bluuebunny/crossref_metadata_2025 huggingface dataset:
Electrocardiographic Evidence of Left Atrial Hypertension in Acute Myocardial Infarction
Authors: CHANDRARATNA PREMINDRA A.N. , HODGES MORRISON
Published: June 2012

The relationship between mean left atrial pressure (LA
m
) and P-wave abnormalities in lead V
1
of standard 12-lead electrocardiograms was evaluated in 30 patients with acute myocardial infarction. In each patient pulmonary artery diastolic pressure or pulmonary wedge pressure was measured, and these values were used as an estimate of LA
m
. Electrocardiograms recorded at the time of the pressure measurements were used for P-wave analysis. Patients with a history of hypertension were excluded from analysis. There was a significant correlation between the magnitude of the P terminal force in lead V
1
(PTF-V
1
) and the estimated LA
m
(r = –0.78,
P
< 0.001). Sixteen patients had a normal PTF-V
1
on admission; 11 of them had a normal LA
m
. All 14 patients with an abnormal PTF-V
1
(more negative than –0.03 mm-sec) on admission had an elevated LA
m
(>12 mm Hg). Thus, in 25 of the 30 patients, the PTF-V
1
correctly identified whether the LA
m
was normal or abnormal on admission. On subsequent days, simultaneous measurements of PTF-V
1
and estimated LA
m
were made in 27 of the patients. Significant changes occurred in both PTF-V
1
and LA
m
; discordant changes were observed on only seven of 56 occasions. Measurement of PTF-V
1
appears to be a useful and reliable estimate of left ventricular filling pressure in patients with acute myocardial infarction.
Congenital Polyvalvular Disease
Authors: BHARATI SAROJA , LEV MAURICE
Published: June 2012

Thirty-six hearts were studied in which all valves were involved in a dysplastic process. This consisted of an increase in spongiosa with vacuolar and lacunar degeneration, and a distinct lack of elastic tissue in the proximalis and in the spongiosa. This process was similar to, but more marked than that seen in a case of a single dysplastic valve as in bicuspid aortic valve. It was completely different than that seen in hemodynamic change. These cases clinically were often associated with trisomy 18 or trisomy 13-15, and called congenital polyvalvular disease. This disease may bear some relationship to Marfan's disease and the "floppy valve".
Lung Changes in Left Heart Failure
Authors: MESZAROS WILLIAM T.
Published: June 2012

The lung changes in left heart failure are grouped into four main categories or stages: (1) pulmonary congestion, (2) interstitial edema, (3) alveolar edema, and (4) miscellaneous findings. Some patients, particularly those with mitral stenosis, develop these changes gradually, passing successively through the stages of pulmonary congestion → interstitial edema → alveolar edema. Other patients, particularly those with hypertension or myocardial infarction, often develop rapid left heart failure and tend to show alveolar edema. The roentgen diagnosis of incipient or early heart failure is important since pulmonary auscultatory findings may be minimal or absent.
Temporal Relation of the First Heart Sound to Closure of the Mitral Valve
Authors: LANIADO SHLOMO , YELLIN EDWARD L. , MILLER HYMAN , FRATER ROBERT W. M.
Published: June 2012

The objective of this study is to describe the mechanism of production of the first heart sound (S
1
). The temporal relation between the major components of S
1
and (1) cessation of flow across the mitral valve, (2) closure of the valve, and (3) time of peak rate of rise of left ventricular pressure (peak LV dP/dt), were investigated in open-chest dogs. Phasic flow across the mitral valve was recorded by a supraannular electromagnetic flow probe, and timing of valve closure was determined by synchronized cinefluorogram of the motion of the valve cusps after they were made radio opaque. Closure of the mitral valve did not occur at the crossing point of atrial and ventricular pressures (at the beginning of systole), but 20-40 msec later due to inertia of mitral flow. The first major component of the first sound coincided with two simultaneous events: cessation of mitral flow and closure of the valve. It did not show a fixed temporal relationship to time of peak dP/dt.
Hemodynamic Abnormalities in Response to Mild and Intense Upright Exercise following Operative Correction of an Atrial Septal Defect or Tetralogy of Fallot
Authors: EPSTEIN STEPHEN E. , BEISER G. DAVID , GOLDSTEIN ROBERT E. , ROSING DOUGLAS R. , REDWOOD DAVID R. , MORROW ANDREW G.
Published: June 2012

Patients are often asymptomatic after operative correction of an atrial septal defect (ASD) or tetralogy of Fallot (TF). However, the maximal functional capacity of their hearts relative to that of normal subjects has not been defined. Twelve asymptomatic patients who had ASDs closed and 10 asymptomatic patients who had total correction of tetralogy of Fallot were evaluated by catheterization studies at rest and during mild and intense treadmill exercise. Except for small right ventricular outflow gradients in the tetralogy of Fallot group (2-21 mm Hg), data recorded at rest were normal or nearly so in each subject. However, at a level of upright exercise sufficiently intense to lower pulmonary arterial oxygen saturation to 30%, cardiac output was below that attained by normal subjects (mean, 8.9 ± 0.3 liters/min/m
2
) in seven of 12 ASD patients (mean, 6.6 ± 0.6 liters/min/m
2
) and in eight of 10 tetralogy of Fallot patients (mean, 6.1 ± 0.3 liters/min/m
2
). Right ventricular (RV) outflow gradients, measured during upright exercise in six TF patients, increased in each; RV systolic pressures reached levels of 75-106 mm Hg in four of the six patients studied. No outflow gradients were observed in the ASD group. Thus, patients with operative closure of an ASD and normal hemodynamic findings at rest may have impairment of their cardiac output response to intense upright exercise in the absence of residual shunts, arrhythmias, or pulmonary arterial hypertension. Although the cardiac output response in patients with corrected tetralogy of Fallot is consistently reduced, it is remarkably good considering the complicated nature of their defect and operative repair; however, the RV outflow gradient and RV systolic pressure may increase markedly with exercise. The longterm significance of these findings remains to be determined.
Aneurysmlike Formations in Relation to Membranous Ventricular Septum
Authors: TANDON RAJENDRA , EDWARDS JESSE E.
Published: June 2012

A left ventriculogram may show an aneurysmal protrusion toward the right ventricle in the subaortic area with or without an associated interventricular communication. The pathologic basis for such a finding is variable.

