bluuebunny/crossref_metadata_2025 huggingface dataset:
Mitral commisurotomy versus replacement. Preoperative evaluation by echocardiography.
Authors: Nanda N C , Gramiak R , Shaah P M , DeWese J A
Published: June 2012

Echocardiographic studies of the mitral valve were performed in 57 patients with pure or predominant mitral stenosis who subsequently underwent surgery (30 commissurotomy, 27 valve replacement). Mitral valve calcification was graded heavy (thick, conglomerate echoes), light (multiple, discrete linear echoes) or none (thin, single or duplicate signals). Valve mobility, measured as the excursion from the systolic closed position to the fully opened position in diastole, was classified as normal (20 mm or over), restricted (16-19 mm) or poor (15 mm or less). Absence of mitral valve caclification was the most useful echocardiographic indicator for commissurotomy (18 of )9 cases. The most reliable criteria for valve replacement were heavy valve calcification (11 of 11 cases) and poor cusp mobility (11 of 11 cases). The poor mobility group included 3 patients with heavily calcified valves. Thus 37 of 57 cases (65%) could be reliably categorized regarding the type of surgery performed using these three parameters. The remaining echocardiographic parameters (normal mobility, restricted mobility and light calcification) were less valuable in the assignment of the operative category. Echocardiographic assessment of mitral valve calcification and mobility appears to be of value in planning the surgical approach in patients with pure or predominant mitral stenosis.
The apical A wave versus the fourth heart sound in assessing the severity of aortic stenosis.
Authors: Kavalier M A , Stewart J , Tavel M E
Published: June 2012

The height of the "a" wave of the apexcardiogram was evaluated as a marker for critical aortic stenosis in patients over 40. Critical aoritc stenosis was defined as an aortic valve area less than .75 cm-2 with no more than mild aortic insufficiency. Phonocardiograms and apexcardiograms were performed on 72 patients with catheterization proven aortic stenosis and on 14 normal controls, all over age 40. The height of the "a" wave of the apexcardiogram was measured as a percentage of the e to o excursion (a/e-o). Fourth heart sound gallops ( S4G) were recorded in 71% (11 of 14) of normal controls, 86% (6 of 7) of patients with less than critical aortic stenosis, and 85% ( 55 of 65) of patients with critical aortic stenosis. The a/e-o was less than 16% in all normals or patients with less than critical aortic stenosis. The a/e-o exceeded 16% in 45% (29 of 65) with critical aortic stenosis. Audibility of the S4G bore no relationship to recordability, apical "a" wave geight, or the severity of the aortic stenosis. In conclusion, therefore, we believe that when one is confronted with findings suggestive of aortic stenosis, the finding of a palpable apical "a" wave (or an "a" wave height of greater than 16% of the total complex on the apexcardiogram) is an important positive feature, suggesting severe aortic stenosis. Its absence, however, does not exclude severe valvar obstruction. Probably because of auscultatory inaccuracy in this condition, the apparent presence or absence of an S4G has not been of much aid in this evaluation. This sound, however, might be more useful in a carefully performed prospective study.
Learned control of blood pressure in patients with high blood pressure.
Authors: Kristt D A , Engel B T
Published: June 2012

Five patients with documented histories of essential hypertension of at least ten years' duration participated in a triphasic study of training to control systolic blood pressure (SBP). Phase 1 was a seven week period during which patients took their BP (systolic and diastolic) at home and mailed these data to us daily. Phase 2 was a three week period during which patients were taught to control SBP using a noninvasive technique: patients were trained to raise, to lower and to alternately lower and raise SBP. Phase 3 was a three month period during which patients again took their BP at home and mailed these data to us daily. Results: (1) all patients learned SBP control: average increas 15%; average decrease 11%; (2) during SBP control heart rates, breathing rates, triceps brachii muscle tension and EEG activity did not change; (3) follow-up tests at one and three months showed evidence of retained SBP control; (4) baseline SBP fell from 153 mm Hg during laboratory training to 135 mm Hg at the three month follow-up; (5) phase 3 home BPs fell 18/8 mm Hg from phase 1 levels; (6) at home patients also were able to reduce SBP from 141 mm Hg (average) to 125 mm Hg (average) by means of the lowering technique learned in the laboratory.
Acute subendocardial myocardial infarction in patients. Its detection by Technetium 99-m stannous pyrophosphate myocardial scintigrams.
Authors: Willerson J T , Parkey R W , Bonte F J , Meyer S L , Stokely E M
Published: June 2012

Eighty-eight patients admitted to a coronary care unit with chest pain of varying etiology but without ECG evidence of an acute transmural myocardial infarction had myocardial scintigrams using technetium-99m stannour pyrophosphate (99m-Tc-PYP). Seventeen of these patients had ECG and enzymatic evidence suggestive of acute subendocardial myocardial infarction. In each of these the scintigrams were postivie demonstrating increased 99m-Tc-PYP uptake either in a faintly but diffusely positive pattern or in a well-localized strongly positive one. The remaining 71 patients did not evolve ECG or enzymatic evidence of acute myocardial infarction. In each of these patients the myocardial scintigram was negative. Thus 99m-Tc-PYP myocardial scintigrams are capable of identifying the presence of acute subendocardial myocardial infarction in patients. The absolute frequency with shich subendocardial myocardial infarction can be recognized utilizing this technique will have to be established in a larger number of patients in the future.
Posterior mitral leaflet motion in mitral stenosis.
Authors: Levisman J A , Abbasi A S , Pearce M L
Published: June 2012

