Bernard L. Brofman

Unilateral Pulmonary Artery Absence or Hypoplasia Radiographic and Cardiopulmonary Studies in Five Patients

The clinical entity of unilateral pulmonary artery absence or hypoplasia can be readily diagnosed on the basis of routine clinical evaluation. This report is based upon 5 patients in whom the diagnosis was suspected and eventually confirmed with the aid of special studies. Characteristic hemodynamic findings were demonstrated by means of cardiac catheterization and contrast visualization of the cardiopulmonary system.

Cardioaortic Fistula Temporary Circulatory Occlusion as an Aid in Diagnosis

Rupture of a sinus of Valsalva aneurysm into the right ventricle produces a dramatic clinical syndrome characterized by a rapid and relentlessly unfavorable course. Early diagnosis is essential for surgical repair before an irreversible stage is reached. Cardiac catheterization and retrograde aortography confirmed the diagnosis in the case reported. With the aid of temporary circulatory occlusion, the fistula was demonstrated by contrast material injected via an aortic catheter. Although the fistula and the accompanying ventricular septal defect were closed at open-heart surgery, the markedly enlarged heart could not resume its function.

Factors affecting the pulmonary “capillary” pressure∗

Abstract 1. 1. Pressure in a major branch of a pulmonary artery beyond an occluding balloon invariably fell to pulmonary capillary levels and resembled the latter closely. 2. 2. Distal pressures correlated well with pulmonary capillary pressures and were normal in control patients and elevated in those with left ventricular failure and/or mitral disease. 3. 3. In pulmonary emphysema, the distal and pulmonary capillary pressures varied greatly with respiration and occasionally reached considerably elevated levels during expiration. Exercise in such patients caused a significant apparent rise in wedge pressure. 4. 4. The role of bronchomotor tone and intraalveolar and intrapleural pressures are discussed with regard to their possible role in regulating pulmonary artery pressure. 5. 5. The method has been of value in obtaining pulmonary capillary or distal pressures in those individuals, particularly with pulmonary artery hypertension, in whom such pressures were otherwise unobtainable. 6. 6. The danger of using a static figure or zero in obtaining pulmonary arterial-pulmonary capillary gradients for calculation of pulmonary resistances, particularly in pulmonary emphysema, is emphasized.

Coronary heart disease III. Chronic arrhythmias as influenced by the beck operation

M ORE TIXAN 350 patients with coronary heart disease were operated on by Dr. Claude S. Beck in Cleveland in the six years covered by this study. The diagnosis of coronary heart disease had been established prior to operation on the basis of existing criteria.‘s2 (Another 200 patients referred for operation were rejected because the diagnosis could not he established, or because other organic disease simulating coronary heart disease was found.) Of profound importance is a unique experience not heretofore available, in patients with coronary heart disease, for direct observations on such hearts. These observations included direct electrocardiographic recording from various epicardial, intramyocardial, and endocardial areas, and extensive hemodynamic studies, including measurements of coronary blood flow and myocardial utilization of oxygen and various substrates. Thus, we have availed ourselves of a remarkable opportunity for a direct correlation of clinical, experimental, surgical, and pathologic observations. Its very nature is such that clinical observation is the sine qun non in evaluating the treatment of coronary heart disease. But this disease continues to defy ‘Lobjective” evaluation. Consequently, its treatment has suffered from a great reluctance to make the necessary correlations between clinical and experimental observations. The historical development of present-daycomprehension of coronary heart disease is characterized by a disposition to marvel at, and then reject, reproducible and significant clinical observations, rather than to suffer the inconvenience of adapting “well-established” concepts to apparently mutually exclusive observations. As a matter of fact, there exists a general resistance toward positive action under any circumstances. The natural reluctance of the physician to transfer laboratoryresults to the patient has reached its greatest peak of development in the field of coronary heart disease. Obvious clinical benefit associated with procedures which have adequate laboratory substantiation should not be categorically rejected merely because human coronary heart disease cannot be reproduced exactly in the laboratory, or because its unpredictability defies simple statistical evaluation. Indeed, if need be, it is possible to achieve “progress without statistics.“R Even nova, during the observation of the tcrcentenary of William Harvey’s death, many of the significant contributions made since his time are still engulfed in controversy. Furthcrmorc, unless there is adequate reappraisal of certain outmoded concepts, such controversy will always be encouraged by seemingly paradoxical but impressive clinical benefits associated with such dissimilar agents as nitroglycerin and surgical operation for coronary heart discasc. Kcither of these presumes to produce tremendous alterations in total coronary inflow, but their admittedly limited contributions are critically decisive in the precariously compensated circulation of a potentially ischemic area.