Flow murmur associated with partial occlusion of the right pulmonary artery.

An 18-year-old male student presented with a brief history of syncope followed by shortness of breath with exertion, and the development of murmur over the right chest. The symptoms and murmurs were related to a pulmonary embolus which partially occluded the right pulmonary artery and its major branches. The murmur gradually diminished and disappeared when right pulmonary perfusion had almost returned to normal as determined by lung scan. The association of pulmonic flow murmurs and pulmonary emboli is reviewed.     

Adverse reactions to quinidine in hospitalized patients: Findings based on data from the boston collaborative drug surveillance program

This study systematically analyzed the incidence and variety of adverse reactions to quinidine sulfate in 652 consecutively monitored hospitalized patients. Fourteen percent of the patients sustained adverse reactions of sufficient severity to warrant discontinuation of the drug. These reactions include GI intolerance, cardiac arrhythmias, fever with and without associated hepatic dysfunction or leukopenia, cinchonism, and hemolytic anemia. Cardiac arrhythmias were infrequent and, when present, generally occurred within 3 days of institution of quinidine therapy. There were no quinidine-related fatalities in this study group.     

Myocardial infarction before age 36 years in women: Predominance of apparent nonatherosclerotic events

To examine whether myocardial infarction (MI) in young women resulted from atherosclerosis, we studied 19 women aged 18 to 35 years who had documented MI at our institution from 1955 to 1979. They were compared to 20 similar men who were selected randomly. All 20 men had at least one major coronary risk factor; six of the women did not (p < 0.01). The risk factors were up to four times more common in men. Coronary anatomy, defined in 13 women and 13 men, demonstrated patent vessels or single stenotic disease in 10 (77%) women but in only one (8%) man, and multilesion disease in only three (23%) women but in 12 (92%) men (p < 0.005). All with patent coronaries were women. Thus atherosclerosis is more advanced and accounts for most myocardial infarcts in young men, but is less evident and accounts for only a minority of MI in young adult women, who have a greater preponderance of nonatherosclerotic related infarcts.     

Quantitative aspects of the metabolic response to pancreatic islet transplantation in rats with severe ketotic diabetes.

Injection of 100-140 mg/Kg of streptozotocin produced severe, ketotic diabetes in 12 pairs of adult rats. Transplantation of intact islets of Langerhans from syngeneic adult donors into a muscle pocket or a pouch created from pancreatic tissue of one animal from each pair eliminated ketonemia in the immediate postoperative period, while ketonemia persisted in the sham-operated controls. Mean survival of transplanted animals was 145 days, versus 70 days for controls. Mean body weight increased and blood sugar decreased in transplanted animals compared with controls; the differences were greatest in those animals which received the largest number of islets per unit body weight. In one animal, all metabolic indices returned to normal for a period of 8 wk following transplantation of 650 islets. After gaining to 300% of initial body weight, diabetes reappeared in this transplanted animal and was again reversed by a second transplantation. The metabolic data indicate that: (1) islet tissue from adult donors survives and functions in severely diabetic, ketotic hosts; and (2) metabolic response to transplantation is a function of the ratio of islet tissue to body mass, a minimum ratio of about 2-3 islets/gm body weight being required to maintain normal homeostasis.     

Ambulatory ventricular tachycardia: Characteristics of the initiating beat

One hundred ten 24-hour Holter ECG recordings from 82 ambulatory patients with 341 episodes of ventricular tachycardia (VT) were analyzed. Most VT was precipitated by ventricular premature beats (VPBs) with prematurity indices (coupling interval/QT) between 1.0 and 2.0. However, a disproportionate number of VPBs initiating VT occurred early and late in the cardiac cycle compared with isolated VPBs. VT rate was not related to preceding heart rate, but faster basic rates appeared to protect against VT of extended duration. Approximately 80% of episodes of VT were initiated by VPB forms also seen in isolation. Of the 20% of VT initiated by a VPB of new morphology, one third occurred late in the cardiac cycle; almost none were early cycle.     

Treatment of preinfarction angina with intraaortic balloon counterpulsation and surgery

Sixteen patients with preinfarction angina unresponsive to medical therapy were treated by Counterpulsation with the intraaortic balloon pump. Chest pain and electrocardiographic changes were abolished or significantly decreased in all but one patient. Counterpulsation reduced peak systolic blood pressure, but had little effect on pulmonary capillary wedge pressure or cardiac output. Coronary anatomy was then defined by coronary angiography. Significant obstructive atherosclerosis of the main left or left anterior descending coronary artery was present in all but one patient. All patients underwent coronary revascularization by saphenous vein aortocoronary bypass graft. Fifteen of 16 patients survived the operation. All survivors are clinically improved, and 13 are completely asymptomatic from 1 to 20 months postoperatively.     

The significance of bundle branch block during acute myocardial infarction.

