Coronary artery fistula: report of three cases

Three children are described with a right coronary artery fistula communicating with a right heart chamber. Each had a continuous murmur like that of a patent ductus arteriosus but situated at a lower level. Aortography established the diagnosis and excluded any accompanying malformation. It is concluded that to prevent complications surgical treatment should be recommended.

The echocardiographic assessment of pulmonary artery pressure and pulmonary vascular resistance

Serial assessment of the status of the pulmonary vascular bed requires bed requires cardiac catheterization. We have demonstrated the right ventricular systolic time intervals (RVSTI) may be measured from the pulmonary valve echo. The right ventricular ejection time (RVET) and right pre-ejection period (RPEP) were measured in 45 normal patients. The RVET and RPEP decreased with increasing heart rate but increased with age. The RPEP/RVET, however, was uninfluenced by either age or heart rate. The RPEP/RVET was, therefore, determined from the pulmonary valve echo in 64 patients with congenital heart disease who underwent cardiac catheterization. Increased pulmonary artery diastolic pressure (PADP), pulmonary vascular resistance (PADP), pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (MPAP) resulted inan increased RPEP/RVET. The use of the RPEP/RVET permitted the serial echographic evaluation of the pulmonary vascular bed in selected patients; marked elevation of the ratio indicated the presence of pulmonary hypertension.

[Nanism caused by water deprivation, with transitory growth hormone deficiency]

Report of a case of a girl admitted for alcoholic poisoning then for a toxic syndrome with considerable hypernatremia. Clinical examination showed a dwarfism (-4 S.D.) with break of the growth curve and bone-age retardation. History revealed cruelty and thirsting since the age of 2 years. Isolated somatotropin insufficiency was found. Separation from the family and free drinking induced a spectacular recovery of growth and normalization of growth hormone level. The relative role and relationships between growth hormone deficiency and chronic dehydration due to water deprivation in the physiopathology of dwarfism due to frustration are discussed.

[Critical outflow valve obstruction under the age of one year (author's transl)]

This report represents the Brompton Hospital experience of infants and neonates with critical pulmonary valve stenosis and aortic valve stenosis. There were 25 patients with critical pulmonary valve stenosis and 8 with critical aortic valve stenosis. Critical pulmonary stenosis: Among the 25 patients up to one year of age, 11 were girls and the commonest presenting symptom was cyanosis seen in 15, the commonest physical sign being a systolic ejection murmur with a single 2nd sound. A more detailed analysis of the symptoms, signs and findings at special investigation will be presented. The evolution of a satisfactory technique of operation will be indicated in these critically ill patients, and the late follow-up will be presented. Critical aortic stenosis: There were 8 patients in this group all of whom were male. Dyspnoea was the commonest presenting symptom with a systolic ejection murmur and hepatomegaly as the commonest signs. All patients in this group underwent open aortic valvotomy and/or valvuloplasty with 3 deaths. A late follow-up of the survivors will be presented. In summary, a series of 33 patients up to the age of one year with critical obstruction of either the pulmonary or aortic valves will be presented. (his is one of the larger series to be reported in this age group.

Congenital fistula between an aberrant systemic artery and a pulmonary vein without sequestration. A report of three cases

Three children had an arteriovenous fistula between an aberrant vessel from the descending aorta and a normal pulmonary vein in the posterior basal segment of a lung. The affected lung was otherwise normally developed. Only a few similar cases could be found in the literature.

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.

[Mechanism of presystolic intensification of mitral diastolic murmur in auricular fibrillation]

On the basis of a study of the sound pattern and of the data of right and left heart catheterization it has been established that the presystolic accentuation of the mitral diastolic murmur in atrial fibrillation is predisposed by the peculiarities of the dynamics of the left ventricular diastolic pressure. When the diastole is becoming shorter, the diastolic pressure does not grow gradually, as it happens under normal conditions, but progressively decreases during the whole period of the diastole which causes the appearence of a pressure gradient across the atrioventricular orifice, increasing during the diastole, an increasing diastolic blood flow rate through the mitral valve and, as a consequence, an accentuation of the mitral diastolic murmur during the diastole.

