Showing papers in "Heart in 1968"

Late systolic murmurs and non-ejection ("mid-late") systolic clicks. An analysis of 90 patients.

Abstract: Evidence has previously been produced from this laboratory (Barlow and Pocock, 1963; Barlow et al., 1963; Barlow, 1965) that apical late systolic murmurs denote mitral regurgitation, and that the commonly associated non-ejection systolic clicks also have an intracardiac, and probably chordal, origin. It has also been suggested that the association of these auscultatory features with a distinctive electrocardiographic pattern and a billowing posterior leaflet of the mitral valve constitutes a specific syndrome (Barlow, 1965; Barlow and Bosman, 1966). In this paper we present an analysis of 90 subjects with either a late systolic murmur, a nonejection click, or both. The intracardiac origin of these murmurs and clicks is reaffirmed and their possible mode of production is considered. The abnormal electrocardiogram, the probable structural abnormality of the mitral valve mechanism, the various underlying aetiological factors, and the prognosis are discussed.

Natural history of persistent ductus arteriosus.

Abstract: The natural history of typhoid fever is not too difficult to describe. It needs only accurate observers who have followed groups of patients for some months. For cardiac infarction, it is more difficult since this leaves some residual disability, a risk of recurrences, and a shorter expectation of life. Several follow-up studies for 10-20 years have, however, given us a fair picture. It is much harder to describe the natural history of persistent ductus arteriosus or of any malformation of the heart, except those like aortic atresia that cause the early death of all subjects. The problem is more akin to that of the Government Actuary in estimating the expectation of life in the general population. Here the observer does not live long enough to follow a group of the observed through their lives, and has to work from the proportions dying each year at various ages and so on. Everyone agrees that the expectation of life for those with persistent ductus arteriosus is shortened, but their lives are often too long to be covered by a doctor's ordinary time in practice. A reasonable, but possibly less accurate, method is dividing the patients into decades when they were under observation, studying the mortality and other events in each decade separately, and combining them to show a picture of the outlook for life. This method was used by Campbell and Baylis (1956) for coarctation, and by Campbell, Neill, and Suzman (1957) for atrial septal defect, and is used here with the much greater precision that follows from measuring the patient-years-the number of patients multiplied by the average number of years they were under observation. There are special difficulties about the natural history of most malformations of the heart because there was such a short interval between the times when they were diagnosed with any frequency and when they began to be relieved or cured by operation. More than a century ago Wilkinson King

Regional venous drainage of the human heart.

Abstract: Blood samples obtained from the coronary sinus in man contain venous blood draining from left ventricular myocardium. It is believed by many investigators that coronary sinus blood in man is composed almost entirely of left ventricular efflux. That this is true in the canine heart is firmly established (Rayford et al., 1959). This principle has been widely accepted in the many studies which have been carried out using highly diffusible indicators to measure coronary blood flow, in which it is presumed that left ventricular flow per unit muscle mass is being measured (Gorlin, 1960). The present study was designed to test the hypothesis that coronary sinus blood is composed primarily of left ventricular efflux. The methods employed are those of detailed analysis of the fine ramifications of the coronary venous system to determine in semiquantitative fashion the number of small vessels contributing to venous drainage from each segment of the myocardium.

The natural history of congenital aortic stenosis.

Abstract: Our knowledge of the natural history of most malformations of the heart is far from complete, mainly because their clinical diagnosis interested so few physicians for any length of time before their surgical treatment became possible. This hampered the study of their natural history because the more severe cases, in varying degrees, were submitted to operation, and most early papers were reports of one or two cases with necropsies. Thus, Thursfield and Scott (1913) reported the sudden death of a boy of 14 with subaortic stenosis: 7 years earlier the diagnosis had been a ventricular septal defect. Christian (1933) reported two congenital defects, one subvalvar in a man of 40 and the other valvar in a man of 27 years, both of whom had died. An unduly pessimistic view was formed from Maude Abbott's 23 necropsies with aortic stenosis among 1000 with all forms of cardiac malformations (Abbott, 1936). The stenosis was subvalvar in 12 and valvar in 11, the mean age at death for the former being 23 years (oldest 58) against 4 years (oldest 24) for the latter. Probably the older patients with valvar stenosis were classified as rheumatic or as calcific aortic stenosis. Most clinical accounts, on the other hand, were too optimistic. Gallavardin (1936) thought most of his 50 patients got on well and reported only 2 deaths, both in the fourth decade, but he does not seem to have followed the patients and probably missed some who died suddenly. Young (1944) described 10 men with aortic stenosis who served in the army with little difficulty. They were found among 18,000 soldiers, an incidence of 0-05 per cent, and Young reported them as having subaortic stenosis but gave no reason for this. Grishmann, Steinberg, and Sussman (1947) reported 23 patients, including 3 who had died aged 4, 9, and 48, and one man aged 33 who had led a very active life till the onset of angina at 28; apart from these, they gave insufficient details to help

