James E. Davia

Congenital bicuspid aortic valve after age 20.

The bicuspid aortic valve is recognized as a frequent cause of aortic stenosis in adults. Aortic stenosis has been reported to occur in as many as 72 percent of adults with a congenital bicuspid aortic valve, with peak incidence occurring in the 5th and 6th decades of life. Review of the clinical records of 152 patients aged 20 years and older found to have a bicuspid aortic valve at autopsy revealed aortic stenosis in only 28 percent. The incidence of aortic stenosis increased progressively with age; 46 percent of patients over age 50 years and 73 percent over age 70 years had some degree of stenosis. The stenotic valves were obstructed by nodular, calcareous masses but commissural fusion was present in only eight cases. The largest group of patients in the series (40 percent) died of infective endocarditis; 77 percent of these were under age 50 years. Primary aortic regurgitation without infective endocarditis was uncommon. Thirty-two percent of the patients in this series had an apparently normally functioning aortic valve, and this rate remained relatively constant with increasing age; 37 percent of patients over age 50 years and 27 percent over age 70 years had an apparently normal valve. The bicuspid aortic valve in patients over age 20 does not invariably become stenotic or insufficient.

Coronary artery disease in young patients: Arteriographic and clinical review of 40 cases aged 35 and under

Abstract Coronary arteriography was performed in 60 patients aged 35 or less with suggested coronary artery disease (CAD). Twenty patients (Group 1) had normal coronary arteries and 40 patients (Group 2) had one or more obstructive lesions. The left anterior descending artery was commonly involved followed by the right coronary and left circumflex arteries. The right coronary artery was most commonly completely obstructed. Single-vessel disease (50 per cent or greater obstruction) was found in 60 per cent of the patients, an incidence that is considerably higher than in studies of older patients. A total of 1.6 diseased vessels per patient was present. A hyperlipoproteinemia (HLP) was found in 68 per cent of Group 2 patients. Patients in Group 2 with an HLP had significantly more CAD than Group 2 patients with normal lipoproteins. The incidence of the following clinical features were not significantly different in Groups 1 and 2: typical angina, atypical angina, positive family history, smoking, hypertension, obesity, abnormal electrocardiogram, positive treadmill test, HLP, and diabetes mellitus. A fourth heart sound and a history of a myocardial infarction were significantly common in Group 2. Since almost all of the previously reported cases of myocardial infarction with normal coronary arteries have occurred in young patients, history of a myocardial infarction does not assure the presence of obstructive coronary artery lesions. It is suggested that coronary arteriography is a justifiable procedure in a young patient who presents with a clinical picture that is either compatible with or cannot be clearly distinguished from CAD.

Type A Behavior and Coronary Artery Bypass Surgery: Intraoperative Blood Pressure and Perioperative Complications

&NA; Previous research has suggested that Type A, compared to Type B patients undergoing coronary artery bypass surgery evidence greater intraoperative increases over hospital admission systolic blood pressure, even though patients are under general anesthesia. The present study sought to examine whether such blood pressure increases are accounted for by elevations occurring entirely during surgery (with conscious mediation minimized), or by increases occurring prior to surgery. A second purpose of the study was to examine the relationship between Type A behavior and complications occurring during and after surgery. Twenty‐seven male patients given a structured interview to measure Type A behavior in advance of surgery comprised the present sample. Results indicated that interview Type A intensity was reliably related to magnitude of systolic, but not diastolic blood pressure increases during, but not prior to surgery. The 12 patients with complications (largely arrhythmias), were reliably higher in rated intensity of Type A behavior (p less than 0.01) than those without complications (n = 14). None of the Type B or Type X patients showed evidence of complications during or after surgery. Results of this study support a body of data linking Type A behavior to cardiovascular reactivity and clinical complications of coronary disease. Since this reactivity is evident under general anesthesia, these data further suggest that conscious mediation may not always be necessary in order to elicit these responses.

Propranolol medication among coronary patients: relationship to type A behavior and cardiovascular response.