Nonrheumatic mitral incompetence

This review clearly indicates that a clinical picture of pure, isolated mitral insufficiency constitutes an interesting diagnostic challenge. In adult patients especially, this common valvular lesion is often nonrheumatic and may be found in a variety of cardiac conditions. The following provides a general orientation for their differential diagnosis. The first clue to the presence of papillary muscle dysfunction, a "spontaneous" chordal rupture, or a congenital or traumatic lesion which may account for the mitral insufficiency, may be derived from the patient's case history. A history suggesting systemic manifestations raises the possibility of atrial myxoma. When a familial incidence is reported, various syndromes or a cardiomyopathy should be considered as the etiology of the mitral incompetence. The auscultatory findings are typical in the mid-late systolic click and murmur syndrome, but recognition of this condition may require careful examination of the patient in different postures. The possibility of obstructive cardiomyopathy may be confirmed by the characteristic carotid pressure tracing. ECG findings of acute or chronic coronary heart disease favor the possibility of papillary muscle dysfunction. In addition, the ECG may support the clinical impression of a cardiomyopathy. Fluoroscopy may show calcification of the coronary arteries and/or dyskinetic left ventricular contractions in papillary muscle dysfunction, intracardiac calcifications in atrial space-occupying lesions, or calcification of a mitral annulus. Chest X-rays may contribute to the diagnosis of acute mitral insufficiency by showing a relatively small left atrium and ventricle in the presence of severe congestive failure. While echocardiography is invaluable as a noninvasive procedure and readily demonstrates the presence of a flail mitral leaflet from chordal rupture, or aids in the recognition of obstructive cardiomyopathy, an atrial space-occupying lesion, or of a billowing mitral leaflet, left ventriculography and coronary angiography constitute the procedure of choice for the fine anatomic diagnosis and functional evaluation of most cases. The accurate diagnosis of the anatomic disruption of the mitral valvular apparatus, as well as of the state of the myocardium and of the coronary arteries, is of particular importance in symptomatic patients, in order to determine the prognosis and to plan the surgical approach.

Saphenous vein graft from aorta to coronary vein with production of continuous murmur. A complication of coronary artery bypass surgery

A saphenous vein graft was inadvertently placed from the aorta to the coronary vein adjacent to the proximal left anterior descending coronary artery in a 53-year-old man with symptomatic coronary artery disease. The post-operative finding of a continuous murmur led to cardiac catheterization and successful surgical correction. The postoperative finding of a continuous murmur must alert the clinician to this possible technical error.

Analysis of homograft valve failure in 311 patients followed up to 10 years

Homograft aortic valve replacement was performed in 311 patients at the tnational Heart thospital, London, between 1964 and 1973. Valve failure has occurred in 61 patients (20%), 32 of whom survived reoperation. From 1963 through 1967, 156 valves were freeze-dried and account for 56 of the valve failures. From 1968 to 1973, 118 fresh or fresh-frozen valves resulted in only 5 failures. Six general types of failure have been identified: calcification (13), dehiscence (15), infective endocarditis (17), prolapse (6), cusp degeneration (5), and tear or perforation (5). Valve failure may be due to surgical technical error resulting in dehiscence or valve incompetence, or it may be related to degenerative changes in the homograft. The clinical results, supported by gross and histological examination and viability testing, enable us to conclude that fresh or fresh-frozen valves are superior to freeze-dried valves, having resulted in only 4% valve failure over the past five years.

Ventricular septal deffect and aortic imcompetence: clinical and haemodynamic study of 12 cases

The incidence of aortic incompetence complicating ventricular septal defect has been estimated as varying from 2-5% (Glasser et alii, 1972) to 5% (Nadas et alii, 1964). Although numerous publications have appeared describing the clinical, pathological and surgical aspects of this syndrome in different parts of the world, documentation of its occurrence in Asian patients has been rare except for reports from Japan (Tatsuno et alii, 1973; Mizuno and Saegusa, 1967). This paper describes our experience of 12 cases collected over 10 years.

[Hemodynamic aspect of infundibular hypertrophy of pulmonary valve stenosis]

Reactional infundibular hypertrophy in pulmonary valve stenosis is usually assessed on the catheterization curves obtained in the infundibulum and in the inflow tract of the right ventricle. It is usually indicated by a peculiar pattern of the infundibular curve: its descending branch is more rapid than in the inflow tract and is slightly curvilinear. This deformity is the more marked the more intense the hypertrophy. Simultaneously a mid-late systolic murmur is recorded into the infundibulum the more intense and high-pitched the more marked the hypertrophy. Comparison with the angiocardiographic data and the operative findings showed a good correlation.

The pathophysiology of idiopathic mitral valve prolapse

Left ventricular structure, function, and the coronary circulation were studied in a subset of patients with mitral valve leaflet prolapse. This group of 26 patients (21 females, five males, with mean age of 46 years), had the syndrome identified as idiopathic mitral valve prolapse (IMVP), which was characterized by a systolic click-murmur, clinical symptoms that were highly variable in duration and intensity, angiographically-documented mitral prolapse, and no obvious associated systemic or cardiovascular disease. Mitral regurgitation was of moderate degree in four, mild in 14, and absent in eight. The left ventricular (LV) end-diastolic volume index was elevated in ten of 25 (40%), the LV mass index was elevated in six of 17 (35%), but the LV anterior wall thickness was increase in only one of 17. Three major patterns of ventricular contraction were identified: 1) normal in seven; 2) abnormal, usually an inferior deformity and/or anterior asynergy, in eight; and 3) hyperkinetic in 11. Normal resting left ventricular function, assessed as an ejection fraction greater than 55%, was present in 17 of 25 (68%). Selective coronary arteriography was essentially normal in all 25 patients studied. An ischemic ECG response was detected during only one of 12 maximal treadmill exercise tests and in none of ten atrial pacing stress tests (AP). Myocardial lactate extraction did not change significantly during AP in six patients. We conclude that cardiomyopathy does not appear to be a primary cause or an important associated component of the IMVP syndrome. Abnormalities of the coronary circulation or of myocardial metabolism were not demonstrated by available methods. A proposed pathophysiological mechanism to explain the clinical and angiographic findings in IMVP is discussed.