It may well represent an aneurysm of the membranous ventricular septum which may be congenital or acquired. Either variety has the potential of rupturing into the right ventricle. The acquired aneurysms are usually mycotic.

An aneurysm resulting from adhesion of the septal leaflet of the tricuspid valve to the rim of a membranous ventricular septal defect and causing complete or incomplete closure may also yield an aneurysmal formation.

Pouches of the tricuspid valve resulting from excessive tissue, in association with a ventricular septal defect, can also be misinterpreted as an aneurysm of the membranous septum or as incomplete closure of a ventricular septal defect with aneurysm formation.

In some cases, even at pathologic examination, the exact nature is difficult to identify. Separation of a true aneurysm of the membranous septum with adherent tricuspid valve from a spontaneously closed ventricular septal defect with aneurysmlike protrusion in the septal leaflet may not be possible.
Artificial Pacemakers
Authors: WRIGHT KINSMAN E. , MCINTOSH HENRY D.
Published: June 2012

The development of artificial pacemakers for the electrical control of the cardiac rhythm has greatly enhanced the physician's ability to treat cardiac dysrhythmias. Pacemakers have been useful in treating Stokes-Adams syndrome and symptomatic bradyeardias; they have helped control the occurrence of tachyarrhythmias and have played an important role in the management of arrhythmias accompanying myocardial infarctions. With their more frequent use, pacemakers have contributed to our knowledge of underlying conduction and natural pacemaker disorders. As new indications for artificial pacemaking have been elucidated, more complex pulse generators have been developed, and newer technics found for their insertion. In spite of recent development the pulse generators in general use have a limited useful lifetime.

This paper reviews the indications for pacemaker insertion that are commonly employed. In addition, an approach to the problem of pulse generator replacement is presented.
Changes in Maximal Exercise Performance in the Evaluation of Saphenous Vein Bypass Surgery
Authors: LAPIN EUGENE S. , MURRAY JOHN A. , BRUCE ROBERT A. , WINTERSCHEID LOREN
Published: June 2012

To evaluate the improvement in myocardial oxygen delivery following saphenous vein graft surgery (SVG) for angina pectoris (AP), 46 patients underwent a multistage treadmill test of maximal exercise capacity before and 3-22 (average 8) months after SVG. Variables from exercise testing were correlated with symptomatic response, left ventricular hemodynamics, and graft patency.

Functional capacity (NYHA) improved in 38 (85%), while 27 (59%) had a significant improvement in exercise performance. Functional aerobic impairment (FAI), or the percentage deviation from expected V

O
O2

max
, improved by a mean of 16% (
P
< 0.001). Maximal systolic pressure-rate product/100 increased 36 (
P
< 0.002). Twenty of 29 (66%) with presurgical S-T segment depression had a normal response after surgery.

Thirty-three patients were studied for graft patency and had quantitative angiography. Seventeen had all grafts patent and demonstrated a mean improvement of 21% in FAI (
P
< 0.0007). Those with occluded grafts showed no improvement in exercise performance. Sixteen of 22 (73%) with severe exercise impairment showed significant improvement, but only four of 14 (29%) with mild impairment showed a significant improvement. There were no mean changes in left ventricular end-diastolic pressure, cardiac index, contraction plot, or systolic ejection fraction (SEF) in any of the patients. Preoperatively nine had a depressed SEF (<50%), and no improvement in exercise performance could be demonstrated.

Maximal treadmill testing has demonstrated objectively that SVG can improve functional capacity and that it is correlated with graft patency. Ideal surgical candidates appear to be those with severe exercise impairment and unimpaired ventricular performance.
Long-Term Use of Procaine Amide following Acute Myocardial Infarction
Authors: KOSOWSKY BERNARD D. , TAYLOR JACK , LOWN BERNARD , RITCHIE ROBERT F.
Published: June 2012

The safety of long-term prophylactic antiarrhythmic therapy with procaine amide was studied in 78 patients recovering from acute myocardial infarction. Patients were randomly allocated to a control or treatment group and followed monthly for up to 2 years with ambulatory ECG monitoring and measurement of serum drug level, antinuclear antibody (ANA) titer, LE preparation, blood count, BUN, and SGOT. Early reactions forced discontinuation of therapy in nine of 39 treated patients within the first 3 weeks. Late reactions were observed in 14 of 16 patients who took procaine amide for 3 months or longer. Every patient on therapy for 1 year or longer demonstrated elevation in ANA titer. Comparison of monitoring data between these two groups revealed no difference in the incidence of occasional or frequent premature ventricular beats. However, during the first 6 months, treated patients tended to have fewer major arrhythmias. There were fewer sudden deaths among treated patients, but this difference did not reach statistical significance at the 5% level. It is concluded that the high incidence of toxic reactions precludes widespread use of long-term prophylactic procaine amide therapy. More precise identification of a sudden death-prone population might justify such therapy in such selected cases.
Effects of Cardiac Surgery with Extracorporeal Circulation on Intellectual Function in Children
Authors: WHITMAN VICTOR , DROTAR DENNIS , LAMBERT SALLY , VANHEECKEREN DANIEL W. , BORKAT GORDON , ANKENEY JAY , LIEBMAN JEROME
Published: June 2012

