Jack J. Greenberg

Myocardial dysfunction associated with valvular heart disease

Abstract Seventy-one patients undergoing valve replacement surgery were studied before and after operation to determine change of clinical condition and ventricular contractility. Preoperatively, all patients had functional class III or IV disease (New York Heart Association classification) and 55 percent had myocardial dysfunction. Post-operatively, the condition of 86 percent of patients improved clinically by at least 1 functional class, but 56 percent of patients had myocardial dysfunction. Cardiac index and left ventricular end-diastolic pressures were closely related to changes in angiographically determined myocardial contractility. Neither patient age, sex, duration of cardiopulmonary bypass, residual uncorrected valve disease nor coronary artery disease alone determined the degree of impairment in left ventricular contractility. A high incidence of myocardial dysfunction was found pre- and postoperatively in this study. In 16 patients with pure mitral stenosis, 6 (38 percent) had left ventricular dysfunction preoperatively, demonstrating intrinsic myocardial disease, possibly chronic rheumatic myocarditis. The demonstration of postoperative myocardial contractile abnormalities in previously normal patients suggests an intraoperative cause, perhaps related to cardiopulmonary bypass. Postoperative dysfunction may (1) exist preoperatively and remain unchanged, (2) occur intraoperatively, or (3) exist in a latent form preoperatively but be aggravated by the stress of surgery. Without both pre- and postoperative microscopic examination of the myocardium in the same patient, it is impossible to determine which process is primary.

Infective endocarditis at autopsy: 1965-1969

Abstract Patterns of infective endocarditis as seen at autopsy during a five year interval, 1965 through 1969, were reviewed. The frequency of infective endocarditis was relatively high (forty-seven of 1,881 patients, 2.5 per cent). Failure of clinical recognition of infective endocarditis in 43 per cent of the forty-seven patients is a major factor in the relatively high mortality of this disease. In sixteen of the forty-seven patients (34 per cent) a prosthetic heart valve was present. Seven of these sixteen had active infective endocarditis on a prosthesis which had not been inserted specifically for the treatment of infective endocarditis. All seven patients were receiving usual antibiotic therapy and represent antibiotic treatment failures. In the remaining nine patients, the prosthetic valves had been inserted to correct hemodynamic sequelae secondary to valve deformity following antibiotic therapy of infective endocarditis. In these nine patients, the infection was inactive at the time of autopsy. Valve perforations were present or had been surgically corrected in twenty-two of the forty-seven patients (47 per cent). Intractable congestive heart failure was the cause of death in only 8.5 per cent of our series. Thus in our experience infection has replaced congestive heart failure as the most frequent cause of death.

Long-Term Results of “Simple” Thrombectomy for Thrombosed Björk-Shiley Aortic Valve Prostheses

During the past two years 8 patients were seen with thrombosis of their Bjork-Shiley aortic valves. Six patients were from our series, an incidence of 4% and 2 patients had their original valve implanted at another institution. All patients had substantial problems with anticoagulation therapy. Three died prior to operation. Early detection and emergency surgical intervention is mandatory for survival. At operation debridement of all thrombotic material from the valve provided satisfactory immediate hemodynamic improvements as well as freedom from complications for up to two years. Therapeutic levels of anticoagulation with warfarin are the only apparent protection from thrombosis of the Bjork-Shiley aortic valve.

Disc Variance of Beall Mitral Valve

Abstract Disc variance in Beall mitral prostheses in 5 patients is reported. All 5 showed disc deformity. Erosion of the Teflon covering of the cage struts was present in varying degrees in 4 of the 5 patients. Disc grooving was present as early as sixteen days after operation. Severe thinning and notching of the disc were noted at autopsy in 3 patients who survived two years following prosthetic valve operation. In I of these two-year survivors the disc destruction was so extensive that incompetence developed; the valve failure contributed to the patients death. Disc variance must be anticipated in patients with Beall mitral prostheses inserted prior to March of 1968, when the valve fabrication was changed.