The present correlational study compared behavioral and psychophysiological characteristics of coronary patients who were either medicated or not medicated with the beta-adrenergic blocking drug propranolol. Eighty-eight patients were given a structured Type A interview (SI) and a history quiz while heart rate and blood pressure were monitored. Data were analyzed controlling for age, sex, extent of coronary artery disease, and history of angina. Results indicated that patients taking propranolol (n = 65) were significantly lower in intensity of Type A behavior than patients not taking propranolol (n = 23). No effects were obtained for patients medicated or not medicated with diuretics, nitrates, or other CNS active drugs. Propranolol patients also showed lesser heart rate and rate-pressure product responses to the interview, but did not differ in blood pressure responses. Components of Type A which were lower in propranolol patients included speech stylistics (loud/explosive, rapid/accelerated, potential for hostility). Content of responses to the SI and scores on the Jenkins Activity Survey did not differ between the groups. An explanation for these results is offered in terms of the effects of propranolol on peripheral sympathetic responses, and evidence for a physiological substrate for Type A behavior. A conceptualization of the Type A pattern in terms of cognitive and physiological components is advanced, and implications for clinical intervention are discussed.

Sinus venosus atrial septal defect: Analysis of fifty cases

Abstract Clinical, hemodynamic, and anatomic data were analyzed in 50 cases of sinus venosus atrial septal defect (SVASD) that underwent surgery. SVASD comprised 12 per cent ( 50 470 ) of ASDs over a 12 year period. All patients had a mid-systolic murmur and fixed splitting of the second sound. Analysis of 48 preoperative ECGs revealed that 46 per cent had a P wave axis of less than 30 degrees. Cardiac catheterization data were not distinctive for SVASD although the demonstration of anomalous pulmonary venous connection (APVC) was highly suggestive. At surgery a persistent left superior vena cava was present in 8 per cent ( 4 50 ). APVC was found in 86 per cent ( 43 50 ). In the 38 patients with APVC in whom accurate anatomic description was available, all had APVC from the right upper lobe. Twenty-five patients also had APVC from the right middle and inferior lobes or from the middle lobe. Distal connections of the anomalous veins were as follows: 27 to the SVC, 6 to the SVC-right atrial junction 7 to the right atrium, 3 to the SVC and to the right atrium, and 1 to the inferior vena cava.

ST-segment elevation with elective DC cardioversion.

Elective direct-current cardioversion was performed in three patients with atrial fibrillation. Transient ST-segment elevation on monitored leads, lasting seconds, was recorded after cardioversion in all three patients. LDH, CPK isoenzymes, and myocardial scintigraphy did not reveal myocardial damage. Elective cardioversion should be performed with caution, for the potential for cardiac damage cannot be ignored.

Congenital aortic stenosis secondary to dysplasia of congenital bicuspid aortic valves without commissural fusion

The hearts of nine children with clinical evidence of congenital valve stenosis and a congenital bicuspid aortic valve were reviewed. Aortic stenosis was diagnosed on the basis of cardiac catheterization data in four patients, operative findings in two and auscultatory findings in three. The patients were 1 month to 9 years old; six were male and three female. In each patient the two commissures of the valve were free to the aortic wall. The cusps were thickened, rolled and redundant; microscopic studies revealed that they consisted of immature loose connective tissue consistent with a dysplastic or incompletely differentiated valve. The valve orifice was obstructed by the dysplastic cusps, and dysplastic changes rather than the commissural fusion were responsible for the observed aortic stenosis. These valves do not appear amenable to valvotomy because obstruction is due to the abnormal valve tissue. These findings may explain the occasional poor results of valvotomy in infants and children with congenital aortic valve stenosis.

Tricuspid insufficiency due to nonpenetrating trauma

This case of tricuspid insufficiency due to nonpenetrating trauma involved a male patient who had received major chest trauma in an automobile accident, had a nonholosystolic murmur that increased slightly during inspiration on standing, and tranient electrocardiographic findings of right bundle branch block. Unlike findings in previous cases, the right atrial V wave was not dominant and was less than 8 mm Hg. An echocardiogram indicating right ventricular volume overload was an essential diagnostic tool that led to cardiac catheterization and definitive diagnosis.

Björk-Shiley mitral valvular dehiscence: Documented by radiography, echocardiography, fluoroscopy, and cineangiography

This case report presents combined radiographic, echocardiographic, fluoroscopic, and cineangiographic findings of the dehiscence of a Bjork-Shiley mitral prosthetic valve. The valvular dehiscence was confirmed at surgery. A distinct rounding of the opening phase of the valve was recorded on the echocardiogram. Other clinical evidence, documenting the severe valvular dehiscence, is reported in detail. Non-invasive procedures are therefore invaluable in recording prosthetic valvular dysfunction.

Laennec's cirrhosis and primary pulmonary hypertension.

Abstract The association of cirrhosis and primary pulmonary hypertension has been rarely reported. This case report adds to the literature a case documented by liver biopsy and cardiac catheterization. The literature on this subject and potential pathophysiologic mechanisms of association are reviewed.