bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanisms of Pulsus Alternans
Authors: COHN KEITH E. , SANDLER HAROLD , HANCOCK E. W.
Published: June 2012

The mechanisms of pulsus alternans were studied in three patients by cineangiographic determinations of left ventricular volume. In two patients with left ventricular disease, pulsus alternans occurred without detectable variation in left ventricular enddiastolic pressure (LVEDP) or end-diastolic volume (EDV), although in the second case these values did alternate in the initial postextrasystolic beats. Another patient with normal left ventricular function had brief postextrasystolic pulsus alternans associated with LVEDV alternations. Twenty-nine patients with valvular aortic stenosis who showed pulsus alternans during left heart catheterization were also studied. Persistent alternation in LVEDP occurred in eight, with transient LVEDP alternation appearing after extrasystoles in 22 cases. Cardiac cycle length and diastolic interval alternation occurred inconsistently.
Raynaud's Disease in Children
Authors: GUNTHEROTH WARREN G. , MORGAN BEVERLY C. , HARBINSON JOHN A. , MULLINS GAY L.
Published: June 2012

Six children with primary Raynaud's disease have been studied with plethysmography and multiple-site skin-temperature readings. All six were free of systemic disease. Each demonstrated the characteristic sequence of pallor, cyanosis, and rubor when subjected to generalized cold, but application of local cold produced only modest reduction in skin temperature and digital pulse. Only one child had a history of vasospastic symptoms associated with emotional stimuli, and she was the only one in whom an emotional challenge was able to produce Raynaud's phenomenon during the physiological studies. Tolazoline, in doses small enough to avoid generalized vasodilatation, was effective in substantially increasing flow to the affected digits.

The involvement of only one or two digits, next to completely uninvolved digits, is a conclusive argument for a primarily local sensitivity. However, the ability to precipitate vasospasm with generalized cold, versus local cold applications, and emotional stimuli indicates the importance of the nervous system in the manifestation of Raynaud's disease.
Surgical Correction of Absence of Proximal Segment of Left Pulmonary Artery
Authors: GREEN GEORGE E. , REPPERT EDMUND H. , COHLAN SIDNEY Q. , SPENCER FRANK C.
Published: June 2012

In a 14-month-old patient who had been repeatedly hospitalized for recurrent pulmonary infections, cardiac angiography found "absence" of the left pulmonary artery, but thoracic aortography demonstrated that a rudimentary patent ductus filled a distal patent pulmonary artery. There was a coexistent vascular ring with a retroesophageal right subclavian artery.

At surgical exploration it was possible to mobilize the distal left pulmonary artery and perform a direct anastomosis between the left pulmonary artery and the main pulmonary artery. This is perhaps the first patient in whom such an operation has been performed. It is emphasized that the absence of a pulmonary artery on pulmonary angiography does not indicate that the entire pulmonary artery is absent. The presence of a patent and surgically reconstructable distal pulmonary artery can be determined only by aortography or possibly by surgical exploration.
Natural History of Congenital Heart Disease
Authors: HOFFMAN JULIEN I. E.
Published: June 2012

It is difficult to make prognoses and decisions on therapy of individuals with congenital heart disease (CHD) and plan efficiently for medical services and training programs because studies on the incidence and relative frequency of different types of CHD at birth, mortality rates, times of death, and prevalence rates in children and adults are incomplete or unrepresentative. The present study assesses the merits of previous surveys and attempts to indicate the best information about these rates.

Specific attention has been directed to data on ventricular septal defect (VSD), with an estimated incidence of at least 20/10,000 live births; about 10% of these children died before 15 years of age. There should thus be about 18/10,000 surviving school children with VSD, yet the most intensive school surveys show only about half this number. This supports the suggestion that there is a high incidence (perhaps 50%) of spontaneous closure of VSD during childhood. Spontaneous closure may also occur frequently after childhood, but this conclusion needs to be confirmed by better surveys.
Atrial Septal Defect in Patients over the Age of Forty Years
Authors: GAULT JAMES H. , MORROW ANDREW G. , GAY WILLIAM A. , ROSS JOHN
Published: June 2012

The fate of 62 patients with atrial septal defect (ASD) who were 40 years of age and older was analyzed in detail. All patients were studied hemodynamically, those who underwent operation were recatheterized postoperatively, and the subsequent clinical courses of the entire group were determined. Cardiorespiratory symptoms were reported by 94% of the patients; 45% were in functional class III or IV. Fifty-four patients had moderate or large left-to-right shunts; pulmonary arterial (PA) hypertension was present in 69% of these patients, and was severe in 28%. PA hypertension or a large left-to-right shunt, or both were found in all 28 patients in functional classes III and IV. Eight patients (13%) exhibited evidence of severe obliterative pulmonary vascular disease, with balanced or predominantly right-to-left shunting. Operative correction of the ASD was performed in 48 patients. The overall operative mortality of 12.5% was reduced to 6.5% in the 31 patients operated upon after 1961.

