Eldon R. Smith

Angiographic diagnosis of mitral valve prolapse: Correlation with echocardiography

Abstract Mitral valve prolapse is characterized clinically by a nonejection systolic click and a late systolic murmur and angiographically by end-systolic bulging of one or both mitral leaflets into the left atrium. If one accepts the end-systolic configuration of the left ventriculogram as the diagnostic standard, recent studies suggest that mitral valve prolapse may frequently be associated with certain other forms of cardiac disease. To determine the incidence of this finding in patients unselected for their primary cardiac diagnosis, the left ventricular angiograms from 336 consecutive patients (223 men and 133 women) were analyzed. Six patients had the clinical diagnosis of click-murmur syndrome, and all six had angiographic prolapse. Leaflet bulging was also present in 52 of 131 patients with ischemic heart disease (40 percent), 27 of 84 with rheumatic valve disease (32 percent), 3 of 19 with cardiomyopathy (16 percent), 5 of 12 with congenital heart disease (42 percent) and 50 of 84 with chest pain and no significant coronary artery disease (60 percent). Technically satisfactory echocardiograms were available from 140 of these patients; mitral valve prolapse was evident in the echocardiograms of 9 (6.4 percent), including 6 with the click-murmur syndrome. Thus, angiographie mitral valve prolapse was present in 43 percent of cases and occurred without predilection for any diagnostic subgroup. Echocardiographic prolapse was less common but correlated well with the presence of the click-murmur syndrome. Some end-systolic bulging of posterior mitral leaflet scallops therefore is a common angiographic finding that should probably not be considered pathologic in the absence of other features of the click-murmur syndrome.

Congenital hypoplasia of portions of both right and left ventricular myocardial walls: Clinical and necropsy observations in two patients with parchment heart syndrome

Clinical and morphologic findings are described in two patients with congenital hypoplasia of portions of both right and left ventricular free walls in the absence of associated coronary or valvular heart disease. One, a 61 year old man who had never had clinical evidence of cardiac dysfunction, died suddenly and unexpectedly. The second, a 55 year old woman, died of progressive, eventually intractable congestive heart failure of 29 months duration. Although at least 22 necropsy patients have previously been reported to have parchment-like thinning of portions of the right ventricular free wall, only one patient has previously been described with such thinning of portions of both right and left ventricular free walls. The spectrum of right or right and left ventricular wall congenital hypoplasia is a broad one, with nearly half of described patients dying of congestive heart failure in the 1st year of life and the other half reaching adulthood with or without manifestations of cardiac dysfunction.

The spectrum of cardiac rate and rhythm in normal newborns.

SummaryThe distribution and variation of cardiac rate and rhythm in normal neonates has previously received little attention. This has made clinical assessment of dysrhythmia in newborns difficult. We therefore performed continuous 24-hour electrocardiography in 29 normal newborn subjects (age range, 1 to 6 days; mean, 3.5 days). The ECG tapes were then analysed in detail to define the normal range of cardiac rate, conduction intervals, and rhythm during waking and sleeping periods.Maximum sinus rate (awake) ranged from 150 to 222 beats per minute (mean, 192±16 [SD]), and minimum rate (awake) from 78 to 140 beats per minute (mean, 107±15). During sleep, the maximum rate ranged from 125 to 210 (mean, 168±23) and the minimum from 72 to 120 beats per minute (mean, 92±11). The maximum variation in rate for any individual during the 24-hour period ranged from 73 to 134 beats per minute (mean, 100±17). Sinus rhythm predominated with mild irregularity occurring episodically in 24 and moderate irregularity in 4 infants. An isolated atrial premature beat was present in 2 subjects, and an atrioventricular (AV) junctional escape rhythm occurred in one other after a sinus pause of 840 msec. Ventricular premature beats or AV conduction abnormalities were not observed. The corrected QT interval (QTc) ranged from 0.298 to 0.514 sec (mean, 0.390±0.026). The maximum variation in QTc over 24 hours ranged from 0.052 to 0.160 sec (mean, 0.097±0.028).We conclude that cardiac rhythm and conduction appear more stable in normal newborns than in older normal subjects and that bradycardia, conduction defects, and ventricular ectopy of the type recently reported in young normal adults seem to be more uncommon in the neonatal period.

Mechanism of persistent S-T segment elevation after anterior myocardial infarction

Abstract Persistent S-T segment elevation after anterior myocardial infarction, reliably predicts the presence of advanced left ventricular asynergy. The genesis of this persistent S-T elevation is unknown, although recent observations suggest that ischemia within or surrounding the infarct zone might be involved. To explore this possibility, a body surface mapping system was utilized to assess the torso distribution of these repolarization potentials, as well as the responsiveness of the S-T segment elevation to three randomized interventions designed to alter the myocardial oxygen supply/demand ratio (40 percent oxygen, sublingual nitroglycerin and isometric exercise). S-T segment amplitude measured 75 msec after the J point (as well as two measurements from time-normalized ST-T segments) was not significantly altered by any intervention in 11 patients, thus indicating that ischemia was an unlikely cause of the persistent S-T elevation. Moreover, plots of the integrated area of the first three eighths of both the QRS complex (Q wave zone) and the ST-T segment (S-T segment) revealed that the initial repolarization maximum (corresponding to the persistent S-T segment elevation) was spatially concordant with the initial depolarization minimum (reflecting precordial Q waves). Because large Q waves usually indicate transmural scar, this surface distribution supports the conclusion that ischemia is not responsible for persistent S-T segment elevation and suggests that the sources for these repolarization potentials are not located in the infarcted area.

A statement on ethics from the HEART Group.

Over the past several years, the editors of leading international cardiovascular journals have met to form the HEART group and to discuss areas of growing, common interest. Recently, the HEART group has developed a document that addresses general ethical principles in the conduct of the scientific process with which all of the editors concur. Published essentially simultaneously in all of the participating journals, including this journal, this document presents the ethical tenets accepted by all of the undersigned editors that will (continue to) guide their decisions in the editorial process. These are the general principles on which the HEART Group is based and by which we, as a group, abide; however, please note that individual journal members and their respective societies may have their own rules and regulations that supersede the guidelines of the HEART Group.

A statement on ethics from the HEART Group

Over the past several years, the editors of leading international cardiovascular journals have met to form the HEART Group and to discuss areas of growing, common interest. Recently, the HEART Group has developed a document that addresses general ethical principles in the conduct of the scientific process with which all of the editors concur. Published essentially simultaneously in all of the participating journals, including this journal, this document presents the ethical tenets accepted by all of the undersigned editors that will (continue to) guide their decisions in the editorial process.

A statement on ethics from the HEART group.

Coronary Artery Disease Burton E. Sobel, MD Editor Over the past several years, the editors of leading international cardiovascular journals have met to form the HEART group and to discuss areas of growing, common interest. Recently, the HEART group has developed a document that addresses general ethical principles in the conduct of the scientific process with which all of the editors concur. Published essentially simultaneously in all of the participating journals, including this journal, this document presents the ethical tenets accepted by all of the undersigned editors that will (continue to) guide their decisions in the editorial process. These are the general principles on which the HEART Group is based and by which we, as a group, abide; however, please note that individual journal members and their respective societies may have their own rules and regulations that supersede the guidelines of the HEART Group.