bluuebunny/crossref_metadata_2025 huggingface dataset:
Aneurysms of the Thoracic Aorta Complicating Coarctation
Authors: EDWARDS JESSE E.
Published: June 2012

Coarctation of the aorta may become complicated by aortic aneurysms involving either the proximal or distal compartment of the vessel. Such aneurysms principally are consequences either of hypertension or of bacterial infection. The aneurysms in either compartment may be of the classical dissecting or saccular types. Saccular aneurysm may result from infection or laceration of the aorta without intramedial dissection of blood.

In the ascending aorta, an additional basis for aneurysm is aortic stenosis, the latter either being congenital, or more commonly, acquired calcific in a congenital bicuspid valve.
Long-Term Evaluation of Tetralogy Patients with Pulmonary Valvular Insufficiency Resulting from Outflow-Patch Correction Across the Pulmonic Annulus
Authors: JONES ELLIS L. , CONTI C. RICHARD , NEILL CATHERINE A. , GOTT VINCENT L. , BRAWLEY ROBERT K. , HALLER J. ALEX
Published: June 2012

In the operative correction of tetralogy of Fallot with a severely narrowed right ventricular outflow tract, widening of the pulmonic annulus is frequently necessary to prevent a high residual pressure gradient and to reduce right ventricular pressure overload. This can be accomplished by incising the pulmonic annulus and inserting a patch graft across the valve, but this usually results in pulmonary valvular insufficiency.

Of 426 patients who underwent total correction of Fallot's tetralogy between 1959 and 1970, 63 required a patch across the pulmonic annulus. The mortality rate for this group was 30.1%, compared with a total mortality among the 426 patients of 18%. The high mortality rate is influenced by the fact that the majority were corrected in the early years of the series.

Fifteen patients were restudied by cardiac catheterization and cineangiography an average of 9.1 years after total correction. Twelve patients were asymptomatic and three patients had only mild symptoms on exertion in spite of angiographically significant pulmonic regurgitation. The average right ventricular systolic pressure was 40 mm Hg; right ventricular end-diastolic pressure was 7 mm Hg; and the right ventricular/pulmonary arterial peak systolic pressure gradient was 14.9 mm Hg. This experience suggests that after a more difficult immediate postoperative period, patients who have right ventricular outflow reconstruction with patches across the pulmonic ic annulus tolerate their chronic pulmonic regurgitation very well.
Does Cardiac Transplantation Significantly Prolong Life and Improve Its Quality?
Authors: GRAHAM ANTHONY F. , SCHROEDER JOHN S. , GRIEPP RANDALL B. , STINSON EDWARD B. , HARRISON DONALD C.
Published: June 2012

The human cardiac transplant experience at the Stanford University Medical Center is presented in order to assess the current therapeutic role of this procedure. Of 47 patients undergoing transplantation from January 1968 to September 1972, 16 are currently alive. A total of 25 patients have survived longer than 3 months following surgery. Twenty of these returned to functional class I cardiac state and their previous activities, for a total of 25.6 patient-years. The current 1-year survival following cardiac transplantation in this series is similar to that for organ function after transplantation with cadaver renal allografts. In addition, functional and vocational rehabilitation are possible for critically ill patients following successful cardiac transplantation.
Recognition of Postoperative Acute Myocardial Infarction
Authors: DIXON SEWELL H. , LIMBIRD LEE E. , ROE CHARLES R. , WAGNER GALEN S. , OLDHAM H. NEWLAND , SABISTON DAVID C.
Published: June 2012

Routine enzymatic and electrocardiographic diagnosis of postoperative acute myocardial infarction (AMI) is frequently inconclusive. The detection and quantitation of isoenzymes of lactate dehydrogenase (LDH) and creatine phosphokinase (CPK), especially the cardiac-specific CPK-MB isoenzyme, have allowed earlier recognition of AMI in nonsurgical patients. Serial monitoring with these methods has been utilized during the postoperative period in 20 noncardiac surgical patients and 100 patients undergoing coronary artery bypass grafting (CABG).

In the noncardiac surgery group, both isoenzymes were accurate in diagnosing AMI in the early postoperative period. Of the 100 patients in the CABG group, CPK-MB appearance in 21 correlated with AMI by electrocardiogram. The absence of CPK-MB postoperatively in 49 patients permitted a 73% incidence of new ECG abnormalities to be effectively resolved. Autopsy confirmation of AMI was obtained in two patients with nondiagnostic ECG, but with elevated CPK-MB. The elevated CPK-MB without ECG evidence of AMI in the remaining patients could possibly be explained by varying degrees of myocardial damage produced by intraoperative cardiac manipulation. These data demonstrate the value and sensitivity of CPK-MB isoenzyme determinations in the early recognition of postoperative acute myocardial infarction.
Experience with Emergency Aortocoronary Bypass Grafts in the Presence of Acute Myocardial Infarction
Authors: KEON WILBERT J. , BEDARD PIERRE , SHANKAR KANAKAIAHNAVARA R. , AKYUREKLI YASH , NINO ALFREDO , BERKMAN FRANK
Published: June 2012

In the past 18 months 15 patients have undergone emergency aortocoronary bypass grafts using saphenous vein in the presence of acute myocardial infarction. Eight patients were in a state of cardiogenic shock, and seven patients were having severe cardiac arrhythmias, persistent hypotension, or signs of extending infarction.