A reduced rate of diastolic closure of the anterior mitral leaflet has been shown to occur in mitral stenosis, primary pulmonary hypertension, and in cases with reduced left ventricular compliance. Posterior notion of the posterior mitral leaflet in diastole has been the distinguishing feature to rule out the diagnosis of mitral stenosis. We have analyzed echocardiograms of 167 patients with mitral stenosis and have found 16 cases where the posterior mitral leaflet moved posteriorly, that is, in an opposite direction from the anterior mitral leaflet. Two other features were found that were helpful in establishing the diagnosis of mitral stenosis in these atypical cases, namely, thickening of the mitral leaflets and reduction or absence of the artrial wave.
Results of routine preoperative coronary angiography in tetralogy of Fallot.
Authors: Fellows K E , Freed M D , Keane J F , Praagh R , Bernhard W F , Castaneda A C
Published: June 2012

In the surgical repair of tetralogy of Fallot, morvidity and mortality are increased by certain coronary anomalies, in particular, an anterior descending branch originating from the right coronary artery or a single coronary artery in which a large coronary branch runs across the pulmonary outflow tract. In series of 94 patients with tetralogy of Fallot who underwent cardiac catheterization, coronary artery visualization was attempted routinely, most often by flush aortography using a venous catheter. Diagnostic coronary visualization was obtained in 84 patients (89%). In these, the incidence of recognized coronary anomalies was 5%; anterior decending from the right coronary artery in four patients (4%), and singly left coronary in one patient (1%). In 195 autopsied cases of tetralogy, the incidence of coronary anomalies was also 5%. Routine preoperative demonstration of the coronary artery anatomy in tetralogy patients usually can be accomplished satisfactorily and conveniently by transvenous flush aortography.
True and false left ventricular aneurysms. Propensity for the altter to rupture.
Authors: Vlodaver Z , Coe J I , Edwards J E
Published: June 2012

Two cases are described of sudden death resulting from rupture of small chronic false aneurysm of the left ventricle with secondary hemopericardium. The cases support the point that rupture of chronic false left ventricular aneurysm tends to occur. This appears to be contrary to the potential for chronic true aneurysms of the left ventricle which tend not to rupture. Rupture of true left ventriuclar aneurysm in its deveoping stahe may, however, occur.
A forty-year review of bacterial endocarditis in infancy and childhood.
Authors: Johnson D H , Rosenthal A , Nadas A S
Published: June 2012

A retrospective review of 149 episodes of bacterial endocarditis (BE) in 141 patients under 25 years of age, at The Children's Hospital Medical Center from 1933 through June of 1972, demonstrates increasing survival and a distinct change in the frequency of underlying congenital heart disease and rheumatic heart disease (RHD). Certain forms of congenital heart disease such as tetralogy of Fallot, small ventricular septal defect, and aortic stenosis are at particular risk for BE. Following BE, patients with ventricular septal defect and tetralogy of Fallot have less morbidity and higher survival rates than children with aortic outflow lesions. over the entire time period, alpha Streptococcus is the most common pathogen and Staphylococcus aureus, second most frequent organism. Surgical correction in patients with congenital heart disease may offer the best form of prevention.
Clinical measurement of myocardial infarct size. Modification of a method for the estimation of total creatine phosphokinase release after myocardial infarction.
Authors: Norris R M , Whitlock R M , Barratt-Boyes C , Small C W
Published: June 2012

A modified method for the measurement of total creatine phosphokinase release from venous blood samples taken four-hourly after myocardial infarction has been used in 43 patients admitted to a Coronary Care Unit. The fractional decay rate (Kd) of enzyme activity has been measured by a standardized method in each patient, and accuracy of the calculation of total enzyme release has been improved by allowance for individual variations in decay rate, and discarding of data from which decay rates cannot be measured within confidence limits of less than plus or minus 15 per cent. Total enzyme release was greater in cases of transmural infarction than in patients with subendocardial infarction, and showed a good positive correlation with clinical indices of the extent of myocardial damage. As noted by previous workers, this method allows for the measurement of the rate as well as the extent of enzyme release, and so should prove useful in the clinical evaluation of therapeutic agents which might accelerate or retard the rate of myocardial necrosis in patients with acute myocardial infarction.
Primary T wave abnormalities caused by uniform and regional shortening of ventricular monophasic action potential in dog.
Authors: Autenrieth G , Surawicz B , Kuo C S , Arita M
Published: June 2012

