bluuebunny/crossref_metadata_2025 huggingface dataset:
Studies on Starling's Law of the Heart
Authors: BRAUNWALD EUGENE , FRAHM CHARLES J.
Published: June 2012

The hemodynamic functions of the left atrium were studied in 26 patients with disturbances of left ventricular function and in 16 subjects without any abnormalities of the cardiovascular system. Attention was directed to the effect of atrial systole on the relationship between mean left atrial pressure (MLAP) and left ventricular end-diastolic pressure (LVEDP). This relationship was considered to be a meaningful one in view of the importance of the LVEDP in determining the characteristics of ventricular contraction, and of the MLAP in determining the symptoms of left heart failure. In the subjects with normal cardiovascular systems, LVEDP-MLAP averaged 0.2 mm. Hg, but this value averaged 9.0 mm. Hg in patients with left ventricular disease, in whom left atrial contraction elevated LVEDP while permitting MLAP to remain at a significantly lower level. The magnitude of the pressure difference between LVEDP and MLAP was found to be dependent on the characteristics of atrial contraction; the height of the "a" wave appeared to be related to the atrial pressure prior to the onset of atrial contraction. The elevation of atrial pressure produced by atrial systole was found to vary directly with the time interval between the onset and the peak of the "a" wave and to vary inversely with the time interval between the peak of the "a" wave and the onset of ventricular contraction. Evidence was presented that in intact human subjects the characteristics of left atrial and left ventricular contraction are functions of the pressures in these chambers prior to the onset of their contraction, thus lending further support to the concept that Starling's law is operative in the human heart.
The Clinical Significance of the Pulmonary Collateral Circulation
Authors: FISHMAN ALFRED P.
Published: June 2012

The clinical significance of the normal and the expanded pulmonary collateral circulation is considered from the point of view of its nutrient, hemodynamic, and respiratory functions.

In the normal lung, the collateral arterial circulation is too diminutive to serve other than a nutrient function. Its roles in preventing pulmonary infarction after embolization, in producing "ischemic lung disease," and in the direct treatment of pulmonary carcinomas are considered.

The expanded collateral arterial circulation associated with localized pulmonary lesions or which occurs after ligation of a pulmonary artery seems to be without appreciable hemodynamic effect on either the pulmonary circulation, the left heart, or the systemic circulation. Only in patients with generalized suppurative disease of the lung has it been shown to affect the pulmonary circulation by diverting mixed venous blood away from diseased areas. The possibility exists that the increment in pulmonary blood flow contributed by the collateral arterial circulation may aggravate pulmonary hypertension in patients with diffuse restriction of the pulmonary vascular bed.

The venous portion of the expanded collateral circulation may conceivably contribute to pulmonary hypertension by aggravating systemic arterial hypoxemia in patients with right heart failure from hypoxemic cor pulmonale.

The expanded collateral arterial circulation may assume a major respiratory function in subjects with systemic hypoxemia and curtailed pulmonary blood flow. In such cases, the "effective" pulmonary collateral blood flow has been shown to equal normal values for pulmonary arterial blood flow.

Different portions of the pulmonary collateral circulation may be responsible for hemoptysis in different diseases: in pulmonary disease, the arterial portion; in mitral stenosis, the venous portion; in pulmonary infarction, an imbalance between the two.

The relationship between the pulmonary collateral circulation and clubbing of the digits remains uncertain.

The pulmonary collateral circulation is considered, finally, with respet to (1) limitations of present methodoloy, (2) principles involved in the development of collateral circulations in general, and (3) therapeutic implications.
Variant Hemodynamic Patterns in Mitral Stenosis
Authors: CARMAN G. H. , LANGE R. L.
Published: June 2012

Of a total group of 86, 11 cases of proved significant mitral stenosis with cardiovascular hemodynamic data are presented.

Four had normal pulmonary wedge and pulmonary artery pressures at rest and low cardiac index at rest and after mild exercise. It is postulated that such persons respond to mitral valve obstruction primarily by lowering cardiac output.

The cardiac index in seven was normal at rest and after mild exercise. Thus there was no evidence that alteration of blood flow had occurred in response to the lesion. The values for pulmonary arteriolar resistance in three of these were qualitatively normal when flow was increased. These are considered to be examples of absent or inadequate changes in pulmonary vascular reactivity.

The existence in a significant percentage of patients with mitral stenosis of a low cardiac output with normal resting pulmonary, arteriolar, and wedge pressures, or normal cardiac output despite elevation of these pressures infers that potent flow-regulating factors tors can operate independently of the obstructive lesion.
Measurement of Mitral Regurgitation in Man from Simultaneous Atrial and Arterial Dilution Curves after Ventricular Injection
Authors: LEVINSON GILBERT E. , STEIN SAMUEL W. , CARLETON RICHARD A. , ABELMANN WALTER H.
Published: June 2012

Measurements of forward and regurgitant flow were obtained in 16 patients with rheumatic disease of the mitral valve by means of simultaneous systemic arterial and left atrial dilution curves after injection of Evans-blue dye into the left ventricle. The results indicate that satisfactory measurements of forward flow may be obtained with injections into the left ventricle and that the calculated regurgitant flow has a good correlation with the severity of mitral insufficiency, as estimated clinically and surgically. The mean and range of regurgitant flow, expressed as a per cent of estimated total left ventricular output, for patients with pure mitral stenosis, predominant stenosis with mild to moderate insufficiency, and predominant or pure insufficiency, were 6 per cent (0 to 11), 21 per cent (8 to 39), and 58 per cent (28 to 82), respectively.