There were three operative deaths, all of which occurred in the cardiogenic shock group of patients. One patient died three months after operation of a cerebrovascular accident. There are 11 surviving patients. One patient presently has angina, and one patient shows signs of left heart failure. The remaining patients are well at the present time.

We feel that angiography and surgery early in the course of a complicated myocardial infarct should diminish the immediate risk of death from both pump failure and cardiac rupture. Controlled prospective studies are required to elucidate the timing and indications for operation.
Ultrasound Assessment of Left Ventricular Function Following Aortocoronary Saphenous Vein Bypass Grafting
Authors: KISSLO JOSEPH , WOLFSON STEVEN , ROSS ALLAN , PASTERNAK RICHARD , HAMMOND GRAEME , COHEN LAWRENCE S.
Published: June 2012

Three serial determinations of left ventricular function were performed by echocardiographic techniques in ten patients undergoing aortocoronary saphenous vein grafting for occlusive coronary artery disease. There were significant increases in maximum posterior wall velocity, mean posterior wall velocity, amplitude of left ventricular wall excursion, and ejection fraction when the preoperative values were compared with those obtained one week and six weeks after surgery. Improvements in these indices seemed independent of heart rate and blood pressure and, therefore, probably reflected an improvement in ventricular function attributable to surgery. These data, of course, must be interpreted with care in patients with coronary artery disease who may have asynchronous ventricular contraction. The findings in this paper support previously reported data showing enhancement of ventricular function following aortocoronary saphenous vein grafting and provide a means for the serial evaluation of large numbers of patients by noninvasive techniques.
Direct Anastomosis of the Bilateral Internal Mammary Artery to the Distal Coronary Artery, Without a Magnifier, for Severe Diffuse Coronary Atherosclerosis
Authors: SUZUKI AKIO , KAY EARLE B. , HARDY JAMES D.
Published: June 2012

Forty-three cases of direct anastomosis of unilateral or bilateral internal mammary artery (IMA) and distal coronary artery (DCA), with or without saphenous vein graft (SVG), for severe, diffuse, ischemic coronary artery disease are reported. The technique of anastomosis of IMA and DCA without a magnifier or microscope is discussed in detail. The operative mortality was less than 5% (2 of 43 patients). The initial patency rate of IMA and DCA anastomosis was 97% (34 of 35). Only 8 patients have been restudied 4 to 16 months after surgery. Flow through the IMA ranged from 30 to 60 cc/min, averaging 45 cc/min at the time of surgery. Postoperative ventricular function studies suggest an increase of left ventricular emptying and endocardial fiber-short-ening rate in those with well-functioning grafts.

The significant advantage of this technique is that it extends the indications for direct coronary artery reconstruction by anastomosing bilateral IMA to DCA near the apex, where the size of the artery is 1 to 1.5 mm and the SVG is more likely to occlude because of the size discrepancy and expected relatively low blood flow.
Clinical and Pathological Findings in Patients with "Floppy" Valves Treated Surgically
Authors: MCKAY ROXANE , YACOUB MAGDI H.
Published: June 2012

Fifty-one patients underwent operation for "floppy" aortic or mitral valves during a three-year period between 1969 and 1972. Aortic valve disease occurred predominantly in men, while mitral valve lesions were equally distributed between men and women. In all groups, the mean age at operation was in the fifth decade; only patients with Marfan's syndrome came to operation before the age of 30 years. The clinical course was characterized by rapid deterioration in left ventricular failure after the onset of symptoms; an asymptomatic murmur was often present for many years prior to decompensation. Hemodynamic findings showed a wide range of abnormalities, with cardiac index consistently reduced to 1.5 L/m
2
/min ± 0.3 in aortic disease, and 1.6 L/m
2
/min ± 0.4 in mitral disease.

At operation the aortic cusps were thin and prolapsing and, in 5 of 11 patients, an aneurysm of the ascending aorta required resection. Mitral valves were soft, voluminous, with elongated and ruptured chordae. Prolapse of the cusps or billowing of a flail segment produced mitral regurgitation. In 3 patients, mitral valve replacement was complicated by acute dissection of the aorta at the site of the aortic clamp; this was diagnosed at operation and successfully repaired in 2 and discovered at autopsy in 1.

Histology of the valves confirmed the presence of diffuse myxomatous tissue in all cusps, cystic medial necrosis in the aorta, and varying degrees of collagen disorganization and necrosis in chordae tendineae. There was frequently deposition of similar myxomatous tissue around chordae and on the ventricular endocardium, possibly as a response to friction. Forty-four patients survived operation and have been followed up for periods up to 36 months. There were 2 late deaths, and 2 valves were replaced at a second operation. There has been no evidence of valve dehiscence.

