence of additional lesions causing less than 50% narrowing was of significant prognostic influence.
Influence of Atropine and of Vagally Mediated Bradycardia on the Occurrence of Ventricular Arrhythmias following Acute Coronary Occlusion in Closed-Chest Dogs
Authors: GOLDSTEIN ROBERT E. , KARSH RICHARD B. , SMITH ELDON R. , ORLANDO MICHAEL , NORMAN DOUGLAS , FARNHAM GARY , REDWOOD DAVID R. , EPSTEIN STEPHEN E.
Published: June 2012

In contrast to previous opinions, recent investigations have suggested that increasing heart rate (HR) with atropine when moderate sinus bradycardia accompanies acute myocardial infarction is not necessarily beneficial. To further characterize the influence of vagally mediated changes in HR during ischemia, we evaluated the effects of atropine and of electric stimulation of the vagus nerves on the incidence of ventricular arrhythmias during acute coronary occlusion in closed-chest dogs. Protection from occlusion-induced arrhythmia was not observed when 28 dogs receiving atropine were compared with 27 control dogs. Rather, the total incidence of ventricular arrhythmias was significantly higher (
P
< 0.05) and ventricular fibrillation tended to occur more frequently in the atropine-treated group. Moreover, fewer ventricular arrhythmias (and total absence of ventricular fibrillation or close-coupled premature beats) were noted in 12 control animals with spontaneous bradycardia (HR<60 beats/min) compared with 15 nonbradycardic animals. When vagal stimulation produced bradycardia (HR = 40-60 beats/min) during coronary occlusion, occurrence and character of ventricular arrhythmias were the same as in dogs with normal rates (HR = 80-100 beats/min). Although these results may not necessarily apply to man, further studies are needed before it can be assumed that all individuals with moderate bradycardia during acute myocardial infarction should receive vagolytic agents.
Occlusion of Coronary Arteries after Vein Bypass
Authors: MALINOW M. R. , KREMKAU E. LOUISE , KLOSTER F. E. , BONCHEK L. I. , RÖSCH J.
Published: June 2012

The coronary arteries of 100 patients were radiographically visualized by selective injection of contrast material. Findings in the three main arteries (left anterior descending, right, and circumflex arteries) were analyzed before and after aortocoronary-saphenous vein graft surgery. Proximal coronary artery stenosis progressed to complete occlusion in almost half the patients on whose stenotic arteries a graft had been placed. The incidence was higher than that observed in nongrafted arteries during the "natural" course of the disease. The frequency of occlusion in grafted coronary arteries was higher in severely stenotic than in moderately stenotic arteries. The fact that the occlusion occurred more often with a patent graft than with a closed graft suggests a hemodynamic component in its pathogenesis. The study indicates that in many patients the prognosis must remain linked to patency of the bypass graft.
A-V Nodal Reentrance
Authors: ROSEN KENNETH M.
Published: June 2012

Electrophysiologic studies were performed in a patient with type B preexcitation and recurrent paroxysmal supraventricular tachycardia (PSVT). Atrial pacing at rates of 80/min and faster produced QRS normalization suggesting failure of the anomalous pathway. At a paced rate of 120/min, Wenckebach periods proximal to the His bundle as well as episodes of PSVT were noted. These episodes all occurred when a critical P-H interval of 300 msec was achieved. PSVT was also induced by coupled atrial pacing. At coupling intervals of 800-530 msec, anomalous pathway conduction was intact. At coupling intervals of 520 msec or shorter, QRS normalization occurred. At intervals of 480-280 msec, PSVT was induced. The P-H interval of the coupled beat inducing PSVT was always between 300 and 350 msec. Intraatrial recording revealed atrial echoes following each QRS of the PSVT.

In summary, critical A-V nodal delay appeared necessary for induction of PSVT. This delay was achieved either by coupled pacing or during pacing-induced Wenckebach periods. The PSVT occurred at rates at which the anomalous pathway would seem to be inoperative. These findings strongly support A-V nodal reentry as the mechanism of PSVT in this patient without participation of the anomalous pathway. In this patient and other patients with similar fiindngs, surgical ablation of the anomalous pathway would probably not be useful in prevention of recurrent PSVT.
Echocardiographic Determination of Mitral Disc Valve Excursion
Authors: JOHNSON MICHAEL L. , HOLMES JOSEPH H. , PATON BRUCE C.
Published: June 2012

Disc excursion and opening and closing velocities of prosthetic disc valves can be measured accurately by diagnostic echocardiography. The ultrasound beam is projected along the longitudinal axis of the valve and the echoes arising from the struts, disc, and suture ring are displayed on the oscilloscope. Twenty-four patients with normally functioning mitral Beall valves of various sizes and three patients with prosthetic valve dysfunction (one Beall, two Kay-Shiley) were studied. Table 1 lists the disc excursions with standard deviations of Beall valves measured by ultrasound.