Eight studies in six patients, however, gave results that were either mathematically absurd, physiologically incredible, in conflict with diagnostic evidence, or otherwise suspect. Moreover, in the seven patients in whom satisfactory duplicate studies were obtained, the reproducibility of results was poor: the mean absolute difference in successive measurements was 17 per cent of total left ventricular output and the coefficient of variation was 23 per cent of an observation.

It is suggested that the principal source of error lies in unrepresentative sampling from the left atrium in the presence of incomplete mixing of indicator with blood in the cardiac chambers. In some patients, an additional and possibly appreciable error may arise from the existence of an enhanced pulmonary collateral blood flow, which provides an alternative short pathway from the left ventricle to the left atrium.

It is concluded that, with conventional sampling technics, this theoretically sound approach is too capricious to be a dependable quantitative method.
Colloid Goiter and Atherosclerosis
Authors: WELSH RONALD A. , STRONG JACK P. , MCGILL HENRY C.
Published: June 2012

The thyroid glands from 453 patients 20 to 79 years of age from the New Orleans area were classified according to the presence of colloid goiter, and the coronary arteries and aortas from these same patients were independently graded for atherosclerotic lesions. There was no correlation between colloid goiter and atherosclerosis; nor was there any difference in the percentages of deaths from atherosclerosis in goitrous patients as compared to nongoitrous patients. Because goiter may differ in its functional manifestations from one geographic area to another, and because one group of investigators in Finland has reported a strong association between the two diseases, similar studies should be conducted in other areas. The subject of increased severity of atherosclerosis in human hypothyroidism was reviewed, and it was concluded that the presently recorded data are not adequate to establish a positive relationship.
Surgical Anatomy of the Coronary Artery Distribution in Congenital Heart Disease
Authors: REEMTSMA KEITH , LONGENECKER CHARLES G. , CREECH OSCAR
Published: June 2012

Distribution of major coronary arteries was studied in 154 congenitally malformed hearts and 24 normal hearts.

The artery to the atrioventricular node constantly arose in the area of the coronary sinus from either the right or left coronary artery. In specimens with ostium primum malformations, this artery coursed immediately beneath the inferior (dorso-caudad) rim of the defect.

Anomalous distribution of the coronary arteries in the region of the right ventricular outflow tract poses a serious problem in openheart surgery. The two most frequent variants were anomalous anterior descending artery arising from the right coronary, and single right coronary artery with the left coronary branch passing across the right ventricular outflow tract.

Such anomalies occur most frequently in transposition complexes and tetralogy with extreme dextroposition of the aorta. Fatalities have been reported following division of these vessels.

Although some anomalies of the coronary vessels may be recognized on inspection of the heart at the operating table, a major vessel may lie buried within the myocardium.
Effect of Pitressin on the Splanchnic Circulation in Man
Authors: SHALDON STANLEY , DOLLE WOLFGANG , GUEVARA LUIS , IBER FRANK L. , SHERLOCK SHEILA
Published: June 2012

The effects of 20 units of pitressin administered intravenously on the splanchnic circulation in four patients without liver disease, 10 patients with cirrhosis and a patent portal vein, 11 patients with cirrhosis and an end-to-side portacaval anastomosis and two patients with an extrahepatic portal vein obstruction and a normal liver structure, were observed. Estimated hepatic blood flow and wedged hepatic venous and intrasplenic pressures were measured in all groups, and the splanchnic, hepatic arteriolar, and hepatic postsinusoidal resistances were calculated. Pitressin reduced the portal pressure by an average of 39 per cent for 1 hour. Estimated hepatic blood flow was reduced by 40 per cent. Splanchnic resistance was increased by 87 per cent and hepatic arteriolar resistance by 77 per cent. Postsinusoidal resistance was not affected. The drop in portal pressure could be related to the increases in splanchnic resistance. There was no difference in the response to pitressin between patients with cirrhosis and patients with normal liver structure and function. It is suggested that the fundamental lesion causing portal hypertension in cirrhosis is an obstruction to the hepatic venous outflow and that mesenteric and hepatic arteriolar venous anastomoses are not operative in the genesis of portal hypertension in cirrhosis. This obstruction to hepatic venous outflow is not alterable pharmacologically and any attempts to lower portal pressure by medical means must be achieved by alterations in the splanchnic resistance. Pitressin appears to be the most potent splanchnic vasoconstrictor available.
A Clinical Appraisal of the Vectorcardiogram in Myocardial Infarction
Authors: HUGENHOLTZ PAUL G. , WHIPPLE GERALD H. , LEVINE HAROLD D.
Published: June 2012

