B. Woodfin Cobbs

Ventricular buckling: A factor in the abnormal ventriculogram and peculiar hemodynamics associated with mitral valve prolapse

Because of intractable ventricualr arrhythmias after a near-fatal episode of ventricular fibrillation, a patient with idiopathic mitral valve prolapse was subjected to mitral valve replacement. Vector analysis and intraoperative epicardial mapping localized the ectopic focus to the region of the posterior papillary muscle. The patient is alive and well two years after surgery; chronically inverted T waves have become upright. But propranolol and diphenylhydantoin are needed to prevent arrhythmias and T wave abnormalities during standing and exercise. Preoperatively, with the onset of mitral regurgitation and a second rapid phase of prolapse, the ventriculogram was deformed by abnormal midsystolic hyperkinesis at both sites of papillary muscle insertion. Postoperatively, focal hypokinesis appeared in the same areas, implying that they had been retracted by the prolapsing valve. Preoperatively, a papillary tip could be seen entering the mitral ring while coronary arteriography showed late systolic elongation of a small vessel feeding the anterior papillary muscle, suggesting that the papillary apparatus was indeed subject to damaging stress during the abnormal basal movement. Three other persons with severe mitral prolapse (but intact chordae) have had valve repacement and developed qualitatively similar changes in the ventriculogram. Papillary speciments in two showed significant fibrosis. Indication for operation in one of these was edpisodic ventricular fibrillation, which has not recurred. A spectrum of ventriculographic abnormality associated with mitral prolapse could be partly explained by hypokinesis of the papillary loops, variably disguised by retraction stress tansmitted from the billowing leaflets, translocation of blood into the expanding valve sail, and various degrees of unloading into the left atrium. Abnormal intraventicular flow may probably result from associated prolapse of the anterior leaflet and from buckling of the papillary sties toward the mitral annulus. Unusual physical findings in the operated cases and in eight other patients define a clinically recognizable syndrome in which severe prolapse abbreviates left ventricular ejection. Liability to symptoms and to progression of disease seems high in this group.

Avoidance of Transverse Midventricular Disruption Following Mitral Valve Replacement

From 1974 through 1977 when our hospital mortality for aortic valve replacement and myocardial revascularization was 3.5% and 1.1%, respectively, hospital mortality for mitral valve replacement (MVR) was 8.3% (13/156)--as high as 14.9% in 1976. Transverse midventricular disruption (TMD) was present in 7 of 10 patients on whom an autopsy was done and was clinically diagnosed in 3 others without postmortem examination. Transverse midventricular disruption presented as refractory myocardial failure immediately on termination of bypass or later (1 to 5 days) after an initial period of good hemodynamics. It appeared to result when volume loading or afterload pressure was returned to the untethered ventricle after MVR performed with potassium-induced, cold cardioplegia and ischemic arrest. Operative techniques were modified to preserve a portion of the mitral suspensory mechanism, to extend the reperfusion interval following cardioplegia and ischemic arrest, and to control strictly ventricular volume and pressure loading following bypass. By utilizing these methods, TMD was avoided from 1978 through 1982, and hospital mortality for MVR was 3.7% (9/241). The improved hospital mortality and avoidance of TMD did not result from patient selection. Allowing adequate time for recovery of the myocardium after cardioplegia plus ischemic arrest prior to ventricular loading, preservation of mitral suspensory function, and strict control of preload and afterload pressures have been effective in lowering hospital mortality for MVR and have eliminated TMD in a 5-year period.

Terminal cardiomyopathy, splitting, and borderline personality organization

A 63-year-old married man with idiopathic terminal cardiomyopathy was admitted to the medical service for treatment of advanced heart failure. A psychiatric consultation was requested to assist the medical treatment team in dealing with the patients abusive behavior. The case is presented and discussed within the context of understanding the borderline personality in the medical setting.

Early diastolic sound of constrictive pericarditis

In two patients with constrictive pericarditis an absent or faint early diastolic sound became prominent with squatting, phenylephrine infusion or injection of contrast medium and was obliterated by nitroglycerin. The lability of the sound allowed correlations to be made with acute changes in the right ventricular pressure curve. By eliciting an otherwise inaudible early diastolic sound, squatting may be a useful bedside maneuver in the diagnosis of constrictive pericarditis.