The 0.06-0.09 cm difference in excursion between models no. 103 and no. 104 valves was detected by ultrasound without prior knowledge of change in design of the valve and demonstrates the extreme accuracy of this technic. The opening and closing disc velocity averaged 22 cm/sec and 40 cm/sec, respectively.

Decrease in expected disc excursion and abnormal motion patterns were found in three patients with prosthetic dysfunction secondary to thrombus formation, and verified at operation. With continuous changes in valve designs it is important to obtain a baseline excursion and motion pattern for each patient immediately postoperatively.

Echocardiography is a useful, noninvasive, reproducible technic for accurate assessment of prosthetic mitral disc valve movement.
Systolic Time Intervals in Infants with Congestive Heart Failure
Authors: PARK SANG C. , STEINFELD LEONARD , DIMICH IVAN
Published: June 2012

Using the apexcardiogram as a time reference for opening and closure of the aortic valve, systolic time intervals (STI) in infants were determined in 150 normal infants ranging in age from 1 day to 1 year. Thirty infants with congestive heart failure secondary to a variety of congenital and acquired heart diseases were studied in a similar manner for comparison. The data revealed that heart failure in the infant is not marked by any one pattern of STI. In specific disease entities associated with congestive heart failure, the STI appear to be consistent. In infants with congestive heart failure due to congenital heart disease, the STI do not correspond with values reported in the adult with hypertensive or arteriosclerotic disease. The differences are explained by viewing STI in infants primarily a function of hemodynamic alterations dictated by an underlying cardiovascular anomaly rather than a result of a primary myocardial derangement. The findings in the infant with chronic heart failure due to primary myocardial disease tend to parallel data previously reported in the adult with arteriosclerotic disease and chronic heart failure.
Variations in Arterial Blood Pressure after Kidney Transplantation
Authors: POPOVTZER MORDECAI M. , PINNGGERA WULF , KATZ FRED H. , CORMAN JACQUES L. , ROBINETTE JOHN , LANOIS BERNARD , HALGRIMSON CHARLES G. , STARZL THOMAS E.
Published: June 2012

The course of hypertension within the first 2 months after kidney transplantation was correlated with renal function, plasma renin activity (PRA), and the daily maintenance dose of prednisone in 18 homograft recipients. During acute rejection blood pressure (BP) closely correlated with PRA. Patients with normal homograft function showed an increase in BP early after transplantation which in most returned to normal 3-8 weeks later. In the latter group no correlation could be found between the level of BP and PRA, however the BP correlated closely with the dose of prednisone. These observations suggest that during acute rejection the increase in BP may at least partly be mediated by a renal pressor mechanism, whereas with normal renal function the high dose of glucocorticoids may play an important role in the development of hypertension.
Renal Cortical Blood Flow, Cortical Fraction, and Cortical Blood Volume in Hypertensive Subjects
Authors: LOGAN ALEXANDER G. , VELASQUEZ MANUEL T. , COHN JAY N.
Published: June 2012

In 15 patients with essential hypertension total blood flow to a single kidney (TRBF) was measured by a constant infusion indicator-dilution technic which had previously been validated in dogs. Indocyanine green indicator-dilution curves then were used to calculate the fraction of renal flow traversing the rapid (cortical) circulation and the blood volume in this cortical compartment. TRBF ranged from 152 to 1033 ml/min/1.73m
2
per kidney and was closely correlated with cortical flow (r = 0.99). The cortical fraction of TRBF ranged from 46 to 93% and varied directly with total flow (r = 0.69). Noncortical flow ranged from 12 to 85 ml/min/1.73m
2
per kidney and showed no correlation with TRBF. Cortical blood volume varied from 12 to 85 ml/1.73m
2
and also was closely correlated with TRBF (r = 0.93).

These data suggest that diminished TRBF in hypertensive patients is due to reduction in cortical flow with preservation of noncortical (medullary) flow and reduction in cortical blood volume. The reduced cortical fraction of TRBF could be a factor in the renal functional abnormalities which occur in hypertension.
Cardiac Malformations Associated with Down's Syndrome
Authors: TANDON RAJENDRA , EDWARDS JESSE E.
Published: June 2012

A review of 55 specimens with congenital heart disease from subjects with Down's syndrome (Mongolism) showed a variety of malformations. For each case a major anomaly was identified and, when present, additional anomalies were recorded.

The three leading types of major anomalies, in order of decreasing frequency, were (1) persistent common atrioventricular canal (60%), isolated ventricular septal defect (29%), and tetralogy of Fallot either alone or in association with persistent common atrioventricular canal (14.5%).