A total of 161 vectorcardiograms was recorded with the Grishman cube system in patients with suspected myocardial infarction. In the group of 49 cases subsequently examined post mortem and of 73 non-autopsied cases, in whom the diagnosis of infarction appeared certain, a comparison was made between the standard electrocardiogram and the vectorcardiogram taken in succession. The vectorcardiogram demonstrated more infarcts than the electrocardiogram. Of a total of 122 cases in which the vectorcardiogram showed infarction, 19 had normal and 17 equivocal electrocardiograms. A number of simple and easily applicable criteria for the vectorcardiographic diagnosis of infarction are given. It appears that even the older, uncorrected cubelead system permits a more accurate diagnosis than currently available standard electrocardiographic procedure. It is suggested that this method of exploration may be useful in cases of suspected myocardial infarction in which the routine electrocardiographic examination leaves doubt.
The Clinical, Hemodynamic, and Pathologic Diagnosis of Muscular Subvalvular Aortic Stenosis
Authors: MENGES HERMANN , BRANDENBURG ROBERT O. , BROWN ARNOLD L.
Published: June 2012

Muscular obstruction to left ventricular outflow is a rare but serious occurrence. Eight cases in which this disease was anatomically proved are presented. The commonest symptoms are angina, dyspnea, and palpitations. Not uncommonly a family history of heart disease may be elicited. A systolic murmur along the left sternal border is the most characteristic physical finding, but a normal aortic second sound, the presence of third and fourth heart sounds, splitting of the second sound, and the absence of a diastolic murmur are all helpful clinical guides. Withdrawal pressures from the left ventricle reveal a characteristic infundibular pressure zone. Other hemodynamic findings include an anacrotic notch on the left ventricular pressure tracing, a rapidly ascending bisferious aortic pulse and a small compensatory beat after extrasystoles.

Necropsy specimens reveal a grossly thickened interventricular septum as compared with normal and hypertrophied control hearts. Microscopic alterations are minimal. The etiology remains obscure but familial and developmental factors, either or both, appear to be implicated.
Association of Specific Behavior Pattern in Women with Blood and Cardiovascular Findings
Authors: ROSENMAN RAY H. , FRIEDMAN MEYER
Published: June 2012

The possible effect of a specific overt behavior pattern upon serum cholesterol levels, blood coagulation, and incidence of arcus senilis and clinical coronary heart disease was studied in two groups of women randomly chosen for study by lay selectors after careful orientation. Women of group A were selected on the sole basis of their habitual exhibition of a behavior pattern (type A) characterized by excessive competitive "drive," ambitiousness, and immersion in "deadlines." Women of group B were selected by lay selectors on the sole basis of their exhibition of entirely opposite behavioral traits (type B). Each group of subjects included a series of nuns respectively exhibiting the type A and B behavior patterns. The women exhibiting pattern A also exhibited markedly higher serum cholesterol levels, often more rapid blood coagulation, three to five times as much arcus senilis, three to seven times more diastolic hypertension, and a four-fold higher incidence of clinical coronary disease. A history of myocardial infarction or angina pectoris only was found in group A. These striking differences were independent of differences in parental incidence of coronary disease, caloric or fat intake, obesity, physical activity, smoking, or "femininity." The strikingly higher incidence of clinical disease in pattern A women also was not found ascribable per se to differences in heredity, obesity, hypertension, caloric or fat intake, smoking, physical activity, blood coagulation, or serum cholesterol levels.

The results closely resemble those previously found in men with similar behavior patterns, and strongly suggest that the type A behavior pattern is itself in some way largely responsible for the observed findings.
Thrombelastographic Studies with a Twenty-Four-Hour Schedule for Subcutaneous Heparin
Authors: ELIOT ROBERT S. , VON KAULLA KURT N. , BLOUNT S. GILBERT
Published: June 2012

In 55 patients 430 thrombelastographic studies after 305 heparin injections revealed that a more complete and more rapid reduction of the over-all coagulability of the blood is obtained by a subcutaneous injection of 40 per cent heparin once every 24 hours than that obtained with prothrombin-depressing agents. The individual dose, by the thrombelastographic technic, is between 3.5 and 4.5 mg./Kg.

Further clinical studies are indicated with use of simple laboratory control technics, such as recalcification time.
The Identification of Right-to-Left Shunts in the Central Circulation by the Injection of Ether
Authors: FRASER ROBERT S. , ROSSALL RICHARD E. , DVORKIN JOSEPH , VALLE-CAVERO CESAR
Published: June 2012

A method is described for localizing central right-to-left shunts by means of anesthetic ether injected through a cardiac catheter at various sites during cardiac catheterization.

The presence and location of right-to-left shunts were correctly demonstrated in 42 of 43 patients in whom the diagnosis was later confirmed at operation or autopsy. The instance in which the site was interpreted incorrectly is explained.

Three false-negative results were obtained from the test and reasons for these are also given.

In our view the test is simple, safe, gives accurate results, allows immediate interpretation, and requires no special equipment. It has proved to be a most useful test for preliminary localization of shunts prior to selective angiocardiography.
The Use of Ascorbate Dilution Curves in Cardiovascular Diagnosis
Authors: FROMMER PETER L. , PFAFF WILLIAM W. , BRAUNWALD EUGENE
Published: June 2012

The instrumentation and clinical applications, in this laboratory, of Clark's sodium ascorbate dilution technic are described. With this method the sensing device, a platinum electrode, is introduced directly into the blood stream, and a reducing agent, sodium ascorbate, is used as the indicator. Time-concentration curves may be obtained without the withdrawal of blood. Observations in 90 patients have indicated that the contours of the dilution curves are essentially identical to indocyanine-green dye-dilution curves, except for diminished peripheral recirculation peaks. The ascorbate-dilution technic has been found of particular value when the sensing electrode is incorporated into a cardiac catheter. This method permits injection and sampling of the indicator from the central circulation and greatly facilitates the study of circulatory shunts and of valvular regurgitation.
Spontaneously Disappearing Murmur of Patent Ductus Arteriosus
Authors: KEITH T. R. , SAGARMINAGA J.
Published: June 2012