It is concluded that heart disease resulting from connective tissue abnormalities is unique in its clinical course, the high incidence of associated aortic aneurysms and ruptured chordae tendineae, and the postoperative complications of valve dehiscence. Homograft replacement has given encouraging results.
Late Complications of Intraoperative Coronary Artery Perfusion
Authors: REED GEORGE E. , SPENCER FRANK C. , BOYD ARTHUR D. , ENGELMAN RICHARD M. , GLASSMAN EPHRAIM
Published: June 2012

Although exceedingly unusual, six significant late and potentially lethal complications of coronary perfusion have been observed. In five patients, angina was a sequel of aortic valve replacement, and in the sixth, ventricular tachycardia occurred. Coronary angiography revealed proximal coronary artery stenosis not present in preoperative study in five of the patients, and a dissecting aneurysm of the right coronary artery in the sixth. In four patients, the findings were confirmed during successful reoperation. These patients illustrate the urgent need for repeating coronary angiography when angina or serious arrhythmia occurs late following aortic valve replacement.
Echocardiographic Evaluation of the Hemodynamic Effects of Chronic Aortic Insufficiency with Observations on Left Ventricular Performance
Authors: DANFORD HAROLD G. , DANFORD DAVID A. , MIELKE JOHN E. , PETERSON LOWELL F.
Published: June 2012

Twelve patients with aortic insufficiency (AI) were investigated by echocardiographic methods using reflected ultrasound. No patients with associated mitral valvular disease were included. Estimates of each patient's aortic valvular total flow (Q
At
) as computed from left ventricular cavity minor-axis dimension changes at end-diastole (D
d
) and end-systole (D
s
) were compared with their respective mitral valvular flows (Q
M
) as estimated from the opening velocity of the anterior mitral leaflet. The arithmetic difference of the two valvular flows permitted calculation of the aortic regurgitant flow (Q
Ar
) as Q
At
-Q
M
=Q
Ar
. In this series of patients Q
At
varied from 5.2 to 12.9 liters/min, Q
M
from 3.3 to 7.3 liters/min, Q
Ar
from 1.1 to 6.5 liters/min, ejection fraction (EF) from 0.37 to 0.60 and regurgitant fraction (Q
Ar
/Q
At
) from 0.15 to 0.58. A statistically significant difference of Q
At
and Q
M
was not evident in a series of 20 patients without AI.

Left ventricular performance in the patients with AI was estimated by echocardiographic methods by measuring the amplitude of systolic excursion of the left ventricular midwall (PWE), the mean velocity of posterior wall motion (mean PWV), and computation of the mean velocity of circumferential fiber shortening (V
CF
) for the left ventricular myocardium.

The data presented appear to provide a simple noninvasive method for serial observations of the hemodynamic consequences of AI and the eventual alteration of myocardial performance in such patients.
Echocardiographic Demonstration of Abnormal Motion of the Interventricular Septum in Left Bundle Branch Block
Authors: McDONALD IAN G.
Published: June 2012

A characteristic abnormality of motion of the interventricular septum was recorded by echocardiography in 17 of 18 patients with left bundle branch block. Early and abrupt contraction of the septum occurs during the pre-ejection period before the delayed commencement of contraction of the posterior wall of the left ventricle. This abnormality can be explained by asynchronous contraction of the left ventricle with early activation and contraction of the septum but delay in activation and contraction of the left ventricular free wall due to a block in the left bundle branch or its peripheral branches.
Differentiation of "A-V Junctional Rhythms"
Authors: SCHERLAG BENJAMIN J. , LAZZARA RALPH , HELFANT RICHARD H.
Published: June 2012

Considerable controversy exists regarding the site(s) of origin of so-called junctional rhythms. However, experimental and clinical evidence indicates that a more precise identification of the origin of these rhythms is now possible. Microelectrode recordings from the atrioventricular (A-V) junction have clearly demonstrated that all three zones of the A-V node (upper nodal [AN], midnodal [N], and lower nodal [NH] regions) exhibit action potentials which are functionally different from those recorded in contiguous atrial and His bundle cells. In addition, the amplitude and rate of rise of A-V nodal action potentials are markedly depressed by acetylcholine, a relative sensitivity not shared by atrial and His bundle cells. Cells of the AN and NH regions of the A-V node do show pacemaker activity as do His bundle cells. Experimental studies using His bundle recording techniques indicate significant differences in heart rate between nodal rhythms produced by sinus node isolation or suppression (average: 94 ± 22 beats/min) and His bundle rhythms caused by A-V nodal destruction (average: 39 ± 9 beats/min). Nontoxic doses of ouabain significantly reduced the average A-V nodal rate to 55 beats/min whereas the same dose regimen did not change the average rate of His bundle rhythms. Several clinical studies have claimed that the absence of "A-V nodal" potentials during so-called middle and lower A-V nodal rhythms indicate a site of origin in the His bundle and not the A-V node. However, the nondescript, sometimes spurious nature of A-V nodal recordings severely limits this approach to differentiation of junctional rhythms. Recent clinical studies using His bundle recordings showed that patients with complete heart block and narrow QRS complexes could be clearly divided into two groups. In one group the heart rates ranged from 45-60 beats/min and invariably increased significantly following atropine administration (A-V nodal pacemakers). In the other group heart rates ranged from 35-45 beats/min and there was no significant response to atropine (His bundle pacemakers). Intra-His bundle block could be documented in several patients in the latter group, confirming the His bundle location of the ventricular pacemaker. In conclusion, evidence gained from experimental
in vivo
and
in vitro
animal studies and from clinical investigations clearly suggests the existence of at least two pacemakers in the A-V junction. The two A-V junctional pacemakers are distinctly different in both heart rate and chronotropic response to cholinergic or cholinergic-blocking agents.
Preinfarctional (Unstable) Angina—A Prospective Study— Ten Year Follow-Up
Authors: GAZES PETER C. , MOBLEY E. MIMS , FARIS HENRY M. , DUNCAN ROBERT C. , HUMPHRIES G. BADGER
Published: June 2012

