A.Calhoun Witham

Double outlet right ventricle; a partial transposition complex.

Abstract Three anatomic variations of a partial transposition complex characterized by pulmonary and systemic arterial circuits arising entirely from the right ventricle are described. Clinical data is presented in the first, the “Eisenmenger type,” in which the heart revealed coarctation and complete transposition of the aorta, large pulmonary artery in normal position, ventricular septal defect, and patent ductus arteriosus. The clinical picture of this syndrome is characterized by slowly developing cyanosis, a parasternal systolic murmur, occasionally a diastolic murmur and signs of aortic coarctation. Survival may reach the second decade. Fluoroscopy reveals plethoric lung fields, combined ventricular enlargement, and a wide supracardiac shadow in the anteroposterior and left oblique views. Another example of this category was complicated by absence of the aortic arch. It was associated with a small separate ascending aorta, absence of the aortic arch, and descending aorta supplied by a patent ductus. All vessels arose from the right ventricle. Survival past the age of 6 years has not been recorded in this type. The second principal variation of the “double outlet” right ventricle is the Fallot type. It resembles the tetralogy of Fallot because of various degrees of pulmonary hypoplasia. Biventricular enlargement, however, suggests that one is not dealing with a true tetralogy, and angiocardiography may demonstrate the exact relationship of the septal defect to aortic and pulmonary orifices.

Cardiomyopathy without cardiomegaly in alcoholics

Abstract For obvious reasons it is important to recognize alcoholic cardiomyopathy early in its natural history. Hemodynamic studies were performed in nine patients with normal ECGs and normal cardiothoracic ratios on chest x-rays. Findings were elevated mean LV end-diastolic pressure, low mean cardiac output, and depressed myocardial contractility. Thus, true functional cardiac impairment may exist in these patients even prior to the development of abnormal clinical parameters such as cardiomegaly.

The vectorcardiogram recorded with sponge electrodes.

Abstract A series of 133 normal young adults has been studied vectorcardiographically by the Helm lead system utilizing sponge electrodes. A quantitative system of analysis, based principally upon loop morphology, was used to describe the loops. Planar and spatial characteristics of five selected vectors, time intervals, rotation, and major components of the scalar orthogonal leads are recorded. Measurements of diagnostic importance are stressed. A comparison has been made with data reported for the Frank system. In general, there was similarity between planar angles for early and late vectors. The Helm mid-loop vectors, however, appear to be more rightward and less posterior; vertically oriented vectors have higher voltages, and posterior ones have lower voltages. Males had significantly higher voltages and more horizontal loops than did the females. The features of normal loops by this system of recording and their common variations are described in detail.

The effect of upright tilt on the volume of the failing human left ventricle

The effect of a passive change from supine to 25-degree head-up tilted position on left ventricular volume was studied by echocardiography and other noninvasive techniques in 18 normal subjects, 6 patients with compensated LV volume overloading, and 12 patients with LV failure. In normal subjects and patients with compensated LV volume overloading, 10 minutes of head-up tilt resulted in a significant decrease in the echocardiographic LV internal dimension equivalent to a decrease in the calculated LV end-diastolic volume of 27 and 16 per cent, respectively. In contrast, no change in LV end-diastolic dimension and volume was noted during tilt in the patients with LV failure. The response of heart rate, blood pressure, and LV ejection fraction to this intervention was insignificant in all groups. These data indicate that volume preload is unresponsive to postural changes in patients with LV failure but not in normal subjects or in those with compensated LV volume overloading. It is suggested that the effect of posture on LV volume and output is primarily determined by the absence or presence of LV failure and the consequences of it on the peripheral circulation.

Diagnosis of ostium primum defects of the atrial septum

Abstract Four cases thought at operation to represent varieties of ostium primum defect and one similar unexplored case are presented together with clinical data, electrocardiograms, x-rays, fluoroscopy, phonocardiograms and catheterization findings. The differentiation of the ostium primum from the more common type defect of the atrial septum is discussed. The majority of the criteria for differentiation depend on the presence of either a cleft mitral leaflet or an incompetent common atrioventricular valve. An interesting but incompletely explained finding is the presence of a remarkably soft apical first sound. It appears likely that the diagnosis can be made preoperatively in the majority of cases. It is probably impossible to distinguish the rare ostium primum defect with normal A-V valves from the usual type of atrial septal defect prior to surgical exploration.

Tricuspid atresia with transposition of the great vessels

Diagnostic and therapeutic experience with patients having tricuspid atresia with transposition of the great vessels is reviewed and contrasted with previous reports of this condition. In the absence of pulmonic stenosis, the clinical picture is nearly indistinguishable from massive left-to-right shunts of all causes, although the electrocardiogram and cardiac roentgenogram usually indicate the correct diagnosis. The presence of naturally occurring pulmonary stenosis markedly alters the clinical picture; surgical creation of pulmonic stenosis appears to be lifesaving.

Mechanical Inscription of the Vectorcardiogram

A modification of the vectorcardiographic method of studying electrical events is presented. Simultaneous scalar leads, taken by any vector lead system, are first recorded. The important time intervals, difficult or impossible to read from the loop itself, are measured from these tracings. Proper pairs of the scalar leads can then be rapidly integrated into vector loops by an easily constructed drawing board based on the pulley system. This instrument is described in detail. It is demonstrated that loops so derived do not appear to differ in their important characteristics from electronically integrated loops.