The effect of extracorporeal circulation during open heart surgery on changes in intellectual function was studied in 18 children. A group of patients undergoing such surgery was compared to a control group undergoing cardiac surgery without extracorporeal circulation. The Wechsler Intelligence Scale for Children was used to evaluate the patients. No significant differences were found in either the performance IQs, verbal IQs, or full scale IQs by comparing the postoperative scores to the preoperative scores either within each group or between the groups. Extracorporeal circulation during open heart surgery does not appear to alter intellectual functioning in the pediatric age group.
Angiographic Appraisal of Distal Vessel Suitability for Aortocoronary Bypass Graft Surgery
Authors: RÖSCH JOSEF , DOTTER CHARLES T. , ANTONOVIC RUZA , BONCHEK LAWRENCE , STARR ALBERT
Published: June 2012

The accuracy of preoperative coronary arteriography in determining distal vessel operability was evaluated in 166 patients studied arteriographically before and after bypass surgery. Appraisal accuracy correlated closely with the type of distal vessel filling, being highest (97%) in poststenotic vessels with antegrade filling; lower (76%) beyond occlusions with generous retrograde collateral flow; and least (65%) in postocclusion vessels filled by insufficient collaterals. Optimum data collection is favored by the use of high-definition serial roentgenography with extended filming in multiple projections; competent interpretation requires the integrated assessment of interdependent variables, including distal vessel morphology, filling patterns, branch disease, run-off capacity, and myocardial status.
His Bundle Electrocardiography during Bidirectional Tachycardia
Authors: MORRIS STEPHEN N. , ZIPES DOUGLAS P.
Published: June 2012

His bundle electrocardiography in a patient with a digitalis-induced bidirectional tachycardia revealed absence of His spike preceding earliest onset of ventricular activation during the bidirectional tachycardia. However, His potential preceded ventricular activation of normal complexes at a constant H-V interval of 35 msec. The presence of fusion QRS complexes, capture QRS complexes, the analysis of cycle lengths, and response to carotid sinus massage all favor a ventricular origin for this tachycardia in the patient presented.
The Effect of Exercise on Intrinsic Myocardial Performance
Authors: WINTERS WILLIAM G. , LEAMAN DAVID M. , ANDERSON RICHARD A.
Published: June 2012

Systolic time intervals were performed on 49 male subjects. Twenty-eight subjects were inactive with respect to a continuing exercise program and were classified as a sedentary group. Twenty-one subjects were physically active and were classified as an active group. The active group was composed of 12 members who were moderately active and nine members of a college track team. Using analysis of covariance no significant difference was found in the total duration of electromechanical systole (QS
2
), left ventricular ejection time (LVET), or the preejection period (PEP) between the moderately active subgroup and the members of the track team. However, a highly significant difference was found between the sedentary and the active group in the QS
2
and PEP. The LVET was not significantly different.

The results of this study appear to be consistent with the hypothesis that an increase in intrinsic myocardial performance is associated with physical conditioning. In addition, it is suggested that published equations for the QS
2
interval and the PEP may be applicable only to sedentary individuals.
Progression of Coronary Arterial Disease After Aortocoronary Bypass Grafts
Authors: BOURASSA MARTIAL G. , GOULET CLAUDE , LESPÉRANCE JACQUES
Published: June 2012

Coronary angiography was carried out pre- and postoperatively, and angiographic patency of vein grafts was assessed two weeks and one year after surgery in 105 patients (154 grafts). Proximal coronary artery stenoses progressed to occlusion in 12 of 13 grafts (92%), occluded after two weeks, in 6 of 15 grafts (40%) occluded after one year, and in 34 of 59 grafts (58%) patent after one year. Nine of 103 patent grafts (8%) showed progression of lesions in vessels distal to the graft. Twelve patients (13%) showed progression of atherosclerosis in other (nongrafted) vessels. These factors significantly influence the late clinical and hemodynamic results of surgery and must be considered in the postoperative assessment of patients.
Infective Endocarditis in Drug Addicts
Authors: GRAHAM DAVID Y. , REUL GEORGE J. , MARTIN RUSSELL , MORTON JEREMY , KENNEDY JOHN H.
Published: June 2012

Isolated tricuspid valvular endocarditis is no longer rare, and its increasing incidence has paralleled the rise in heroin addiction. In the period between December, 1969 and December, 1971, 16 episodes of bacterial endocarditis occurred in 13 individual drug abusers at the Ben Taub General Hospital, Houston. The tricuspid valve (TV) was involved in all cases. Two patients required surgery during the acute infection; one underwent total excision of the TV without replacement, and one received aortic and TV prostheses because of progressive heart failure. Antibiotic therapy was individualized and guided by tube dilution sensitivities and serum bactericidal levels. In view of the excellent response to antibiotic therapy, surgery for infected prosthetic or natural valves is presently reserved for those patients with progressive cardiac failure or infections unresponsive to medical therapy.
Experience with the Björk-Shiley Prosthetic Valve
Authors: LEPLEY DERWARD , REUBEN CHARLES F. , FLEMMA ROBERT J. , HUSTON JOHN H. , MANLEY JOHN C. , HOFFMAN JAMES F. , TECTOR ALFRED J.
Published: June 2012