Calcific aortic stenosis and congenital bicuspid aortic valves.

Abstract: cases were reported as congenital and some thought that nearly all were rheumatic, the sclerotic and calcific changes being secondary to earlier infection. This paper is concerned mainly with the clinical evidence about the nature of calcific aortic stenosis, with the frequency of sudden deaths in all forms of aortic stenosis, and with the incidence of congenital bicuspid aortic valves and the part they play in producing aortic stenosis. After a few early cases and views have been mentioned, 60 cases of lone calcific aortic stenosis from Dr. Keith Simpson's necropsy records are analysed. The clinical evidence that bicuspid aortic valves become thickened and rigid at an early age and be-

Juxtaposition of the atrial appendages: a sign of severe cyanotic congenital heart disease.

Abstract: Juxtaposition of the atrial appendages is an apparently rare congenital cardiac anomaly in which the atrial appendages lie side by side, both to the left or to the right of the great arteries, known as left or right juxtaposition of the atrial appendages, respectively (Dixon, 1954). This abnormality now may readily be diagnosed by angiocardiography (Ellis and Jameson, 1963), and it is widely regarded as an ominous sign of severe cyanotic congenital heart disease. Beyond this general impression, however, the specific types of cardiac malformation likely to be associated with juxtaposition of the atrial appendages, and the relative frequencies of each, remain far from clear. This is not surprising since only 21 post-mortem cases have been published, to our knowledge, almost all as isolated case reports (see Table III). This paper represents an attempt to clarify the picture.

Necropsy study of endomyocardial fibrosis and rheumatic heart disease in Uganda 1950-1965.

Abstract: Endomyocardial fibrosis is a relatively common form of heart disease in Uganda (Davies, 1948; Shaper and Williams, 1960) and accounts for some 10 per cent of heart disease seen at necropsy in Kampala (Davies, 1961). It is characterized in the established condition by fibrosis in the endocardium and subjacent myocardium affecting particularly the inflow tract and the apex of one or both ventricles. The aetiology of this disorder is not known, and hypotheses have been put forward in attempts to incriminate virus or filarial infections, plantain diets, and rheumatic heart disease. The disorder has also been described in West Africa, Ceylon, South India, and Central Africa, and wellauthenticated cases have been seen in Europeans resident in tropical areas (Brockington, Olsen, and Goodwin, 1967). Mulago Hospital, Kampala, is situated in Buganda, the largest province of Uganda, and about half the patients admitted to the hospital belong to the local Ganda tribe (Fig. 1). There is also a large immigrant population in Buganda, coming in particular from Rwanda and Burundi (herein referred to as 'Rwandans') and from the Western Province of Uganda (Kigezi, Ankole, Toro, and Bunyoro districts). An analysis of the tribal origins of cases of endomyocardial fibrosis coming to necropsy at Mulago Hospital in the period 19501961 showed a preponderance of this condition among those groups immigrant to Buganda, in particular those originating from Rwanda and Burundi. The condition was far less common than expected among the indigenous Ganda people (Shaper and Coles, 1965). This analysis of the tribal origins of subjects with endomyocardial fibrosis has now been extended to cover the period 1950-1965, and a similar analysis

Long-term results of DC reversion of atrial fibrillation.