Analysis of the course of 71 patients with acute myocardial infarction complicated by bundle branch block (BBB) confirms a high incidence of atrioventricular (A-V) block (42 per cent) and severe pump failure (35 per cent) in these patients. Hospital mortality was not correlated with BBB per se, but rather with the associated development of second or third degree A-V block (57 per cent with A-V block vs. 12 per cent without A-V block; p less than .0005) or severe pump failure (35 per cent with vs. 11 per cent without severe pump failure; p less than .001). However, late mortality was high and not significantly different among those surviving hospitalization whether transient A-V block was present or absent. Eight of 11 late deaths were sudden. Temporary pacing could not be shown to alter hospital survival statistically, but made the onset of complete heart block a hemodynamically smooth and clinically undetectable event in several patients who later survived. The place of permanent pacing in these patients cannot be clearly determined on the basis of this study or in the available literature. More data obtained either by pooling the experience of several centers or from a prospective randomized study are needed to determine the indications for permanent pacemakers.     

Electrical effects of a highly conductive mass inside the thorax

Model experiments were conducted using an artificial dipole to determine the effect of the volume of a highly conducting mass (such as the heart) inside a finite volume conductor (such as the body) on the dipole moment obtained from integrals of body surface potentials, and on the boundary potential distribution. In one series of experiments, a dog's urinary bladder filled with fluid of conductivity similar to that of the blood, was placed in a tank having the shape of the human thorax and filled with fluid of conductivity similar to that of the tissues. An electric dipole was placed in direct contact with the bladder, and the effect of varying the volume and the position of the bladder on the boundary potential distribution was studied. It was found that the surface potentials depended greatly on the position and the volume of the bladder. In another series of experiments, the effect of the volume of the bladder on the magnitude of the dipole moment was studied. The results showed that the physical presence of the bladder and the volume of the bladder had a definite effect on the magnitude of the resultant dipole moment. Two empirical equations, describing this effect, were derived.     

Lactate dehydrogenase and isoenzyme changes in rats with experimental thiamine deficiency.

Heat and liver lactate dehydrogenase (LDH) and isoenzyme distributions were studied in rats with experimental thiamine deficiency. No change in total heart LDH activity was observed on days 24 and 40 of a thiamine deficient diet. At the time of symptoms (average 53 days on diet), total heart muscle LDH was slightly decreased in thiamine deficient rats (248 +/- 12 U/g tissue, Mn +/- SE) compared to ad lib fed controls (293 +/- 12, p less than 0.05), but did not differ from pair fed controls (273 +/- 15). Heart muscle LDH isoenzyme distribution showed a relative increase in the H4 band and a decrease in the H2M2 and HM3 bands in thiamine deficiency on day 24. This pattern became more promient by day 40. Calculated total M-LDH activity of heart muscle in thiamine deficient rats was significantly decreased at day 40 (44 +/- 3) compared to pair fed controls (57 +/- 5, p less than 0.05) and ad lib fed controls (85 +/- 7 p less than 0.001). Further changes were not observed in the symptomatic stage. Total H-LDH in heart muscle did not change during the period of study, while total liver LDH activity was reduced in thiamine deficient rats at the symptomatic stage (137 +/- 15) compared with pair fed controls (193 +/- 12, p less than 0.05) and ad lib fed controls (407 +/- 50, p less than 0.01). Liver isoenzyme electrophoresis showed an almost 100% distribution to the M4 band. The present investigation demonstrates a decrease in cardiac muscle M-LDH in experimental thiamine deficiency. Differences in LDH isoenzyme distribution in chronic hypoxia and thiamine deficiency are discussed.     

The quiz electrocardiogram: a new diagnostic and research technique for evaluating the relation between emotional stress and ischemic heart disease.

To evaluate possible cardiovascular effects of emotional stress, a specially designed 12 minute tape-recorded stress quiz was administered to 43 subjects while blood pressure and the electrocardiogram were monitored. For the entire group, the heart rate and blood pressure rose from respective control levels of 76 beats/min and 136/87 mm Hg to a mean during the quiz of 87 beats/min and 158/94 mm Hg. This difference was highly significant. Of the 43 subjects, 33 were classified as executives and 10 as nonexecutives. There were three groups of executives: control and angina with and without a history of hypertension. Both groups of executives with angina responded with a significantly higher heart rate than that of the executive control group. Blood pressure response was significantly greater in executives with angina and hypertension than in the other groups. Heart rate and systolic blood pressure responses to the quiz were lower in nonexecutives with angina than in executives with angina. During the quiz, 10 of 14 executives with angina had S-T segment depression greater than 0.5 mm; of these, 7 evidenced greater than 1.0 mm depression, andin 3 of these the depression was greater than 1.5 mm and in 2 greater than or equal to 2.0 mm. None of the executive control subjects had S-T depression greater than 0.5 mm Among nonexecutives, 2 had S-T depression greater than 0.5 mm but none greater than 1.0 mm S-T depression. Seventeen of the patients also were given a bicycle exercise tolerance test. There was a significant correlation between S-T depression in response to exercise and to the quiz (r = 0.63; P less than 0.01). The quiz electrocardiogram is presented as a new research technique and diagnostic test for evaluating the relation of emotional stress to ischemic heart disease.     