One hundred and eighty-nine patients who had valvular replacement with 213 Björk-Shiley prosthetic heart valves are presented who are 6 months to 2½ years postoperative. Surgical mortality was 2.6% in mitral valve replacement and 8.8% in aortic valve replacement. The late mortality for the entire series was 2.9%. Four patients had episodes of embolization, all from mitral prostheses. Only two incidences of paraprosthetic leaks were noted in patients with mitral valves, and none in patients with valves in the aortic position. The authors believe this prosthesis to be superior in its hemodynamic characteristics and wear durability, with few late complications.
Computer-Based Analysis of Preoperative and Postoperative Prognostic Factors in 100 Patients with Combined Aortic and Mitral Valve Replacement
Authors: MELVIN DAVID B. , TECKLENBERG PAUL L. , HOLLINGSWORTH JEFFERSON F. , LEVINE FREDERICK H. , GLANCY D. LUKE , EPSTEIN STEPHEN E. , MORROW ANDREW G.
Published: June 2012

From 1963 to 1971, aortic and mitral valves were replaced in 100 patients; 22 died in hospital. Follow-up in survivors is 100%. Catheterization was performed preoperatively in 99 patients and postoperatively in 85% of survivors. The influence of 19 preoperative potential risk factors on hospital mortality, postoperative symptomatic improvement, and long-term survival (assessed by monthly cohort-adjusted survival tables) was determined. Long-term survival was also assessed by comparing average values of the various risk factors in patients surviving 1, 2, and 3 years with values in patients who died during these intervals. In addition, changes induced by operation were studied 6 months postoperatively and their value in predicting subsequent longevity assessed.

Significant (
P
< 0.05) findings were: a higher hospital mortality in patients with left atrial pressures ≥30 mm Hg or with fabric-covered valves; less postoperative symptomatic improvement in older patients; lower long-term survival rate in men and in patients with high left atrial, right atrial, pulmonary arterial, or right ventricular end-diastolic pressures. A decrease in radiographic heart size or a New York Heart Association class I or II status 6 months postoperatively was associated with a favorable subsequent prognosis. Postoperative hemodynamic values did not predict subsequent survival.
Postoperative Hemodynamic Evaluation of a New Fabric-Covered Ball-Valve Prosthesis
Authors: O'ROURKE ROBERT A. , PETERSON KIRK L. , BRAUNWALD NINA S.
Published: June 2012

Previous in vitro and in vivo experimental studies have indicated that insertion of the Braun-wald-Cutter fabric-covered ball-valve prosthesis results in negligible thromboembolic complications and hemodynamic performance comparable to that of noncovered mitral and aortic ball-valve prostheses. To assess the clinical efficacy of this fabric-covered valve prosthesis, 35 patients have been followed for 4 to 26 months (540 patient-months) after mitral and/or aortic valve replacement, and 13 have had extensive hemodynamic re-evaluation.

In eight patients with the mitral valve prosthesis, the mean diastolic gradient averaged 4.8 mm Hg (range 0 to 8) and the end-diastolic gradient 0.8 mm Hg (range 0 to 2) at a time when the mean heart rate was 75 beats/min (range 50 to 100) and the cardiac output averaged 5.1 L/min (range 3.4 to 8.0). The calculated effective mitral valve orifice size averaged 2.68 cm
2
(range 1.92 to 3.46). In six patients with the aortic valve prosthesis, the average peak systolic gradient was 13 mm Hg (range 0 to 22), and the mean systolic gradient averaged 14.5 mm Hg (range 0 to 24) when the mean heart rate was 82 beats/min (range 64 to 120) and the cardiac output averaged 6.2 L/min (range 3.2 to 9.3). The average effective aortic valve size in the five patients with a mean systolic transvalvular gradient was 1.41 cm
2
(range 1.26 to 1.62).

Only one postoperative thromboembolic complication has been observed, and this occurred in a patient with atrial fibrillation and a large left atrium three weeks after discontinuing anticoagulant therapy because of gingival bleeding.

These data indicate that use of the fabric-covered Braunwald-Cutter ball prosthesis produces few thromboembolic complications and a satisfactory hemodynamic result.
Serial Hemodynamics During Intra-aortic Balloon Counterpulsation for Cardiogenic Shock
Authors: DILLEY RALPH B. , ROSS JOHN , BERNSTEIN EUGENE F.
Published: June 2012

The use of intra-aortic balloon counterpulsation (IABC) has achieved some success in the treatment of cardiogenic shock, but there has been little objective documentation of the serial hemodynamic effects of counterpulsation in man. Six patients who satisfied strict criteria for refractory cardiogenic shock were treated with IABC. The following determinations were made serially: systemic blood pressure (BP), pulmonary artery pressures (PAP), pulmonary artery wedge pressure (PAW), cardiac index (CI), stroke volume index (SVI), and A-VO
2
difference. The average duration of balloon assist was 5.8 days (range 1.5 to 21 days). There was immediate improvement in all patients in that pressors could be maintained at lower levels. Although mean systolic BP did not change significantly from control values, augmented diastolic BP was maintained between 112 and 120 mm Hg. Initially, there were significant decreases in mean PAP (–13.4 mm Hg,
P
< 0.02), mean PAW (–10 mm Hg,
P
< 0.01), and A-VO
2
difference (–2.12 ml/100 ml) and increases in CI (+ 1.02 L/min/m
2
,
P
< 0.05). The improvement in diastolic BP, CI, and A-VO
2
difference persisted in each patient, but mean PAP increased from 22.6 to 32.3 mm Hg (
P
< 0.05) and mean PAW from 14.4 to 22 mm Hg (
P
< 0.05) by the fourth day of IABC. We conclude that IABC causes marked immediate improvement in hemodynamic variables and that prolonged survival is possible. However, progressive elevation of mean PAP and PAW, reflecting deterioration of left ventricular function, occurs and can prohibit a successful outcome with IABC alone.
ST-Segment Elevation in Acute Myocardial Infarction
Authors: NIELSEN BENT LYAGER
Published: June 2012