At the initial follow-up, which averaged 8 months postoperatively, 29 of 41 patients, including all those in classes III and IV, were improved by at least one functional class. No patient was worse, and only four of 20 patients in class II failed to benefit symptomatically. PA hypertension was abolished in 15 of 25 patients, and in the remainder an average reduction in systolic PA pressure of 20 mm Hg occurred. Symptomatic benefit has been sustained in all but three of 37 patients in whom late (average, 5 years) follow-up information after operation was obtained. It is concluded that operative treatment of ASD may be undertaken with a relatively low operative mortality in patients in the fifth decade, despite the presence of PA hypertension, large left-to-right shunt, or congestive heart failure, and that sustained clinical and hemodynamic benefit may be anticipated, even in patients with advanced symptomatic disability.
Some Aspects of the Biological Role of Adenosine 3',5'-monophosphate (Cyclic AMP)
Authors: SUTHERLAND EARL W. , ROBISON G. ALAN , BUTCHER REGINALD W.
Published: June 2012

Cyclic AMP (adenosine 3',5'-monophosphate or cyclic adenylate) has now been established as a second messenger mediating many of the effects of a variety of hormones. Several of the metabolic effects mediated by cyclic AMP are discussed, and it is suggested that certain other ("functional" or "mechanical") hormonal effects may be similarly mediated. In particular, the evidence presented supports the hypothesis that the positive inotropic response to the catecholamines is mediated by cyclic AMP. Although knowledge of the biological role of cyclic AMP has not been widely applied clinically, sufficient knowledge has now accumulated to make research in this area desirable.
Atrial Pressure-Flow Dynamics in Atrial Septal Defects (Secundum Type)
Authors: LEVIN AARON R. , SPACH MADISON S. , BOINEAU JOHN P. , CANENT RAMON V. , CAPP M. PAUL , JEWETT PAUL H.
Published: June 2012

This study was conducted to determine the instantaneous pressure-flow relationships across secundum atrial septal defects. Simultaneous right and left atrial pressures and the pressure difference (determined with an analog computer) were recorded with matched catheter systems. Biplane cineangiocardiography was used to evaluate the timing of the shunts in various phases of the cardiac cycle.

These studies indicated that the major left-to-right shunt and pressure gradient occurred over an interval encompassing late ventricular systole and early diastole. Also, there was augmentation of the left-to-right shunt during atrial contraction. Minute right-to-left shunting and pressure gradients occurred at two times in the cardiac cycle: (1) with the onset of ventricular contraction; and (2) during early ventricular diastole (heart rate, 80 to 100 beats/min). Detection of systemic right-to-left shunts by dye curves was enhanced by relatively slow heart rates (prolonged diastasis) which allowed the shunted blood to flow into the left venrticle. The effects of respiration during phasic changes in intrathoracic pressure resulted in an increasing left-to-right gradient during periods of increasing intrathoracic pressure and a fall in the left-to-right gradient across the defect during periods of decreasing intrathoracic pressure.
Effects of Atrial Fibrillation on Exercise Performance in Patients with Cardiac Disease
Authors: HORNSTEN TOM R. , BRUCE ROBERT A.
Published: June 2012

Cardiac performance in 25 male and 40 female cardiac patients with atrial fibrillation was compared with that of age, sex, and function-matched controls with sinus rhythm. All had rheumatic valvular heart disease treated with digitalis. Multistage maximal exercise was tested on a motor-driven treadmill with increasing work loads every 3 minutes to the limits of fatigue.

Mean heart rates of patients with atrial fibrillation were greater at rest, at all levels of exercise, and immediately after it regardless of sex or anatomic lesion; however, recovery heart rate was significantly higher in the males than in the females with sinus rhythm.

As is true for normals, mean duration and intensity of exercise was greater in male than in female cardiac patients regardless of rhythm or anatomic lesion.
Reduced Protamine Dosage for Heparin Neutralization in Open-Heart Operations
Authors: BERGER ROBERT L. , RAMASWAMY KRISHNASWAMY , RYAN THOMAS J.
Published: June 2012

Two comparable groups of open-heart patients were given 0.79 and 1.37 mg of protamine for neutralization of exogenous heparin. The influence of protamine dosage on postoperative bleeding was then evaluated. The lower protamine dosage was associated with a more rapid neutralization of heparin, reduced postoperative blood loss, and a reduced incidence of exploratory thoracotomy for excessive bleeding.
Replacement of Left Ventricular Myocardium
Authors: COLLINS HAROLD A. , COLLINS ISABELLA S.
Published: June 2012

The feasibility of resection and prosthetic replacement of left ventricular myocardium as a therapeutic adjuvant in myocardial infarction was assessed in a series of 72 dogs. Intracardiac pressures and cardiac output were measured in each dog several days preoperatively. During temporary cardiopulmonary bypass a large segment of the anterolateral wall of the left ventricle was excised. The defect was closed with either Teflon felt, woven Teflon cloth, or a pedicled diaphragmatic flap. Cardiac outputs and intracardiac pressures were measured immediately before and for several hours after myocardial replacement. Survivors were evaluated for periods up to three years by cardiac catheterization at appropriate intervals and pathological observation.

Forty-four dogs survived longer than 24 hours. The immediate hemodynamic consequences of myocardial replacement were a diminished systemic arterial pressure and a low, fixed cardiac output. The arterial pressure and cardiac output gradually increased over a period of weeks, occasionally attaining preoperative levels. Left ventricular end-diastolic pressures were always within normal limits.

