Egbert H. Fell

Intrarenal arteriovenous fistula with hypertensive cardiovascular disease; review of the literature.

Abstract Arteriovenous fistulas of the renal vessels are of particular interest because of the ability of these lesions to produce not only the systemic effects of an arteriovenous fistula but also, theoretically, those of a Goldblatt kidney. Intrarenal arteriovenous fistula is a rare lesion. We have been able to find only eleven cases reported in the literature; six of these were congenital, four were acquired and one was of undetermined etiology. We believe our case is the twelfth recorded of intrarenal arteriovenous fistula and the third of traumatic etiology. Although arteriovenous fistulas of other systemic vessels do not produce a significant hypertension, those of the renal vessels may. Clinical opinion indicates that there may be ischemia distal to an arteriovenous fistula, and experimental evidence indicates that there is ischemia and decreased pulse pressure distal to an arteriovenous fistula. The Goldblatt phenomenon of producing hypertension by partial occlusion of the renal artery is well known. We believe that the hypertension associated with certain renal arteriovenous fistulas may be explained on the basis of the Goldblatt phenomenon resulting from the altered renal hemodynamics produced by the fistula.

FURTHER OBSERVATIONS ON THE NATURAL HISTORY OF ISOLATED VENTRICULAR SEPTAL DEFECTS IN INFANCY AND CHILDHOOD. SERIAL CARDIAC CATHETERIZATION STUDIES IN 75 PATIENTS.

Serial cardiac catheterization has been performed in 75 patients with isolated ventricular septal defect. At the time of the first cardiac catheterization, 39 were under 1 yearof age, 19 were between 1 to 3 years, 14 between 3 to 10 years, and three over 10 years. In 68 patients the second catheterization was performed 1 to 7 years after the first, and in seven patients a third cardiac catheterization was performed 2 to 5 years after the second.Normal pulmonary artery pressure was observed at the initial study in 25 patients. Of these, only one revealed a slight rise in pulmonary artery systolic pressure by 19 mm. Hg; the rest revealed no significant hemodynamic changes.Mild pulmonary hypertension (31 to 59 mm. Hg systolic pressure) was noted in 28 patients at first catheterization, at which time moderate or severe pulmonary hypertension (60 mm. Hg or more systolic pressure) was present in 22 patients. In 33 of these 50 cases, the initial investigation was done during infancy and not later than the second year. In three fourths of the cases with mild pulmonary hypertension, and in two thirds of those with moderate or severe hypertension studied at this very early age, a significant drop in pulmonary pressure and flow was observed at the subsequent catheterization. This was interpreted to indicate most likely relative reduction of the functional size of the defect during early childhood. In eight patients hemodynamic and angiocardiographic evidence of the ventricular septal defect disappeared, indicating probable functional closure.Progressive pulmonary vascular obstruction was observed in six patients, one of whom already had Eisenmengers complex at the initial examination. All but one, an 11-month-old infant, had significantly elevated pulmonary vascular resistance already present during the first cardiac catheterization. In seven patients with similar findings at the initial examination, striking reduction in pulmonary vascular resistance was observed. The progressive pulmonary vascular obstruction is interpreted to indicate failure of the pulmonary vascular bed to undergo maturation, whereas the diminution in pulmonary resistance observed in the other group is interpreted to indicate delayed onset of pulmonary vascular maturation.The therapeutic significance of these findings is discussed.

Surgical injury to the conduction system in ventricular septal defect

Abstract The conduction systems of 9 hearts with ventricular septal defect coming to autopsy after open heart surgery were studied by serial section. In 2 cases severe A-V block was present; in 2, complete right bundle branch block; and in the remainder there was no clinical evidence of A-V block after surgery. The severe A-V block in both cases could be ascribed to injury of the penetrating portion of the A-V bundle. An alternate explanation in 1 case was the injury to the branching bundle and the posterior radiation of the left bundle branch. The right bundle branch block in 2 cases for which a postoperative electrocardiogram was available was associated with severe injury to the right bundle. In double outlet right ventricle with an anterior ventricular septal defect, the branching portion of the A-V bundle may lie considerably to the left of the summit of the ventricular septum as in some cases of tetralogy. In a case of double outlet right ventricle with a massive posterior ventricular septal defect, the conduction system resembled that of common A-V orifice or single ventricle.

The Diagnosis of Aortic Septal Defect by Retrograde Aortography Report of a Case

This rare congenital malformation is a round or oval opening between the ascending aorta and the main pulmonary artery above the semilunar valves. It is practically impossible to differentiate this malformation from a patent ductus arteriosus clinically because both malformations may present the same physical, fluoroscopic, roentgen and electrocardiographic findings. Even angiocardiography and cardiac catheterization do not differentiate these congenital malformations. The authors have studied 2 patients with aortic septal defects. One was operated at another clinic for a suspected patent ductus arteriosus, and the other case presented here was diagnosed by retrograde aortography.

Calcified polyp of the heart.

The fluoroscopic visualization of a calcified polypoid tumor of the heart introduces a diagnostic sign to aid in the infrequent recognition of these rare tumors during life. The preoperative or antemortem diagnosis of primary heart tumors has been made several times in the past from symptomatology, clinical findings, and electrocardiographic evidence (2, 13, 18, 21). Routine roentgenographic studies, though usually suggestive only in retrospect, have aided in the correct clinical diagnosis during life in several instances (5, 15, 16, 18). Because of the successful removal of some of these tumors in the past (1, 4, 17), and the possibility of the removal of a larger number, it is imperative that every roentgenographic means be utilized for their identification, localization, and delineation. Pathology The classification and microscopic features of primary cardiac tumors have been adequately discussed elsewhere (6, 11, 12, 19). In interpreting the roentgenographic findings, however, it is important to recon...

A comparative study of prosthesis applied to the outflow tract of the right ventricle

Abstract 1. 1. A number of different kinds of prosthesis were inserted in the outflow tract of the right ventricles of fifty dogs. They were observed up to one year after surgery. 2. 2. Woven Teflon® with its inner surface covered with autogenous pericardium proved the most satisfactory prosthesis. Autogenous pericardium, woven Teflon alone and diaphragmatic fascia follow in order as to their observed satisfactory response. 3. 3. Homogeneous aortas were the easiest to manipulate and satisfactory immediately after the surgery, but were unsatisfactory in the later periods. The application of this graft for clinical use is not recommended. 4. 4. Free transplantations of muscle tissue of diaphragm or chest wall were not satisfactory and have no clinical value. 5. 5. Five out of twenty-one dogs studied electrocardiographically showed evidence of right ventricular hypertrophy, believed caused by pulmonary valvular insufficiency.