Four hundred and four patients who were admitted to the hospital with their first myocardial infarction within 24 hours of the onset of symptoms were studied. In 315 patients the ECG findings in 12 standards leads (I, II, aVF, aVR, aVL, V
1
-V
6
) showed the infarction to be in the anterior wall, the inferior wall, or in multiple areas. The patients in each of these three categories were further subdivided into two groups according to the magnitude of the ST-elevation; those with major ST-elevation and those with minor ST-elevation. Occurrence of the risk factors of diabetes, hypertension, hyperlipidemias, age, and complicating chronic pulmonary and renal diseases were comparable, but since women predominated in one group (anterior wall infarction/ minor ST-elevation) the clinical course of the disease in men and women was studied separately. The patients with major ST-elevation had a more unfavorable course: cardiac arrest (
P
< 0.0005), congestive heart failure (
P
< 0.0005), death (
P
< 0.001), atrial fibrillation (
P
< 0.005), cardiogenic shock (
P
< 0.005), atrioventricular (A-V) block 2°-3° (
P
< 0.01), and ventricular extrasystoles and ventricular tachycardia (
P
< 0.025) all occurred with significant frequency. The magnitude of ST-elevation thus gives valuable prognostic information, useful in selecting patients for prolonged monitoring.
Prosthetic Valve Endocarditis
Authors: DISMUKES WILLIAM E. , KARCHMER ADOLF W. , BUCKLEY MORTIMER J. , AUSTEN W. GERALD , SWARTZ MORTON N.
Published: June 2012

In 38 cases of prosthetic valve endocarditis, 19 were
early
cases (onset ≦ 60 days after insertion of prosthesis) and 19,
late
cases (onset ≧ 60 days). Nine
late
cases had onsets 12 to 53 months after surgery. The sources or predisposing factors in
late
cases included dental disease or manipulation; genitourinary tract procedures; and skin, urinary, or wound infections. In contrast, most
early
cases were secondary to complications of operation. Streptococci were the most common organisms causing
late
endocarditis, whereas staphylococci were most common among
early
cases. Four of the six patients who survived
early
onset were treated with antibiotics alone; the others, with antibiotics plus reoperation. In contrast, seven of the 11
late
cases that survived were treated with antibiotics alone; the other four, with antibiotics plus reoperation. The lower mortality (42% vs 68%) in the
late
group probably reflects the less virulent infecting organisms and the better clinical condition of the hosts. Regardless of whether prosthetic valve endocarditis occurs
early
or
late
, intensive and prolonged administration of appropriate antibiotics together with aggressive surgical reintervention in selected situations appears necessary for cure. Any patient who has a prosthetic valve and undergoes any procedure likely to produce bacteremia should receive antibiotic prophylaxis in an attempt to prevent
late
endocarditis.
Depression of Myocardial Contractility with Low Doses of Ethanol in Normal Man
Authors: AHMED S. SULTAN , LEVINSON GILBERT E. , REGAN TIMOTHY J.
Published: June 2012

Depression of myocardial contractility after ethanol ingestion in man has previously been shown only in patients with heart disease. In the present study, normal subjects, aged 23-30 years, ingested six ounces of 43% alcohol over a two hour period (Group I, 6 subjects) or a one hour period (Group II, 5 subjects). Systolic time intervals were measured every 15 min from simultaneous ECG, phonocardiogram and carotid pulse tracings. Heart rate, total electromechanical systole and left ventricular ejection time (LVET) were not changed at any time from pre-alcohol values and, except for a small (5 mm Hg) and transient change in diastolic pressure in Group II, aortic pressures also were unchanged. However, in Group I, after 60 min, at a blood ethanol of 74 ± 3 mg%, left ventricular depression was manifested by increased pre-ejection period (PEP) from 90 ± 2 to 96 ± 3.1 msec, isovolumic time (IVT) from 44 ± 3.5 to 52 ± 4 (
P
< .01), and PEP/LVET ratio from 0.299 ± 0.009 to 0.323 ± 0.01 (
P
< .05). Further depression occurred at two hours with blood ethanol at 111 ± 6 mg%. Doubling ingestion rate (Group II) produced reduction of left ventricular performance at 30 min at a blood level of 50 ± 3 mg%. Feeding of isocaloric sucrose in 5 subjects (Group III) as a control produced a decrease in PEP, IVT, and PEP/LVET. Thus, alcohol in nonintoxicating doses elicits a depression of cardiovascular function in normal unhabituated subjects.
Natural History of Tetralogy of Fallot in Infancy
Authors: BONCHEK LAWRENCE I. , STARR ALBERT , SUNDERLAND CECILLE O. , MENASHE VICTOR D.
Published: June 2012