The most common cause of death in the first two postoperative weeks was graft detachment. Observations of healing characteristics revealed Teflon felt to be the most satisfactory prosthesis. The diaphragmatic flap frequently necrosed, and woven Teflon produced intraventricular thrombus and incomplete healing.

This study demonstrated the feasibility of resection and prosthetic replacement of large segments of left ventricular myocardium. Complications of the procedure were related to a temporarily diminished cardiac output and inadequate healing of the prosthesis to myocardium.
Rational Approach to the Surgical Management of Tricuspid Atresia
Authors: GLENN WILLIAM W. L. , GARDNER THOMAS H. , TALNER NORMAN S. , STANSEL HORACE C. , MATANO ICHIRO
Published: June 2012

A rational approach to the surgical management of tricuspid atresia with diminished blood flow to the lungs is as follows: A cava-pulmonary artery shunt is performed as the initial operation whenever possible. In the newborn infant and in patients where the pulmonary artery is less than one-half the diameter of the superior vena cava where the two vessels cross, the right pulmonary artery is anastomosed end-to-side to the ascending aorta. Subsequently, when the right pulmonary artery has enlarged, it is detached from the aorta and anastomosed to the superior vena cava.

Closure of the outflow from the right ventricle to the left lung can be expected in tricuspid atresia after the first year of life, and unless the ductus remains patent, a systemic artery-pulmonary artery shunt on the left side will be required to supplement the cava-pulmonary artery shunt. This shunt will also be required as a preliminary step to replacing the ascending aorta-right pulmonary artery shunt with a cava-right pulmonary artery shunt if blood flow to the left lung is by bronchial collateral arteries only.

Banding of the pulmonary artery is indicated in those patients with excessive blood flow to the lungs.

In the present series of 19 patients with tricuspid atresia, there were 17 with diminished flow to the lungs and two with excessive flow.

Eight patients with small pulmonary arteries had a shunt made between the ascending aorta and right pulmonary artery. Five patients were less than two weeks of age. All survived operation; one died a year postoperatively of unknown causes. Two shunts have been replaced with cava-pulmonary artery shunts.

Ten patients had a shunt made between the superior vena cava and the right pulmonary artery one to eight years ago. There has been no operative or late mortality. A supplemental systemic artery-pulmonary artery shunt on the left side has been established in three patients. Two patients have had operative enlargement of the interatrial communication.

Excessive blood flow to the lungs was present in two patients. Neither patient survived banding of the pulmonary artery.
Left Ventricular Function in Children Studied by Increasing Peripheral Resistance with Angiotensin
Authors: KROVETZ L. JEROME , MCLOUGHLIN THOMAS G. , SCHIEBLER GEROLD L.
Published: June 2012

Response to angiotensin infusion was evaluated in 11 normal children and 24 patients with suspected left ventricular dysfunction. This included 12 patients with endocardial fibroelastosis, three with idiopathic myocardial hypertrophy, one with cardiac glycogenosis, and eight with the Hunter-Hurler syndrome. In 20 of these 24 patients, cardiac catheterization findings confirmed the clinical suspicion of decreased left ventricular function. In 11 instances left ventricular dysfunction was diagnosed by an elevation of resting left ventricular end-diastolic pressure. In eight instances this was ascertained by a decrease in resting left ventricular stroke work when compared to the expected range, derived by using a linear regression formula based on 24 normal subjects. In only four instances were both abnormal; that is, the resting left ventricular stroke work was decreased and the left ventricular end-diastolic pressure was increased. In five of these 20 patients, abnormal left ventricular function was elicited only on infusion of angiotensin. Thus this test is a significant adjunct in our ability to determine myocardial malfunction at cardiac catheterization.
Alterations in Regional Pulmonary Blood Flow in Patients with Congenital Heart Disease Studied by Radioisotope Scanning
Authors: FRIEDMAN WILLIAM F. , BRAUNWALD EUGENE , MORROW ANDREW G.
Published: June 2012

External scintillation scanning of intravenously administered
131
I-labeled macro-aggregates of human serum albumin (
131
I-MAA) was employed to evaluate the distribution of pulmonary arterial blood flow in 61 normal subjects and in 100 patients with various congenital cardiovascular malformations. Intra-aortic administration of
131
I-MAA demonstrated that blood flow through subclavian-pulmonary artery anastomoses is directed principally to the lung on the side of the anastomosis; the relative concentration of
131
I-MAA in each lung after intravenous injection provided an index of the patency of the anastomosis or of the development of pulmonary atresia or pulmonary hypertension. In contrast to the findings in patients with a patent subclavian-pulmonary shunt, scans obtained from patients with a patent ductus arteriosus did not reveal a separation of the systemic arterial and systemic venous inflows to the lungs. The patency of superior vena caval-right pulmonary arterial anastomosis could be assessed after injection of
131
I-MAA into an upper-extremity vein.

Anomalies characterized by increased pulmonary blood flow or elevated pulmonary arterial pressures, or both, increased the ratio of pulmonary blood flow in the lung apices relative to that in the dependent lung zones. Anomalies characterized by elevated pulmonary venous pressure, such as cor triatriatum and mitral regurgitation, were readily detected by demonstrating both a decrease in blood flow to the lung bases as well as an increase to the apices. Thus, in patients with known pulmonary arterial hypertension (mean pressure, >30 mm Hg) the ratio of upper to lower zone blood flow was always significantly higher if the arterial hypertension was accompanied by venous hypertension. For this reason, lung scans facilitated the screening of patients with pulmonary arterial hypertension for surgically correctable lesions such as cor triatriatum and mitral stenosis.