A 10-year-old girl with patent ductus arteriosus had most unusual auscultatory changes, but the typical roentgenologic and electrocardiographic findings. There was an intermittent, spontaneous disappearance and reappearance of the entire machinery murmur. At surgery, a valve, or veil-like structure, was found inside the ductus at its entrance into the pulmonary artery. This valve apparently accounted for the "spontaneous" intermittent disappearance of the murmur, which was first discovered when the child was 10 years old.
Supravalvular Aortic Stenosis
Authors: WILLIAMS J. C. P. , BARRATT-BOYES B. G. , LOWE J. B.
Published: June 2012

Facial resemblance to a patient in whom supravalvular aortic stenosis was discovered and successfully relieved at operation has led to the correct diagnosis of supravalvular stenosis in three other patients. All four patients are mentally subnormal. The presence of supravalvular aortic stenosis in mentally retarded patients with the unusual facial features here detailed may constitute a syndrome that has not previously been described.
Roentgen Television Study of Cardiac Calcifications
Authors: EDLING N. P. G.
Published: June 2012

A study on roentgen television of cardiac calcifications is reported.
Pulsating Varicose Veins in Functional Tricuspid Insufficiency
Authors: BRICKNER PHILIP W. , SCUDDER W. TRACY , WEINRIB MICHAEL
Published: June 2012

To the 19 previously reported cases of pulsating varicose veins of the legs in tricuspid insufficiency, another case is added. Simultaneous electrocardiographic and venous pressure tracings of a pulsating varicose vein were recorded. A single broad "v" wave with loss of a conspicuous "x" descent, characteristic of tricuspid insufficiency with atrial fibrillation, was noted. The clinical manifestations of tricuspid insufficiency disappeared as the patient's cardiac status improved, suggesting the functional nature of the insufficiency in this case.
Comparison of Effects of Angiotensin and Norepinephrine on Pulmonary Circulation, Systemic Arteries and Veins, and Systemic Vascular Capacity in the Dog
Authors: ROSE JOHN C. , KOT PETER A. , COHN JAY N. , FREIS EDWARD D. , ECKERT GERALD E.
Published: June 2012

In dog experiments, angiotensin II and norepinephrine were compared in regard to some components of the generalized pressor response each of these agents produces. It was found that angiotensin II has no direct effect on pulmonary blood vessels, in contrast to the pulmonary vasoconstrictor effect of norepinephrine. Angiotensin II appeared to have no effects on veins or the systemic vascular capacity, while norepinephrine was a potent venoconstrictor with, therefore, a marked ability to reduce the systemic vascular capacity.
Hemodynamics of Angiotensin in Man
Authors: FINNERTY FRANK A.
Published: June 2012

These data demonstrate that in normal subjects, angiotensin II is 10 times as potent as norepinephrine which it resembles hemodynamically. An increase in the systolic pressure is associated with a significant increase in diastolic pressure, an increase in venous pressure, a decrease in heart rate, a slight decrease in cardiac output and a striking increase in total peripheral resistance, a decrease in renal blood flow, decreased glomerular filtration rate, increase in filtration fraction, and slight decrease in urinary volume.

Preliminary studies in patients in shock suggest that angiotensin II is 2 or 3 times as potent as norepinephrine. Continuous administration is
not
associated with the development of tachyphylaxis, and sloughing of tissues does not occur if there is leakage outside the vein.
Results of Surgical Treatment for Congenital Aortic Stenosis
Authors: ELLIS F. HENRY , ONGLEY PATRICK A. , KIRKLIN JOHN W.
Published: June 2012

Open operation by means of extracorporeal circulation has been used on 47 patients with congenital aortic stenosis at the Mayo Clinic between April 1955 and July 1, 1960; 33 patients had valvular stenosis, 11 had subvalvular stenosis, and three had supravalvular stenosis. The over-all operative mortality rate was 13 per cent; 6 per cent of patients with valvular aortic stenosis died in the hospital.

Severe aortic insufficiency did not develop in any patient operated on for valvular aortic stenosis although a diastolic murmur was present after operation in some. Rarely, however, was the transvalvular gradient completely eliminated by operation although 90 per cent of the surviving patients were either asymptomatic or had definite clinical improvement. Late follow-up hemodynamic studies suggest that a persistent transvalvular gradient may regress in time.

Relief of obstruction caused by subvalvular variety of aortic stenosis is difficult whether stenosis is localized or diffuse. Even in this gruop, however, it has been possible to achieve good results with careful attention to certain technical details.

Patients with congenital aortic stenosis should be operated on before the development of the sequelae of severe left ventricular hypertension.
Phlegmasia Cerulea Dolens
Authors: GILLENWATER JAY Y. , BRESLOW IRWIN H. , LISKER SAMUEL
Published: June 2012

Two cases of phlegmasia cerulea dolens are presented with acute venous obstruction, arterial spasm, and compromise of circulation to the extremity.
The Detection of Heart Disease in Children
Authors: MILLER ROBERT A. , SMITH JACQUES , STAMLER JEREMIAH , HAHNEMAN BETTY , PAUL MILTON H. , ABRAMS IRVING , HAIT GERSHON , EDELMAN JOEL , WILLARD JOEL , STEVENS WILLIAM
Published: June 2012

A mass field trial was accomplished utilizing a heart sounds tape-recording procedure to detect organic heart disease in school children.