One hundred and forty patients with preinfarctional (unstable) angina were followed for ten years for the purpose of determining the natural history and the prognostic significance of electrocardiographic findings. The cumulative survival rate for the 140 patients was as follows: 12 months: 82%; 24 months: 75%; 36 months: 69%; 60 months: 61%; and 120 months: 48%. Twentyone percent (29 of 140) of the patients developed an acute myocardial infarction within eight months of the onset of the diagnosis of preinfarctional angina with an associated mortality of 41.4% (12 of 29). A combination of high-risk factors in a patient, e.g., frequent angina in the hospital, prior stable angina, and ischemic ST change during pain, identified his as a high-risk case. The high-risk subgroup (54) had a cumulative survival rate as follows: 12 months: 57%; 24 months: 47%; 36 months: 37%; 60 months: 27%; and 120 months: 19%. Thirty-five percent (19 of 54 patients) of this subgroup developed a myocardial infarction within three months of the onset of preinfarctional angina with an associated mortality rate of 63% (12 of 19 patients). At the first year follow-up, 18% (25 of 140) of the patients died; 74% (104 of 140) had less angina; and 8% (11 of 140) did not show a change in their anginal pattern. These data can be used as a basis for a controlled trial of surgical treatment for preinfarctional angina.
Fifteen-to Twenty-Year Study of One Thousand Patients Undergoing Closed Mitral Valvuloplasty
Authors: ELLIS LAURENCE B. , SINGH JANG B. , MORALES DANTE D. , HARKEN DWIGHT E.
Published: June 2012

A study is reported of an annual follow-up over a 15- to 20-year period of the survivors of the first 1,000 patients undergoing closed mitral valvuloplasty for mitral stenosis. In addition to a report of the status of the patients at each year of follow-up, a detailed analysis has been made of the factors influencing results of surgery 15 years after operation. The most important factor adversely influencing long-term results is significant mitral valve calcification. This is true regardless of age, sex, preoperative status, concomitant mitral insufficiency or minor degrees of aortic valve disease. A beneficial effect of younger age (below 40 years at surgery) or lack of associated mitral insufficiency is apparent only in Group III patients with noncalcific valves, and in these two subgroups the results were 41 and 37 percent improved, respectively. These figures do not include the large number of patients who have again been improved following a second or even third operation. Late systemic embolization occurs infrequently after such surgery. (1.1% per patient year of follow-up). In patients without significant valvular calcification and without substantial mitral incompetence or significant associated valvular disease, closed mitral valvuloplasty is the operation of choice. The indications for closed versus open operation for mitral stenosis are discussed in detail.
The Effects of Atrial Pacing on the Synergy and Hemodynamics of the Orthotopically Transplanted Canine Heart
Authors: MATTILA SEVERI , INGELS NEIL B. , DAUGHTERS GEORGE T. , ADLER STEPHEN C. , WEXLER LEWIS , DONG EUGENE
Published: June 2012

Instantaneous left ventricular dynamics were measured from cineradiographs utilizing implanted tantalum coils as myocardial site markers in the orthotopically transplanted canine heart. Four parameters of myocardial synergy were obtained: mean shortening, anisotropy of contraction, mean time to half shortening, and asynchrony of contraction. Estimates of end diastolic volume, end systolic volume, stroke volume, ejection fraction, and cardiac output were obtained. Heart rate was altered by pacing the left atrium of the donor heart. Of the nine parameters, only cardiac output was significantly changed by alterations in heart rate. The invariance of stroke volume with rate resulted in a proportional increase in cardiac output with cardioacceleration.
Ventricular Fibrillation Induced by Conducted Sinus or Supraventricular Beat
Authors: SAKAMOTO TOHRU , YAMADA TAKASHI , HIEJIMA KAZUMASA
Published: June 2012

We report a case of a 35-year-old housewife who had a repetitive ventricular fibrillation following cardiac surgery. This arrhythmia was induced by sinus or supraventricular ectopic beats conducted to the ventricles and interrupting the preceding T or T+U wave during incomplete A-V dissociation. The cycle length (Q-Q) and the Q-Q/Q-T ratio of the beats preceding fibrillation were significantly shorter than the Q-Q and Q-Q/Q-T ratio of the beats not preceding fibrillation. These findings suggest that ventricular fibrillation is more likely to occur when the supraventricular impulse is conducted to the ventricles early in the cycle and interrupts the T or T+U wave.
Function of Cardiac Receptors
Authors: LINDEN R. J.
Published: June 2012

Stimulation of right and left atrial receptors causes an increase in activity in sympathetic nerves [see table in the PDF file] to the sinoatrial node resulting in 1) an increase in heart rate, 2) a decrease in activity in nerves to the kidney, with an unknown effect, and 3) a diuresis caused by a blood-borne agent which is said by others to be a reduction in the concentration of antidiuretic hormone.

This exciting finding leaves us with many questions both pure and applied. One may be important to us now. Remembering that these receptors have been vividly demonstrated in the atria of man should we not ask, Are these two small chambers not more important in man than commonly appreciated?
Demonstration of Dual A-V Nodal Pathways in Patients with Paroxysmal Supraventricular Tachycardia
Authors: DENES PABLO , WU DELON , DHINGRA RAMESH C. , CHUQUIMIA RUBEN , ROSEN KENNETH M.
Published: June 2012

Electrophysiological evidence suggestive of dual atrioventricular (A-V) nodal pathways is presented in two patients with normal P-R interval and reentrant paroxysmal supraventricular tachycardia (PSVT). His bundle recordings and atrial stimulation were used to obtain this electrophysiological evidence.