The method described is technically simple, without risk, easily applicable to large numbers of patients, and provides clinically important information concerning many forms of congenital heart disease.
Idiopathic Hypertrophic Subaortic Stenosis
Authors: FRANK STUART , BRAUNWALD EUGENE
Published: June 2012

While considerable information concerning the hemodynamic and angiographic features of idiopathic hypertrophic subaortic stenosis (IHSS) is available, data concerning the natural history of the disease are limited. The clinical courses of 126 patients with hemodynamically documented IHSS, examined repeatedly for up to 12 years, were analyzed. The older patients tended to be more severely symptomatic. Although the course was extremely variable, the patients who were asymptomatic initially tended to remain so, while those who were more disabled generally deteriorated, died, or improved spontaneously. Bacterial endocarditis occurred in three patients. Ten patients died as a consequence of the natural history of IHSS; six of these deaths were unexpected. Sudden deaths occurred usually in patients with no or mild obstruction, and in patients with both the familial and sporadic forms of the disease. Atrial fibrillation was observed in 8% of the patients, and abnormalities of atrioventricular conduction, in 30%. Absence of voltage criteria for left ventricular hypertrophy occurred more frequently in asymptomatic patients, those with mild obstruction, and those with familial IHSS. Pulmonary hypertension occurred in one third of the patients, and was associated with considerable clinical disability. Obstruction to right ventricular outflow occurred in eight patients (15%), two of whom had no associated obstruction to left ventricular outflow.
Effects of Five Per Cent Dextrose-Water Infusions in Normal and Hypertensive Man
Authors: CANNON PAUL J.
Published: June 2012

During infusions of 5% dextrose in water urinary sodium excretion and the renal tubular rejection of filtered sodium (E/F Na %) were significantly higher in hypertensive than in normotensive subjects. Increased E/F Na % did not result from alterations in plasma sodium, in filtered sodium, or from an osmotic diuresis.

Fractional sodium reabsorption in proximal (isosmotic) portions of the nephron was diminished in the hypertensive patients. Free water formation (C

H
H2
o

rose with increased "distal" sodium delivery (V) in both groups; however, fractional sodium reabsorption in the "distal" nephron was significantly impaired in the hypertensive patients and urinary osmolality was increased.

Mean arterial blood pressure and E/F Na % were related in curvilinear fashion in the 31 studies, and there was a direct relation between E/F Na % and the magnitude of renal vascular resistance. The data suggested that alterations of renal arterial pressure and vascular resistance in hypertensive disease modify sodium transport in proximal and diluting segments of the nephron and determine to a major extent the increased natriuresis exhibited by hypertensive subjects during infusions that expand extracellular fluid volume.
Patterns of Anomalous Pulmonary Venous Drainage
Authors: SNELLEN H. A. , INGEN H. C. , HOEFSMIT E. CH. M.
Published: June 2012

All of our cases of abnormal pulmonary venous connections collected to the middle of 1965 and verified at surgery or autopsy have been reviewed by means of diagrams and tabulations, using a specially devised code to facilitate the survey. The material consisted of 52 autopsy cases (half of them obtained after surgery) and the cases of 72 patients who survived operation. The postmortem group was much younger than the surgical group and differed also from the latter by showing male preponderance as well as relatively many instances of total abnormal pulmonary venous connection and frequently associated cardiac anomalies.

Partial anomalous connection of right pulmonary veins was 10 times more frequent than that of the left pulmonary veins. This was caused by (1) the frequent drainage of some of the right pulmonary veins into the junctional area between right atrium and superior vena cava in the presence of normal left pulmonary veins, and (2) the complete absence of isolated left pulmonary venous connection to the right atrium. Abnormal connection of solitary pulmonary veins was always effected to the most proximal venous structure among the four possible ones which are derived from the main embryonic channels (superior vena cava and inferior vena cava on the right side, and left superior vena cava and coronary sinus on the left side). Common pulmonary veins from one lung also drained in accordance with this proximity rule, if this may be taken to apply also to the drainage of right pulmonary veins into the right atrium. The one exception in our material was the drainage of all right pulmonary veins into the portal venous system. Total abnormal pulmonary venous connection may be found with all structures mentioned, but most frequently with the left superior vena cava, or coronary sinus, or both, usually by way of a common pulmonary vein. In a few cases however, drainage into different sites, all of them abnormal, did occur. Then again the proximity rule seemed to apply.