Of the additional anomalies, the most common took the form either of an atrial septal defect at the fossa ovalis (50%) or patent ductus arteriosus (47%).
Pacemaker Arrhythmias and Electrocardiographic Recognition of Pacemakers
Authors: CASTELLANOS AGUSTIN , LEMBERG LOUIS
Published: June 2012

Adequate interpretation of pacemaker arrhythmias requires a thorough knowledge of the clinical situation in which they appear, the type of pacemaker, and modality of stimulation used, as well as knowledge of the corresponding electronic specifications. At times, this information is essential to reach the correct diagnosis. The significant features of the various (atrial, ventricular, or sequential atrioventricular) pacemakers were stressed placing special emphasis on the most used pacing system, namely, the transvenous QRS-inhibited (demand) ventricular pacemaker. Arrhythmias specific to the latter which could be seen during its normal or abnormal function included magnet-induced vagaries and significant shortening or lengthening of automatic (spike-to-spike) and escape (natural-to-QRS) intervals. Obtaining the maximal efficiency from artificial pacemakers requires the cooperation of patient, manufacturer, cardiovascular surgeon, and clinical cardiologist.
Exercise Stress Testing in Evaluation of Aortocoronary Bypass Surgery
Authors: BARTEL ALAN G. , BEHAR VICTOR S. , PETER ROBERT H. , ORGAIN EDWARD S. , KONG YIHONG
Published: June 2012

Graded exercise treadmill tests (ET) were performed on 123 patients who had undergone aortocoronary bypass surgery. All had angina preoperatively (preop) and 77% were in Class III or IV for angina. Postoperatively (postop), 68% were free of angina. Eighty-three patients had ST-segment changes of 0.1 mV or greater during stress preop (positive), 38 of which (46%) converted to electrocardiographically negative postop. Among the 30 patients (36%) remaining positive during stress postop, 19 (63%) were angina free despite ST-segment depression during stress. Among the 17 patients with negative ET preop, there were no conversions to positive postop. Twenty-three patients had undetermined ET preop; 13 remained undetermined postop, 4 were positive and 6 were negative. Patients experiencing a perioperative myocardial infarction more frequently had a negative postop ET. Among 27 selected patients undergoing postop angiography, there was good correlation between relief of symptoms and successful myocardial revascularization.

This study demonstrates that dramatic improvement in angina after aortocoronary bypass surgery can be objectively substantiated in most patients. Subjective symptoms of angina are frequently absent during myocardial ischemia postop, emphasizing the importance of exercise testing in objective evaluation of surgical results.
Ultrasonographically Monitored Postocclusive Reactive Hyperemia in the Diagnosis of Peripheral Arterial Occlusive Disease
Authors: FRONEK A. , JOHANSEN K. , DILLEY R. B. , BERNSTEIN E. F.
Published: June 2012

The femoral artery postocclusive reactive hyperemia response was monitored by transcutaneous Doppler ultrasonography. Normal values which were established from a group of 25 volunteers included a mean percentage increase [See Equation in PDF File] of 225.8% and a mean recovery half time of 25.2 secs. In a group of 22 patients with angiographically documented arterial occlusive disease, the respective mean values were 55.9% and 47.1 secs (
P
< .001). There was no statistically significant difference in the percentage velocity increases in repeat examinations. On the other hand, the recovery half time of the second postocclusive reactive hyperemia response was significantly shorter than the preceding one. The described technique proved to be very useful as a simple and objective procedure to screen and follow-up the development of arterial occlusive disease before and after reconstructive vascular surgery.
Atrioventricular Conduction in Secundum Atrial Septal Defects
Authors: ANDERSON PAGE A. W. , ROGERS MARK C. , CANENT RAMON V. , SPACH MADISON S.
Published: June 2012

The atrioventricular (A-V) conduction time in patients with secundum ASD who had left-to-right shunts of 40-65% of their pulmonary flow was evaluated utilizing intracardiac electrograms. The A-V conduction time was divided into three components: (1) P-A interval, from the onset of the P wave to the time of excitation of muscle in the vicinity of the A-V node, (2) A-H interval, from the time of excitation of low right atrial muscle to that of the His bundle, and (3) H-V interval, from the time of the His bundle deflection to the onset of ventricular activation. The mean P-R interval of the ASD group (154 msec) was significantly longer (
P
< 0.01) than that of the control group (135 msec). The internodal conduction time (mean P-A interval) of the ASD group (52.2 msec) was significantly longer (
P
< 0.001) than that of the control group (29.1 msec). The A-H and H-V intervals of the two groups were not significantly different. Both the increased size of the atrium and the increased distance for internodal conduction produced by the defect itself can account for the prolonged internodal conduction time.
Permanent Pervenous Atrial Synchronized Ventricular Pacing
Authors: MOSS ARTHUR J. , RIVERS ROBERT J. , KRAMER DAVID H. , RESNICOFF SETH
Published: June 2012