Abstract: Early enthusiasm for DC shock as a means of restoring sinus rhythm in patients with atrial fibrillation has been followed by a period of uncertainty as to the place of such treatment in the long-term management of this arrhythmia. Whatever the haemodynamic advantages of co-ordinate and appropriately-phased atrial contraction (Braunwald, 1964; Burchell, 1964), restoration of sinus rhythm seems therapeutically justifiable only when it is likely to persist for a worth-while period; otherwise any such advantages will be ephemeral and the risk of embolism is unlikely to be favourably influenced. We, therefore, attempted to clarify the position by follow-up of patients treated over two years ago in order to determine the rates of persistence of normal rhythm at one or two years after reversion in different aetiological groups.

Haemodynamic effects of rapid digitalization following acute myocardial infarction.

Abstract: Digitalis is now in common use following acute myocardial infarction, and the danger of producing arrhythmias appears to be no greater than in other groups of patients (Askey, 1951). The drug is frequently given intravenously for a rapid effect and to ensure that it will enter the circulation, but little is known of the immediate effects of such administration on the circulation. Malmcrona, Schr6der, and Werko (1966) have reported on 10 patients and we report here our results in a further 11 patients.

Appraisal of electroconversion in treatment of cardiac dysrhythmias.

Abstract: In 1962 Lown and his colleagues (Lown, Amarasingham, and Neuman, 1962a; Lown et al., 1962b) described the experimental development and successful clinical use of direct-current shock for the conversion of atrial and ventricular dysrhythmias to sinus rhythm, which was soon confirmed by others (O'Brien, Resnekov, and McDonald, 1964; Oram et al., 1964; Morris et al., 1964). An analysis of the indications, results, and complications of the method is presented below; this is based on observations that have been made on 220 consecutive patients with atrial and ventricular dysrhythmias which were associated with a wide variety of underlying heart disease, and treated by direct-current shock.

ABO blood groups and ischaemic heart disease in men.

Abstract: In 1954 Gertler and White found a significant deficit of group 0 patients in a series of 81 young male survivors of myocardial infarction. Between 1961 and 1966, a further 9 series of survivors ofmyocardial infarction were reported, and in 7 of these there was again a deficit of O's, the deficit being slight in 3 of the series but significant in 4 (Table I). Furthermore, Jaegermann (1962) found, in a series of 828 fatal cases, a significant excess of A's predisposed to ischaemic heart disease in general, as evidenced by early or well-marked atheromatous changes in the coronary arteries. In view of these findings a survey has been made of 353 male survivors of ischaemic heart disease, with special reference to duodenal ulcer, age, occupation, and family history of ischaemic heart disease.

Haemodynamic effects of beta-adrenergic blockade.

Abstract: Several studies have shown a beneficial effect in treating patients with coronary disease with betaadrenergic blockade (Hamer and Sowton, 1965; Grant et al., 1966; Gillam and Prichard, 1966; Rabkin et al., 1966). In normal subjects blockade with propranolol decreases cardiac output both at rest and during exercise mainly by reducing heart rate, and increases the end-diastolic pressure in the left ventricle, which would suggest some deterioration of left ventricular function (Cumming and Carr, 1966). In subjects with hyperkinetic circulation the effect of blockade is more pronounced (Bollinger, Gander, and Forster, 1965). Malmborg (1965) found that patients with coronary disease had a hypokinetic circulation compared with controls of about the same age, and more than 50 per cent ofthese patients had increased left ventricular filling pressure during exercise. Hamer and Sowton (1965) predicted a greater fall in cardiac output after beta-adrenergic blockade in patients with ischaemic heart disease than in normal subjects. The purpose of the present investigation was to study the influence on the circulation of betaadrenergic blockade during exercise which induced angina pectoris.

Vascular pattern of myocardium of right ventricle of human heart.

Abstract: Apart from comparisons of the density of the blood supply of the right and left ventricles in various age-groups (e.g. Gross, 1921; Campbell, 1929; Whitten, 1930a, b; Ehrich, de la Chapelle, and Cohn, 1931; Gross and Kugel, 1933), the arterial pattern of the myocardium of the right ventricle of the human heart has, in the past, received little attention. More recently, Mitchell and Schwartz (1965) and Fulton (1965) have published radiographs of the blood supply of both ventricles, but except for Fulton's description of the anastomotic vessels these investigators did not comment on the normal detailed vascular anatomy of the right ventricle. This paper describes the vascular pattern of the right ventricle seen in a study of a series of human hearts,t and discusses the possible importance of the left coronary arterial tree in the supply of the right ventricle.

Large tonsils and adenoids in small children with cor pulmonale.