A tentative embryological explanation is given for the patterns described.
Effect of the Thyroid State on Myocardial Contractility and Ventricular Ejection Rate in Man
Authors: AMIDI MORTEZA , LEON DONALD F. , DEGROOT WILLIAM J. , KROETZ FRANK W. , LEONARD JAMES J.
Published: June 2012

Although the circulatory changes in various thyroid states are well known, the alterations of myocardial contractility of hypothyroidism and hyperthyroidism have remained controversial. The changes in the length of the ejection time (ET) and isovolumic contraction time (ICT) are used as indicative of alterations in inotropic state of the myocardium. Isovolumic contraction time, ejection time, and pre-ejection period were measured externally in 10 normal, 13 hyperthyroid, and five hypothyroid subjects. Cardiac outputs, mean rate of left ventricular ejection index, and predicted ejection times were calculated. More shortening of ICT and ET in hyperthyroid and more prolongation of these intervals in hypothyroid subjects than could be attributed to other factors were interpreted as indicative of increased and decreased myocardial contractility, respectively. Catecholamine depletion in hyperthyroid subjects with adequate administration of intramuscular reserpine induced no changes in cardiac output and oxygen consumption and caused no alteration in different phases of ventricular systole; consequently it had no effect on enhancement of hyperthyroid myocardial contractility.
Hemodynamic Studies in Patients with Borderline Blood Pressure Elevation
Authors: JULIUS STEVO , CONWAY JAMES
Published: June 2012

Ninety-four patients with occasionally elevated (borderline) blood pressure, 61 patients with asymptomatic established hypertension, and 63 normal subjects have been studied at rest and during a progressive exercise test on a cycle ergometer. Subjects with borderline blood pressure had increased cardiac output in the resting recumbent position, but this was not maintained in the sitting position or during exercise. In the resting recumbent position there was overlap in the total peripheral resistance of normal subjects and patients with borderline blood pressure, but when analyzed in relation to the cardiac output, the total peripheral resistance of patients with borderline blood pressure was significantly elevated. In the sitting position the peripheral resistance of the patients with borderline blood pressure was elevated and remained elevated during light exercise, but fell into the normal range at higher loads. In this respect patients with borderline blood pressure differed from hypertensive patients who maintain a higher peripheral resistance than the normal subjects do at all levels of exercise. In conclusion, patients with occasional elevation of blood pressure have an abnormal peripheral resistance in relation to cardiac output both at rest and at low levels of exercise. This observation may indicate a prehypertensive state.
Supraventricular Tachycardia with Left Aberrant Conduction due to Retrograde Invasion into the Left Bundle Branch
Authors: WELLENS H. J. J. , DURRER D.
Published: June 2012

A description is given of a patient with an atrioventricular nodal tachycardia with left aberrant conduction changing into nonaberrant conduction after a ventricular premature beat. Functional left bundle-branch block by retrograde invasion into the left bundle branch is thought to be responsible for this phenomenon.
Vocational and Emotional Status of 263 Patients After Heart Surgery
Authors: BLACHLY P. H. , BLACHLY B. J.
Published: June 2012

The vocational and emotional status of 263 patients following heart surgery was sampled with a questionnaire mailed to 329 patients thought to be living. Return to work was most clearly related to the duration of unemployment. Age and sex did not influence rate of return to work. The kind of operation had a small but definite influence. A "Law of the Year" stating that if a person is unemployed for more than a year for any reason, the chance of reemployment is poor is proposed. From one third to one half of the patients complained that their "nerves were worse" postoperatively. The number complaining of worsening exceeded those improving by two to five times and was directly related to the type of operation.

Most pleasant recollection of the surgical experience was the dedicated attitude of doctors and staff. There was wide diversity of opinion about most unpleasant experiences, but complaints about environmental conditions in the recovery room, noise, unpleasant roommates, and insufficient visitors were minimal.

Establishment of a cardiac reconditioning program is recommended, since 41% felt unable to work.
Diminished Glucose Tolerance and Immunoreactive Insulin Response in Patients with Nonischemic Cardiac Disease
Authors: ETTINGER PHILIP O. , OLDEWURTEL HENRY A. , WEISSE ALLEN B. , REGAN TIMOTHY J. , Weber Marilyn A.
Published: June 2012

Intravenous infusion of glucose in patients with compensated nonischemic cardiovascular disease has demonstrated that the glucose disappearance slope, G
K
, is significantly lower than in normal subjects. Immunoassay of plasma insulin in 13 of these cardiac patients showed a reduced insulin response to hyperglycemia in the majority. All had a delayed decline of plasma insulin values.

Plasma free fatty acids (FFA) were significantly elevated in the fasting state but were not significantly correlated with the reduced G
K
. During the acute hyperglycemia, plasma free fatty acid, potassium, and inorganic phosphate concentrations declined as in the normal subjects. Although cardiac index was reduced in most patients, a linear correlation with G
K
was not obtained.

To examine the possible role of enhanced sympathetic stimulation seen in cardiac patients, norepinephrine was infused into normal subjects during a glucose-tolerance test (GTT). A decline in glucose tolerance and plasma insulin was observed to levels approximating those seen in the cardiac patients, suggesting a neurohumoral mechanism for the glucose intolerance in cardiac patients. It would therefore appear that the glucose intolerance in compensated cardiac subjects with a reduced cardiac output is frequently an acquired rather than a genetically determined metabolic disorder.
Abnormalities of the Digital Vasculature as Related to Ulceration and Gangrene
Authors: CONRAD MARGARET C.
Published: June 2012