Permanent pervenous atrial synchronized ventricular pacing was successfully accomplished in three patients. Atrial sensing was obtained from an electrode positioned in the coronary vein. Atrial electrograms with P waves greater than 1.5 mv were present in all three cases. Ventricular stimulation was accomplished through a separate electrode placed in the right ventricular apex. The left cephalic vein admitted both catheters, and the two electrodes were connected to an implantable P wave synchronized unit. The beneficial hemodynamic effects of atrial synchronized ventricular pacing were clinically evident. This new pervenous technique provides an optimal method of synchronized pacing in patients with heart block, intact sinoatrial activity and significantly compromised cardiac function.
Effects of Posture on Exercise Performance
Authors: SPODICK DAVID H. , QUARRY-PIGOTT VERONICA M.
Published: June 2012

Because posture significantly influences cardiac performance, the effects of moderate supine and upright ergometer exercise were compared on the basis of proportional (+37%) rate increments over resting control. Supine exercise produced significant decreases in left ventricular ejection time (LVET), pre-ejection period (PEP), and isovolumic contraction time (IVCT). Ejection time index (ETI) and "corrected ejection time" (LVETc) did not change significantly. Upright exercise produced greater decreases in PEP and LVET, but despite the rate increase there was no change in LVET, which resulted in sharp increases in ETI and LVETc. The discordant directional effects on LVET and its rate-correcting indices between the two postures were consistent with hemodynamic studies demonstrating lack of stroke volume change during supine exercise and increased stroke volume over control during light to moderate upright exercise. Concordant effects on PEP and IVCT are consistent with the inotropic effect of exercise in both postures with an additional Frank-Starling effect postulated during upright exercise.
Pressure-Flow Studies in Man: Effect of Respiration on Left Ventricular Stroke Volume
Authors: RUSKIN JEROME , BACHE ROBERT J. , REMBERT JUDITH C. , GREENFIELD JOSEPH C.
Published: June 2012

The pressure gradient technique was used to evaluate effects of respiration on left ventricular stroke volume in 22 patients: 11 normal patients; eight patients with airway obstruction; and three patients with pericardial tamponade. In normals, stroke volume, systolic pressure, and pulse pressure fell an average of 7, 3 and 11% (
P
< 0.01), respectively, during inspiration. In patients with airway obstruction, these parameters decreased by 25, 12 and 23% (
P
< 0.001), respectively. After breath-holding, stroke volume also fell immediately with the onset of inspiration in both groups. These results are consistent with a reduction in left ventricular filling during inspiration as the factor primarily responsible for the fall in stroke volume. In patients with pericardial tamponade, variations in left ventricular stroke volume, systolic pressure and pulse pressure were related to: (1) an immediate fall in stroke volume with the onset of inspiration; and (2) a subsequent increase in stroke volume presumably due to an inspiratory increase in right ventricular stroke volume.
Arrhythmias in the Denervated Transplanted Human Heart
Authors: BERKE DAVID K. , GRAHAM ANTHONY F. , SCHROEDER JOHN S. , HARRISON DONALD C.
Published: June 2012

Multiple cardiac arrhythmias have been noted following cardiac transplantation, and these observations suggest that denervation does not protect the heart from the initiation of arrhythmias. The sequential electrocardiograms of 45 of 47 cardiac transplant patients at Stanford were reviewed. Currently, 16 patients are alive for periods up to 40 months post-transplantation. Atrial arrhythmias were noted in 72% of patients, and were usually associated with acute rejection episodes. Ventricular premature beats were detected in 57% of patients post-transplantation. Two documented episodes of ventricular fibrillation have occurred during severe acute rejection episodes. Two long-term survivors died suddenly of a presumed ventricular arrhythmia, and at autopsy both showed severe coronary atherosclerosis. This experience suggests that innervation is not necessary in the genesis of cardiac arrhythmias in the transplanted human heart.
What Is the Relationship Between the Response of Angina to Coronary Surgery and Anatomical Success?
Authors: MATLOF HARVEY J. , ALDERMAN EDWIN L. , WEXLER LEWIS , SHUMWAY NORMAN E. , HARRISON DONALD C.
Published: June 2012

Analysis of clinical response, graft patency, and treadmill performance was carried out in 72 patients one year after aortocoronary saphenous vein bypass surgery. Thirty-four of 46 patients with complete relief of angina had all grafts patent at one year, as opposed to 4 of 14 unimproved patients (
P
< 0.01); 84.4% of 77 grafts in the former group were patent, as compared with 48% of 25 grafts in the latter group (
P
< 0.01). Similarly, treadmill tolerance and end-exercise heart rate were significantly increased in patients experiencing significant or complete clinical relief. Unimproved patients showed no improvement in these parameters. Individual observations indicated that graft patency did not always ensure clinical relief or abolition of ischemic treadmill responses.
Surgical Treatment of Double-Outlet Left Ventricle
Authors: PACIFICO ALBERT D. , KIRKLIN JOHN W. , BARGERON L. M. , SOTO BENIGNO
Published: June 2012