Abstract: Although small children with large inflamed nasopharyngeal lymphoid masses have been part of human ecology since the move east of Eden, the syndrome of cor pulmonale consequent to upper airway obstruction was not described until 1965 (Menashe, Farrehi, and Miller, 1965; Cox et al., 1965). These and subsequent reports (Noonan, 1965; Luke et al., 1966) defined the clinical syndrome of noisy, stertorous respirations, somnolence, clinical and electrocardiographic evidence of right ventricular hypertrophy, radiological findings of cardiomegaly, and occasionally pulmonary oedema and right heart failure. Like all clinical syndromes, there are numerous variations about the central unifying theme. Through recounting our experience with six of these patients, observed within a two-year period, we wish to illustrate some of these variations. Particular emphasis will be directed toward lability of the clinical, electrocardiographic, and radiological findings; and the ever present danger of death from either respiratory or cardiac arrest.

Haemodynamic effects of ethyl alcohol in patients with coronary heart disease.

Abstract: or prevents angina in many instances, but Russek, Naegele, and Regan (1950) and Russek, Zohman, and Dorset (1955) have shown that the exercise electrocardiogram is not improved and the benefit of alcohol has been attributed to its psychological effect. In these and similar studies little attention has been paid to the dose of alcohol, its rate of absorption, and the blood levels attained. Several haemodynamic studies of the action of alcohol exist. With a few exceptions they have been carried out on healthy anaesthetized dogs or heart-lung preparations and, though detailed, the results are often conflicting. Thus coronary sinus flow has been shown to rise (Lasker, Sherrod, and Killam, 1955; Ganz, 1963) or fall (Degerli and Webb, 1963; Leighninger, Rueger, and Beck, 1961). Cardiac output probably declines though again there is no unanimity (Degerli and Webb, 1963). A fall in arterial pressure may occur (Willard and Horvath, 1964); and Moss, Chenault, and Gaston (1959) have demonstrated unusual vulnerability to surgical shock, but in the main little change has been noted. In many cases alcohol has been given intravenously and by this route high blood levels are quickly reached, even with moderate dosage. Clearly, the application of the findings of such experiments to patients with heart disease must be cautious. The present study, therefore, examines the haemodynamic consequences of a drink of alcohol in patients with coronary heart disease and includes observations on blood alcohol concentrations.

Factors affecting cardioversion of atrial arrhythmias with special reference to quinidine.

Abstract: Synchronized direct current shock (Lown, Amarasingham, and Neuman, 1962) has rapidly become established as an effective and safe method of treating cardiac arrhythmias, but controversy remains about the use of antiarrhythmic drugs in maintaining sinus rhythm following the procedure. Although quinidine is potentially dangerous (Thomson, 1956; Oram and Davies, 1964; Davies, Leak, and Oram, 1965), many authors state that it should be used prophylactically (Lown et al., 1963; Hurst et al., 1964; Korsgren et al., 1965; Morris, Peter, and McIntosh, 1966). However, Halmos (1966) and Szekely, Batson, and Stark (1966) have suggested that quinidine does not prolong the duration of sinus rhythm. In this paper we describe our experience in using direct current shock to treat 149 patients with atrial arrhythmias. The effect of prophylactic quinidine on the maintenance of sinus rhythm in a group of patients with rheumatic heart disease is compared with another group on no quinidine. A number of other factors have been analysed to determine their influence on results.

Mode of action of nitrglycerin in angina pectoris. Correlation between haemodynamic effects during exercise and prevention of pain.