Mitral valve prolapse and coronary artery disease. Clinical, hemodynamic, and angiographic correlations

Among 95 patients with angina pectoris and angiographically documented coronary artery disease (CAD), prolapse of the scallops of the posterior leaflet of the mitral valve (PLMV) was noted in 30 patients. Left ventriculograms in the right anterior oblique (RAO) projection revealed isolated prolapse of the posteromedial commissural scallop (PMCS) in 12 patients and the anterolateral commissural scallop (ALCS) in two patients. Seven patients had prolapse of both PMCS and ALCS, three had prolapse of the PMCS and middle scallop (MS), and six had prolapse of all three scallops of the PLMV. Left ventricular dilatation with increase trabeculations was observed in 19 patients. Contractility determined in a quantitative fashion by segmental motion analysis was markedly impaired in 29 patients. None of the patients had angiographic evidence of mitral insufficiency. Left ventricular dysfunction was documented in 28 patients by either elevated left ventricular end-diastolic pressure (LVEDP), low cardiac index (CI) or decreased ejection fraction (EF). In two patients in whom left ventricular contractility improved after aortocoronary by pass, previously prolapsed scallops could not be identified in the postoperative ventriculogram. Prolapsed PLMV is a frequent angiographic finding in patients with angiographically observed CAD. Impaired contractility of the ventricular myocardium and papillary muscles, left ventricular dilatation, and hypertrophy appear to play a significant role in the pathogenesis of this abnormality through distortion of the directional axis of the papillary muscles, asynergic contraction of the related free wall of the left ventricle, and changes in the normal spatial alignment necessary for mitral valve closure. The syndrome of papillary muscle dysfunction in patients with coronary artery disease represents a wider clinical spectrom than previously described.

Assessing the hemodynamic severity of acute aortic regurgitation due to infective endocarditis

Nine patients who underwent aortic-valve replacement for acute aortic regurgitation due to infective endocarditis were studied for clinical features that may be useful in assessing the severity of this condition. The traditional physical signs of a wide pulse pressure were absent. As compared to a group of patients with chronic aortic regurgitation, the mean (plus or minus S.D.) pulse pressure (55 plus or minus 7 vs. 105 plus or minus 22 mm Hg), left ventricular end diastolic volume (146 plus or minus 28 vs. 264 plus or minus 64 ml per square meter) and stroke volume (89 plus or minus 22 vs. 163 plus or minus 57 ml per square meter) were significantly smaller in the acute group (P less than 0.01). Left ventricular pressure exceeded left atrial pressure in late diastole, causing premature closure of the mitral valve, and the degree of early closure reflected the increase in left ventricular end diastolic pressure. Premature closure of the mitral valve was demonstrated by echocardiography in all patients. Those with echocardiographic signs of very early mitral-valve closure have severely volume-overloaded ventricles and are candidates for early valve replacement.

[Electrocardiographic and phonocardiographic findings in Ebstein's anomaly with special regard to its severity (author's transl)]

Electrocardiographically, the combination of the P-dextro-atriale and the RBBB without right ventricular overload almost certainly constitutes a pathognomonic finding in Ebstein's anomaly. The height of the P wave and the duration of the QRS complex are related the the severity of the anomaly. So the higher the P wave, the wider the QRS complex, the more severe is the Ebstein'ngs are detectable in the phonocardiogram. In the mild form, however, a loud systolic click and occasionally a low systolic murmur are present, while in severe forms, there is only a loud systolic murmur, and no systolic click.

Cardiac involvement in Whipple's disease

Although cardiac involvement in Whipple's disease has been reported previously, the extent and significance of such involvement has not been stressed. In our series of 19 patients, 58% had clinical cardiac findings and 79% had gross cardiac lesions at autopsy. Histologically there were PAS-positive macrophages in the pericardium, myocardium, and valves of each of these patients. These collections of macrophages were associated with chronic inflammatory cells and foci of fibrosis with resultant adhesive pericarditis, focal myocardial fibrosis similar to the fibrosis of idiopathic cardiomyopathy, and valvular fibrosis with deformity grossly resembling the valvular lesions of chronic rheumatic heart disease. Four of the patients with mitral valvular deformity had cardiac murmurs, and ECG changes were noted in six patients with mitral myocardial fibrosis. In addition, pericardial friction rubs were heard in two patients. By electron microscopy rod-shaped bodies, presumably bacteria, were noted in the mitral valve and myocardium. The structures are identical to those described in the small intestinal mucosa of patients with Whipple's disease and presumably are the causative agent of the pancardiopathy.