We correlated primary T wave changes with the changes of monophasic action potentials (MAP) recorded with suction electrodes from the ventricular surface of the dog heart following systemic or intracoronary infusions of small doses of isoproterenol (ISP). The portions of the heart perfused with ISP were excised and weighed to determine the mass of perfused tissue. ISP shortened the ventricular MAP by an average of 12-18 msec in the entire ventricular mass following systemic administration, in 34 plus or minus 6 per cent of the ventricular mass after injection into the left circumflex coronary artery (LCA), in 8.5 plus or minus 2.6% of the ventricular mass after injection into a branch of LCA and in 17 plus or minus 8 per cent of the ventricular mass after injection into the right CA. The MAP changes induced by ISP were similar to the transmembrane action potential changes recorded with microelectrodes from papillary muscles excised from the same dogs. The most important results of this study showed that: 1) the early and the late effects of ISP administration produced opposite effects on the T wave polarity. The early T wave change was associated with nonhomogeneous and the late change with homogeneous MAP shortening; 2) the T wave change was greater after infusion into LCA than after systemic administration, 3) the T wave change was greater after infusion into LCA than after infusion into LCA branch apparently because of greater mass of the ISP-perfused myocardium; 4) the T wave change was greater after infusion into LCA branch than after infusion into RCA, apparently due to the unequal regional repolarization contribution to the T wave; 5) the ventricular gradient did not always reflect the magnitude of the primary T wave change. Our study helps to identify factors contributing to high sensitivity and low specificity of T wave abnormalities.
"Supernormal conduction" of a premature impulse utilizing the fast pathway in a patient with dual atrioventricular nodal pathways.
Authors: Denes P , Wyndham C R , Wu D , Rosen K M
Published: June 2012

Electrophysiological studies with atrial extrastimulus technique suggested the presence of dual atrioventricular (A-V) nodal pathways in a patient with hypothyroidism, as evidenced by a sudden increase of H1-H2 intervals at critical A1-A2 coupling intervals. Following the atrial extrastimulus (A2), a third impulse (A3) occurred spontaneously. During slow pathway conduction of A2, and A3, appearing at a critically timed interval allowed fast pathway conduction, resulting in an earlier than expected QRS (a form of supernormal conduction). This demonstration of fast pathway conduction during slow pathway conduction adds strong evidence for the existence of dual A-V nodal pathways.
Echocardiographic detection of tricuspid valve prolapse.
Authors: Chandraratna P N , Lopez J M , Fernandez J J , Cohen L S
Published: June 2012

The echocardiographic findings in 12 patients with tricuspid valve prolapse are presented. Eight of these patients had associated mitral valve prolapse. Only one of the above patients had the characteristic physical signs of tricuspid incompetence. Two types of abnormality were noted on the echocardiogram of the tricuspid valve. In eight patients, the systolic segment of the tricuspid valve showed an initial horizontal motion followed by a posterior motion in midsystole. Four patients exhibited posterior motion of the tricuspid valve in early systole, which reached a maximum in midsystole, and this was followed by an anterior motion, thus producing a hammock-like configuration. We conclude that echocardiography is useful in the diagnosis of tricuspid valve prolapse. Since this condition may be associated with clinically significant tricuspid incompetence or bacterial endocarditis, its recognition is of clinical importance.
Variability of echocardiographic discontinuity in double outlet right ventricle and truncus arteriosus.
Authors: French J W , Popp R
Published: June 2012

The widespread application of echocardiography to the field of congenital heart disease has led to the development of a concept of "echocardiographic discontinuity" for the diagnosis of some conditions. Although this is a valuable sign in differentiating such entities as tetralogy of Fallot, truncus arteriosus and double outlet right ventricle, the reported cases illustrate that the echocardiographic recognition of discontinuity may be complicated by technical factors. In addition, the differential diagnosis must include truncus arteriosus with coexistence of anterior and posterior discontinuity.
Cardiac performance and mortality early after intracardiac surgery in infants and young children.
Authors: Parr G V , Blackstone E H , Kirklin J W
Published: June 2012

One hundred thirty-nine infants and small children less than 48 months old were studied during the first 72 hours after intracardiac surgery for a variety of lesions. The hospital mortality rate was 19.4% (27 patients); 16 of those dying succumbed from acute cardiac failure. Deaths from acute cardiac failure were commonest in patients with low cardiac index (CI), and a continuous probability curve relates the two. The mean CI for all patients was 2.51 plus or minus 0.794 l-min minus 1-m minus 2, and that for individual patients varied between 0.6 and 4.9. Cardiac output normalized by surface area (cardiac index) correlated weakly with age. cardiac output normalized by weight did not correlate with age; Mean mixed venous oxygen partial pressure (P-vO2)varied between 17 and 60 mm Hg, and the weighted mean for the group of 80 patients in whom it was obtained was 33.1 plus or minus 6.57 mm Hg. CI and P-vO2 were only slightly related. Acute cardiac deaths occurred more frequently in patients with low P-vO2. Acute cardiac death was more reliably predicted using CI and P-vO2 together than either alone. The average of the mean arterial pressure was 80.5 plus or minus 2.53 mm Hg, and this did not correlate with CI. Mean average systemic vascular resistance was 30.0 plus or minus 8.395 SRU. We conclude that in such patients treatment should be directed toward keeping CI greater than 2.0 l-min minus 1-m minus 2 and P-vO2 greater than 30 mm Hg; that the possibility of maintaining adequate CI and P-vO2 is not related to the age of the patient but is related to the malformation treated; and that a therapeutic trial of reducing left ventricular afterload is indicated in some of these patients.
Nontraumatic determination of left ventricular ejection fraction by radionuclide angiocardiography.
Authors: Schelbert H R , Verba J W , Johnson A D , Brock G W , Alazraki N P , Rose F J , Ashburn W L
Published: June 2012