Four patients with double-outlet left ventricle and ventricular septal defect have been successfully corrected surgically. Three of the patients had pulmonary stenosis, and one did not. Three patients had
d
-position of the great arteries, and one patient had
l
-position with the aorta anterior and to the left. Surgical correction was accomplished by repairing the ventricular septal defect, closing the connection between left ventricle and pulmonary artery, and creating a conduit between right ventricle and pulmonary artery. The preferred conduit is a composite valved one.
New Arteriographic and Surgical Techniques for Vertebral Arteriopathies
Authors: WESOLOWSKI S. ADAM , GILLIE EDWARD , MCMAHON JAMES D. , SANTOS DELFIN S. , CALI J. ROBERT , UCHIDA HATSUZO
Published: June 2012

Vertebral arterial insufficiency syndromes are being diagnosed with greater frequency, and would appear to be at least as common as carotid disease in causing cerebrovascular insufficiency. Carotid lesions are nearly always arteriosclerotic, but vertebral obstructions are caused at least as frequently by nonarteriosclerotic lesions, including tortuosity with kink and external bands, slings, bony compression, and congenital aberrations.

A method of cerebral arteriography has been standardized and a new radiographic sign of comparative opacification times of the intracranial carotid and basilar arteries has been tested as a pathognomonic sign of vertebral-basilar arterial insufficiency.

The concept of the innominate-subclavian-vertebral complex as a single surgical geometric unit has allowed the development of a graded surgical approach of arteriolysis, endarterectomy, and resection and anastomosis in managing 97% of obstructive vertebral arteriopathies.

A new surgical operation of distal subclavian resection and anastomosis to correct vertebral and/or subclavian arterial tortuosity with kinking has proven helpful in ablating symptoms of vertebral-basilar arterial insufficiency.
Tetralogy of Fallot with Absent Pulmonary Valve
Authors: STAFFORD EDWARD G. , MAIR DOUGLAS D. , MCGOON DWIGHT C. , DANIELSON GORDON K.
Published: June 2012

From 1957 through 1971, 18 patients whose ages ranged from 10 months to 18 years underwent surgical correction of tetralogy of Fallot with absent pulmonary valve. All patients had associated pulmonary arterial aneurysms; in two the left pulmonary artery also was absent. Right middle lobectomy had been performed previously on one patient for lobar emphysema; seven other patients had recurrent pulmonary infections.

The ventricular septal defect was closed with a patch in 12 patients and by direct suture in 6. Concomitant infundibular resection was done in all. In four the narrow pulmonary valve annulus was enlarged with an outflow patch, and multiple radial incisions were made in the valve annulus in seven others. The pulmonary arterial aneurysms were not resected in any patients.

There were three hopsital deaths (17%) and two late deaths. Complete heart block developed intraoperatively in three patients, all operated on prior to 1963, contributing to the early death of one patient and to the late deaths of the other two.

In a follow-up of all 13 survivors at 8 months to 15 years (median 6 years), results were excellent and equal to those of patients who have undergone repair of tetralogy of Fallot with pulmonary valve.
Lethal Postoperative Infections Following Cardiac Surgery
Authors: ENGELMAN RICHARD M. , CHASE RANDOLPH M. , BOYD ARTHUR D. , REED GEORGE E.
Published: June 2012

Seventeen of 1,494 patients (1.1%) succumbed to infection following open-heart operations at New York University Hospital between January, 1968 and December, 1971. All but two of these patients had Starr-Edwards ball-valve prostheses inserted. One had repair of a tetralogy of Fallot, and one had aortic commissurotomy and a double coronary bypass graft. The sites of infection were pulmonary (15 patients), urinary tract (14), mediastinum or pleura (10), and blood (15). Pulmonary infection appeared as the source of endocarditis in 13 patients and as a source of pleural or mediastinal infection in nine. Candida species infection was directly responsible for the deaths of 10 of the 17 patients, being the sole organism isolated in 5 of the 10.

Predisposing factors to infection were preoperative bacterial endocarditis 2 patients, prolonged cardiopulmonary bypass (>3½ hours) 6 patients, a "low output" state following operation 12 patients, postoperative cerebral dysfunction 6 patients, and postoperative disseminated intravascular coagulation 4 patients.