Plastic casts were made of digital vessels of 13 extremities amputated for severe atherosclerosis obliterans. Prior to amputation, blood flow averaged 0.02 cc/min/5 cc of digit (normal, 0.5), and digital systolic pressure average 16 mm Hg. There were more occlusions of terminal arteries (<30 µ in diameter) in the first and fifth toes than in the third toes and on the plantar and proximal dorsal surfaces than in the nail bed; this observation suggests relationship to local trauma and shoe pressures. Occlusion was most severe in 30 to 50 µ arteries, decreased with increasing vessel size, and was greater in uninvolved areas of ulcerated toes than in nonulcerated toes. Occluded arteries smaller than the digital artery terminated abruptly; this observation suggests stasis thrombosis; occlusions did not occur preferentially at sites of branchings. In occluded digital arteries, areas of partial occlusion lay adjacent to complete block, reflecting plaque formation. At the rim of an ulcer crater all vessels terminated abruptly which suggests destruction of vasculature secondary to necrosis. The findings suggest the following sequence of events: (1) marked reduction in pressure and flow due to proximal disease, (2) resultant stasis thrombosis accentuated by shoe pressures and local trauma, and (3) death of tissue in ischemic digits leading to further loss of vasculature in the necrotic area.
Subintimal Dissection of the Coronary Arteries
Authors: HAAS JOHN M. , PETERSON CHARLES R. , JONES ROBERT C.
Published: June 2012

Selective coronary arteriography is now the procedure of choice in the determination of the existence and the delineation of the extent of chronic obstructive coronary artery disease. Since Sones and Shirey's original description of this technique, variations in the procedure and the approach have evolved. More recently, the percutaneous transfemoral artery approach to selective coronary arteriography has gained increasing favor because of the ease of intubation of both coronary arteries, stability of the catheter once positioned in the coronary ostium, and the high quality of cinefluorography and direct serial radiography.

Because of the tapered-tip design and positrol feature, the depth to which the coronary artery can be cannulated, and the angle formed by the tip of the catheter and the intima of the vessel, the possibility of subintimal dissection of the coronary arteries as an inherent complication of this approach arises.

Two such cases of subintimal dissection of the left coronary artery are described with cinefluorographic documentation.

It is recommended that after cannulation of the coronary vessels the catheter be withdrawn several millimeters from the lumen of the vessel in order to avoid this complication of an otherwise valuable diagnostic approach to selective coronary arteriography.
Variations of Aberrant Ventricular Conduction in Man: Evidence of Isolated and Combined Block Within the Specialized Conduction System
Authors: COHEN STAFFORD I. , LAU SUN H. , STEIN EMANUEL , YOUNG MELVIN W. , DAMATO ANTHONY N.
Published: June 2012

Aberrant ventricular conduction (AbC) was produced in 52 subjects, including 14 normal volunteers, by the introduction of atrial premature beats through a transvenous catheter electrode. Simultaneous standard electrocardiograms and vectorcardiogams permitted detailed analysis of configuration. Multiple patterns of AbC were produced in 29 of 52 subjects. The general categories and their frequency were as follows: right bundle-branch block without significant axis shift from control, 31; right bundle-branch block with left axis deviation, 27; left axis deviation, 14; inferior axis deviation, six; right bundle-branch block with inferior axis deviation, seven; and complete left bundle-branch block, six. These patterns were believed to depend on the location of isolated or combined functional block in the major pathways of the specialized conduction system, which include the right bundle branch, common left bundle branch, anterior division of the left bundle branch, and posterior division of the left bundle branch. The present study has documented the general varieties of AbC, their relevance to clinical cardiology, and the varieties most likely to cause diagnostic difficulty.
Certain Clinical Characteristics Correlated with Extent of Obstructive Lesions Demonstrated by Selective Cine-Coronary Arteriography
Authors: PROUDFIT WILLIAM L. , SHIREY EARL K. , SHELDON WILLIAM C. , SONES F. MASON
Published: June 2012

The duration of the history of angina pectoris, the distribution of the pain, the factors precipitating the pain, and serum cholesterol levels in the men less than the age of 40 years were studied in a group of 337 patients who had angina pectoris. Also the number of obstructed coronary arteries in 588 patients with severe obstruction in a larger study group of which the 337 patients were a part was compared with the number in men less than 40 years of age with severe lesions. The distribution of coronary arterial obstructions shown by selective cine-coronary arteriography was determined in relation to the clinical characteristics mentioned, and they were found to be of little predictive value. In most patients who had congestive heart failure occurring in the absence of recognized complications, multiple severe arterial obstructions were found. Division of patients who have anginal syndrome into groups on the basis of duration of history cannot clarify the natural history of symptomatic obstructive coronary arterial disease.
Morphological Studies in Tricuspid Atresia
Authors: GULLER BARBARA , TITUS JACK L.
Published: June 2012

Fourteen hearts with tricuspid atresia were reviewed at autopsy. The study included examples of normally related great arteries and of transposition of the great arteries; instances of pulmonary stenosis were present in both groups. In these examples of tricuspid atresia the size of the right ventricle depended on the size of the ventricular septal defect. The ventricular septal defect and the right ventricle usually were smaller in proportion to the size of the heart in specimens with normally related great arteries. In the absence of transposition of the great arteries, the ventricular septal defect was found to be the site of obstruction to pulmonary flow, and its size in relation to the size of the aorta determined the size of the pulmonary artery. Morphologic abnormalities exist in the region in which the proximal portions of the major atrioventricular conduction system (A-V node, bundle of His, origin of bundle branches) normally are located; thus, anatomic abnormalities in the course of the atrioventricular conduction tissue could be expected in tricuspid atresia. Based on histologic evidence, severe elevation of pulmonary vascular resistance, in general, does not occur in infancy in tricuspid atresia.
Control of Recurrent Tachycardia of Wolff-Parkinson-White Syndrome by Surgical Ligature of the A-V Bundle
Authors: DREIFUS LEONARD S. , NICHOLS HENRY , MORSE DRYDEN , WATANABE YOSHIO , TRUEX RAYMOND
Published: June 2012