We employ a classification system for tetralogy (TF) that correlates clinical findings with the nature and severity of right ventricular (RV) outflow obstruction. Group 0 infants are acyanotic, Group 1 and 2 infants have intermittent or mild cyanosis with hypoxic spells, Group 3 infants have severe cyanosis without spells, and Group 4 infants have severe cyanosis and pulmonary artery (PA) hypoplasia without spells. Since 1964, 59 infants were identified as having TF, documented by catheterization. Contrary to previous reports, the
majority
(40 of 59) were acyanotic (Group 0) at birth. Cyanosis and hypoxic spells subsequently developed at mean ages of 6.1 and 13.4 mo respectively, due to increasing muscular infundibular hypertrophy, as well as fibrosis and growth failure of the RV outflow tract, due to diminished pulmonary blood flow. At catheterization (mean age 12.7 mo) only two were still in Group 0. An understanding of the progressive nature of TF suggests that infants in groups 1-3 can have total correction before significant undergrowth of the RV outflow tract occurs. Shunts are performed only in Group 4 infants. Twenty-eight infants from ten weeks to two years old had total correction. Five were under six months. There were two operative deaths (7%) and no late deaths. Heart block did not occur. Late hemodynamic studies in 17 patients reveal good relief of RV obstruction (mean RV-PA gradient 19 mm Hg) and no significant shunts. The natural history of TF in infancy can be successfully interrupted in most cases by early correction.
The Spectrum of Transposition of the Great Arteries
Authors: GOOR DANIEL A. , EDWARDS JESSE E.
Published: June 2012

One hundred and sixty five cases of various types of transposition complexes were studied. Based on this and on recent studies of the embryology of the conotruncus, the following observations were made. Regardless of their relations with the ventricles, the semilunar valves may show
d
-transposition or
l
-transposition. In the situs solitus heart, the
d
-type of semilunar transposition is found in the bulboventricular heart, double outlet right ventricle type II, Taussig-Bing malformation, complete transposition of the great arteries, and double outlet left ventricle. This type of transposition of the great arteries results from lack of conotruncal inversion and the differences between the various entities are manifestations of varying degrees of leftward shift of the conoventricular junction and conal absorption. In
l
-transposition, the conotruncus rotates in the wrong direction. This may occur as an isolated process as in anatomic corrected transposition of the great arteries or with
l
-looping as in physiologic corrected transposition. Conal absorption and conoventricular shift account for the various entities in each of these two groups of
l
-transposition. It is proposed that the term transposition of the great arteries should refer only to the mutual interrelationships of the semilunar valves regardless of their ventricular origin.
Comparative Evaluation of Sublingual Long-Acting Nitrates
Authors: KLAUS ANDREW P. , ZARET BARRY L. , PITT BERTRAM L. , ROSS RICHARD S.
Published: June 2012

Ten hospitalized patients performed two exercise tests per day on five consecutive days to determine the efficacy and duration of action of three sublingual long-acting nitrate preparations: isosorbide dinitrate, pentaerythritol trinitrate, and erythrityl tetranitrate. The duration of exercise to the point of ischemia, manifest as typical anginal pain and/or 1.0 mm ST-segment depression, was determined 45 min and 100 min after each long-acting nitrate was administered.

These results were compared with the duration of exercise after placebo and two minutes after nitroglycerin administration. The mean durations of exercise in two tests after placebo were 62.5 sec and 58.4 sec (not significant) and the mean durations of exercise after nitroglycerin administration were 90.5 sec and 88.4 sec, both different from placebo (
P
< .001). There was no difference from placebo found 55 min after taking nitroglycerin. The mean durations of exercise 45 min after erythrityl tetranitrate, isosorbide dinitrate and pentaerythritol trinitrate were 89.1, 87.5, and 87.5 sec respectively and all were different from placebo (
P
< .01). Mean durations of exercise 100 min after erythrityl tetranitrate, isosorbide dinitrate, and pentaerythritol trinitrate were 76.4, 75.5, and 69.7 sec and none were significantly different from placebo.

This study indicates that each long-acting nitrate is effective for at least 45 min and suggests that they should not be given on a fixed dosage schedule but rather should be taken prophylactically whenever an angina-provoking situation is anticipated.
Diagnostic Electrocardiographic Sequences in Acute Pericarditis
Authors: SPODICK DAVID H.
Published: June 2012

Diagnostic electrocardiographic patterns were analyzed in 50 consecutive patients who had unequivocal clinical evidence of acute pericarditis. Distributions of P and QRS, and of P-R segment, ST-segment and T wave changes were plotted by lead and by mean frontal vector (Â). Transient gross deviations of P-R segments, mainly in Stages 1 and/or 2, occurred in 41 patients (82%) and could produce an optical illusion of ST elevations when the J-points were actually on the baseline. Â P-R was close to 180° opposite to Â P and was not related to P wave or heart rate changes. In Stage 1, Â ST tended to be concordant with Â QRS and Â T. T wave inversions in Stage 3 produced an Â T which was distributed over an arc of 210° with no range of predilection.

Transient increase in magnitude of a normally oriented PR vector was consistent with the subepicardial atrial injury of acute pericarditis. It is the analogue of the classic Stage 1 ST-segment abnormalities of subepicardial ventricular injury and was equally as widespread in the electorcardiogram and almost as prevalent. P-R segment deviations were always depressions for leads of "epicardial" patterns. ST-segment deviations departed from the classic elevation pattern in 10 patients: 7 patients in whom ST was depressed in Lead III, 5 of whom had a horizontal QRS axis; and 3 patients in whom ST was depressed in aVL, two of whom had a vertical QRS axis. In Stage 3, the much wider range for Â T as compared with the relatively concentrated early injury vectors, Â P-R and Â ST, is ascribed to greater inhomogeneity of post-injury ventricular repolarization.
The Complications of Coronary Arteriography
Authors: ADAMS DOUGLASS F. , FRASER DAVID B. , ABRAMS HERBERT L.
Published: June 2012