Abstract: Nitroglycerin isgenerallyagreed tobethemost effective drugavailable forthetreatment ofangina pectoris, butitsmodeofaction remains uncertain. Two mainexplanations havebeenputforwird. Thefirst suggests that itactsbylowering thearterial pressureandsoreducing cardiac work;thesecond thatitactsbydilating thecoronaryarteries andso improving themyocardial bloodsupply. Formany yearsthecoronarydilator action ofthedrughas beenwidely accepted astheprobable mechanism for itstherapeutic effect, anditsaction inreducing blood pressurehasbeenregarded asofsecondary importance, ifnotactually harmful. Attempts to demonstrate a beneficial effect on coronaryflowin patients withischaemic heartdisease, however, havemetwith no success,anditappearsthatsublingual nitroglycerin isunable toincrease themyocardial bloodsupply whenthecoronaryarteries are diseased (Gorlin etal., 1959; Bernstein etal., 1966). Thisfailure toconfirm thecoronarydilator theory hasledtorenewed interest inthepossibility that the drugactsbyreducing cardiac work,buttheevidencetosupportthisviewisinconclusive. Most studies oftheeffect ofnitroglycerin on thecirculatory responsetoexercise haveshownthat thedrug reduces arterial pressurebothinnormalsubjects and in patients withischaemic heartdisease (Eldridge etal., 1955;MullerandR0rvik, 1958; Christensson, Karlefors, and Westling, 1965; Najmi etal., 1967).Innoneofthese investigations, however, havethechanges inthecirculatory response beencorrelated withthealteration in capacity forexercise. Inconsequence,though itis generallyaccepted thatnitroglycerin doescause some attenuation ofthecirculatory responseto exercise, ithasbeenimpossible toassesstheextent

Observer variability in recording the peripheral pulses.

Abstract: Examination of the leg and foot pulses is indispensable in the assessment of the patient with suspected peripheral arterial disease, so it is important to know how much weight to attach to the findings. The topic of observer variability is of increasing interest in clinical medicine, while population studies can only be of use if methods are reproducible, that is provide \"the same results on the same subject on two or more occasions, in the hands either of the same or of more than one observer, the subject of the test being in the same state of health or disease\" (Fletcher and Oldham, 1964). A previous study of observer variability in recording pulses in the foot gave results from which the authors concluded that there was \"very great observer error with respect to the detection of ankle pulses\", and that \"the inability to detect an ankle pulse by one observer is quite without significance\" (Ludbrook, Clarke, and McKenzie, 1962). These are disturbing suggestions for the clinician and the epidemiologist, particularly in view of the considerable attention currently being paid to the detection of early peripheral arteriosclerosis (Widmer, Greensher, and Kannel, 1964; Cooper, Hill, and Edwards, 1967; Lancet, 1967). Preparing for population studies of peripheral arterial disease, it was obviously necessary first to carry out a similar study to that of Ludbrook et al. (1962), in order to reassess the value of palpation of the pulses. Apart from an unexplained random element, intra-observer variability may be due to real biological changes of the factor considered, e.g. seasonal changes in blood cholesterol or changes in blood pressure with emotion. In addition, errors generated by the observer and/or his instrument may result in different recordings on separate occasions for a factor that has not altered, e.g. the observer

Myocardial metastases. A pathological and electrocardiographic study.

Abstract: Reports differ concerning the frequency and localization of carcinomatous metastases in the myocardium as well as the different primary tumours giving rise to myocardial metastases. Series that are thoroughly investigated generally reveal a higher incidence, and Willis (1952) considers that inadequate examination is responsible for the opinion that myocardial metastases are rare. Not all investigators distinguish between true embolic metastases and tumours invading the heart from the lung or mediastinum. In some instances pericardial metastases are included. It is difficult to diagnose myocardial metastases by electrocardiography. Hanfling (1960) concludes, for instance, that \"there are no diagnostic patterns . . .\", while the New York Heart Association's 6th edition of Nomenclature and Criteria for Diagnosis notes concerning myocardial metastases that \"electrocardiographic abnormalities, especially inversion of the T wave and persistent displacement of the S-T junction and segment, are occasionally observed in the presence of tumours in the ventricular myocardium\". On the subject of pericardial metastases it is noted that \"the electrocardiogram may display nonspecific abnormalities ....\". On the other hand, there is also a large number of reports on myocardial metastases diagnosed in vivo. An extensive review has been compiled by Hurst and Cooper (1955). Our records contain a large homogeneous series of cases in which the pathological anatomy has been thoroughly examined. This has prompted a study ofthe incidence and localization of myocardial metastases for various primary tumours as well as the extent to which they could be demonstrated by electrocardiography. The retrospective nature of this material makes it difficult to assess from a purely clinical point of view.

Clinical diagnosis and prognosis of ventricular aneurysm.

