John R. Tobin

Natural Course of Peripartum Cardiomyopathy

Twenty-seven patients presented in the puerperium with cardiomegaly, abnormal `ECG, and congestive cardiac failure and were considered to have peripartum cardiomyopathy (PPCM). The incidence of PPCM was significantly higher in women over 30 years of age, in women in their third or subsequent pregnancy, and in the presence of twins or toxemia. Within 6 months, 14 patients had normal sized hearts (group A), and 13 patients maintained cardiomegaly (group B).The 14 patients in group A have been followed for 3 to 21 years (average 10.7 years). Two have died of unrelated causes. Of the remaining 12, eight are functional class I and four are functional class II. Eight patients had 21 subsequent pregnancies, with no permanent deterioration of cardiac function. Of 13 patients in group B, 11 (85%) have died of congestive cardiac failure. Their average survival was 4.7 years; six of 11 were dead in 3 years. Their clinical course was punctuated by repeated admissions for congestive cardiac failure. Six had pulmonary emboli, one had a systemic embolus, and three of six patients with subsequent pregnancies deteriorated in the puerperium. Of the two surviving patients, one is functional class I and the other is functional class II.Therefore, in those patients in whom cardiomegaly persisted, the prognosis was poor, and subsequent pregnancies were likely to lead to permanent deterioration. In those in whom the heart size returned to normal the prognosis was excellent.

The natural course of alcoholic cardiomyopathy.

Abstract Fifty-seven patients with cardiomyopathy associated with alcoholism were followed for an average of 40.5 months (range, 4 months to 8 years). None of the patients were treated with prolong...

Hemodynamic measurements in a coronary care unit.

H YPOTENSION, shock, congestive heart failure or any other manifestation of present or impending circulatory collapse in a patient with acute myocardial infarction is indication for hemodynamie monitoring of his cardiovascular system. The measurements to be made include central venous pressure, intra-arterial pressure, cardiac output and central temperature. Such monitoring will soon assume importance equal to electrocardiographic monitoring of patients developing arrhythmias in this disease. Such measurements can be made clinically and should be available in most community hospitals when sufficient personnel are trained. Other measurements of value and available include arterial blood gases, pH, lactic acid and pyruvie acid. The potency of modem therapeutic agents and the impending development of mechanical circulatory assistance make necessary the perfection of routines for application of hemodynamic monitoring methods to patients with acute myocardial infarction. Although on-line computer analysis and correlation of data plus use of transponders to alter therapy may be an ultimate goal of developing more sophisticated methods for measurements of hemodynamic events in a coronary care unit, 1-s present methods provide information which may be crucial for patient care. It is our purpose to discuss the experience of our shock unit with such hemodynamic measurements in patients with acute myocardial infarction and in patients referred because they were thought to have myocardial infarction.

Isolated congenital pulmonic insufficiency: Differentiation of mild from severe regurgitation∗

Abstract The clinical, phonocardiographic and hemodynamic manifestations of isolated congenital pulmonary insufficiency in 4 patients are reported. Two clinical varieties of this anomaly have been observed, and a review of the reported cases with adequate documentation support this concept. Group I includes the older patients with physical evidence of right ventricular overload; roentgenologic evidence of right ventricular enlargement, prominent pulmonary arteries and a vigorous “hilar dance;” electrocardiographic abnormalities; phonocardiograms which demonstrate a low-pitched, crescendodecrescendo, mid-diastolic murmur; and hemodynamic evidence of early equilibration of the diastolic pressures in the pulmonary artery and right ventricle. The available evidence suggests that the individuals in this group have moderate to severe pulmonic insufficiency. Group II is composed of younger patients with minimal or no physical evidence of right ventricular overload; milder roentgenologic and electrocardiographic abnormalities; phonocardiograms which demonstrate a higher-pitched, decrescendo diastolic murmur; and end-diastolic equilibration of the pulmonary artery and right ventricular pressures. Patients in this group have a milder degree of insufficiency.

The spatial vectorcardiogram in left bundle branch block

Abstract Vectorcardiographic criteria have been set up for the diagnosis of typical left bundle branch block on the basis of what is known about the sequence of ventricular depolarization in this condition. Forty-eight patients were classified into typical and atypical groups on this basis, and this separation has been correlated with the incidence of infarction as determined clinically (29 patients) and by autopsy study (19 patients). The high incidence of infarction in the atypical group and almost complete absence of infarction in the typical group suggest that these are useful criteria for the recognition of myocardial infarction in the presence of left bundle branch block.

The apex cardiogram in left bundle-branch block.

The apex cardiogram and its relation to intracardiac events has been well studied (Benchimol and Dimond, 1963; Tafur, Cohen, and Levine, 1964; Tavel et al., 1965; Coulshed and Epstein, 1963). This simple clinical procedure can be used to determine the length of isovolumic contraction, and this may relate to the state of myocardial contractility (Sambhi, 1960; Reeves et al., 1960; Siegel and Sonnenblick, 1963; Wallace et al., 1963), or to changes in conduction within the ventricle. This study was undertaken to determine if the apex cardiogram in the presence of left bundlebranch block would serve to differentiate patients with myocardial infarction from patients without myocardial infarction. The presence or absence of myocardial infarction was determined by vectorcardiogram, using previously described criteria (Neuman et al., 1965; Doucet, Walsh, and Massie, 1966).