David C. Levinson

Dissecting Aneurysm of the Aorta: Its Clinical, Electrocardiographic and Laboratory Features: A Report of Fifty-eight Autopsied Cases

The literature has been reviewed, and 58 autopsied cases of dissecting aneurysm of the aorta observed at the Los Angeles County Hospital over a ten year period have been carefully studied. Clinical-pathologic correlation has been attempted whenever possible, with emphasis on diagnostic features. The increasing incidence of accurate diagnosis of dissecting aneurysm has been noted, and it is hoped that this review will help solidify the clinical syndrome or syndromes of the condition and thus facilitate diagnosis in dubious instances.

A study of the beneficial effects of anticoagulant therapy in congestive heart failure.

Excerpt Thromboemboli are a frequent cause of death in patients with congestive heart failure. In 565 patients with rheumatic heart disease and congestive heart failure, autopsied at the Los Angele...

Cardiovascular findings in children with sickle cell anemia

Abstract Cardiovascular findings are described in seven children with sickle cell anemia. Clinically the following features were noted: (1) exertional dyspnea and fatigue; (2) wide fixed splitting of the second heart sound; (3) third “filling” heart sound in five of the seven cases; (4) systolic murmur of grade II intensity or louder, most prominent over the upper left sternal border; (5) roentgenographic evidence of diffuse cardiomegaly and increased pulmonary vascularity; (6) abnormal electrocardiograms in four cases. Laboratory findings of note were: (1) hemoglobins from 6.3 to 9.5 gm. per cent and hematocrit readings from 18 to 27 volumes per cent; (2) increased total blood volumes and plasma volumes in five of six patients. Right heart catheterizations in these patients revealed the following: (1) normal vena caval, right atrial, pulmonary artery and wedged pulmonary artery pressures; (2) normal or low pulmonary vascular resistances at rest and with exercise; (3) cardiac indices averaging twice normal; (4) increased stroke indices; (5) arterial oxygen unsaturation at rest and after breathing 100 per cent oxygen in all cases; (6) relatively small arteriovenous oxygen differences at rest and with exercise; (7) relatively high coronary sinus oxygen saturations; (8) an abnormal Valsalva response.

Acquired interventricular septal defects due to myocardial infarction and nonpenetrating trauma to the chest

Abstract 1. 1. Acquired interventricular septal defects have been discussed and two new cases presented. 2. 2. In both cases the diagnosis was confirmed by cardiac catheterization and the presence of moderate pulmonary hypertension was observed. 3. 3. The pulmonary hypertension, in the absence of congestive failure, appears to be related to the magnitude of left to right shunt and therefore should be reversible by surgical correction of the defect. 4. 4. The degree of the left to right shunt may indicate the size of the opening in the ventricular septum and is due to either single or multiple defects. 5. 5. The shunt flows and cardiac outputs in postmyocardial infarction septal defects are lower than in the post-traumatic cases. This is most likely caused by pre-existing myocardial disease present in the postinfarction group.

Increasing Bacterial Resistance to the Antibiotics A Study of 46 Cases of Streptococcus Endocarditis and 18 Cases of Staphylococcus Endocarditis

Observations on bacterial resistance to antibiotics in 64 patients with bacterial endocarditis are reported. Streptococcus endocarditis is contrasted with staphylococcus endocarditis as regards course, bacterial resistance to antibiotics, and mortality. The management of bacterial resistant patients is stressed and particular emphasis is placed upon the role of the newer antibiotics such as aureomycin.

Hemodynamic findings in heart block with slow ventricular rates

Abstract Six patients with acquired heart block and ventricular rates below 40 per minute were catheterized. Pertinent hemodynamic findings were: (1) elevated right atrial and right ventricular systolic pressure; (2) atrial systolic waves transmitted to both the right ventricle and main pulmonary artery successively; (3) giant atrial a waves occurring at the time of simultaneous atrioventricular systoles, but not when this occurred in or near early diastole of the preceding ventricular beat; (4) systolic pulmonary hypertension; (5) reduced mean brachial artery pressure, but elevated mean pulmonary artery pressure; (6) increased total vascular resistance of both the pulmonic and systemic circulations; (7) reduced oxygen consumption; (8) reduced cardiac index; and (9) increase of stroke index to 28 per cent or less above normal in four of the six patients. The injection of Isuprel via a catheter directly into the main pulmonary artery in two patients resulted in: (1) more rapid ventricular rate; (2) conversion to a sinus rhythm in one; (3) unaltered stroke volume; (4) increased cardiac output; (5) unaltered oxygen consumption; (6) decreased arteriovenous oxygen difference; and (7) decreased total vascular resistance in both the pulmonic and systemic circulations.