Abstract: Where a full thickness infarct has occurred with replacement of myocardium by fibrous tissue, this inert portion of the ventricular wall cannot take part in concentric contraction and herniates outwards during ventricular systole. This localized disturbance of ventricular contraction after acute myocardial infarction is seen not only in large ventricular aneurysms but alsowith smaller full thickness infarcts (minor aneurysms) that have not caused a definite protrusion of the external surface of the heart. In this paper the range of localized disorders of ventricular contraction has been studied clinically, radiologically, at operation, and at necropsy. In diagnosis, special emphasis has been placed on abnormalities of the cardiac impulse, readily appreciated at the bedside, and on the information obtained from detailed fluoroscopy. The prognosis after acute myocardial infarction depends not only on the possibility of a further infarct occurring, but also on the degree of damage that the infarct has inflicted on the ventricles as an efficient pump. The influence of major and minor aneurysms on prognosis following myocardial infarction has been examined.

Cardiovascular disease in air travellers.

Abstract: There has been a great increase in civil aviation in the post-war years. In 1966, more than a million passengers a month passed through London Airport. Flying has become so safe and convenient that many disabled people elect to travel by this means. In fact, as many as 5 per cent of passengers on routine scheduled services are suffering from some form of disability, though less than 1 per cent are self-declared invalids. In the modem jet airliner, the passengers are exposed to a mild degree of hypoxia at ordinary cruising altitudes, due to the reduction in cabin atmospheric pressure. This degree of hypoxia is insufficient to affect healthy adults, but may prove an embarrassment to passengers with impairment of the cardiovascular or respiratory systems. This group accounts for up to 20 per cent of self-declared invalids. This paper analyses some 25 patients who were admitted to Hillingdon Hospital, a large general hospital near London Airport, during the years 1963, 1964, and 1965. All had collapsed with conditions affecting their cardiovascular systems, either during or immediately after a normal routine flight. The pertinent physiological and environmental factors are discussed, and the routine procedure for handling invalid passengers is described.

Left atrial function after electrical conversion to sinus rhythm.

Abstract: Atrial fibrillation is undesirable because it reduces the efficiency of the heart, particularly the diseased heart (Kory and Meneely, 1951) and gives rise to systemic or pulmonary embolism in about one-third of the cases (Goldman, 1960). The recent introduction of the use of the synchronized directcurrent shock (Lown, Amarasingham, and Neuman, 1962) has simplified the restoration of sinus rhythm, but little is known about the return of the mechanical activity to the atrium. Bramwell and Jones (1944) have suggested that an effective left atrial contraction may be absent in sinus rhythm, and cardiac catheterization studies have shown that the return of a P wave to the electrocardiogram may not be accompanied by the restoration of detectable mechanical activity to the left atrium (Braunwald, 1964; Logan et al., 1965). It is important to know if or when mechanical activity returns to the atrium; its failure to return may be a cause of continuing disability, and its delayed return may be associated with late embolism. Left heart catheterization is not a technique that is suitable for repeated use after conversion. This paper describes a study of the left atrial contraction, by a simple bedside technique, in patients recently converted to sinus rhythm.

Left heart haemodynamics at rest and during exercise in patients with mitral stenosis.

Abstract: Transseptal and retrograde catheterization of the right and left heart (Cournand and Ranges, 1941; Seldinger, 1953; Ross, 1959) provided methods of studying human cardiac haemodynamics on a large scale, which was particularly necessary in view of the widening scope of the surgical treatment of mitral stenosis and other valve defects. In such cases, measurement of left heart pressures and pressure gradients are particularly important. Increased experience with cardiac catheterization drew attention to the fact that apart from the mechanical obstruction by the stenosed mitral valve, the so-called myocardial factor might also play a role. This assumption of a left ventricular myocardial defect is supported by the following observations made in patients with mitral stenosis: low cardiac output both at rest and during exercise (Harvey et al., 1955), its increase after administration of digitalis (Ferrer et al., 1952), signs of cardiac failure with low cardiac output with normal pulmonary capillary venous pressure (Fleming and Wood, 1959), and increased left ventricular diastolic pressure (Feigenbaum et al., 1966). In such cases, surgical dilatation of the mitral valve cannot bring about the expected improvement; the operation may be even contraindicated because the increased post-operative load on the left ventricle may cause deterioration. Study of this problem has shown that catheterization, at rest, of patients with rheumatic mitral stenosis is inadequate for assessing the cardiac state. It does not take into account the haemodynamics during activity and when performing various types of work. Such conditions may be simulated by subjecting the patient to physical exercise during catheterization. The response to exercise helps to estimate the degree of mitral stenosis on the basis of increased

Cardio-circulatory effects of beta-adrenergic blockade in organic heart disease. Comparison between propranolol and CIBA 39,089-Ba.

