Henry A. Zimmerman

Correlation between coronary arteriography and the postexercise electrocardiogram.

Abstract Seventy-five patients with chest pain were studied with a double Master exercise test (post-exercise electrocardiogram) and coronary cine-arteriography to determine the correlation between these two methods of indicating the presence and severity of coronary artery disease. In 33 patients, the description of the chest pain was not that of classic angina pectoris. In this group, coronary cinearteriography revealed no disease while 10 patients had a positive double Master exercise test. Forty-two patients had pain that was quite characteristic of angina pectoris. In this group, coronary artery disease was demonstrated in all patients by coronary cinearteriography while 24 of these patients had a negative Master test. Study of the coronary arteriograms showed no significant difference in the severity and distribution of the disease between patients with a positive postexercise electrocardiogram and those with a negative postexercise electrocardiogram. The incidence of demonstrable collateral channels was identical in both groups. Selective coronary arteriography has confirmed previous doubts regarding the diagnostic reliability of the postexercise electrocardiogram in the individual patient with chest pain.

The electrocardiogram in interatrial septal defects and its correlation with hemodynamics

Abstract The authors have presented an electrocardiographic study in 44 patients with interatrial septal defects and established a correlation with the hemodynamic data. Changes in the electrocardiogram after the closure of the defect under

Internal Mammary Artery Bypass Graft—Long-term Patency Rate and Follow-up

Abstract Between December, 1968, and January, 1974, 814 internal mammary artery and 351 saphenous vein bypass graft procedures were performed in 628 patients. Operative mortality during the past 3 years has been 1.7%. Internal mammary artery bypasses were performed to the anterior descending, circumflex, obtuse marginal, distal right, and posterior descending right coronary arteries. Ninety-one patients having 137 internal mammary artery and 32 saphenous vein grafts were studied angiographically 12 to 36 months postoperatively. All but 2 internal mammary artery bypasses were patent, a patency rate of 98.5%; 27 of the 32 saphenous vein bypasses in this group were patent (84.3%). The majority of the internal mammary artery bypasses were to distal coronary arteries, while the saphenous veins were used primarily for proximal anastomosis. Cineangiographic volume/flow studies were also performed. The average flow in the more distal internal mammary artery bypasses was 61 ml. per minute as compared with 91 ml. per minute in the proximal saphenous vein grafts.

Intravenous injection of hyaluronidase in acute myocardial infarction: Preliminary report of clinical and experimental observations

Abstract A preliminary communication is presented on the intravenous injection of hyaluronidase in acute myocardial infarction. Six cases are reported and electrocardiographic changes are shown after the administration of the drug. The results of studies in seven dogs are reported. Apparently, hyaluronidase acts by reducing intramyocardial edema during the acute phase following coronary occlusion. The physiopathology of this intramyocardial edema is discussed, as well as the possible mechanisms of action of this enzyme. The authors stress the necessity of further investigations before hyaluronidase can be accepted as an efficient drug in the management of acute myocardial infarction.

Auricular overloadings: Electrocardiographic analysis of 193 cases

The authors studied the auriculograms of 193 patients presenting mitral lesions (41 cases), congenital cardiac malformations (100 cases), and pulmonary disease (52 cases). In the great majority of the cases hemodynamic correlations were established and in 20 patients the vectorcardiogram was analyzed. n nThe chief characteristics of the P wave and the P vector in left, right, and combined atrial overloading are stressed. n nThe following conclusions are drawn: n1. n(1) The most important findings for left atrial overloading are a marked backward orientation of the P vector, appearance of notching and increase in the duration of the P waves in the limb and left precordial leads. n n2. n(2) There seems to exist a correlation between the duration of the P waves and the degree of left atrial dilatation. n n3. n(3) P waves with normal duration may exist in the presence of hypcrtrophied but not significantly dilated left auricles. n n4. n(4) A tendency of the AP to deviate to the right in patients with mitral lesions was found whenever the right auricular pressures were elevated. n n5. n(5) In all cases of significant right auricular systolic overloading (systolic pressure above 10 mm Hg) in our series of congenital heart diseases, the amplitude of the P waves was above 2 mm either in the limb or precordial leads. n n6. n(6) Arterial oxygen desaturation tends to increase the amplitude of the P waves. Patients with both elevated right atrial pressures and arterial desaturation presented the highest P waves in this study. n n7. n(7) Slight degrees of right atrial overloading, particularly in patients with interatrial septal defect, were detected in many cases by the presence of peaked P waves of normal amplitude, mostly in V1 and V2. n n8. n(8) The interpretation of the ventricular complex adds important data in the diagnosis of right atrial overloading. n n9. n(9) Pulmonary emphysema and arterial desaturation as a consequence of disturbance in the mechanism of hematosis, in patients with chronic disease of the lungs, produce marked changes in the P waves and the P vector. The P waves become tall and peaked and the AP is deviated rightward and downward. n n10. n(10) In the presence of pulmonary emphysema with arterial desaturation, it is very difficult to decide by the auriculogram whether there also exists right auricular overloading. n n11. n(11) The existence of combined auricular overloading may be suspected from the ECG for two reasons: (a) the presence of morphologic signs compatible with overloading of both atria; (b) the existence of morphologic signs of left atrial overloading associated with a tendency of the AP to deviate to the right. n n12. n(12) Vectorcardiogram: P loops with leftward and backward orientation, increased in width, and sometimes showing eight-shaped figures are very suggestive of left atrial overloading. P loops with normal width, increased magnitude and a forward orientation are diagnostic of right atrial overloading.

