Jay L. Ankeney

The Distensibility Characteristics of the Portal Vascular Bed

The distensibility of the splanchnic portion of the portal system has been evaluated by studying pressure and volume changes with or without any interruption of blood flow. The results of these determinations indicate two types of distensibility of the system: (1) a rapid elastic distension representing relatively small volumes, and (2) a secondary phase of slow distension, designated “delayed compliance,” which represents a significantly greater volume change. It is concluded that delayed compliance is of major importance in the pooling of blood in peripheral blood vessels under conditions of maintained elevation of venous pressure.

The Clinical Diagnosis and Surgical Management of Ruptured Mitral Chordae Tendineae

Six patients with mitral insufficiency secondary to ruptured chordae tendineae are presented. Each patient underwent surgical correction of the deformed valve. In two instances the posterior leaflet was involved while in four the anterior leaflet was affected. Three patients had definite bacterial endocarditis that appeared to be related to the onset of cardiac symptoms. In the two instances of posterior valve involvement there were an aortic thrill and a harsh systolic murmur, whereas in two of the four with rupture of the anterior leaflet an aortic systolic murmur was heard but no thrill was felt. The other two with anterior leaflet disease disclosed no murmurs in the aortic area. These findings are considered to be a result of the direction of the regurgitant jet and the area in which they strike the left atrium. None of the patients had hemodynamic evidence of aortic valve disease and in each instance the aortic systolic murmur decreased or disappeared after surgery. Each patient had gross left atrial enlargement. Although relatively uncommon, mitral insufficiency due to rupture of the mitral chordae tendineae is readily corrected surgically.

Congenital right coronary artery to left atrium fistula

Abstract The first case of connection of a branch of the right coronary artery with the left atrium is presented. This branch is probably the sinus node artery. 26 Only 6 cases of fistula from a coronary artery to the left side of the heart were found in the literature; all involved the left coronary artery. This is also the first time that a fistula from a coronary artery to the left heart chamber has been recognized preoperatively and the anatomic details established by cineangiocardiography. Mitral regurgitation was present prior to surgery, and its possible etiology is discussed. Ligation of the abnormal vessel was followed by development of diaphragmatic myocardial infarction. Selective coronary cinearteriography postoperatively demonstrated a large collateral flow from the left coronary artery into the irfarcted area.

Clinical Experience with an Improved Mitral Valve Prosthesis

Abstract More than five years ago a Dacron velour-covered Teflon-disc mitral valve prosthesis was introduced in an effort to decrease thromboembolic complications of mitral valve replacement. Numerous reports have demonstrated an extremely low incidence of thromboembolic complications with this prosthesis. Efforts toward improving the prosthesis have been aimed at using more durable materials, and a Dacron velour-covered mitral prosthesis using Pyrolite carbon for both the disc and the cage legs now is available. Animal investigations with scanning electron microscopical wear analysis predicted 140 years of wear prior to penetration of the Pyrolite carbon coating. Clinical trials then were begun, and combined experience with this prosthesis in three centers now includes 175 cases. There have been no deaths related to the prosthesis, and only four thromboembolic episodes have occurred; the only fatal one was an embolus from the left atrial appendage that occluded the prosthesis. This improved prosthesis appears to offer significant advantages.

Further Experimental Evidence that Pulmonary Capillary Pressures Do Not Reflect Cyclic Changes in Left Atrial Pressure (Mitral Lesions and Pulmonary Embolism)

Wedged catheter pressures (PC) were compared with those in the aorta, left atrium, and pulmonary artery before and after production of mitral stenosis, insufficiency, and pulmonary embolism. In general it was found that “PC” pressures follow closely changes in left atrial pressures even when pulmonary artery pressure changes in an opposite direction (for example, pulmonary embolism). However, properly recorded “PC” pressure pulses did not display the large cyclic pressure variations recorded from the left atrium during mitral stenosis and insufficiency. It is concluded that pressures recorded through a properly wedged catheter represent the constant pulmonary capillary pressure but do not reflect cyclic pressure variations in the left atrium.