Abstract: Beta-adrenergic blockers are increasingly used in the treatment of angina pectoris (Hamer et al., 1964, 1966; Srivastava, Dewar, and Newell, 1964; Gillam and Prichard, 1965, 1966; Keelan, 1965; Rabkin et al., 1966; Wolfson et al., 1966), cardiac arrhythmias (Stock and Dale, 1963; Fiene, Griffin, and Harrison, 1965; Ginn, Irons, and Orgain, 1965; Harrison, Griffin, and Fiene, 1965; Bath, 1966; Harris, 1966; Rowlands, Howitt, and Markman, 1965; Schamroth, 1966; Szekely et al., 1966), and some other less common conditions (Harrison et al., 1964). The danger of inducing or aggravating heart failure by beta-blockade remains a matter of controversy (Stephen, 1966). Whereas this risk has been considered as relatively small and acceptable by Snow (1965, 1966), undesirable side-effects and sometimes severe complications related to the depressant action of propranolol on myocardial contractility have been reported, in isolated instances with fatal outcome (Fleckenstein et al., 1964; Vogel, 1965; Scheu, 1966; Luthy and Hegglin, 1966). This risk undoubtedly represents an important drawback to this kind of therapy. In the present study, propranolol was given intravenously to patients with organic disease of the left heart, and its circulatory effects were assessed during the course of standard pre-operative catheterization of the heart. In a second stage of this study, these effects were compared with those of CIBA 39,089-Ba, a new specific beta-adrenergic blocking agent. Fig. 1 shows the chemical structures of isoprenaline, propranolol, and CIBA 39,089-Ba. Fig. 2 shows that the two drugs are apparently equipotent beta-blockers in terms of their negative chronotropic effect. This study

Epicardial and intramural excitation of normal heart in six patients 50 years of age and older.

Abstract: Our knowledge of the pathway of excitation in the human heart is restricted mainly to the time sequence of subepicardial muscle depolarization, but even this aspect of cardiac excitation is known insufficiently, despite a large number of investigations. In many of these studies direct-writing apparatuses of low frequency response are used; these give rise to deformation ofthe QRS complexes, difficulties in recognition of the intrinsic deflections, and therefore inaccuracies in the measurement ofthe time of occurrence. In some studies a string galvanometer with its better physical properties has been used as a recording instrument. Groedel and Borchardt (1948) recorded cardiac potentials by placing small electrodes on the pericardial surface during artificial pneumothorax. The localization of the exploring electrode during this procedure is difficult, and it is not possible to explore a sufficient number of points. In the classic study of Barker, Macleod, and Alexander (1930), 15 regions located at the anterior and posterior epicardial surfaces of an exposed human heart were explored. Their results, so far as the excitation pattern during normal beats is concerned, will be discussed later. A highfidelity recording machine and fast running film were used by Jouve et al. (1958, 1960). Highly detailed complexes from many parts of the epicardial surface of the human heart were recorded. In our study, a similar technique was used. Epicardial exploration was combined with the introduction into the left ventricular wall of one intramural electrode in each patient, in whom the left ventricular surface was explored. The normal hearts were those of 6 patients between 50 and 68 years of age, undergoing pneumonectomy for pul-

Dissecting aneurysm of the aorta due to giant cell arteritis.

Abstract: Giant cell arteritis is a rare cause of dissecting aneurysm. Nine examples have been hitherto reported, and in this paper 2 new cases are recorded. Review of 77 examples of dissecting aneurysm in the necropsy records of this department has failed to reveal any further cases attributable to giant cell arteritis. Shennan (1934) and Sailer (1942) who reviewed 300 and approximately 500 necropsies, respectively, of patients with dissecting aneurysm, did not describe any with lesions resembling giant cell arteritis, though they did refer to a small number in which there was syphilitic or rheumatic aortitis. In Manley's series of 27 dissecting aneurysms (Manley, 1962), there were 2 cases of giant cell aortitis, one with coexisting cystic medionecrosis. Harrison (1948), in his review of 75 patients with giant cell arteritis, including 12 necropsies, found 9 in which the aorta was involved, but none where dissecting aneurysm had occurred.