The debilitated state of the patients, multiple sites of infection, degree of tissue destruction, and the variety and resistance of the organisms involved all combined to produce treatment failure. Removal of the infected valvular prosthesis coupled with antimicrobial therapy is considered the treatment of choice in instances of bacterial endocarditis when chemotherapy fails and in all cases of established fungal endocarditis.
Development of Subaortic Stenosis After Pulmonary Artery Banding
Authors: FREED MICHAEL D. , ROSENTHAL AMNON , PLAUTH WILLIAM H. , NADAS ALEXANDER S.
Published: June 2012

Palliation of children with large ventricular septal defects (VSD) by pulmonary artery banding (PAB) is associated with a variety of unfavorable sequelae. We document another possible complication of PAB, the development of subaortic stenosis, which occurred in 4 of 40 infants with large VSD and PAB. Prior to surgery all had congestive heart failure, cardiomegaly, pulmonary plethora, and biventricular or right ventricular hypertrophy on electrocardiogram. At cardiac catheterization all had large VSD with pulmonary artery hypertension. No gradient between left ventricle and systemic artery was demonstrated. PAB was followed by improvement in all four children. Repeat catheterization at 4 to 11 years of age revealed that they had developed a significant (30 to 100 mm Hg) gradient across the left ventricular outflow tract.

Although the etiology of the subaortic stenosis is not known, it is felt that the hypertrophied and possibly leftward deviated conal septum was impinging on the left ventricular outflow tract in three of the four.

Since the subaortic stenosis was not suspected prior to the second catheterization, we feel that preoperative evaluation of children with VSD and PAB should include evaluation of the left ventricular outflow tract to be certain that no obstruction is present.
Intra-aortic Balloon Pump Assist for Cardiogenic Shock After Cardiopulmonary Bypass
Authors: BUCKLEY MORTIMER J. , CRAVER JOSEPH M. , GOLD HERMAN K. , MUNDTH ELDRED D. , DAGGETT WILLARD M. , AUSTEN W. GERALD
Published: June 2012

Intra-aortic balloon pump assist (IABP) was applied to 26 patients who could not be with-drawn from total cardiopulmonary bypass (CB) subsequent to elective surgery for multiple cardiac procedures. Eighty-eight per cent were able to separate from CB with IABP and were assisted for 36 to 168 hours. Seventeen were withdrawn from the balloon. Eleven (42%) are hospital survivors. Ten (38%) are alive at the time of this report.

IABP was most effective when applied early to patients who had recognizable acute ischemic injury to the myocardium at the time of operation and/or presence of hypertrophied left ventricular myocardium with small chamber volume. Support in these conditions gave 50% survival. Poorest results were in patients with either extensive acute infarction or severe chronic irreversible myocardial damage.
The Role of Angiography in Cardiogenic Shock
Authors: LEINBACH ROBERT C. , GOLD HERMAN K. , DINSMORE ROBERT E. , MUNDTH ELDRED D. , BUCKLEY MORTIMER J. , AUSTEN W. GERALD , SANDERS CHARLES A.
Published: June 2012

Eighty patients with cardiogenic shock secondary to myocardial infarction were treated with the intra-aortic balloon pump (IABP). The initial response to pumping was good, with resolution of shock in 80%. Sixty-eight patients did not tolerate subsequent withdrawal from IABP and were termed balloon-dependent. Selective coronary and left ventricular cineangiography in 52 balloon-dependent patients identified 30 possible surgical candidates. Operative procedures in 24 produced 9 survivors (37%). Persistent dependence upon mechanical circulatory assistance after myocardial infarction may not indicate massive ventricular infarction. Early angiography after initial hemodynamic improvement on IABP is an essential step in the identification of those patients with persistent, reversible ischemia in whom emergency surgery may be indicated.
Assessing the Severity of Aortic Stenosis by Phonocardiography and External Carotid Pulse Recordings
Authors: BONNER ANTHONY J. , SACKS HARVEY N. , TAVEL MORTON E.
Published: June 2012

Phonocardiograms and carotid pulse tracings were done on a group of 47 patients with all degrees of aortic stenosis and were compared with two groups of normals. Indices evaluated were pre-ejection period, left ventricular ejection time, maximum rate of arterial pulse rise, arterial half rise time (T time) and upstroke time, and timing of the peak intensity of the systolic murmur in relation to the electrocardiographic QRS and first heart sound. The indices most indicative of the presence of aortic stenosis and best correlated with its severity were the ejection time index, the maximal rate of rise of the carotid pulse and the timing of the peak of the systolic murmur. If, in a given case, all three of these indices fall outside of certain limits (ejection time index >0.42 sec, maximum rate of arterial pulse rise <500 mm Hg/sec, and Q wave to peak of murmur >0.19 sec), then severe aortic stenosis is almost invariably present.
Detection of Left Ventricular Asynergy by Echocardiography
Authors: JACOBS JAMIE J. , FEIGENBAUM HARVEY , CORYA BETTY C. , PHILLIPS JOHN F. , Black Mary Jo , Chang Sonia , Haine Charles L.
Published: June 2012

The purpose of this study was to determnie if echocardiography could detect left ventricular asynergy. Forty-eight patients underwent selective coronary arteriography and cineventriculography for the evaluation of chest pain. Four patients were studied twice: three before and after myocardial revascularization and one before and after an intervening myocardial infarction. Echocardiographic M-mode scans were registered on a strip chart as the left ventricle was scanned with an ultrasonic beam from the aortic root to the region of the posterior papillary muscle approximately 18 hrs prior to the catheterization studies.