Diagnostic accuracy of M-mode echocardiography in active infective endocarditis and prognostic implications of ultrasound-detectable vegetations

Sensitivity, specificity, diagnostic accuracy, and prognostic implications of the M-mode echocardiographic pattern of vegetations were examined prospectively in consecutive patients referred with potential active infective endocarditis (IE). A pattern of definite echo vegetations was present in 37% of 51 patients diagnosed clinically to have active IE. Specificity in 138 patients without IE was 96%. Diagnostic accuracy of a positive test was 76% and that of a negative test was 80%. Five of six false positive studies involved patients with prior IE or valvular thrombosis. If possible echo vegetations were included, sensitivity increased to 47% and specificity decreased to 89%. Echographic vegetations were significantly correlated with congestive heart failure and need for valve replacement and/or death. Seven of eight patients with definite aortic valve vegetations died or required surgery, compared with 1 of 11 patients with mitral or tricuspid vegetations alone. Prognostic importance of echocardiographically documented vegetations appears to depend upon their site within the heart.     

Echocardiographic diagnosis of left ventricular thrombi

Left ventricular thrombi have not been commonly recognized by M-mode or by cross-sectional echocardiographic techniques despite their frequency at postmortem examination in patients dying of cardiovascular disease. We discuss two patients, with left ventricular thrombi recognized echocardiographically and confirmed by pathologic and/or angiographic evaluation, whose M-mode and cross-sectional echocardiographic abnormalities add to the variable spectrum of appearance of left ventricular thrombi. The sensitivity and specificity of echocardiographic techniques in the diagnosis of intracardiac thrombi are discussed.     

Catheter-induced arrhythmias

Catheter-induced arrhythmias, which occurred several hours to several days following successful placement of temporary transvenous right ventricular electrodes or flow-directed pulmonary artery catheters were observed in six out of 106 patients. The arrhythmias took the form of ventricular bigeminy, ventricular tachycardia and, in one instance, isorhythmic dissociation. These arrhythmias were resistant to high doses of antiarrhythmic medication. The diagnosis can be suspected by noticing an excessive catheter loop or an altered catheter position in the chest x-ray or by observing faulty sensing, erratic pacing, or an increased threshold for ventricular stimulation. Corroborative evidence can be obtained from the electrocardiogram, where the catheter-induced depolarizations usually take a left bundle branch block pattern and the coupling interval of the ectopic beats may vary widely. Some pacing catheter-induced beats resemble the paced beats in configuration. In other cases, the rhythm cannot be explained by established principles. The diagnosis of catheter-induced arrhythmia is confirmed when the arrhythmia ceases following removal or repositioning of the catheter.     

Cardiologic manpower resources and their distribution: a challenge for the future.

All of us have some familiarity with the cardiology manpower study that has been published.¹ The results of this study must in large measure serve as the data base for the deliberations of this Symposium and for our planning for the future. Let me start, therefore, with a rather selective overview of the data pertinent to our task. Let us remember that, although I shall use the present tense, the data base refers to 1972–1973.     

Pigmented villonodular synovitis: A review with illustrative case reports

The histopathology of PVNS is characterized by giant cells, hemosiderin, variable collagenization, foam cells, and a histiocytic infiltrate. In the diffuse form of PVNS, the synovium displays numerous gross microscopic villi. It is unlikely that repeated trauma or hemorrhage are primary etiologic factors, and the disease is not a malignancy. Histiocytic proliferation may play a fundamental role in pathogenesis.PVNS occurs in two forms, localized and diffuse. Localized PVNS presents either as asymptomatic, solitary, nodular tenosynovitis, frequently on the digits of the hand, or as an intraarticular nodule, usually at the knee, with symptoms of internal derangement. Diffuse PVNS occurs as a monarticular arthritis with chronic swelling and stiffness; lobulated synovial thickening may be found on physical examination. Laboratory data are normal, except for a preponderance of red blood cells on synovial fluid analysis. Plain films show soft tissue swelling without periarticular osteopenia, and usually without joint space narrowing. Occasionally, x-rays in both the diffuse and localized forms of PVNS also show nonmarginal osseous cysts, either single or multiple. In DPVNS, arthrography may reveal a suggestive picture of multiple filling defects. Definitive diagnosis requires examination of tissue. In the differential diagnosis it is imperative not to confuse PVNS for a synovial sarcoma, in order to avoid unnecessarily radical surgery.PVNS is generally treated with surgical excision, either locally or, in diffuse disease, with synovectomy. Recurrences, which are frequent, are treated with repeat surgery, or, occasionally, radiotherapy. Both natural history and optimal therapy are unknown.