The survey involved 35,934 children, with selection of an 8.2 per cent stratified random sample of Chicago elementary public-school children, drawn from eight representative geographic-socioeconomic-racial areas of the city.

Of the total base population, 33,026 (91.9 per cent) were recorded.

A total of 506 children was recalled for direct auscultation, based on suspicious findings on the tape recordings.

Effective detection required that the tapes be interpreted by two specially trained cardiologists.

Of the 506 children scheduled for recall, 492 were actually examined; 85 were evaluated as having probable organic heart disease, and were referred for complete work-up.

Definite organic heart disease was ultimately diagnosed in 64 children, of whom 48 had congenital heart disease and 16 rheumatic heart disease. The prevalence rate of organic heart disease in the stratified random sample was 2 per 1,000, 1.5 for congenital heart disease and 0.5 for rheumatic heart disease.

Of the total cases, 1 per 1,000 were previously unknown; all such cases have been brought under appropriate medical management as a result of their detection.

A special study of the nonrespondents (those not tape recorded) revealed a six-fold higher prevalence rate of organic heart disease in these children, compared with those surveyed.

A census was also made of cardiac children in special schools for the handicapped, in hospitals, or under home care. Based on the data from the sample, the nonrespondent study, and the foregoing census, the over-all prevalence rate of organic heart disease in Chicago elementary public-school children was estimated to be 3.4 per 1,000, 2.1 for congenital heart disease and 1.3 for rheumatic heart disease.

A validity study was accomplished by randomly inserting 34 cases of known organic heart disease among 2,525 children in one school. Thirty-one of these 34 cases (91.2 per cent) were detected; two of the three cases missed had aortic insufficiency with highpitched grade II murmurs.

It is concluded that this tape-recording procedure is a valid, feasible, and efficient method for the detection of organic heart disease in school children.
Glycogen-Storage Disease of the Myocardium with Obstruction to Left Ventricular Outflow
Authors: EHLERS KATHRYN H. , HAGSTROM JACK W. C. , LUKAS DANIEL S. , REDO S. FRANK , ENGLE MARY ALLEN
Published: June 2012

A case of glycogen-storage disease of the myocardium with the clinical and hemodynamic picture of left ventricular outlet obstruction was presented. The concept of muscular subaortic stenosis is discussed and the diagnostic features are reviewed.

In a survey of the literature 53 cases of cardiac-type glycogen-storage disease were found. The criteria for diagnosis, sex incidence, familial occurrence, symptomatology and physical signs, and laboratory studies including roentgenograms of the chest, electrocardiogram and muscle biopsy are discussed.
Combined Aortic and Pulmonic Stenosis
Authors: NADAS ALEXANDER S. , VAN DER HAUWAERT LUKE , HAUCK ANNA J. , GROSS ROBERT E.
Published: June 2012

Combined aortic and pulmonic stenosis is a rare lesion. The clinical, hemodynamic, and pathologic findings in four patients are presented. The presence of a forceful left as well as right ventricular impulse (in four patients), the difference in the character of the ejection murmur at the second left as opposed to the second right interspace (in two patients), and a diastolic rumble at the apex (in four patients) were characteristic. The electrocardiogram showed right ventricular hypertrophy in all patients; additional and definite left ventricular hypertrophy was found in one. Radiologically, there was evidence of right ventricular enlargement in all and suggestive left ventricular enlargement in three. Simple valvular stenosis of both valves was found in only one patient, and valvular pulmonary and supravalvular aortic stenosis in another. The two remaining patients, those with corrected transposition of the great arteries, had complicated lesions including a single ventricle in one and small ventricular septal defect in the other.

Attempts at surgical correction were unsuccessful in all cases.
Congenital Mitral Insufficiency with Cleft Posterior Leaflet
Authors: CREECH OSCAR , LEDBETTER MARION K. , REEMTSMA KEITH
Published: June 2012

A case of congenital mitral insufficiency in a 2-year-old infant is reported. No other intracardiac defect was found, although pressure studies suggested an area of supravalvular aortic stenosis.

Diagnostic studies included combined right and left heart catheterization. Dye-dilution curves confirmed the presence of mitral insufficiency.

The anatomic defect, a cleft posterior leaflet of the mitral valve, was repaired by direct suture of the valve leaflet.

During 18 months of postoperative observation, the child has shown symptomatic improvement and decrease in the size of the left ventricle, although a systolic mitral murmur and left atrial enlargement persist. Residual insufficiency is probably due to short chordae that restrict mobility of the posterior leaflet.
Congenital Aortopulmonary Septal Defect
Authors: MORROW ANDREW G. , GREENFIELD LAZAR J. , BRAUNWALD EUGENE
Published: June 2012

The clinical, hemodynamic, and angiographic findings in six patients with aortopulmonary septal defect are described. A basal systolic murmur was present in each of the patients and in none was a continuous murmur audible or recordable. Five of the patients had experienced diminished cardiac reserve and at right heart catheterization a large left-to-right shunt and severe pulmonary hypertension were found. In the sixth patient the predominant circulatory shunt was right-to-left. The diagnosis was established preoperatively in all patients with the aid of indicator-dilution curves, injections of Kr
85
and selective angiography.