A nationwide survey was undertaken to determine the rate of complications due to coronary arteriography during 1970-71. The responses from 173 hospitals-including a total of 46,904 coronary arteriograms-were analyzed in relationship to the technique employed and to the number of examinations performed at each hospital during the two-year period. The overall mortality rate was 0.45% (brachial 0.13%, femoral 0.78%). The mortality rate in institutions performing fewer than 200 examinations per two years was eight times higher than in institutions performing more than 800 examinations per two years. Similarly, the incidence of myocardial infarction and cerebral embolism was significantly higher when a smaller number of examinations was performed. The incidence of major complications-including death, myocardial infarction, and cerebral embolism-was higher in examinations using the femoral approach than the brachial approach. The incidence of arterial thrombosis and contrast agent reactions was higher for the brachial approach. Factors which may help to explain these differences are considered and discussed.
Ischemic Polarcardiographic Changes Induced By Exercise
Authors: DOWER GORDON E. , BRUCE ROBERT A. , POOL JAN , SIMOONS MAARTEN L. , NIEDERBERGER MANFRED W. , MEILINK LAURA J.
Published: June 2012

The polarcardiographic responses to exercise in normal men, young and middle-aged, have been compared with those of men who show ischemic responses on the electrocardiogram. Changes in the ST-vectors are the most significant. These changes have been reduced to a single numerical quantity based on the spatial magnitude of the vector at the end of the QRS complex and the spatial direction of a vector occurring at a clearly specified time during the period of the ST-segment. The assets of polarcardiography are that it enables study of
direction and magnitude
of ST-vectors in a time sequence. Thus it provides information of clinical importance which cannot be obtained by either electro- or vectorcardiography.
Sudden Death and the Familial Occurrence of Mid-Systolic Click, Late Systolic Murmur Syndrome
Authors: SHAPPELL STEPHEN D. , MARSHALL CHARLES E. , BROWN ROSS E. , BRUCE THOMAS A.
Published: June 2012

The propositus, one of six family members with the ballooning posterior mitral leaflet syndrome, had experienced five syncopal episodes prior to initial presentation with cardiac arrest. Subsequent evaluation, after nearly complete recovery, revealed slight Q-Tc prolongation but no arrhythmia, despite extensive ECG monitoring and maximum exercise testing. Intravenous propranolol failed to alter the Q-Tc interval or the magnitude of ballooning of the posterior mitral leaflet at cardiac catheterization. Therapy with oral Dilantin to the point of clinical toxicity failed to significantly shorten the Q-Tc interval. While on oral propranolol, the patient, during a stressful argument, suffered her final cardiac arrest. Detailed post mortem studies were performed, with histochemical identification of the "myxomatous" material not previously reported.
Congenital Diverticulum of the Left Ventricle Associated with Hypoplastic Right Ventricle and Ventricular Septal Defect
Authors: ORSMOND GARTH S. , JOFFE HYMIE S. , CHESLER ELLIOT
Published: June 2012

A case of congenital diverticulum of the left ventricle associated with a ventricular septal defect and severe hypoplasia of the right ventricle without tricuspid or pulmonary atresia is described and the relevant literature is reviewed. The distinction between true muscular diverticulae and congenital apical aneurysms is made, the latter term being preferred for similar abnormalities described as fibrous diverticulae or congenital epicardial cysts. Rupture is rare in true muscular diverticulae and the high pressure recorded in our case is thought to have been caused by catheter entrapment.
Regional Myocardial Blood Flow in Patients with Residual Anterior and Inferior Transmural Infarction
Authors: DWYER EDWARD M. , DELL RALPH B. , CANNON PAUL J.
Published: June 2012

Regional myocardial perfusion rates were estimated in ten patients with a residual transmural anterior wall infarction and ten patients with a residual transmural inferior infarction. The results in these two groups of patients were compared to the regional myocardial perfusion patterns obtained in 25 patients with normal coronary arteriograms who failed to demonstrate any electrocardiographic evidence of a myocardial infarction. Clearance rates of xenon-133 from multiple areas of the heart were monitored externally with a multiple-crystal scintillation camera following selective injection of the isotope into either coronary artery. Local myocardial blood flow rates were calculated by the Kety formula.

In patients with normal coronary arteriograms, mean myocardial perfusion rates in the left ventricle (62 ml/l00g/min) exceeded flow rates in the right ventricle and atrium. There was slight inhomogeneity of local perfusion rates but no significant differences among major subregions (anterior descending, diagonal, or circumflex) within the left ventricle.

In the group with an anterior transmural infarction, myocardial blood flow rates were significantly depressed (44 ml/l00g/min) and asynergy was present in the region of the left ventricle supplied by the anterior descending artery, which was >80% narrowed. Diminished capillary blood flow was found in the right ventricular region in the patients with an inferior transmural infarction and right coronary artery narrowing of >80%. There was no evidence of nutrient flow to the inferior surface of the left ventricle after right coronary
133
Xe injection.

The data indicate that myocardial perfusion was reduced in regions of the heart which correspond to the electrocardiographic and angiographic location of residual transmural infarction. The perfusion rates observed in areas showing electrocardiographic evidence of transmural infarction and regional ventricular asynergy, although subnormal, were surprisingly high and suggested the presence of residual viable myocardial cells.
Platelet Function Studies in Coronary Artery Disease
Authors: STEELE PETER P. , WEILY HUGH S. , DAVIES HYWEL , GENTON EDWARD
Published: June 2012

Platelets have been implicated and abnormal platelet function proposed in the pathogenesis of coronary artery disease (CAD). This investigation examines platelet function in men with stable, arteriographically defined CAD and correlates results with lipid pattern, history of angina or myocardial infarction and smoking habits. Platelet survival (
51
Chromium method), adhesiveness, and aggregation were measured in 21 men with CAD. Twelve patients had Type IV hyperlipoproteinemia and nine patients had normal lipoprotein level. Eighteen had angina and 13 had had infarction.