Ten of the forty-eight patients had no evidence of coronary artery disease. All ten patients had normal ventriculograms in right anterior oblique projection and their echocardiographic scans showed all areas of the left ventricular posterior wall endocardium to move anteriorly 0.9-1.4 cm (mean 1.2 cm) and all parts of the left side of the interventricular septum to move posteriorly 0.3-0.8 cm (mean 0.5 cm) during systole. The 38 patients with significant obstructive coronary artery disease had a total of 42 studies; 25 of these studies showed left ventricular asynergy on the ventriculogram taken in right anterior oblique. The echocardiograms associated with all but one of these studies demonstrating left ventricular asynergy had abnormal motion of some part of the interventricular septum and/or left ventricular posterior wall. Seventeen studies in patients with significant coronary artery disease did not exhibit left ventricular asynergy on the ventriculogram but eight of these studies were associated with distinctly abnormal echocardiograms.

None of the ten patients with significant coronary artery disease and normal echocardiograms had evidence of transmural infarction on their electrocardiograms. Echocardiographic abnormalities correlated with the anatomic area predicted by the myocardial infarction pattern on the electrocardiogram in 18 of 20 patients.

All patients demonstrating abnormal echographic interventricular septal motion had a significant obstructive lesion in the left anterior descending coronary artery. In the absence of significant involvement of the left anterior descending coronary artery, echographically recorded interventricular septal motion was invariably normal. On the other hand, eight patients had significant obstruction in their left anterior descending coronary artery and their echographic interventricular septal motion was normal.

The results of this correlative study indicate that M-mode echocardiographic scans can detect left ventricular asynergy and may possibly predict regional myocardial involvement in coronary artery disease.
Echocardiography in Truncus Arteriosus
Authors: CHUNG KYUNG J. , ALEXSON CHLOE G. , MANNING JAMES A. , GRAMIAK RAYMOND
Published: June 2012

Nine patients with a clinical presentation suggestive of truncus arteriosus were examined by echocardiography. Subsequent intracardiac studies including cardiac catheterization and angiocardiography divided this group into five patients with truncus arteriosus and four patients with other congenital heart diseases. In all patients with proven truncus arteriosus, it was possible to identify only one semilunar valve with a large truncal vessel overriding the ventricular septum. In none of these patients could a second semilunar valve be found.

This study indicates that echocardiography may provide a direct, yet noninvasive method to exclude the diagnosis of truncus arteriosus by finding the pulmonic valve. However, the diagnosis of truncus arteriosus is not tenable when based solely on the inability to demonstrate the pulmonic valve. The importance of the clinical application of this method is discussed.
Left Ventricular Abnormalities in Prolapsed Mitral Leaflet Syndrome
Authors: SCAMPARDONIS GREGORY , YANG SING SAN , MARANHÃO VLADIR , GOLDBERG HARRY , GOOCH ALDEN S.
Published: June 2012

Eighty-seven patients with proven mitral leaflet prolapse were studied emphasizing cardiodynamics and left ventricular asynergy. Significant associated features were female preponderance (83%), skeletal anomalies (pectus excavatum, straight back, scoliosis, narrow antero-posterior diameter of the chest), and anomalous coronary arteries (cork-screw patterns, short left main coronary artery, anomalous origin of the coronary arteries). Prolapse of the tricuspid leaflets was found in 15 (54%) who had right ventriculography. Five types of abnormal left ventricular systolic contraction patterns were seen in 82% of the cases and these were categorized as: 1) "ballerina foot" pattern (vigorous posteromedial contraction with anterior convexity), 2) "hour glass" pattern (vigorous ring-like contraction involving the middle portion of the left ventricle), 3) inadequate long axis shortening, 4) posterior akinesis, and 5) cavity obliteration pattern. The over-all left ventricular performance was normal generally, as indicated by normal values for functional parameters including left ventricular end-diastolic pressure, cardiac index, ejection fraction, contractility index (stroke work per end-diastolic volume) and pre-ejection period/left ventricular ejection time (PEP/LVET). The myocardial component of the syndrome of prolapsed mitral (and/or tricuspid) leaflets is expressed as asynergistic patterns of ventricular motion and usually does not impair over-all cardiac dynamics.
Left Anterior Hemiblock Obscuring the Diagnosis of Right Bundle Branch Block
Authors: ROSENBAUM MAURICIO B. , YESURÓN JACOBO , LÁZZARI JULIO O. , ELIZARI MARCELO V.
Published: June 2012