Previous reports have suggested that left ventricular ejection fraction can be assessed by recording the passage of peripherally administered radioactive bolus through the heart. The accuracy and validity of this technique were examined in 20 patients undergoing diagnostic cardiac catheterization. 99m-Tc-human serum albumin was injected via a central venous catheter into the superior vena cava and precordial activity recorded with a gamma scintillation camera interfaced to a small digital computer. A computer program was designed to generate time-activity curves from the left ventricular blood pool and to calculate left ventricular ejection fractions from the cyclic fluctuations of the left ventricular time-activity curve which correspond to left ventricular volume changes during each cardiac cycle. The results correlated well with those obtained by biplane cineangiocardiography (r equals 0.94) and indicated that the technique should allow accurate and reproducible determination of left ventricular ejection fraction. The findings, however, demonstrated that the time-activity curve must be generated from a region-of-interest which fits the left ventricular blood pool precisely and must be corrected for contributions arising from noncardiac background structures. This nontraumatic and potentially noninvasive technique appears particularly useful for serial evaluation of the acutely ill patient and for follow-up studies in nonhospitalized patients.
Plasma dopamine-beta-hydroxylase activity in oral contraceptive hypertension.
Authors: Rockson S G , Stone R A , Gunnells J C , Schanberg S M , Kirshner N , Robinson R R
Published: June 2012

A prospective study was undertaken to evaluate the relative contribution of changes in sympathetic nervous system activity, as reflected by changes in dopamine-beta-hydroxylase (DBH) activity, to the pathogenesis of oral contraceptive-induced hypertension. Precontraceptive and serial post contraceptive determinations of blood pressure, plasma renin activity (PRA), DBH activity, and changes in body weight were obtained in twelve control patients and forty-one oral contraceptive users. Forty-four percent of oral contraceptive users had increases in blood pressure but remained normotensive and 17% became frankly hypertensive. The precontraceptive and average post contraceptive levels of mean arterial pressure (MAP), PRA and DBH activity in each patient were compared using paired group analysis. Control patients (group I) exhibited no significant changes in these variables, while the patients with contraceptive-induced increases in MAP (groups III and IV) underwent significant, parallel increases in DBH activity. Finally, the linear regression of changes in MAP on the percent change in DBH activity was examined. The positive slopes in groups III and IV differed significantly from the negative slope of the controls (group I). The data have been interpreted to reflect an inappropriate oral contraceptive-induced stimulus to sympathetic nervous system activity, leading to increases in MAP in susceptible individuals.
Follow-up of mass screening for coronary risk factors in 1817 adults.
Authors: Aronow W S , Allen W H , De Cristofaro D , Ungermann S
Published: June 2012

The prevalence of coronary risk factors was assessed in 1,817 asymptomatic adults in Long Beach, California, at the beginning and end of a 10-11 month interval. The risk factors evaluated were hypercholesterolemia, hypertriglyceridemia, hypertension, smoking, hyperglycemia, and marked obesity. The results of the tests were sent to the participants and to their physicians. An educational program aimed at reducing coronary risk factors was offered to the first 1,250 persons screened. Eight hundred and seventy-two of those 1,250 allocated to the education group returned for a second screening. The prevalence of 0, 1, 2, 3, 4, 5, or 6 coronary risk factors did not change significantly between the two screens in either the total group of 1,817 adults or in the 872 adults in the educational program. The Long Beach Heart Association mass screening program for coronary risk factors was ineffective in reducing the number of coronary risk factors.
Technetium stannous pyrophosphate myocardial scintigrams in patients with chest pain of varying etiology.
Authors: Willerson J T , Parkey R W , Bonte F J , Meyer S L , Atkins J M , Stokley E M
Published: June 2012

Technetium-99m stannous pyrophosphate was utilized for myocardial imaging in 202 patients admitted to the hospital with chest pain of uncertain etiology. One hundred and one patients had clinical and evolved electrocardiographic and enzymatic evidence of acute myocardial infarction. Ninety-six of these 101 patients had increased myocardial uptake of the technetium stannous pyrophosphate and positive myocardial scintigrams; there was nearly precise correlation between the ECG and myocardial imaging localization of the area of infarction for acute transmural myocardial infarctions. In the five patients with negative myocardial images the scintigrams were obtained after seven or more days had elapsed following the myocardial infarction. In the remaining 101 patients no clinical, ECG, or enzymatic evidence of infarction developed; 92 of these patients had negative myocardial scintigrams. Seven of the remaining nine patients were admitted with "unstable angina pectoris", and despite the absence of diagnostic ECG and enzyme evolution each of these patients had faintly and diffusely positive myocardial scintigrams. The remaining two patients had positive myocardial scintigrams but no definite ECG or enzymatic evidence of acute myocardial infarction. Thus the technetium pyrophosphate imaging technique appears safe, inexpensive and to correlate well with ECG and enzyme identification of the presence of infarction and with ECG localization of myocardial infarction. In addition the positive myocardial scintigrams in some patients with "unstable angina" suggest that there may be limited myocardial necrosis that is ordinarily undetected by ECG and enzymes in these patients. The incidence of false positive and false negative scintigrams appears to be small.
Compensatory changes of the distal coronary vascular bed during progressive coronary constriction.
Authors: Gould K L , Lipscomb K , Calvert C
Published: June 2012