Refractory periods were measured with the atrial extra-stimulus technique. Plotting of H
1
-H
2
responses against A
1
-A
2
coupling intervals revealed that as A
1
-A
2
decreased, H
1
-H
2
decreased appropriately. At a critical A
1
-A
2
, a sudden marked increase in H
1
-H
2
occurred, suggesting failure of fast pathway, (defining the fast pathway effective refractory period ERP). Further shortening of A
1
-A
2
defined a second H
1
-H
2
curve. The longest A
1
-A
2
with no H
2
response was defined as the slow pathway ERP. Echo zones coincided with A
1
-A
2
intervals equal to or less than the fast pathway ERP.

These results provide the first electrophysiological demonstration of dual A-V nodal pathways in patients with normal P-R interval and PSVT, as manifest by dual A-V nodal conduction times and refractory periods. Antegrade failure of the fast pathway with subsequent availability for retrograde conduction could allow A-V nodal reentry. These findings provide a basis for reentrance in some patients with reentrant PSVT.
P Wave Analysis in 2464 Orthogonal Electrocardiograms from Normal Subjects and Patients with Atrial Overload
Authors: ISHIKAWA KYOZO , KINI P. MANOHAR , PIPBERGER HUBERT V.
Published: June 2012

The purpose of this study was to establish limits of normal for P wave measurements, and to propose criteria for routine electrocardiographic readings and for multivariate analysis to recognize left atrial overload (LAO) and right atrial overload (RAO) in the orthogonal electrocardiogram (ECG). Frank ECG's were obtained from 2464 subjects, including 580 normals, 164 patients with mitral valve disease (MVD) forming the LAO group, and 623 with chronic lung disease (CLD) as the RAO sample. Each group was divided into training and test sets. Using a digital computer, 120 different P wave measurements were computed for each ECG to find optimal discriminators between normal (N), LAO, and RAO.

In the training set of MVD, using three scalar measurements, LAO was recognized in 57% with 3% false positives. These criteria diagnosed LAO in 70% of the test cases of MVD. Four discriminators identified RAO in 30% and 37% of training and test cases of CLD with 11% false positives.

A set of 15 measurements obtained by multivariate analysis was used in a classification in which the three groups, N, LAO, and RAO were considered simultaneously. Ninety-four percent N, 74% LAO, and 45% RAO in the training sets, and 95%, 71%, and 24% in N, LAO, and RAO test sets were correctly identified. An attempt was made to correlate the rate of recognition of LAO with the degree of LAO estimated by cardiac catheterization. Data reported in the present study can serve as standard for P wave analysis in the Frank ECG.
An Acute Effect of Cigarette Smoking on Platelet Function
Authors: LEVINE PETER H.
Published: June 2012

In a controlled, double blind study, the smoking of a single cigarette has been shown to increase the platelet's response to a standard aggregating stimulus. This phenomenon appears to be specifically related to the inhaling of tobacco smoke; it does not follow the smoking of lettuce leaf filled cigarettes. The platelet effect seems independent of the rise in plasma free fatty acids which follows cigarette smoking. Smoking-induced potentiation of platelet aggregation may help to explain the increased incidence of arterial thrombi and/or atheromatous plaques in cigarette smokers.
Correlations Between the Chest Film and Hemodynamics in Acute Myocardial Infarction
Authors: KOSTUK WILLIAM , BARR JOHN W. , SIMON ALLEN L. , ROSS JOHN
Published: June 2012

A series of 169 standardized chest films was analyzed relative to hemodynamic parameters obtained within 2 hr of the roentgenogram in 86 patients with acute myocardial infarction. The films were evaluated for cardiomegaly using the cardiothoracic ratio and the standardized, external left heart dimension. The radiographic appearance of the pulmonary vasculature was divided into levels of increasing severity: normal, pulmonary venous congestion, interstitial pulmonary edema, alveolar pulmonary edema. These were compared with wedge pressure levels of ⪕12, 13-18, 19-25, and >25 mm Hg, respectively. Correlations with the admission films of the 86 patients showed: 1) The appearance of the pulmonary vasculature accurately predicted the patient's wedge pressure on admission in 43% of the cases, overestimated it in 33% and underestimated it in 24%. 2) The presence of cardiomegaly and/or pleural effusion indicated an elevated wedge pressure with a high degree of certainty; however the absence of these signs did not exclude an elevated wedge pressure. 3) In only 62% of the studies was the chest film able to detect or exclude the presence of pulmonary venous hypertension. However, when wedge pressures were elevated to 19-25 mm Hg and over 25 mm Hg, 74% and 100%; respectively of roentgenograms had some evidence of pulmonary venous hypertension. 4) There was a high degree of correlation between the patient's admission physical findings, as evidenced by clinical classification, and the radiologic assessment of pulmonary venous hypertension.

There was no statistical variation in the accuracy of the estimate of wedge pressure in relation to the time elapsed from onset of symptoms of myocardial infarction. However, a therapeutic phase lag was encountered in 21 patients, the chest films remaining abnormal for a period of 1 to 4 days following return of the wedge pressure to normal. A diagnostic phase lag was encountered in 6 patients in whom the chest film did not correlate with elevation of wedge pressure for up to 12 hr. Furthermore, in 17 patients the films were normal in spite of a persistently elevated wedge pressure for 6 to 24 hr.