Three cases in which left anterior hemiblock (LAH) obscured the diagnosis of right bundle branch block (RBBB) are reported. The RBBB was incomplete in one case and complete or of high degree in the other two. The LAH was intermittent in two cases. In the three cases, the LAH abolished not only the S waves in leads I and aVL, but also the terminal R wave in Vl. The possibility that RBBB, complete or incomplete, can be totally missed in the presence of LAH may imply a significant clinical danger, because some of the well known diagnostic and prognostic connotations of this association of conduction disturbances may then be overlooked. However, if the QRS interval is excessively wide or more than expected for pure LAH, the concealed or hidden RBBB can be suspected. It can be readily uncovered if additional unipolar high and right sided chest leads are recorded. The vectorcardiogram can also be helpful, if the possibility of concealed RBBB is kept in mind.
Influence of the Sympathetic System on the Pacemaker Suppression Which Follows Overdrive
Authors: PLIAM MICHAEL B. , KRELLENSTEIN DANIEL J. , VASSALLE MARIO , BROOKS CHANDLER McC.
Published: June 2012

When ventricular pacemakers are electrically stimulated at a fast rate, the cessation of the drive is followed by a temporary suppression of automaticity ("overdrive suppression"). The role of the sympathetic system in the regulation of this overdrive suppression was studied and the following results obtained: 1) Hypotension induced during overdrive by amyl nitrite inhalation caused a shortening of the pause which follows the drive. 2) Bilateral resection of the stellate ganglia led to the opposite effect. 3) Maximal stellate ganglion stimulation halved the pause duration. 4) Norepinephrine infusion accelerated the idioventricular rate and shortened the pause. 5) Beta adrenergic blockade decreased the idioventricular rate and prolonged the pause.

It is concluded that the tonic sympathetic discharge not only controls the basal idioventricular rate but also plays a regulatory role in the suppression of idioventricular automaticity which follows overdrive. This regulatory role can be dissociated from changes in idioventricular rate prior to overdrive.
His Bundle Recordings in Patients with Bundle Branch Block and Transient Neurologic Symptoms
Authors: SCHEINMAN MELVIN , WEISS ALAN , KUNKEL FREDERICK
Published: June 2012

His bundle electrograms were recorded in 19 patients with bundle branch block (BBB) and transient neurologic symptoms allowing for determination of intra-atrial (P-A), atrioventricular (A-V), nodal (A-H) as well as infranodal conduction (H-Q) times. The patients were initially monitored in a coronary care unit and have been followed for a mean period of 8 ± 4 months. In six patients (Group I) neurologic symptoms were observed in the absence of electrocardiographic evidence of A-V block. In six patients (Group II) the cause of symptoms was uncertain; two of these patients had relief of symptoms after permanent cardiac pacemaker insertion and were presumed to have episodic high grade A-V block. In seven subjects (Group III) complete A-V block was documented as the cause of the symptoms; these patients were studied when 1:1 antegrade A-V conduction returned. There was no significant difference between mean P-A, A-H, and QRS durations among the patients in the three groups. Mean H-Q (89 ± 20 msec) for Group III was significantly longer than that for Group I (56 ± 9 msec) or Group 11 (64 ± 11 msec) (
P
< .001). All patients with presumed or documented episodes of high grade A-V block had abnormal H-Q intervals, and six of the nine patients with presumed or documented complete A-V block had H-Q intervals >80 msec. The present data suggest that patients with transient neurologic symptoms, bifascicular or left BBB associated with marked prolongation of H-Q (≧80 msec), should be seriously considered as candidates for insertion of a permanent cardiac pacemaker even in the absence of documented high grade or completeA-V block.
Reproducibility of a Multi-Stage Near Maximal Treadmill Test for Exercise Tolerance in Angina Pectoris
Authors: SMOKLER PAUL E. , MACALPIN REX N. , ALVARO ANTHONY , KATTUS ALBERT A.
Published: June 2012

A retrospective analysis was made of the reproducibility of a treadmill exercise tolerance test performed on patients with angina pectoris to an end point of moderately severe (3+) angina. One hundred and forty tests (70 pairs) in 63 patients were found to meet criteria for inclusion in the study. In 30 patients a comparison of the first test the patient had ever had with a subsequent test revealed a significantly poorer performance on the first test; mean differences ± one standard error of the mean between the first test and the subsequent tests were 0.90 ± 0.20 min of walking from the start of the test to the onset of angina, 2.3 ± 0.33 total min of walking, and 5.8 ± 0.86 "exercise units" attained at the end point of "3+" angina. In 40 patients a comparison of two tests, neither of which was the patients' first test, revealed no significant differences in performance; mean differences between the two tests were 0.20 ± 0.23 min of walking at the onset of angina, 0.11 ± 0.07 min of walking and 0.18 ± 0.15 exercise units attained at the end point of "3+" angina. There were no significant differences in maximum heart rates attained between any of the tests.

In using treadmill testing to quantitate exercise capacity in angina pectoris, the first test is likely to yield a poorer performance than subsequent ones. Tests subsequent to the first are highly reproducible when a specifically defined symptomatic end point of moderately severe intensity is employed.