The degree and effectiveness of compensatory changes in the distal coronary vascular bed during progressive proximal coronary stenosis have not been described. In this study, coronary vascular bed resistance and pressure gradient-flow relationships were determined for 157 different stenoses in nine opened-chest dogs by measuring coronary flow, aortic pressure, and coronary pressure distal to a coronary constrictor while flow was varied from resting to maximal values by the intracoronary injection of Hypaque-M, 75% (previously shown to cause transient, maximal vasodilatation comparable to ten second occlusion). This approach provided a means of hemodynamically characterizing coronary stenoses in a standary, experimental manner for quantitative analysis of different arteries at different flow rates as found in the intact coronary circulation. The results show that 1) pressure gradient-flow characteristics or hydraulic resistance of stenoses do not become abnormal enough to alter normal resting coronary flow nor to elicit compensatory changes for stenoses up to constriction of approximately 60% of the diameter, 2) compensatory vasodilatation of the distal coronary vascular bed maintains near normal resting flow for lesions between 60% and 85% diameter stenosis but adaptive vasodilatation fails to compensate for the high resistance of lesions greater than 85% diameter stenosis, and 3) there is vasodilator reserve still present when total coronary artery flow is reduced below normal by a stenosis. This vasodilator reserve probably exists in the epicardium since the endocardium is characteristically underperfused due to the low coronary pressure caused by stenosis and is therefore likely to be maximally vasodilated with no remaining vasodilator reserve.
Cardiac involvement in Whipple's disease.
Authors: McAllister H A , Fenoglio J J
Published: June 2012

Although cardiac involvement in Whipple's disease has been reported previously, the extent and significance of such involvement has not been stressed. In our series of 19 patients, 58% had clinical cardiac findings and 79% had gross cardiac lesions at autopsy. Histologically there were PAS-positive macrophages in the pericardium, myocardium, and valves of each of these patients. These collections of macrophages were associated with chronic inflammatory cells and foci of fibrosis with resultant adhesive pericarditis, focal myocardial fibrosis similar to the fibrosis of idiopathic cardiomyopathy, and valvular fibrosis with deformity grossly resembling the valvular lesions of chronic rheumatic heart disease. Four of the patients with mitral valvular deformity had cardiac murmurs, and ECG changes were noted in six patients with mitral myocardial fibrosis. In addition, pericardial friction rubs were heard in two patients. By electron microscopy rod-shaped bodies, presumably bacteria, were noted in the mitral valve and myocardium. The structures are identical to those described in the small intestinal mucosa of patients with Whipple's disease and presumably are the causative agent of the pancardiopathy.
Sinus node function and conduction system after complete repair of tetralogy of Fallot.
Authors: Niederhauser H , Simonin P , Friedli B
Published: June 2012

Twenty-three children underwent electrophysiological studies during routine postoperative catheterization two months to five years after complete correction of tetralogy of Fallot. The aim of the study was to investigate the whole conduction system, including sinus node function, suing His bundle recordings and atrial pacing. H-V intervals were normal at rest and with pacing in twenty-two patients, including four patients with evidence of bifascicular block on the surface ECG. One patient with cardiomegaly and evidence of diffuse myocardial damage had a prolonged H-V interval but did not develop a block at this level during pacing A-H interval was slightly prolonged in four patients and normal in all others. The threshold of pacing-induced atrioventricular block ranged from 75 to 240/min and was somewhat age dependent (r = -0.55). Two patients fell below the 95% confidence limit of this regression and are considered abnormal. One returned to normal after intravenous injectionof atropine. Corrected sinus node recovery time ranged from 60 to 2000 msec. Three patients had values above 500 msec which are considered abnormal. These patients had other minor signs of sinus node dysfunction, i.e., episodes of sino-atrial block at rest or intermittent sinus bradycardia. Thus, while the His Purkinje system performed satisfactorily in all patients, sinus node dysfunctional and A-V node dysfunction were demonstrated in a few patients after correction of tetralogy of Fallot.
The pathophysiology of idiopathic mitral valve prolapse.
Authors: Nutter D O , Wickliffe C , Gilbert C A , Moody C , King S B
Published: June 2012