THE ELECTROCARDIOGRAM IN PECTUS EXCAVATUM

Pectus excavatum is a deformity of the chest that consists of backward displacement of the sternum and costal cartilages giving rise to a depression in the xiphisternal area. This malformation may appear isolated or associated with other anomalies. The occurrence of pectus excavatum with congenital heart disease has been reported by several observers (Evans, 1946; and McKusick, 1955). Embarrassment of circulation amounting to heart failure has also been described (Ravitch, 1951). Even in the absence of any cardiac condition, electrocardiographic changes are to be expected, because of alterations in the position of the heart. Whether these changes occur as a consequence of cardiac rotation only or also on account of compression of the heart by the chest cage has not yet been established. However, the recent advances in electrocardiography based on vectorial concepts allow us to consider that in cases of pectus excavatum, in the absence of associated cardiac disease, the modifications in the position of the heart are the most important factors, so far as the electrocardiographic changes are concerned. Previous reports on the electrocardiogram in this malformation exist. Dressler and Roesler (1950) in 10 of their 13 cases, reported inversion and notching of the T waves in praecordial leads (from Vl to V4) as the mostremarkable findings. Althoughmost patients in their series were adults, we are not sure that these T wave changes can be considered strictly pathological, since in our experience we have noticed that many normal women retain the juvenile T wave pattern through adult life. Wachtel et al. (1956), studying 13 other cases, described the changes in QRS complex in lead VI as the most important finding in pectus excavatum: in eight of these patients, an rsr pattern was observed. The authors stressed that the above pattern does not indicate disturbance in conduction, but is the consequence of cardiac rotation. They further emphasized the fact that the anatomical configuration of the chest in this malformation, making the correct application of the prmcordial lead electrodes difficult, does not permit an exact evaluation of the T wave changes.

Pathologic physiology of Lutembacher syndrome

Abstract An attempt has been made to discuss the interplay of hemodynamic alterations that may result from superimposition of mitral stenosis and interatrial septal defect upon each other. It is concluded that there are reasons to believe on a hemodynamic basis that one lesion could possibly exert a beneficial influence over the other. These factors are possibly responsible for an occasional case of this syndrome having a surprisingly long and normal asymptomatic life.

Correction of Mitral Insufficiency under Direct Vision

The incompetent valves in the majority of patients with mitral regurgitation can be surgically corrected by the technics described above. The ease and effectiveness of the correction are largely dependent upon the severity of the pathologic process. The roles of chronic myocarditis, myocardial failure, pulmonary vascular sclerosis, and the presence of other valvular defects are important factors in the eventual result. Fortunately, the abnormality in the majority of valves can be corrected, and the myocardial reserve is usually sufficient to provide satisfactory function. With continued progress in this field, earlier surgical intervention, and probably less severe disease from improved treatment, better results can be anticipated in the future.

Corrective Surgery for Tetralogy of Fallot Evaluation of Results

Fifty patients with tetralogy of Fallot have had surgical correction of their complex defects made possible by the open technic during the past 5 years. The overall 5-year operative mortality was 18 per cent. This was reduced to 15 per cent during the past 2 years in 20 patients. Forty-one of the patients are alive, asymptomatic, and have normal physical activity. Ffteen patients have had cardiac evaluation studies including cardiac catheterization from 1½ to 3 years postoperatively. Thirteen patients had normal cardiac hemodynamics. In only two patients was there evidence of incomplete hemodynamic improvement even though marked clinical improvement was gained.

Mitral stenosis: Comparative analysis of postoperative results following the closed and open operative approach

Abstract The postoperative benefit obtained in patients with mitral stenosis operated upon by the closed technic was compared to that obtained by the open technic as evidenced by electrocardiographic, radiographie and hemodynamic evaluation studies. Superiority of results was noted following the open technic in each category. The operative mortality and morbidity for comparable lesions were not only no greater by the open technic but the versatility of the open approach allowed correction of many defects that could not have been corrected by the closed approach. The superiority of the results of the open technic were such that if the facilities and experience for open operation are available, there should be no question as to its use.