These studies document the limitations of the chest roentgenogram in predicting the hemodynamic status of patients with acute myocardial infarction.
Angiographic Changes in Aortocoronary Vein Grafts:
Authors: LESPÉRANCE JACQUES , BOURASSA MARTIAL G. , SALTIEL JACQUES , CAMPEAU LUCIEN , GRONDIN CLAUDE M.
Published: June 2012

The angiographic aspect of aortocoronary vein grafts was reviewed three years after operation in 43 patients. These patients had been previously subjected to two selective angiographic studies: two weeks and one year after operation. The review of these angiographic studies suggests that the attrition rate of aortocoronary vein grafts levels off after the first year. Only three occlusions (5.4%) were found on the three-year study in the 55 grafts which were patent on the study conducted at one year. Two of the three occlusions occurred in grafts which had already displayed severe segmental reduction in size after one year. Moreover, the slight to moderate reduction in caliber noted in more than 70% of vein grafts between two weeks and one year after operation did not progress between one and three years. Thus, it appears that fibrous hyperplasia. which is believed responsible for these changes, is a time-limited process, and is not expected to progress after the first year.
Dynamic Geometry of the Left Ventricle in Mitral Regurgitation
Authors: VOKONAS PANTEL S. , GORLIN RICHARD , COHN PETER F. , HERMAN MICHAEL V. , SONNENBLICK EDMUND H.
Published: June 2012

High-speed biplane left ventricular (LV) cineangiograms were analyzed for changes in volume, shape, and dimensions in 35 patients. Ventriculographic studies in ten normal subjects characterized by an ejection fraction (E.F.) of 67 ± 2% and an end-diastolic volume (EDV) of 90 ± 8 ml/m
2
were compared with results from 25 patients with isolated mitral regurgitation of varying severity. Patients with mitral regurgitation (MR) were subdivided according to whether or not the ejection fraction was normal. Those with normal E.F. (70 ± 2%) were termed compensated MR (CMR) and had EDV 192 ± 7 ml/m
2
. Those with decreased E.F. 34 ± 3% were termed decompensated MR (DMR) and had EDV 277 ± 17 ml/m
2
. In normal subjects no significant changes in LV dimensions were noted during the isovolumic phase of contraction while in patients with compensated MR the transverse axis shortened an average of 5.2% with no change in the longitudinal axis (L). Changes in geometry prior to ejection were less evident in the group with decompensated MR. In normal subjects during ejection the extent of circumferential fiber shortening was 38 ± 1%, and longitudinal shortening was 18 ± 1%. In CMR slightly greater changes were observed in LV dimensions. In DMR both circumferential and longitudinal shortening was significantly reduced (17 ± 2% and 8 ± 1%, respectively). Assuming an ellipsoidal model of the LV chamber, eccentricity (e) was calculated to assess the degree of roundness. In normal subjects, e increased from 0.85 at end-diastole to 0.92 at end-systole. In compensated MR, end-diastolic shape was more rounded with e increasing from 0.75 to 0.88 during systole. In decompensated MR there was only a small change in e from 0.70 to 0.73 during systole, indicating that a globular configuration persisted in systole as well as diastole.

These differences could not be satisfactorily explained in terms of etiology, age, regurgitant volume load or its duration. The differences between the two groups of patients were best expressed by the difference in ejection fraction and globularity of the LV. A relationship to absolute EDV between the two groups was less evident. These differences may be due to development of organic changes in the architecture of heart wall in those patients with decompensated MR.
Critical Pulmonary Stenosis with a Diminutive Right Ventricle in Neonates
Authors: FREED MICHAEL D. , ROSENTHAL AMNON , BERNHARD WILLIAM F. , LITWIN S. BERT , NADAS ALEXANDER S.
Published: June 2012

Thirteen of 19 neonates seen in the first months of life with critical pulmonary stenosis (PS) and an intact ventricular septum had a diminutive right ventricle (RV) evidenced by electrocardiographic and angiocardiographic criteria. All were critically ill and at catheterization had hypoxemia secondary to right-to-left shunting at the atrial level, and RV hypertension. Right ventricular angiogram was useful to evaluate RV size and differentiate the children with PS from those with pulmonary atresia.

Pulmonary valvulotomy was the procedure of choice and in ten children the operation resulted in marked improvement with disappearance of cyanosis and cardiomegaly within one year. All are well six months to eight and one half years later. Two children had an additional unrecognized infundibular stenosis and required a shunt after valvulotomy because of persistant cyanosis. One child had a shunt without valvulotomy and died three years later in congestive failure.

The three children who have been recatheterized at two to three years postoperatively have RV pressures less than 60 mm Hg. In two the right ventricles more than doubled in size but remain small.

These children are critically ill and a good salvage rate depends on rapid evaluation and valvulotomy.
Pathogenetic Mechanisms of Prolapsing Aortic Valve and Aortic Regurgitation Associated With Ventricular Septal Defect
Authors: TATSUNO KATSUHIKO , KONNO SOUJI , ANDO MASAHIKO , SAKAKIBARA SHIGERU
Published: June 2012

The developmental mechanisms of prolapse and regurgitation of the aortic valve which complicate ventricular septal defect (VSD) were investigated from the anatomical, angiographic, and surgical viewpoints on the basis of autopsied heart specimens, preoperative thoracic aortography, and surgical records.