Left ventricular structure, function, and the coronary circulation were studied in a subset of patients with mitral valve leaflet prolapse. This group of 26 patients (21 females, five males, with mean age of 46 years), had the syndrome identified as idiopathic mitral valve prolapse (IMVP), which was characterized by a systolic click-murmur, clinical symptoms that were highly variable in duration and intensity, angiographically-documented mitral prolapse, and no obvious associated systemic or cardiovascular disease. Mitral regurgitation was of moderate degree in four, mild in 14, and absent in eight. The left ventricular (LV) end-diastolic volume index was elevated in ten of 25 (40%), the LV mass index was elevated in six of 17 (35%), but the LV anterior wall thickness was increase in only one of 17. Three major patterns of ventricular contraction were identified: 1) normal in seven; 2) abnormal, usually an inferior deformity and/or anterior asynergy, in eight; and 3) hyperkinetic in 11. Normal resting left ventricular function, assessed as an ejection fraction greater than 55%, was present in 17 of 25 (68%). Selective coronary arteriography was essentially normal in all 25 patients studied. An ischemic ECG response was detected during only one of 12 maximal treadmill exercise tests and in none of ten atrial pacing stress tests (AP). Myocardial lactate extraction did not change significantly during AP in six patients. We conclude that cardiomyopathy does not appear to be a primary cause or an important associated component of the IMVP syndrome. Abnormalities of the coronary circulation or of myocardial metabolism were not demonstrated by available methods. A proposed pathophysiological mechanism to explain the clinical and angiographic findings in IMVP is discussed.
Clinical conference: De subitaneis mortibus. XIII. Multifocal Purkinije cell tumors of the heart.
Authors: James T N , Beeson C W , Sherman E B , Mowry R W
Published: June 2012

Multifocal Purkinje cell tumors were found in the heart of a nine-month-old black female infant who died with arrhythmias which had become progressively more frequent and severe until they were completely intractable. The Purkinje cell tumors were composed of exactly the same type of cells found in the left bundle branch and the right bundle branch, and they were also located in the expected region of the His bundle. In none of these locations were these Purkinje cells forming normal longitudinally oriented Purkinje fibers, however, and no such fibers were found anywhere in this heart. The cells of the tumors contained glycogen but not in excess of that normally expected to be present in Purkinje cells. No evidence for a generalized abnormality of glycogen metabolism or storage was present. Except for the Purkinje cells, the remaining myocardial cells of the heart were all normal. The fundamental fault appeared to be failure of the Purkinje cells to organize into the normal histological pattern which is characterized by longitudinally oriented Purkinje fibers. Instead, all the Purkinje cells were rounded or polygonal and generally aggregated together into small discrete nodules of varying size. Future cases of this nature deserve careful attention to the nature of their cardiac rhythm and conduction, and in fatal cases there should be special studies of the histological appearance of their cardiac centers of impulse formation and conduction.
Arteriovenous fistulae secondary to renal cell carcinoma. Clinical and cardiovascular manifestations: report of a case.
Authors: Rodgers M V , Moss A J , Hoffman M , Lipchik E O
Published: June 2012

A 63-year-old woman presented with progressive congestive heart failure and unexplained cardiomegaly. Diagnostic workup revealed large arteriovenous fistulae in the lower pole of the left kidney. A total left nephrectomy was performed and microscopic exam revealed renal cell carcinoma. Following surgery, the congestive heart failure cleared and the patient has been asymptomatic for one year. The pertinent findings of the 22 patients who have been reported previously in the literature with arteriovenous fistulae complicating renal cell carcinoma are reviewed. Thirty percent of the patients presented with cardiovascular complaints, and 60% had significant cardiovascular findings during the course of evaluation. An abdominal bruit was the most discriminating finding on physical exam, and it occurred in 72% of the reported cases. The diagnosis was unexpectedly established by surgery in 13%, and by angiography in 87% -- usually in the course of a workup for hypertension, abdominal pain, hematuria, or during search for an occult malignancy. An extensive evaluation is required for early diagnosis of this correctible cause of hypertension and heart failure.
Echocardiographic findings in atrial flutter.
Authors: Zoneraich S , Zoneraich O , Rhee J J
Published: June 2012

Echocardiographic studies were performed in 22 patients with atrial fibrillation and atrial flutter. In atrial flutter, the echocardiograms consistently demonstrated regular undulatory waves of the posterior left atrial wall and upper left interventricular septum coinciding with each flutter wave of the electrocardiogram. The mitral valve was slightly reopened by each flutter wave occurring after diastolic mitral closure. The phonocardiogram simultaneously recorded with the echocardiogram showed only occasional atrial sounds. Coarse atrial fibrillation produced undulatory low frequency motion of both leaflets of the mitral valve during diastole. Atrial fibrillation with fine fibrillatory waves failed to show any significant and constant undulations of the left atrial wall and upper left interventricular septum. Echocardiographic evaluation of patients with atrial flutter could have diagnostic implications in doubtful cases with nondiagnostic electrocardiograms.
Congenital absence of the left circumflex coronary artery in the systolic click syndrome.
Authors: Gentzler R D , Gault J H , Liedtke A J , McCann W D , Mann R H , Hunter A S
Published: June 2012