The defect was successfully divided and closed at open operation in the five patients with predominant left-to-right shunts. Two of them were operated upon with the aid of general hypothermia and three with cardiopulmonary bypass. Postoperatively all patients have been improved and the pulmonary artery pressure has fallen markedly. The clinical picture, hemodynamic findings, and surgical results in 65 previously reported patients are also summarized.
Patterns of Electrolyte Excretion in Edema Loss without the Use of Diuretics
Authors: AXELROD D. ROBERT
Published: June 2012

Sodium, potassium, chloride, and water losses were studied in patients while they lost all of their edema. The fluid which was excreted was hypotonic to body fluids, but did not change the osmotic concentration of the fluid that remained. Since the fluid excreted did not have the same composition as the edema fluid in the body, the interpretation of the results is that there is an internal redistribution and osmotic inactivation of a portion of the ions of the edema fluid of the body, and that the kidney is not the sole mechanism involved in the formation or loss of edema. Relating sodium loss to weight loss revealed two patterns; one group lost approximately 100 mEq. of sodium per kilogram of weight loss, and the other group lost less than 50 mEq. of sodium per kilogram. There is an indication that this difference is related to liver function.
Termination of Refractory Tachycardia by External Countershock
Authors: ZOLL PAUL M. , LINENTHAL ARTHUR J.
Published: June 2012

External electric countershock has been used to terminate refractory supraventricular and ventricular tachycardia and atrial fibrillation in eight patients. General anesthesia is necessary when the patient is conscious. This technic is indicated when the patient's condition is desperate or intolerable and drug therapy is ineffective, too slow, or otherwise inadvisable.
The Heart in Periarteritis Nodosa
Authors: HOLSINGER DONALD R. , OSMUNDSON PHILIP J. , EDWARDS JESSE E.
Published: June 2012

The records of 66 necropsied cases of periarteritis nodosa in which there was no associated collagen disease were reviewed with reference specifically to the heart.

Clinically, congestive heart failure and its manifestations were the most important cardiac findings. Congestive heart failure developed some time during the illness in 57 per cent of the patients, and 44 per cent died as a direct result of this cardiac condition. Myocardial infarction was diagnosed clinically in only three cases.

The electrocardiogram was abnormal in 35 of 41 cases but was diagnostic of left ventricular hypertrophy in only six cases and of acute myocardial infarction in only three cases; in the other cases the changes were of a nonspecific nature.

Pathologically, 41 of the 66 hearts had evidence of necrotizing arteritis of the coronary arteries; in 39 of these the arteritis had been acute, and in two it had healed. Forty-one of the 66 hearts exhibited myocardial infarcts. Evidence of acute pericarditis was found in 22 hearts; nine of these cases were attributed to uremia, one was due to transmural myocardial infarction, three could not be classified, and the remaining nine were attributed directly to the periarteritis nodosa. Forty-one of the 64 hearts that had been weighed were hypertrophied.
An Autopsy Study of Cerebrovascular Accident in Diabetes Mellitus
Authors: ALEX MORRIS , BARON ESTHER K. , GOLDENBERG SIDNEY , BLUMENTHAL H. T.
Published: June 2012

A two-part study has been presented dealing with a comparison of cerebrovascular accident (CVA) as between diabetic and nondiabetic subjects. In the first part it has been shown that the frequency of CVA is increased in diabetes. While cerebral hemorrhage occurs slightly more commonly in the nondiabetic group, cerebral infarction and focal encephalomalacia occur about 1.5 times more frequently in the diabetic group. In the second part a comparison has been made of the frequency of hemodynamic, inflammatory, atheromatous, thrombotic, and proliferative vascular disease between 75 cases of diabetes and 77 nondiabetic subjects. It has been shown that hemodynamic disease of small intraparenchymal cerebral vessels occurs more frequently in the diabetic group, but the increase is of essentially the same order of magnitude as the increase in the frequency of hypertension in diabetes. No significant difference between the two groups was found as regards the frequency of inflammatory, atheromatous, or thrombotic vascular disease. Proliferative lesions of small intraparenchymal cerebral vessels were present about 2.5 times more often in diabetes. The possible role of such lesions in accounting for the increase in the frequency of focal areas of encephalomalacia and in enhancing infarct formation when there is impairment of circulation in the larger cerebral arteries has been pointed out. A hypothesis, with some suggestive supporting evidence indicating that these proliferative lesions may be immunogenic in origin, has been discussed.
Determination of Fraction of Left Ventricular Volume Ejected per Beat and of Ventricular End-Diastolic and Residual Volumes
Authors: FOLSE ROLAND , BRAUNWALD EUGENE
Published: June 2012