Two major, conceptually distinct but functionally interdependent factors contribute to the aortic valve's prolapse into the VSD. The major feature of the first category is the lack of anatomical support for the valve. In subpulmonary VSD, a regional defect of the conal septal musculature which supports a section of the right coronary sinus and the annulus was observed. In infracristal VSD, a deficiency of the sinus of Valsalva was noted.

The hemodynamic effects, which actually produce prolapse of the anatomically unsupported valve into the VSD, is the second contributing factor. The left-to-right shunt of blood through the VSD during the early systolic phase pulls the sagging aortic valve into the defect. The distinctive feature of the second category is that prolapse of the anatomically unsupported valve is produced by hemodynamic effects. Diastolic aortic pressure does not appear to contribute greatly to bulging of the aortic valve into the right ventricular cavity. However, in the diastolic phase, the closed valve is subject to intra-aortic pressure, causing the free margin of the prolapsed cusp to hang down, to gradually become elongated, and finally to separate from the free margin of the other two cusps, and thus be rendered incompetent.
The Value of Left Parasternal Impulse Recordings in the Assessment of Mitral Regurgitation
Authors: BASTA LOTFY L. , WOLFSON PAUL , ECKBERG DWAIN L. , ABBOUD FRANCOIS M.
Published: June 2012

Left parasternal cardiograms were recorded at the fifth intercostal space in 30 patients with mitral regurgitation. Early systolic outward movements (E), late systolic outward movements (LOM), and the ratio of the LOM area to the total area occupied by the left parasternal cardiogram (LPC area) were examined. Thirteen patients had pure mitral regurgitation due to ruptured chordae tendineae (ten patients) or "floppy mitral valve" (three patients). In these patients LOM/E correlated significantly with the regurgitation volume determined by the difference between angiographic and Fick stroke volumes, (
r
= 0.93,
P
< 0.01), and with the height of the "v" wave in the pulmonary artery wedge pressure tracings (
r
= 0.79;
P
< 0.01). Simultaneous recordings of left parasternal movements and pulmonary wedge pressures in eight patients in this group showed a close relationship between LOM and "v" waves.

Fourteen patients had rheumatic heart disease and mitral regurgitation associated with mitral stenosis of varying degrees of severity. In this group there was no significant correlation between LOM/E or LOM area/LPC area and the regurgitation volume or the height of the "v" wave. Of three patients who had congenital atrial septal defect in addition to mitral regurgitation, none had prominent LOM in the left parasternal cardiogram.

This study suggests that if mitral stenosis and atrial septal defect can be excluded on clinical evidence, the left parasternal cardiogram may be used to obtain a noninvasive assessment of the severity of mitral regurgitation, particularly in patients with recent onset of the disease.
Multiscan Echocardiography
Authors: BOM NICOLAAS , LANCÉE CHARLES T. , VAN ZWIETEN GERARD , KLOSTER FRANK E. , ROELANDT JOS
Published: June 2012

The principle of a prototype multiple element echocardiographic instrument is described. The major goal of this system is instantaneous visualization of moving cross-sections of the heart. As a result a direct impression of cardiac anatomy and dimensions may be obtained. The transducer contains 20 small acoustic elements positioned in a row. System characteristics and transducer details are given. A flexible five lever time-gain compensation unit which permits independent gain setting for specific depth ranges is described. Recording modes include video tape, photographic, film and line scan techniques. The signal from any selected element of the Multiscan transducer may be recorded in the conventional time-motion display, thus combining Multiscan capabilities with conventional echocardiographic techniques.
Multiscan Echocardiography
Authors: KLOSTER FRANK E. , ROELANDT JOS , CATE FOLKERT J. TEN , BOM NICOLAAS , HUGENHOLTZ PAUL G.
Published: June 2012

A multiple element ultrasound system has been developed which provides moving cross-sectional images of the heart. Unique features are the capacity to display substantial segments of cardiac structures and to show them in continuous, real-time motion. Two standard transducer positions have been established of which one produces images of a sagittal cardiac cross-section in the plane of the septum and the other a horizontal section across the ventricles. Studies with satisfactory detail were possible in most children and in two-thirds of adults investigated. Clinical information may be obtained regarding anatomic relationships of major structures in congenital heart disease and about cardiac valve motion and thickening or calcification in valvular heart disease. Measurements of aortic root dimensions are accurate when compared with angiography. Ventricular dimensional measurements are not validated as yet. The Multiscan concept is still under development, but shows promise of significantly expanding the capabilities of clinical echocardiography.
The Effect of Clinical Pharmacy Services on Patients with Essential Hypertension
Authors: McKENNEY JAMES M. , SLINING JUDITH M. , HENDERSON H. RICHARD , DEVINS DOUGLAS , BARR MARTIN
Published: June 2012

The effect of clinical services provided by a pharmacist to 25 study patients with essential hypertension was evaluated and compared to the course followed by 25 control hypertensive patients not receiving these services. Results show a significant improvement (
P
< 0.001) in the study patients' knowledge of hypertension and its treatment, a significant increase (
P
< 0.001) in the number of study patients who complied with prescribed therapy, and a significant increase (
P
< 0.001) in the number of study patients whose blood pressures were kept within the normal range during the study period. Most of these study patients had been hypertensive and noncompliant before, and they reverted to this status after the study period. The 25 control patients were hypertensive and noncompliant before, during, and after the study period. Fifty-nine incidents of suspected adverse reactions to antihypertensive drugs were identified in the study patients, occurring more frequently in those patients who were noncompliant, hypertensive, or taking progressively larger numbers of antihypertensive drugs. Patients were receptive to this service and kept appointments with the pharmacist investigator 92% of the time. The services provided which may have contributed to the success of treatment are discussed. It is concluded that pharmacy clinical services are beneficial and that pharmacists should become more involved in the long term care given hypertensive patients.
Procaine Amide Against Re-Entrant Ventricular Arrhythmias
Authors: GIARDINA ELSA-GRACE V. , BIGGER J. THOMAS
Published: June 2012

