Edward R. Dorney

Parachute mitral valve: Further observations and associated lesions

Abstract The clinical, hemodynamic and anatomic findings in 3 patients with parachute mitral valve are presented. In each an abnormality not previously described in such patients was found. One had mitral regurgitation without stenosis; 2 had right ventricular outflow obstruction, which was due to an anomalous right ventricular muscle bundle in 1 patient and to valvular pulmonic stenosis in the other. The association of parachute mitral valve with other obstructive lesions in the systemic circulation has been emphasized in the past, but many other malformations also occur in patients with parachute mitral valve. The diversity of such malformations makes both diagnosis and operative treatment difficult.

Bacterial endocarditis: A review of 148 cases

Abstract One hundred and forty-eight cases of bacterial endocarditis seen in the Emory University Medical School affiliated hospitals between January 1948 and April 1960 are reported. The age, sex, and race distribution and classification of infecting organisms are presented. No change in the relative frequency of occurrence of any of the organisms was found during the twelve years of this study. Recognition of endocarditis was the single most important factor affecting prognosis. The paucity of classic physical findings in patients with proved endocarditis is emphasized. Complications resulting from emboli were the primary factor in hospital mortality. The long-term prognosis of those patients with healed endocarditis was good; 82 per cent were alive five years after discharge from the hospital. Congestive heart failure was shown to be the major cause of death in those patients who survived the period of hospitalization. The time of appearance of symptoms, the mortality and the pathologic findings are shown to be a function of the virulence of the individual organism rather than an attribute of any particular group of organisms. A regimen of penicillin and streptomycin in dosages suited to the individual organism is proposed as the treatment of choice, with addition of vancomycin, erythromycin or chloramphenicol as needed for specific organisms.

Coronary Bypass for Relief of Persistent Pain Following Acute Myocardial Infarction

Between January, 1976, and April, 1980, 116 patients had urgent myocardial revascularization for clinical instability within 30 days of acute myocardial infarction (MI). Group 1 (8 patients) had coronary bypass grafting within 24 hours of acute MI; Group 2 (20 patients) had coronary bypass grafting 2 to 7 days after acute MI; and Group 3 (88 patients) had coronary bypass grafting 8 to 30 days after infarction. Indications for operation were persistent or recurrent pain (81%), pain plus ventricular arrhythmias (12%), and pain plus compelling anatomy. The incidence of single-vessel, triple-vessel, and left main coronary artery disease was 28%, 31%, and 12%, respectively. There were no hospital deaths in the series. The incidence of inotropic requirements, postoperative intraaortic balloon pumping, ventricular arrhythmias, and perioperative infarction was higher in patients operated on within 7 days of acute MI than for patients having coronary bypass grafting after this time. There have been 5 late deaths during a mean follow-up of 14 months. Actuarial survival was 97% at 18 months. Seventy-one percent of patients are presently pain free. Graft patency was 84% in 17 patients recatheterized after coronary bypass grafting and in 14 patients, grafts placed into the area of infarction were patent. This study suggests that the frequency of perioperative complications will be increased in patients operated on within one week of MI, but after this period, coronary bypass grafting can be accomplished with the same morbidity as the of elective operation.

Propranolol therapy in patients undergoing myocardial revascularization.

The records of 185 consecutive patients having myocardial revascularization were reviewed with regard to preoperative administration of propranolol and intraoperative or postoperative complications. Tachycardia and hypertension before cardiopulmonary bypass were slightly more common in patients never taking propranolol or those who had discontinued it for more than 48 hours before operation. There was no statistically significant difference in the incidence of postbypass hypotension among patients who took propranolol within 24 hours of operation, those who discontinued it more than 24 hours before operation, and those who never took the drug. Operative mortality was not significantly different among patients who received propranolol within 48 hours of operation (3%), those who never took it and those who discontinued it more than 48 hours before operation (4%). Early in the series, five patients had an acute myocardial infarction within 48 hours after routine preoperative withdrawal of propranolol. Because complete withdrawal of propranolol in patients with unstable angina pectoris may lead to acute myocardial infarction, we recommend gradual withdrawal of the drug during 48 hours before operation. If this is not possible because anginal pain recurs or intensifies, then reduced doses may be given safely up to 10 hours before revascularization, provided that the patient is a satisfactory candidate for bypass and that adequate myocardial revascularization can be accomplished.

Marfan's syndrome with massive calcification of the mitral annulus at age twenty-six

Abstract A 26 year old white man with a typical Marfans syndrome and massive calcification of the mitral annulus unaccompanied by obvious involvement of the mitral leaflets is presented. He underwent surgical correction of an ascending aortic aneurysm with a Teflon graft, and the replacement of an incompetent aortic valve with a No. 12 Starr-Edwards prosthesis. His postoperative course was uneventful. No murmurs were associated with the calcified annulus. It is not clear whether the calcified annulus can be included as a connective tissue defect characteristic of Marfans syndrome or whether it occurred as an isolated finding typical of a noninflammatory degenerative aging process.

Bacterial endocarditis in congenital heart disease

Abstract A study was made of 38 patients who developed bacterial endocarditis as a complication of congenital heart disease; in these patients, who were seen from 1947 through 1960, the staphylococcus was the infecting organism found most frequently. All patients presented with fever, and 79 per cent developed splenomegaly at sometime during the illness. Embolic manifestations often masked the underlying disease. Congenital anomalies, which cause significant pressure gradients and jet effects across defects or valves, predispose to endocarditis. Penicillin in adequate doses, together with streptomycin, is the mainstay of treatment and should be administered from 3 to 4 weeks. On occasion, other antibiotics are added. Seventy-nine per cent of the patients survived hospitalization. Only 1 patient died subsequent to discharge. With the exception of 4 patients who were lost to follow-up, the others are alive, 1 month to 12 years after hospitalization.

TREATMENT OF SHOCK FOLLOWING MYOCARDIAL INFARCTION. DIVERSE ACTIONS OF DRUGS USED.

Almost every drug used in the treatment of myocardial infarction accompanied by shock can have serious adverse effects. Inadequate myocardial contractility apparently is at least partly responsible for the hypotension. Accordingly, sympathomimetic amines having direct myocardial actions (norepinephrine, mephentermine, metaraminol) appear to be more suitable than amines having little or no myocardial effect (methoxamine, phenylephrine). However, therapy must be tailored to individual needs; the amines are not interchangeable.