The anatomy of the coronary artery circulation was examined by means of selective coronary arteriography in 19 patients, evaluated because of disabling chest pain and ECG abnormalities, with typical clinical findings of the systolic click syndrome (SCS). In 17 (89.5%), the elft circumflex coronary artery (LCCA) was absent; a single marginal branch arose from the left main vessel, but no vessel was present in or near the atrioventricular (A-V) groove. In contrast, the LCCA was identified in 74 of 78 control patients (94.9%) considered to have representative normal distribution of coronary artery branches, All but two patients with SCS exhibited reduced contraction of the segment of left ventricular (LV) myocardium surrounding the mitral valve ring (extent of systolic diameter decrease 1.4 +/- 3.1% vs normal 31.8 +/- 3.4%, P lwss than 0.001), as well as of the LV inflow tract (diameter decreasce 16.2 +/- 2.5% vs normal 38.6 +/- 1.8% P less than 0.001); both of these regions of the left ventricle derive their vascular supply from the LCCA, An identical segmental LV contraction disorder was observed in seven patients with functionally single vessel occlusive coronary artery disease involving the LCCA, An identical finding in this study was a relatively high incidence of absent LCCA (42%) in 19 patients with atypical angina and normal coronary arteriograms. It is concluded that a congenital anomaly of the coronary circulation, with absent LCCA, may be responsible for segmental myocardial dysfunction in some patients with SCS. In turn, this segmental contraction disorder may determine functional abnormality of the mitral valve apparatus.
Lordotic right posterior oblique projection of the left coronary artery: a speical view for special anatomy.
Authors: Arani D T , Bunnell I L , Greene D G
Published: June 2012

The lordotic right posterior oblique projection of the left coronary artery is obtained by combining cranial angulation of the X-ray beam with rotation of the patient into the right posterior oblique position. This projection is helpful for separation of the main left coronary artery and the proximal portions of the left anterior descending and circumflex divisions, especially in patients in whom the left anterior descending artery is directed cephalad early in its course. The obtaining of an image from the lordotic right posterior oblique projection adds less than two minutes to the procedure and improves arteriographic assessment of the left coronary artery.
Alternate pathways to pulmonary venous flow in left-sided obstructive anomalies.
Authors: Beckman C B , Moller J H , Edwards J E
Published: June 2012

In cardiac anomalies causing severe obstruction in the left side of the heart, such as aortic atresia, mitral atresia, or occasionally severe aortic stenosis, maintenance of circulation depends upon shunting of pulmonary venous blood into the right atrium. The usual pathway by which the shunt is achieved is across the atrial septum through the foramen ovale. When this route is closed or severely narrowed, alternate but less common pathways may exist. These involve either anomalous connections of pulmonary veins to systemic veins or communications with the coronary venous system. In the latter, as commonly occurs in aortic atresia, left ventricular myocardial sinusoids carry pulmonary venous blood from the left ventricular cavity and into the cardiac veins. In other instances of severe left-sided obstruction, a direct communication may exist between the left atrium and the coronary sinus.
The status of cardiac transplantation, 1975.
Authors: Rider A K , Copeland J G , Hunt S A , Mason J , Specter M J , Winkle R A , Bieber C P , Billingham M E , Dong E , Griepp R B , Schroeder J S , Stinson E B , Harrison D C , Shumway N E
Published: June 2012

Since December 1967, 263 human cardiac transplant operations have been performed throughout the world. Eighty-two of these were performed at Stanford University Medical Center, In 1974, 27 such operations were performed, 15 at Stanford Survival rates for the entire Standford series are 48% at one year and 25% at three years; survival rates at one and three years for patients surviving the first three critical months after transplantation are 77% and 42%, respectively. Recipients under the age of 55 years, with New York Heart Association Class IV cardiac disability, are selected for transplant procedures according to criteria dictated by experience over the past seven years. A routine immunsuppressive regimen for organ transplantation, incorporating prednisone, azathioprine, and antithymocyte globulin is employed early postoperatively, and prednisone and azathioprine are used for indefinite maintenance therapy. Acute cardiac graft rejection in nearly all recipients is diagnosed by clinical signs, electrocardiographic changes, and percutaneous transvenous endomyocardial biopsy. Ninety-five percent of acute rejection episodes are reversible with appropriate immunosuppressive treatment, but infectious complications are common and have accounted for 56% of all postoperative deaths. The Stanford experience in cardiac transplantation has demonstrated the potential therapeutic value of this procedure. Maximum survival now extends beyond five years. Satisfactory graft function has been documented in long-term surviving patients, the majority of whom have enjoyed a high degree of social and physical rehabilitation.
Electrophysiological evaluation of the Wolff-Parkinson-White syndrome: problems in assessing antegrade and retrograde conduction over the accessory pathway.
Authors: Svenson R H , Miller H C , Gallagher J J , Wallace A G
Published: June 2012

The effect of atrial pacing and recording site and ventricular pacing site on assessment of conduction over the accessory pathway (AP) was examined in a group of patients with the Wolff-Parkinson-White syndrome. The importance of initial localization of the AP by recording the sequence of retrograde atrial activation during circus movement tachycardia is demonstrated. Inability to record or pace near the AP may lead to significant errors in the assessment of the antegrade and retograde conduction properties of the AP. During ventricular pacing, retrograde atrial fusion was consistently demonstrated with laterally located APs.
The effect of vagus nerve stimulation upon vulnerability of the canine ventricle: role of sympathetic-parasympathetic interactions.
Authors: Kolman B S , Verrier R L , Lown B
Published: June 2012

