Glucose-insulin-potassium induced alterations in individual plasma free fatty acids in patients with acute myocardial infarction

Total and individual plasma free fatty acids (FFA) were measured on admission and over the next 4 days in 24 patients admitted to the hospital with chest pain and suspected acute myocardial infarction (AMI). In a prospective randomized fashion, the patients were either given an infusion of 300 gm of glucose, 50 units of inuslin, and 80 mEq of KCl per liter at a rate of 1.5 ml/kg/hr over the initial 48 hours of hospitalization, or they served as controls receiving conventional therapy. Eleven patients were in the control group and 13 were in the glucose-insulin-potassium (G-I-K) group. Twenty-one of the patients had an AMI by CK-MB rise and ECG changes (in the G-I-K group three did not evolve AMI). The total plasma FFA were 840 ± 134 μM/L in the controls and 933 ± 160 μM/L in the G-I-K group initially (prestudy). Total FFA rapidly fell in the G-I-K group and then rebounded when G-I-K was stopped. In contrast, total FFA values fell gradually in the control group over the 4-day period. The individual FFA had similar percentages initially in the two groups. In the control group the percent of individual plasma FFA was unchanged over the period studied, although there was some mild random day-to-day fluctuation. In contrast in the G-I-K group linoleic acid fell both during and after the infusion was stopped (26.8% to 19.1% P < 0.001). Arachidonic acid doubled in percentage of the total FFA value during G-I-K infusion (3.1% to 6.5%, P < 0.002) and returned to the control value when it was stopped. Thus G-I-K infusion during AMI reduces the total level of plasma FFA while increasing the percent of arachidonic and decreasing the percent of linoleic acid, observations proposed to reflect improved membrane stability of the ischemic myocardium.     

Univentricular heart: An angiographic study

Axial angiograms of 54 patients with a univentricular heart were reviewed to determine the anatomic details demonstrated by this technique. The main ventricular chamber was of left ventricular morphology in 36, right ventricular morphology in 13 and indeterminate in 5 patients. Forty-three patients had a rudimentary ventricular chamber that was supporting a great artery in 35 patients. Eighteen patients had separate atrioventricular (A-V) valves. In four of them, one A-V valve was overriding the trabecular septum, but predominantly committed to the main ventricular chamber. Eleven patients had a single right and 13 a single left A-V valve; a common A-V valve was present in 12.The techniques used provided good demonstration of the morphology of the ventricular mass, particularly the position and orientation of a septum when present. They also delineated the morphology of the A-V valve or valves and their precise ventricular connection. Ventriculoarterial connections and relations were readily determined. It is concluded that these methods are superior to isolated frontal and lateral views and provide thorough demonstration of the intracardiac anatomy of patients with a univentricular heart.     

Angiography of atrioventricular canal defects

The axial angiograms of 20 patients with an atrioventricular (A-V) canal defect were carefully examined and compared with anatomic observations made at operation. A common A-V valve was present in 15 patients and two separate valves in 5. The atrial septal defect, the anatomy of the ventricular septum and the morphology and functional status of the A-V valves were well demonstrated. There was consistent angiographic deformation of the normally straight contour extending from the noncoronary aortic cusp to the crux cordis observed in the four chamber and elongated right anterior oblique projections of the left ventricular angiogram of each patient. This deformity is caused by the deficiency or absence of the A-V septum and is the best angiographic sign of the malformation. The differentiation of two separate valves from a common A-V valve was uniformly made. When a common A-V valve was present, three of the five leaflets were usually identified but distinction of the free floating from the tethered anterior leaflet was not always possible. It is concluded that axial techniques provide more complete angiographic definition of the anatomic abnormalities of A-V canal defects than are demonstrated from frontal and lateral views.     

Early diagnosis of pericarditis in acute myocardial infarction

Pericarditis complicating acute myocardial infarction assumes increasing importance in this era of quantitating infarct size by precordial ST segment mapping. Early recognition of this complication avoids diagnostic and therapeutic errors. In this study we looked for factors that could alert to the early diagnosis of pericarditis, such as ST elevation measured within 24 hours from onset, extent of CPK, LDH, and SGOT elevation, as well as degree of pump dysfunction. ST segment elevation in millimeters on admission seemed to be one factor that was of predictive value in this condition.Pericarditis occurred in three forms: (1) within a few hours from the onset of myocardial infarction and this form seems to carry a high mortality rate; (2) a more common variety occurs within 24 to 72 hours from onset and carries a higher mortality rate than matched controls; and (3) the late syndrome of Dressler's, not observed in our series. Aside from increased incidence of heart failure, other complications of myocardial infarction and the coronary risk factors were not significantly higher in patients with pericarditis. Salicylate treatment offers immediate relief in the majority of patients.     