A technic has been developed for determining the fraction of left ventricular end-diastolic volume that is ejected during each cardiac cycle. Radioiodinated Diodrast was rapidly injected into the left ventricle at the time of transseptal left heart catheterization and the fraction of isotope discharged from this chamber per beat was determined with a well-shielded scintillation probe placed on the chest wall over the left ventricle. Left ventricular end-diastolic volume was estimated from the stroke volume, determined by the dye-dilution method, and the fraction of isotope discharged per beat. Difficulties resulting from inadequate mixing of isotope in the left ventricle were minimized by this technic, since the probe detected indicator in the entire left ventricular cavity. The accuracy of this technic was first demonstrated in a circulatory model and then in open-chest dogs in which ventricular dimensions were continuously monitored by means of mercury-in-rubber gages. In 21 patients without detectable abnormalities of left ventricular function the fraction of left ventricular volume discharged averaged 37±8 per cent per beat and the end-diastolic volumes averaged 89±26 ml./M.
2
B.S.A. In 21 patients with heart failure or valvular regurgitation, or both, in whom left ventricular function was compromised, the fraction of left ventricular volume discharged into the aorta averaged 16±5 per cent per beat and the end-diastolic volumes averaged 209±75 ml./M.
2
B.S.A. This technic has been found to be sensitive to changes in left ventricular function and practical to apply routinely in the course of left heart catheterization.
Effect of Acetylcholine on the Pulmonary Circulation in Patients with Chronic Pulmonary Disease
Authors: CHARMS BERNARD L. , GIVERTZ BERNARD , TOSHIHIKO INOUE
Published: June 2012

Twenty-seven patients with various forms of chronic pulmonary disease have been studied with constant infusion of acetylcholine directly into the pulmonary artery.

Although many showed a slight decrease in pulmonary artery pressure, this was not great and those with the highest pressures showed the least response.

Pulmonary resistances showed similar small changes, if any.

Arterial oxygen saturations did not fall uniformly and in those with the lowest levels, an actual increase was observed.

It is suggested that vasomotor activity is only one of several factors determining pulmonary artery pressure in patients with chronic pulmonary disease and that anatomic or extravascular factors may become primary.

Vasomotor activity seems to be relatively unimportant in the regulation of ventilation/perfusion relationships in patients with far-advanced disease.
Preoperative Diagnosis and Surgical Correction of Supravalvular Mitral Stenosis and Ventricular Septal Defect
Authors: LYNCH M. F. , RYAN N. J. , WILLIAMS G. R. , CAYLER G. G. , RICHARDSON W. R. , CAMPBELL G. S. , TAYBI H.
Published: June 2012

A child with supravalvular mitral stenosis plus ventricular septal defect is reported in whom the correct diagnosis was suspected clinically, confirmed by cardiac catheterization, and successfully treated surgically. Only eight previous cases of supravalvular mitral stenosis have been reported; five of the eight have had associated ventricular septal defects. None was correctly diagnosed before autopsy or surgery.

Our patient had a murmur and thrill characteristic of a ventricular septal defect. The pertinent clinical findings suggesting concomitant mitral stenosis consisted of a mitral mid-diastolic murmur that was unusually loud for the magnitude of the left-to-right shunt; a presystolic component to the diastolic murmur; marked left atrial enlargement by x-ray with only moderate pulmonary plethora; and electrocardiographic evidence of left atrial hypertrophy and marked pure right ventricular hypertrophy. Right heart catheterization showed labile passive pulmonary hypertension. Left atrial puncture revealed high proximal and low distal pressure.

Surgical correction of both lesions by total cardiac bypass was accomplished through a midline sternal-splitting incision. The supravalvular mitral membrane was excised from the right atrium through an incision in the atrial septum.
Total Anomalous Pulmonary Venous Connection with Severe Pulmonary Venous Obstruction
Authors: HASTREITER ALOIS R. , PAUL MILTON H. , MOLTHAN MARIAN E. , MILLER ROBERT A.
Published: June 2012

The clinical, physiologic, and anatomic features of a special group of cases of total anomalous, pulmonary venous connection are reviewed.

The occurrence of severe pulmonary venous obstruction in total anomalous pulmonary venous connection produces a characteristic syndrome:

1. Very early onset of dyspnea and heart failure.

2. Considerably more cyanosis than the usual case without obstruction.

3. Typical x-ray showing diffuse hazy lung fields with reticulated appearance without cardiac enlargement.

4. Electrocardiographic evidence of severe right ventricular hypertrophy with a tall R or qR pattern in lead V
1
and reversal of the R/S ratio over the precordium.

5. Physiologic findings of practically normal pulmonary flow, right ventricular and pulmonary arterial pressures greater than systemic, and a marked gradient between the pulmonary arterial "wedge" and right atrial pressures.

6. Rapid deterioration and death in the first weeks or months of life.
Massive Infarction of Spinal Cord and Vertebral Bodies as a Complication of Dissecting Aneurysm of the Aorta
Authors: HILL C. STRATTON , VASQUEZ JESUS M.
Published: June 2012

A case of spinal cord and vertebral body necrosis as a complication of dissecting aneurysm of the aorta has been presented. Previous report of vertebral body necrosis complicating this entity could not be found. The incidence of intercostal and lumbar artery involvement in this condition is not known; a disparity appears between the incidence of involvement and necrosis of structures supplied by them. Factors believed to be important in assessing the significance of involvement of these vessels are mentioned. All cases of dissecting aneurysm in which there are neurologic signs should have thorough study of the spinal cord and vertebral bodies if they come to autopsy.
The Mode of Action and Use of Chlorothiazide and Related Compounds
Authors: LARAGH JOHN H.
Published: June 2012

Chlorothiazide acts to inhibit renal tubular reabsorption of electrolytes. Experimental data are presented which indicate that, under various conditions, anion reabsorption is depressed unselectively so that the pre-existing ratio (Cl/HCO
3
) is not changed during chlorothiazide diuresis. The data suggest that chlorothiazide acts primarily to block sodium ion reabsorption.