Haemodynamic features of severe endomyocardial fibrosis of right ventricle, including comparison with constrictive pericarditis.

Abstract: Endomyocardial fibrosis, first described from Uganda by Davies (1948), is a disease of the heart characterized by a fibrosis of the endocardium and subendocardial layers of either the left or right ventricle or both. The fibrosis affects mostly the inflow tracts and the apices of the ventricles, and involvement of the papillary muscles may lead to mitral or tricuspid incompetence. The ventricular outflow tracts are unaffected and the aortic and pulmonary valves are normal. Van der Geld et al. (1966) have demonstrated a predisposition to autoimmune reactivity to the heart in endomyocardial fibrosis. Connor et al. (1967, 1968) have recently published a detailed account of the histopathology of endomyocardial fibrosis in Uganda. From a clinical survey of all cardiac diseases, excluding hypertensive heart disease, at Mulago Hospital, Somers and D'Arbela (1964) found the incidence of endomyocardial fibrosis to be approximately 12 per cent. Over the past three years 28 patients with severe endomyocardial fibrosis of the right ventricle have been investigated here by right heart catheterization. Their clinical features are' described elsewhere (Somers, Brenton, and Sood, 1968). This present paper records the observations made during catheterization of these patients, and compares the data with those obtained in 11 patients with constrictive pericarditis. The effect of an intravenous administration of a digitalis preparation in 11 patients with right ventricular endomyocardial fibrosis is reported. The results of a similar study have been published by Parry and Abrahams (1963). Many of their

Nornal and diseased vascular pattern of myocardium of human heart. I. Normal pattern in the left ventricular free wall.

Abstract: During the past 40 years investigations into the blood supply of the ventricles of the human heart have concentrated mainly on the problem of atheroma of the main portions of the coronary arteries and on arterial anastomoses. Little attention has been paid to the finer details of the normal and diseased patterns of arteries, arterioles, and capillaries within the myocardium. Consequently, a study was carried out to establish the variations that exist within the normal pattern and then the changes that occur in hearts from patients with long-standing heart disease and, in particular, myocardial scarring or infarcts. In order to do this a technique was devised which made possible the uniform injection of the smallest vessels of the heart, including capillaries, with radiopaque media, and a method of taking microradiographs was used which allowed considerably greater magnification of x-rays of these small vessels than had hitherto been possible. This present paper describes the normal arterial pattern seen in the left ventricle of the human heart.

Second heart sound in pulmonary hypertension.

Abstract: The clinical diagnosis of pulmonary hypertension may be difficult. Atrial systolic ('a') waves in the venous pulse are an inconstant finding; abnormal right ventricular movement may be absorbed by the chest wall or confused with systolic expansion of the left atrium; ejection sounds may be aortic rather than pulmonary. Electrocardiographic changes are late, or may be concealed by left ventricular hypertrophy. Radiological changes may be absent. Although there is a great deal of information about splitting of the second heart sound (recently summarized by Leatham (1964)), the effect of pulmonary hypertension has been strangely neglected. Wood (1952) stated that the second sound in pulmonary hypertension was abnormally closely split, with accentuation of the puilmonary component. We shall show that though this may be correct in a certain situation, no such generalization can be made.

Chronic haemolysis following insertion of ball valve prostheses.

Abstract: Intravascular haemolysis after the insertion of intracardiac prosthetic material has been reported by Sayed et al. (1961), Verdon, Forrester, and Crosby (1963), Sigler et al. (1963), Gehrmann and Loogen (1964), Reed and Dunn (1964), Marsh (1964), and Yacoub, Rogers, and Taylor (1965). The haemolysis may be sufficient to produce clinical haemolytic anaemia or may cause a compensated haemolytic state (Yacoub et al., 1965). The possible harmful effects of mild continuous chronic haemolysis on the kidney and liver have been pointed out by Song (1957) and by Andersen, Gabrieli, and Zizzi (1965). The purpose of this paper is to study red cell survival after the insertion of Starr-Edwards prostheses in the aortic and mitral areas.