Nine patients with coupled ventricular premature depolarizations (VPDs) were treated with intravenous procaine amide to abolish the arrhythmia. The effect of procaine amide on the electrocardiogram was carefully observed. Seven patients were treated with intermittent intravenous therapy-100 mg of procaine amide was injected every five minutes-and two were treated by constant intravenous infusion-200 µg/min/kg body weight; blood for plasma procaine amide concentration was obtained 4.5 to 5 min after each dose. As the cumulative dose of procaine amide increased, plasma drug concentration increased and the frequency of coupled VPDs progressively decreased. Moreover, in every patient an interesting electrocardiographic phenomenon was observed: as plasma drug concentration increased, the coupling interval progressively increased until the arrhythmia was completely abolished. A hypothesis for procaine amide's antiarrhythmic action is offered based on this new observation. This hypothesis suggests that procaine amide prolongs conduction in the depressed portion of a re-entrant pathway such that conduction is further delayed and block finally occurs, thereby terminating the arrhythmia.
The Missing Waveform Information in the Orthogonal Electrocardiogram (Frank Leads)
Authors: KORNREICH F.
Published: June 2012

The orthogonal electrocardiogram (Frank leads) is a reasonable compromise between the demands of practicability and diagnostic accuracy. The accuracy has been enhanced by the use of computerized multivariate statistical procedures. The work of the last two or three decades, however, has shown that these leads account for only part of the total available surface information. In this paper, the missing waveform information with respect to the Frank leads is quantitatively and systematically determined and a method of retrieval is worked out.

The essence of this method rests on the empirical evidence obtained by testing each of the 126 surface electrocardiograms for the XYZ content. The results are analyzed by a least squares, best fit procedure. The poorly fitted curves are considered as additional waveform sources. The number and the sites of the additional information are determined on a test group of 207 patients. The "total" surface waveform information is found to be represented by nine surface leads. This set of waveforms is then tested on a control group consisting of 205 patients. An average resynthesis coefficient of 96% is reached. No further resynthesis is looked for because of the estimated noise level.

Although the waveforms recorded at these sites represent the minimum number of unique building blocks capable of synthesizing any waveform on the body surface, they cannot predict the surface potential distribution at all surface points. This information is "total" as far as statistical procedures-performing discriminant analysis on time-functions—are concerned. This "total" waveform information consists of a set of electrocardiograms recorded in each individual at nine well-defined anatomical locations.
Hemodynamic and Metabolic Responses to Vasodilator Therapy in Acute Myocardial Infarction
Authors: CHATTERJEE KANU , PARMLEY WILLIAM W. , GANZ WILLIAM , FORRESTER JAMES , WALINSKY PAUL , CREXELLS CARLOS , SWAN H. J. C.
Published: June 2012

Hemodynamic effects of vasodilator therapy (phentolamine or nitroprusside) were studied in 38 patients with acute myocardial infarction (AMI). Cardiac metabolism was studied in 19 of the 38 patients. According to the initial level of left ventricular filling pressure (LVFP) and left ventricular stroke work index (SWI), patients were divided into three groups: Group I-nine pa- tients with LVFP 15 mm Hg or less; Group II-14 patients with LVFP > 15 mm Hg and SWI >20 g-m/m
2
; Group III-15 patients with LVFP > 15 mm Hg and SWI < 20 g-m/ m
2
. In Group I most patients were clinically uncomplicated. In Group IL most patients had clinical left ventricular failure including one patient who had clinical features of cardiogenic shock. Group III patients all had severe left ventricular failure, with eight patients in clinical shock.

In all groups LVFP, pulmonary artery pressure, right atrial pressure, and systemic and pulmonary vascular resistance decreased significantly with vasodilator therapy with only a slight to moderate decrease in arterial pressure. In Group I patients SVI decreased (-7%) together with an increase in heart rate. Significant improvement in left ventricular performance, however, was observed in Groups II and III as indicated by increased stroke volume index (SVI) and cardiac index (CI) and decreased LVFP. The increase in SVI and CI was of similar magnitude in both Group LI (SVI +18%, CI +24%) and Group III (SVI +28%, CI +29%) patients, a change suggesting that vasodilation thereby may be applicable and beneficial even in the presence of severe depression of cardiac performance.

Improved left ventricular performance in group II and III patients was accompanied by a slight decrease in coronary blood flow, myocardial oxygen consumption, and transmyocardial oxygen extraction. There was no change in myocardial lactate metabolism in any group. In vitro studies in isolated cat papillary muscle preparations showed no direct positive inotropic effect of either phentolamine or nitroprusside. Thus, significant improvement in left ventricular performance occurs during vasodilator therapy in patients with AMI and elevated LVFP, even in the presence of severe depression of cardiac performance. Furthermore, this improvement is not accompanied by increased metabolic cost. Vasodilator therapy, therefore, may have an important role in the treatment of pump failure complicating myocardial infarction.