The effect of vagus nerve stimulation (VNS) upon ventricular vulnerability was studied in 30 mongrel dogs subjected to varying levels of adrenergic stimulation. Vulnerability was assessed both by determining the minimum current required to produce ventricular fibrillation (VF threshold) and by plotting VF threshold throughout the vulnerable period (VF zone). Chloralose-anesthetized animals were studied by means of sequential pulses applied to the apex of the right ventricular endocardium. Testing was carried out in closed-chest dogs, in open-chest dogs with and without left stellate ganglion stimulation (LSGS), and in open- and closed-chest dogs pretreated with propranolol. In the absence of adrenergic stimulation. VNS was without significant effect on either the VF threshold or the VF zone under closed- or open-chest conditions. During LSGS, however, VNS was associated with a 93 +/- 22% (mean +/- SE) increase in VF threshold (P less than 0.01) and constriction of the VF zone. Vagus nerve stimulation combined with LSGS raised VF threshold to the control value, but not beyond. After beta-adrenergic blockade with propranolol, VNS was without effect on VF threshold in either open- or closed-chest animals. It is concluded that augmented sympathetic tone is a precondition for a VNS-induced elevation in VF threshold. The vagal effect is indirect and is expressed by opposing the effects of heightened adrenergic tone on ventricular vulnerability.
Use of atropine in patients with acute myocardial infarction and sinus bradycardia.
Authors: Scheinman M M , Thorburn D , Abbott J A
Published: June 2012

Fifty-six patients with acute myocardial infarction complicated by sinus bradycardia (SB) were treated with intravenous atropine and monitored in a coronary care unit. Atropine decreased or completely abolished premature ventricular contractions (PVCs) and/or bouts of accelerated idioventricular rhythm in 27 of 31 patients (87%) and brought systemic blood pressure up to normal in 15 of 17 patients (88%) with hypotension. In addition, atropine administration was associated with improved atrioventricular conduction in 11 of 13 patients (85%) with acute inferior myocardial infarction associated with 2 degrees or 3 degrees atrioventricular block. Seven patients developed ten significant adverse effects: ventricular tachycardia or fibrillation in three, sustainedsinus tachycardia in three, increased PVCs in three, and toxic psychosis in one. These major adverse effects correlated with either a higher initial dose of atropine (i.e., 1.0 mg aa compared with the usual 0.5 or 0.6 mg) or a total cumulative dose exceeding 2.5 mg over 21/2 hours. Atropine is the drug of choice for management of patients with SB and hypotension and is effective in the treatment of ventricular arrhythmias as well as conduction disturbances in patients with inferior myocardial infarction. Serious adverse effects, however, preclude use of atropine without careful medical supervision.
Surgical palliation of tricuspid atresia.
Authors: Kyger E R , Reul G J , Sandiford F M , Wukasch D C , Hallman G L , Cooley D A
Published: June 2012

In the 20-year period ending December 31, 1973 we operated on 105 patients for palliation of tricuspid atresia (TA) with reduced pulmonary blood flow. Pott's anastomosis (85), Blalock-Taussig anastomosis (19), intrapericardial aorta (Ao)-to-right pulmonary artery (RPA) (18), Glenn procedure (3) and miscellaneous shunts (2) have been used. Of patients undergoing operation more than 15 years ago, 45% (9/20) are still alive. The over-all operative mortality was 9%. It was highest in patients less than one month of age (7/23, 30%). There were no operative deaths in patients older than 12 months. The median age at first operation for the entire series was five months. Our results indicate the Pott's anastomosis and Ao-to-RPA anastomosis are superior to the Blalock-Taussig anastomosis (BT) for palliation of TA. Of patients surviving BT, 69% (11/16) required reoperation, compared to 22% (17/78) surviving Pott's anastomosis and 13% (2/16) surviving Ao-to-RPA shunts. All three patients undergoing Glenn procedures (superior vena cava-to-RPA anastomosis) required reoperation or died without significant benefit. Ballon atrial septosomy and Pott's anastomosis appear to be indicated for infants less than six months of age, and Ao-to-RPA shunt with simultaneous atrial septectomy (if indicated) for older children.
Aortic sinus of Valsalva aneurysms simulating primary right-sided valvular heart disease.
Authors: Bulkley B H , Hutchins G M , Ross R S
Published: June 2012

While acute regurgitation is the most common valvular lesion associated with aortic sinus of Valsalva aneurysms, this report describes the pathological findings in five patients in whom primary right-sided valve dysfunction was simulated by sinus of Valsalva aneurysms. In two patients aneurysms of the noncoronary sinus projected into the right atrium at the level of the tricuspid valve and caused tricuspid incomptence. In three patients aneurysms of the right sinus of Valsalva projected into the right ventricle immediately below the pulmonic valve and caused pulmonary outflow tract obstruction. In only one of these patients was the aneurysm perforated at necropsy. Although valvular dysfunction was evident clinically, in none was there a clinical suspicion of a sinus of Valsalva aneurysm. In addition to valvular dysfunction, two patients had conduction disturbances and two, right coronary arterial occlusions found to be the result of aneurysms. The risks of valve dysfunction, arrythmias, aneurysm rupture, and sudden death and the ability to correct this lesion surgically make it especially important to consider aortic sinus of Valsalva aneurysm as a cause of obscure right-sided valvular disease.