In a patient with WPW, type A, pharmacological therapy and radioactive iodine failed to control the disabling, life-threatening arrhythmia. Surgical ligation of the A-V bundle was undertaken in view of the rapidly deteriorating clinical course. Failure to identify A-V block after several sutures were placed in the A-V junction and subsequent activation of the ventricles in a heart with known A-V block demonstrates that the accessory A-V bundles may completely activate the ventricles. Complete elimination of the recurrent tachycardias after A-V ligation suggests that the normal A-V transmission system may be a crucial link in the circus pathway of WPW tachycardia.
Cigarette Smoking
Authors: JENKINS C. DAVID , ROSENMAN RAY H. , ZYZANSKI STEPHEN J.
Published: June 2012

The association of the incidence of coronary heart disease (CHD) with smoking habits was studied for 4½ years in over 3,000 healthy, employed men, aged 39 to 59 years, at intake into a prospective, epidemiological investigation. The risk of CHD was significantly associated both with current and former cigarette usage. More specifically, this association was found to prevail in men suffering symptomatic and fatal myocardial infarction but not in men sustaining silent myocardial infarction or angina pectoris only and was much stronger in younger than in older age groups. Altered risk of CHD was not found in pipe or cigar smokers.

Cigarette habits at intake were associated with differences in serum lipids and other risk variables, but when the latter were controlled statistically, the smoking-CHD associations remained.

The cigarette-CHD relationship was studied further in men with and without the coronary-prone behavior pattern (type A). In the younger age decade the increased risk of CHD associated with moderate and heavy cigarette smoking occurred primarily in men with the type A behavior pattern.
Interrelationships of Hyperinsulinism and Hypertriglyceridemia in Young Patients with Coronary Heart Disease
Authors: TZAGOURNIS MANUEL , CHILES ROSS , RYAN JOSEPH M. , SKILLMAN THOMAS G.
Published: June 2012

Fasting serum lipid levels, glucose tolerance, and immunoreactive insulin concentrations of 50 young patients with coronary heart disease (CHD) and 30 control subjects were evaluated to study the interrelationships of these metabolic factors. Abnormalities in one or more of these factors could be shown in 90% of the patients and 20% of the control subjects. Thirty-four of the 50 patients had elevated cholesterol or triglyceride levels, or both, 30 had abnormally elevated or delayed insulin responses after glucose, and 17 had abnormal glucose tolerance. A significant correlation existed between serum triglyceride and insulin concentrations. When insulin levels were reduced by phenformin, triglyceride concentrations fell toward normal.

These findings indicate that carbohydrate, insulin, and lipid abnormalities are rather prevalent in patients with CHD. Excessive insulin secretion secondary to mild glucose intolerance probably induces hepatic synthesis of triglycerides and hypertriglyceridemia. Dietary alterations or pharmacological agents may help to control some of the metabolic abnormalities associated with premature CHD.
Atherosclerosis
Authors: PAGE IRVINE H.
Published: June 2012

The effectiveness of the research endeavor in atherogenesis is searchingly considered because neither how to prevent nor how to cure atherosclerosis is known, and there is no decision about what atherosclerosis looks like.

In the overview one of the most serious problems is failure to see the whole problem. Systematic marshalling of detail is vital; yet there must be a longer look. The first broad suggestion is to curtail the divisive trends, view the blood vessels and heart as a whole, and declare unabashedly in favor of atherosclerosis as the prime interest no matter where it appears or under what guise. The time has come when those who study atherosclerosis and myocardial infarction should rethink their approach. Research excellence is the ability to select the few experiments most likely to get at the heart of the matter. An important question is, If the experiment is successful, will it contribute to the solution of the problems of atherogenesis?

There is urgent need to reduce the amount of repetitive, almost trivial, investigation and to seek more creative approaches. Several problems are suggested as examples: the neural component, the atherogenic mosaic, and the inextricable association of atherosclerosis with myocardial infarction. Even such sacrosanct rights as how to do research are briefly considered. This all constitutes an apologia of the author's own failures in this pressingly important field.
Acute Metabolic Responses to Myocardial Infarction
Authors: LEBOVITZ HAROLD E. , SHULTZ KIRKWOOD T. , MATTHEWS MINOR E. , SCHEELE RICHARD
Published: June 2012

Glucose utilization and secretion of insulin and growth hormone after intravenous administration of glucose were measured during the evolution of myocardial infarctions. Two patterns of responses were found. Patients who developed myocardial infarction with either no prior cardiovascular disease or stable coronary artery disease had depressed glucose utilization for the first 48 hours and exhibited a hyperinsulinemic response to glucose during the sixth to fourteenth day; and, about 50% of them, had an increase in the secretion of growth hormone during the initial 4 days of the infarction. Patients who had had progressively increasing angina in the 7 to 14 days preceding infarction showed a different pattern. No initial depression of glucose utilization was found. Their hyperinsulinemic response occurred within the first 96 hours of the occlusion. Growth hormone secretion was increased in 83% of the patients during the first 96 hours. The data suggest the possibility that the exaggerated insulin secretion may be associated with myocardial repair processes while the changes in growth hormone secretion may be related to the acute stress or necrosis of the infarction.
Congenital Heart Disease in Taiwan, Republic of China
Authors: SHANN MARY K. M.
Published: June 2012