Chlorothiazide diuresis is potentiated experimentally by KHCO
3
and clinically by acetazoleamide, organomercurials, or spirolactone. The latter two can also operate to block the potassium wastage of chlorothiazide.

Increased potassium excretion caused by chlorothiazide is viewed as a consequence of the activity of the drug in blocking sodium reabsorption proximal to the site of potassium secretion. According to this concept, all chlorothiazide-type compounds will cause potassium depletion in proportion to their capacity to block proximal sodium reabsorption by diverting more sodium distally to the site of potassium secretion.

Unlike mercurial agents, chlorothiazide either depresser or does not change excretion of free water during a water diuresis. These data suggest that chlorothiazide acts both in the proximal and distal portions of the nephron, while mercurial agents may act largely in the proximal tubule.

The different mode of action of chlorothiazide on tubular reabsorption of electrolytes, as compared with other diuretic agents (acetazoleamide, organomercurials, spirolactone), affords evidence that a number of discrete tubular transport mechanisms participate in the regulation of electrolyte and water balance and provide a rational basis for combined use of various types of diuretic agents in treating edematous patients.

The nature of the antihypertensive action of chlorothiazide has not yet been elucidated. The effect may be related to electrolyte and fluid depletion, but evidence for a more direct action on the circulation is reviewed.

Other aspects of the pharmacology of chlorothiazide and its derivatives are considered, and the application of this information in treatment of states of edema or hypertension is discussed.
Clinical Diagnosis of Cardiac Involvement in Systemic Lupus Erythematosus
Authors: KONG THOMAS Q. , KELLUM ROBERT E. , HASERICK JOHN R.
Published: June 2012

A review was made of the case histories and autopsy reports of 30 patients with systemic lupus erythematosus who had clinical cardiovascular involvement. The presence of an enlarged heart or of gallop rhythm strongly suggests myocardial involvement, but the electrocardiogram is not specific. Signs and symptoms referable to the heart are unusual as a first manifestation of systemic lupus erythematosus, and in patients receiving suppressive chemotherapy they do not further worsen the prognosis. Systolic murmurs cannot be interpreted as conclusive evidence of Libman-Sacks valvulitis.
Cellular Infiltration of the Human Arterial Adventitia Associated with Atheromatous Plaques
Authors: SCHWARTZ C. J. , MITCHELL J. R. A.
Published: June 2012

Homogeneous collections of cells resembling small lymphocytes have been found in the adventitia of atheromatous arteries, and the prevalence and degree of cellular infiltration have been shown to correlate closely with the severity of the plaques. The cells are found in the aorta, coronary, iliac, and carotid arteries; but in the carotid arteries the infiltration is less marked. Arterial blocks containing recent thrombus show more cellular infiltration than blocks without thrombus and with recanalizing thrombus.

The location and significance of the adventitial cellular infiltration is unknown, but it may play a part in the etiology or pathogenesis of arterial plaques.
Endocardial Cushion Defect
Authors: SCOTT LEWIS P. , HAUCK ANNA J. , NADAS ALEXANDER S. , GROSS ROBERT E.
Published: June 2012

Preoperative and postoperative data on 44 patients with endocardial defect, 32 with the incomplete and 12 with the Complete form are presented. Nineteen per cent of the incomplete form died with per cent of the deaths occurring early and 9.5 per cent late. The mortality rate for the complete form was 75 per cent.

Late follow-up results were evaluated in 28 patients 1 to 2½ years following surgery. Catheterization data in nine of 10 and clinical observations in 18 indicated no residual shunt. One patient showed questionable evidence of a left-to-right shunt by cardiac catheterization. Evidence of mitral regurgitation was present in seven (25 per cent) of the survivors. Short chordae attaching the closed cleft margin of the mitral leaflet to the ventricular septum rendered the valve incompetent in nine of 12 autopsied specimens. Surgical exploration of the underside of the cleft margins for such chordae is recommended. No evidence of residual tricuspid regurgitation was found.
Pressor Responses to Noxious Stimuli in Hypertensive Patients
Authors: SHAPIRO ALVIN P.
Published: June 2012

The pressor and pulse rate responses to three standardized noxious stimuli were determined in groups of hypertensive patients receiving reserpine and chlorothiazide, alone and in combination. Although the drugs caused a significant decline in resting blood pressure, they failed to diminish the actual magnitude of the elevations in pressure and heart rate resulting from either physical or psychological stimuli. The possible physiological interpretations and the therapeutic implications of these data have been pointed out.
Congenital Saccular Aneurysms of the Aortic Ring
Authors: MACMAHON H. EDWARD , KELLER DIETER H.
Published: June 2012

Congenital saccular aneurysms arising in the area of the aortic ring are not common. They may be located deep in the aortic sinus, at the commissure of two adjacent cusps, or in the area involving the membranous portion of the interventricular septum. They may be found at any age. This report concerns a child 2 years of age with a relatively large saccular aneurysm of the aortic ring just at the site of the commissure between the right and noncoronary cusps of the aortic valve. Terminally, this anomaly was complicated by infection leading to vegetative and ulcerative endocarditis. Death was sudden and was apparently directly related to the complications of the deformity.