The average platelet survival for the total group was normal (6.8 ± 0.24 days, avg ±
sem
), but survival was shortened in 11 and normal in ten. There was no significant difference between: (1) patients with hyperlipoproteinemia (6.8 ± 0.30 days) and those with normal lipoproteins (6.9 ± 0.41 days); (2) patients with angina (6.8 ± 0.28 days) and without (6.6 ± 0.26 days); (3) patients with infarction (6.8 ± 0.26 days); and without (6.8 ± 0.50 days); (4) patients with varying patterns of arteriographic involvement; and (5) with varying smoking histories. Adhesiveness was normal in all. Aggregation was normal in 14. Neither adhesiveness nor aggregation correlated with platelet survival or defined the subgroups of CAD. Results suggest an abnormal short platelet survival frequently occurs in patients with CAD, but there is no discernible difference in platelet survival among the various clinical subgroups of CAD.
Echocardiographie Criteria for Normal Newborn Infants
Authors: HAGAN ARTHUR D. , DEELY WILLIAM J. , SAHN DAVID , FRIEDMAN WILLIAM F.
Published: June 2012

Echocardiograms were obtained from 200 normal newborn infants ranging from 6 to 10 pounds in weight and from 10 to 72 hours in age. A continuous recording technique is described employing a 5 MHz transducer. Criteria have been established for a normal echocardiographic profile in the full-term neonate. This profile consists of obtaining quantitative measurements of mitral valve excursion and velocity, tricuspid valve excursion and velocity, pulmonary artery diameter, aortic root diameter, left atrial diameter, and interventricular septal thicknesses. In addition, qualitative assessment is made of the septal contour, position of the aortic root to pulmonary artery, continuity of mitral valve with posterior aortic root, and continuity of tricuspid valve with anterior aortic root. No correlation was found between the magnitude of any one parameter and either body surface area or weight. The establishment of normal echocardiographic criteria for the newborn may be expected to significantly facilitate application of this noninvasive technique to infants born with congenital heart disease.
The Complementary Roles of Chest Radiography, Lung Scanning, and Selective Pulmonary Angiography in the Diagnosis of Pulmonary Embolism
Authors: MOSES DAVID C. , SILVER TERRY M. , BOOKSTEIN JOSEPH J.
Published: June 2012

The chest X-ray, perfusion lung scan, and selective pulmonary arteriogram were independently reviewed in 104 patients with suspected pulmonary embolism. Thirteen patients also had
133
Xe ventilation studies. Of the 45 patients with angiographically-documented pulmonary emboli, 37 had perfusion scans interpreted as
high probability
of pulmonary embolism (82% sensitivity). Fifty of 59 patients without angiographic evidence of pulmonary embolism had perfusion scans interpreted as
low probability
of pulmonary embolism,
other
, or
normal
(85% specificity).

Of the 41 patients with acute pulmonary embolism, only three had normal chest X-rays. In 26 (63%) the abnormality on perfusion scan was more extensive than that on chest X-ray.

When both the scan and chest X-ray pointed strongly in the same direction, a correct diagnosis could usually be made, and accuracy was greater than when diagnosis was based on the perfusion scan alone. The lung scan was of limited value in patients with cardiomegaly or left heart failure. The differential role of the
133
Xe ventilation study remains unclear. On the basis of the present and other data, guidelines for the selection of patients for pulmonary arteriography are proposed.
Differentiation of Physiologically Significant Coronary Artery Lesions by Coronary Blood Flow Measurements During Isoproterenol Infusion
Authors: HORWITZ LAWRENCE D. , CURRY GEORGE C. , PARKEY ROBERT W. , BONTE FREDERICK J.
Published: June 2012

At cardiac catheterization, the effect of isoproterenol on coronary blood flow was compared in six patients with normal coronary arteries and normal left ventricular function, and eight patients with angiographically defined coronary lesions. Coronary blood flow was measured by selective coronary artery injection of xenon-133 and external monitoring of disappearance curves with a dual probe, digital scintillation counter. Resting values did not differ in the two groups. In the normal group isoproterenol increased mean coronary blood flow 93 ml/100 g/min (152%) and cardiac output 2.3 liters/min (42%); coronary resistance/100 g decreased 60 ± 4% (
sem
), while total peripheral resistance decreased 29 ± 4%. In the coronary disease group coronary blood flow increased 20 ml/100 g/min (33%) and cardiac output increased 2.8 liters/min (62%); coronary resistance decreased 26 ± 9% and total peripheral resistance decreased 37 ± 4%. In all normal patients the percent increase in coronary blood flow markedly exceeded the percent increase in cardiac output and the percent fall in coronary resistance markedly exceeded the percent fall in total peripheral resistance. In six of the eight patients with coronary lesions the percent increase in coronary blood flow was less than the percent increase in cardiac output and the fall in coronary resistance was less than the fall in total peripheral resistance. Thus measurement of coronary blood flow, cardiac output, and aortic pressure before and during isoproterenol infusion may permit differentiation of those subjects with physiologically significant coronary obstructions.
AN APPRECIATION OF PAUL DUDLEY WHITE, 1886-1973
Authors: HURST J. WILLIS
Published: June 2012

Dr. J. Willis Hurst was the last Cardiac Fellow of Dr. White at the Massachusetts General Hospital (1947-49). He is a recent past president of the American Heart Association and a Member of the National Advisory Heart and Lung Council. He is presently professor and chairman of the Department of Medicine at Emory University. The article which follows contains Dr. Hurst's remnarks at the Memorial Service for Dr. White in the Harvard Memorial Chapel, Cambridge, Massachusetts on November 13, 1973. Dr. White died on October 31, 1973.