A 20-year review of ostium primum defect repair in children

Between July, 1963, and July, 1983, a total of 69 patients (35 boys and 34 girls) underwent ostium primum defect repair. There were four perioperative deaths and four patients were subsequently lost to follow-up, leaving 61 children followed for 6 months to 20 years (mean 5 years). Results of surgery were assessed by cardiac catheterization in 17 of 61 patients, while the remaining patients were evaluated noninvasively. Postoperative mitral insufficiency was found to be absent in 19 patients, mild to trivial in 35, moderate in four, and severe in two. Four patients were found to have large residual atrial septal defects. Significant late postoperative arrhythmias were found in 14 of 61 patients. The types of arrhythmias included isolated complete atrioventricular block in 5 of 14, complete atrioventricular block with sinus node dysfunction in 2 of 14, and isolated sinus node dysfunction in 7 of 14. Pacemakers have been implanted in 8 of 14 of these patients. Based on this 20-year review of a large number of children: (1) ostium primum defect repair is associated with a low mortality rate, (2) residual mitral insufficiency although common is usually mild to trivial and nonprogressive, and (3) significant arrhythmias are a frequent complication and often require pacemaker implantation.

Left atrial aneurysm.

Abstract A case of aneurysmal dilatation of a portion of the left atrium resulting in a diverticulum or aneurysm of considerable size is described. The patient presented with a paroxysmal arrhythmia as the only symptom and this was associated with clinical, radiological, and electrocardiographic signs suggesting ventricular enlargement with a mild degree of mitral insufficiency. These features suggested a primary cardiomyopathy. Further investigation revealed normal ventricular hemodynamics and anatomy, with anterior displacement of the left ventricle by the posteriorly situated aneurysmal mass. Failure to opacify this mass at ventriculography despite some opacification of the left atrium led to the assumption that it was not connected with the cardiac cavities. The association of apparent cardiac enlargement, arrhythmia, and a mass suggested a cardiac or pericardial tumor, and the true diagnosis was not revealed until thoracotomy was performed.

Effects of Cardiac Surgery with Extracorporeal Circulation on Intellectual Function in Children

The effect of extracorporeal circulation during open heart surgery on changes in intellectual function was studied in 18 children. A group of patients undergoing such surgery was compared to a control group undergoing cardiac surgery without extracorporeal circulation. The Wechsler Intelligence Scale for Children was used to evaluate the patients. No significant differences were found in either the performance IQs, verbal IQs, or full scale IQs by comparing the postoperative scores to the preoperative scores either within each group or between the groups. Extracorporeal circulation during open heart surgery does not appear to alter intellectual functioning in the pediatric age group.

Influence of Glomerular Filtration Rate upon the Renal Tubular Reabsorption of Sodium.

Summary 1. When the plasma sodium concentration is progressively elevated in dogs by the administration of hypertonic saline, the rate of renal tubular reabsorption of sodium remains constant in those experiments where the glomerular filtration rate is not significantly affected. If the filtration rate increases or decreases in response to the hypertonic saline, the rate of sodium transport deviates in the same direction. Therefore, in experiments where the sodium level is elevated for a period of one hour or less, any alteration in the rate of sodium transport is dependent upon the concomitant change in filtration rate. 2. Hypertonic saline exerts a profoundly depressant effect upon the PAH Tm, and a significant but less marked influence upon the glucose Tm. This depression is believed to be nonspecific in nature and contra-indicates the use of these determinations as an index of effective tubular mass in experiments in which variations in sodium concentration are involved.

Resolution of Surgically Induced Right Bundle-Branch Block

In a retrospective study, the serial electrocardiograms of all patients with surgically induced right bundle-branch block (RBBB) were reviewed. None of these patients had had RBBB prior to operation. Seven patients who had RBBB from 6 to 16 days after operation showed resolution in ECGs done 3 to 8 months later. Two patients are reported, with documentation by vectorcardiogram, in whom RBBB resolved by 3 and 12 years after operation. The origin of transient forms of RBBB may be different from the long-standing form. If RBBB of long duration is due to operative injury to the proximal right bundle, Purkinje fiber network, or distal branch or branches of the right bundle, or to combinations of these tracts, one may speculate about the possibility of regeneration of the right ventricular conduction system. Since no data are available concerning the long-term prognosis of RBBB and since a progressive conduction disturbance can occur, the resolution of RBBB after many years might carry a better prognosis than its persistence.