Critical analysis of clinical factors in estimating severity of aortic valve disease

Clinical data were analyzed in a group of 79 patients with aortic stenosis or combined aortic stenosis and insufficiency by the usual methods and by discriminant function analysis. It was possible to predict the level of aortic-left ventricular gradient (above or below 50 mm Hg) from signs and symptoms in approximately 83 percent of patients. The analyses performed yielded insight into the significance of the various commonly presenting symptoms in these lesions. For example, the slope of the carotid upstroke, calcium in the valve, T wave inversion and a large thrusting left ventricular impulse all indicated a high peak gradient, whereas syncope did not contribute to the separation of values. Heart failure made an insignificant contribution to prediction of the level of gradient.     

Quantitative axial oblique contrast left ventriculography: Validation of the method by demonstrating improved visualization of regional wall motion and mitral valve function with accurate volume determinations

To compare the relative merits of conventional and axial $\text{RAO}\text{LAO}$ angiography, we performed biplane left ventricular (LV) cineangiograms in 36 patients in both the conventional 30-degree $\text{RAO}\text{60}\text{-}\text{degree}$ LAO projection and in the axial 45-degree $\text{RAO}\text{60}\text{-degree}\text{LAO}\text{25}\text{-degree}$ cranial projection, in random sequence. LV volumes were calculated by a computerized system utilizing modification of the area-length method. End-diastolic volume, end-systolic volume, and ejection fraction correlated closely between the two projections (r = 0.93, 0.95, and 0.86, respectively). The axial 60-degree LAO view projected the LV apex inferiorly, the LV outflow tract superiorly, reduced LV foreshortening, and “uncovered” the LV outflow tract in all cases. Segmental wall motion abnormalities of the ventricular septum, apex, and posterior wall were better evaluated by the axial 60-degree LAO view in patients with regional asynergy in these zones. The 45-degree RAO, compared to the 30-degree RAO view, allowed a true tangential view of the mitral valve and provided a large “clear area” between the mitral valve and descending aorta, which improved the ability to quantify mitral regurgitation. Thus, axial oblique LV angiography improves evaluation of LV regional wall motion and mitral valve function without compromising LV volume quantitation.     

Effects of isolated interventricular septal ischemia on global and segmental function of the canine right and left ventricle

The effects of isolated septal artery ligation were studied in 17 dogs. Contraction of the interventricular septum (IVS) and the free walls of both ventricles was measured by implanting ultrasonic crystals. Global ventricular function was assessed by Starling function curves. Following septal artery ligation, IVS shortening was immediately replaced by systolic lengthening. Thirty minutes after septal artery ligation, the right ventricular (RV) stroke work (SW) was significantly depressed at end-diastolic pressure (EDP) of 7 and 8.5 mm Hg from control values of 7.6 ± 0.4 and 8.6 ± 0.6 gmM to 6.7 ± 0.4 and 7.4 ± 0.5gmM respectively. However, LVSW after septal artery ligation was similar to control values for EDP from 5 to 19 mm Hg. These changes were associated with unchanged RV free wall movement of 21 ± 3% in the inflow region and 23 ± 5% in the outflow region. LV free wall systolic shortening following septal artery ligation increased by 16 ± 3%. It is concluded that canine septal artery ligation causes global dysfunction of the RV but not of the LV.     

Left ventricular function in systole and diastole in constrictive pericarditis

Left ventricular function was studied in systole and diastole in 30 patients with constrictive pericarditis. Left ventricular end-diastolic volume was used to divide the patients into three arbitrary groups: severe constriction (EDV < 25 ml./M.²), moderate constriction (EDV 25 to 50 ml./M.²), and mild constriction (EDV > 50 ml./M.²).The patients had high ventricular diastolic and venous filling pressures (mean LVEDP = 23 ± 7 mm. Hg, mean RVEDP = 20 ± 7 mm. Hg). Measurements related to absolute fiber shortening (stroke index, stroke work index, and left ventricular ejection rate) were reduced and linearly related to the degree of constriction as assessed by the end-diastolic volume.Measurements of relative fiber shortening or lengthening (ejection and filling fraction and circumferential fiber shortening) were normal despite great reduction in ventricular volumes.Velocity measurements, peak LV $\text{dp}\text{dt}$ and mean velocity of circumferential fiber shortening were normal or slightly reduced.These changes were reflected in the systolic time interval measurements pre-ejection phase, left ventricular ejection time, and the ratio $\text{PEP}\text{LVET}$.Diastolic function of the ventricle was abnormal; the distensibility index of the ventriculo-pericardial system ($\text{ΔV}\text{ΔP}$) was low and the passive elastic modulus in-increased. The change in compliance correlated with the degree of constriction and there was a linear relationship between compliance and EDV.The ventricle was underloaded despite the high filling pressure and stroke work index was reduced; extrinsic compression raised the diastolic pressure and reduced left ventricular volumes.