DDD Pacemakers Maximize Hemodynamic Benefits and Minimize Complications for Most Patients

A 44‐month retrospective analysis was performed on 666 pacemakers implanted at Mt. Sinai Medical Center. Mapping techniques and endocardial waveform analyses were used during lead positioning to ensure the best electrical environment. The optimal pacing lead type was selected based on the clinical situation. Follow‐up evaluations were rigorous. Patient population ranged in age from 28 to 103 with a mean of 78 years at time of implant. Seventy percent of the patients received DDD pacemakers with an 81% survival incidence at 44 months, of the WI population (30% of the implants), there was a 62% survival incidence. Most problems associated with the pacing systems were related to the atrial channel. Loss of atrial sensing occurred in 7.5% of the population and was corrected noninvasively in 5.8%. Due to chronic loss of atrial sensing, 1.7% of the population remained programmed to DVI/VVI. A total of 7.7% were chronically reprogrammed from DDD to WI, 5.6% secondary to atrial fibrillation. Reoperations were necessary in 1.2% of the malfunctioning systems that could not be corrected by reprogramming. The following conclusions were reached: (1) maximizing hemodynamic benefits and minimizing pacemaker complications permitted a survival rate equal to or better than that of the general population, and (2) chronic problems related to the atrial lead and malfunctions of the pacing system were minimized by careful patient selection, appropriate pacemaker and lead selection, endocardial waveform analysis, and thorough follow‐up.

Clinical and Hemodynamic Findings Following Replacement of the Mitral Valve with a Beall Valve Prosthesis (Dacron Velour-Covered Teflon-Disc Valve)

The first 21 survivors of mitral valve replacement with a Beall valve prosthesis were evaluated clinically and hemodynamically five months after surgery. Significant clinical improvement was noted in 18 of 21 patients. When compared with preoperative data, a significant improvement occurred in pulmonary artery and left atrial pressures, cardiac index, pulmonary vascular resistance, and in the mitral valve gradient. However, the majority of the patients still had mildly elevated left atrial and pulmonary artery pressures secondary to a mean resting prosthetic gradient of 7 mm Hg. Right heart pacing and exercise significantly increased the gradient and left atrial and pulmonary artery pressures. A remarkable freedom from thromboembolic complications was noted in this series of patients.

A Noninvasive Technique for the Study of Cardiac Hemodynamics Utilizing C15O2 Inhalation1

A new technique for the study of cardiac hemodynamics is described which utilizes single-breath inhalation of C15O2 (T 1/2 = 124 sec.) and the recording of activity vs. time curves with scintillation counters placed externally over the left ventricle and right lung. The results from 10 normal volunteers and 28 patients with acquired or congenital heart disease have been compared to the findings at cardiac catheterization. The technique is safe, rapid, and nontraumatic, and yielded no false positives or negatives in this series.

Hemorrhagic myocardial infarction due to cardiac vein thrombosis: Report of two cases

Abstract Two patients are reported with a hemorrhagic myocardial infarction due to cardiac vein thrombosis. Venous myocardial infarctions differ grossly and histologically from arterial ones by the more extensive hemorrhage and the less prominent necrosis and polymorphonuclear leukocytic infiltration.

Temporary pervenous pacing catheter insertion through a triscuspid prosthetic valve

Abstract This report presents experiences and observations with emergency insertion of pervenous electrode catheters through tricuspid prostheses in 2 patients requiring temporary cardiac pacing after surgery. Although insertion was simple and without deleterious hemodynamic effect, the need for precautionary implantation of insulated wire in all patients undergoing open heart surgery is stressed, since this would obviate emergency procedures. Such implanted wire may serve as an accessible means for therapeutic, diagnostic and investigational purposes in the postoperative period.

Preoperative and Postoperative Cardiac Output Determinations Using an Instantaneous Pulmonary Capillary Blood Flow Method

Abstract Instantaneous pulmonary capillary blood flow was estimated by the nitrous oxide method using a sensitive pneumotachygraph, and the values compared well with measurements obtained by dye-dilution techniques. Pulmonary capillary pulsatility diminished postoperatively in the majority of patients. This was probably related to a rise in pulmonary arterial resistance or compliance. A decrease in cardiac output under anesthesia compared to basal output in the awake state was a poor prognostic sign, and patients with an output lower than 1.05 liter per minute per square meter died from myocardial failure.