A correlation of the spatial vectorcardiogram with right ventricular hypertrophy

Abstract 1. 1. A vectorcardiographic study of thirty-four patients with congenital heart disease and mitral stenosis is reported. All patients had cardiac catheterization and none except one had left ventricular hypertrophy. 2. 2. With increasing right ventricular work, there is an increased rightward and anterior deviation of the horizontal plane loop and of the spatial vectorcardiogram to the right anterior inferior octant in both lesions. 3. 3. There is a better correlation between the vectorcardiogram and right ventricular work than between the electrocardiogram and right ventricular work. 4. 4. The vectorcardiogram shows the pattern of right ventricular hypertrophy clearly. The electrocardiogram is usually reliable only in the classical pattern of right ventricular hypertrophy but not when incomplete right bundle branch block is present. In nine patients with incomplete right bundle branch block, the vectorcardiogram clearly shows that this lesion also represents right ventricular hypertrophy, thus confirming previous studies in congenital heart disease and extending them to patients with mitral stenosis as well. 5. 5. The vectorcardiogram may serve as a gross quantitative estimate of the degree of right ventricular hypertrophy, especially in congenital heart disease.

Clinical Studies on Involvement of the Pulmonary Artery by Syphilitic Aortic Aneurysms

Cardiac catheterization and angiocardiography studies are reported in two patients with syphilitic aortic aneurysms, both of which compromised the pulmonary circulation. In the first instance the right main pulmonary artery was compressed and pulmonary hypertension proximal to the compression resulted. In the second patient the aneurysm ruptured into the pulmonary artery producing an aortic-pulmonary fistula. This patient also had pulmonary hypertension and evidence at cardiac catheterization of a large left-to-right shunt. The difficulty of making the clinical diagnosis of pulmonary artery compression by an aortic aneurysm is discussed. Cardiac catheterization and angiocardiography were essential for establishing this diagnosis in life.

The electrocardiogram in congenital heart disease and mitral stenosis; a correlation of electrocardiographic patterns with right ventricular pressure, flow, and work.

Abstract 1.1. Mean levels of right ventricular pressure, flow, and work, but particularly mean levels of right ventricular work, are considerably higher in congenital heart disease than in mitral stenosis. 2.2. In congenital heart disease only abnormal electrocardiograms appeared above a mean right ventricular systolic ejection pressure of 30 mm. Hg. In mitral stenosis normal or borderline electrocardiograms appeared frequently up to a mean pressure level of 60 mm. Hg. 3.3. In congenital heart disease almost all electrocardiograms were abnormal above a right ventricular work load of 1 kg. M./min./sq.M. In mitral stenosis, normal electrocardiograms often occurred at work levels above 1 kg. M./min./sq. M. 4.4. In both mitral stenosis and congenital heart disease, the pattern of partial right bundle branch block appeared at almost all levels of right ventricular pressure and work, and thus this pattern appeared to be almost as significant as the classic pattern of right ventricular hypertrophy in the detection of right ventricular hypertension and presumptive right ventricular hypertrophy. 5.5. Gross electrocardiographic differences between congenital heart disease and mitral stenosis were present in all precordial leads; this was most marked in V 3R and V 1 , where the R wave in congenital heart disease was three to four times as tall as the comparable R wave in mitral stenosis. 6.6. In congenital heart disease, the electrocardiogram is remarkably accurate (91 per cent of cases) in the detection of right ventricular hypertrophy. In this disease no definite correlation was present between abnormalities of individual waves such as the height of R or RS ratio over the right precordium and levels of pressure or work. 7.7. The electrocardiogram in mitral stenosis is less diagnostic (51 per cent of cases) in the detection of right ventricular hypertrophy. But when the electrocardiogram is abnormal, a definite correlation is present between the height of R and RS ratios over the right precordium and levels of right ventricular pressure and work. 8.8. These differences in the total electrocardiographic picture suggest fundamental differences in the genesis of right ventricular hypertrophy in the two diseases.

Evidence for retrograde transpulmonary propagation of the V (or regurgitant) wave in mitral insufficiency

Abstract 1. (1) Seven patients with mitral insufficiency and giant V waves in the wedged pulmonary artery position have been studied. 2. (2) The systolic peak of the V (or regurgitant) wave approximated the systolic peak of the right and main pulmonary artery pressure curves. 3. (3) Pulmonary arteriolar resistance was found to be normal or reduced. 4. (4) A consideration of the hemodynamic data favors the concept that in mitral insufficiency a retrograde transmission of the V wave may occur and that it results from an increase in the tone of the pulmonary vascular system without an increase in the pulmonary vascular resistance.