A review of 5 years' experience with congenital heart disease in National Taiwan University Hospital, Taipei, Taiwan, Republic of China, shows that congenital aortic valvar and supravalvar stenosis are not seen and the incidence of coarctation is very low. Statistics on congenital heart disease as reported in studies on all groups of patients from several other Asian countries were collected and compared with those from European and North American countries. The low incidence for the two mentioned congenital cardiac defects in the reports from Asian countries is probably not due to chance, but may represent a true difference in incidence. In the discussion of etiological factors possibly responsible for the low incidence of coarctation and aortic stenosis, it is postulated that dietary factors may be responsible for the observed differences in incidence.
A Study of Heart Block in Man Using His Bundle Recordings
Authors: DAMATO ANTHONY N. , LAU SUN H. , HELFANT RICHARD , STEIN EMANUEL , PATTON ROBERT D. , SCHERLAG BENJAMIN J. , BERKOWITZ WALTER D.
Published: June 2012

The technique of recording His bundle electrograms in man by a tripolar electrode catheter was applied in a study of patients with first, second, and third-degree heart block. In all patients with first-degree heart block (congenital, acquired, or induced by atrial pacing), the delay in A-V conduction occurred proximal to the His bundle as evidenced by a prolonged P-H interval. The enhancement of A-V conduction (shortening the P-H interval) due to isoproterenol was qualitatively similar in the three forms of first-degree block. In cases of Wenckebach phenomenon the P-H interval progressively increased until a dropped beat occurred. The nonconducted P wave was not followed by a His deflection, indicating block proximal to the His bundle. Cases of 2:1 and 3:1 block occurring proximal to the His bundle were also studied. The usefulness of His-bundle recordings in the diagnosis of cases of complete and incomplete bilateral bundle-branch block is also demonstrated.
Sequential Cardiorespiratory Events During and After Dextran-4O Infusion in Normal and Shock Patients
Authors: MOHR PATRICIA A. , MONSON DAVID O. , OWCZARSKI CYNTHIA , SHOEMAKER WILLIAM C.
Published: June 2012

Sequential measurements of cardiac output, intravascular pressures, blood gases, pH, blood volume, and oxygen consumption were made in normal subjects and patients in shock before, during, and after infusions of dextran-40. In eight normal subjects the responses were: increased central venous pressure, increased cardiac index, decreased peripheral resistance, and decreased hemoglobin concentrations. These changes were of short duration and were attributed largely to increased plasma volume from the infusion.

Nineteen of 26 patients in shock responded to administration of dextran-40 with increased central venous pressure, cardiac index, plasma volume, and central blood volume, as well as decreased mean transit time and total peripheral resistance. Lesser increases in blood pressure, stroke index, and left ventricular stroke work were observed. The increase in cardiac index was preceded by increased central venous pressure and decreased peripheral resistance. The hemodynamic changes were more marked and of longer duration than those of the normal subjects. In addition to these hemodynamic changes, dextran increased oxygen consumption in all but one of the patients whose major problem was hemorrhage and trauma. Increased oxygen consumption suggests that tissue perfusion improved after dextran possibly because of increased small vessel flow as well as increased plasma volume.

In patients who were in shock because of sepsis, no change in oxygen consumption was observed despite hemodynamic improvement. As in the normal subjects, these hemodynamic changes were attributable to plasma expansion.

In seven patients, dextran increased central venous pressure without improving cardiac index or other hemodynamic parameters. It is suggested that these patients were functioning with limited cardiac reserve.
Overweight and Hypertension
Authors: CHIANG BENJAMIN N. , PERLMAN LAWRENCE V. , EPSTEIN FREDERICK H.
Published: June 2012

The interrelationships between hypertension and obesity, two common and major health hazards, are reviewed. Comparisons of simultaneous intra-arterial and cuff blood pressure measurements indicate in general that the association between blood pressure and body weight is real and independent of arm circumference. Hypertension is more common among the obese than among the nonobese and, conversely, a significant proportion of hypertensive persons in the population are overweight. Obese hypertensive subjects experience a greater risk of coronary heart disease than the nonobese, and mortality rates for obese hypertensive persons are higher than for those with obesity alone or hypertension alone. Weight reduction has been shown to lower blood pressure, and it may bring about a more favorable prognosis in obese hypertensive persons. Possible mechanisms that may be responsible for the frequent association between obesity and hypertension have been discussed. Irrespective of the underlying pathophysiologic mechanisms, the adverse metabolic and hemodynamic effects of obesity upon hypertension impose an extra burden and strain on the circulatory system and compromise its functional adequacy. Although it is not precisely known to what extent weight reduction alone may be effective in controlling or preventing the lesser degrees of hypertension, the control of obesity should be an intrinsic part of any therapeutic or preventive antihypertensive regimen.