John W. Keyes

PSEUDOANEURYSM OF THE HEART. REPORT OF A CASE AND REVIEW OF LITERATURE.

A case is reported of coronary atherosclerosis leading to myocardial infarction of the left ventricle and rupture of the left lateral posterior wall with limitation of the hemorrhage by fibrotic parietal pericardium. Formation of the false aneurysm allowed the patient to survive 5 years and 10 months after it was clinically recognized.

Survival Rates after Acute Myocardial Infarction with Long-Term Anticoagulant Therapy

Evidence is set forth to show the value of continuous long-term anticoagulant therapy by comparison with a control group of patients who have also had multiple coronary occlusions or single infarcts, followed by severe angina pectoris or episodes of coronary failure. Statistical life-estimate determinations are included. Bleeding complications are encountered less frequently with improved methods of management and are considered a justifiable risk, in view of the serious consequences of the natural progress of the disease. After a program of long-term anticoagulant treatment has been instituted, cessation of therapy may be hazardous.

Recurrent Stenosis of the Mitral Valve

Forty-three patients with suspected restenosis of the mitral valve are reported. Forty of these occurred in a series of 672 mitral commissurotomies. A significant degree of recurrent stenosis was found in 40 of the 43 cases at the time of the second operation. The clinical features and findings in these patients are discussed, as well as the probable etiologic factors. Left heart catheterization is indicated in many of these cases to define precisely the hemodynamic status, particularly in those individuals with suspected concomitant mitral incompetency or myocardial disease. Open-heart surgery should significantly improve the results of a repeat mitral commissurotomy.

THE USE OF THE NEWER DIURETICS IN THE TREATMENT OF CARDIAC DISEASE

The introduction of chlorothiazide in 1957 was rapidly followed by that of several analogues of the benzothiadiazine series. Slight changes in basic structure have been noted to alter markedly the potency of the drug, while less marked but definite changes occur in the electrolyte excretion pattern. One of the most significant of these changes has been the reduction in potassium excretion with the trifluoromethyl derivatives. Hydrochlorothiazide, flumethiazide, hydroflumethiazide, and benzydroflumethiazide, in addition to benzothiadiazine, are all potent oral diuretics, approaching the parenteral mercurial diuretics in effectiveness. While they are not as potent in single-dose administration as mercurials, they are superior to the mercurials for diuretic practice in many ways. The practical and economic advantages of oral therapy are obvious. The drugs have been extremely well tolerated, have a low incidence of toxicity, remain effective on repetitive or continuous administration, produce increased sodium excretion and water loss, and tend to stabilize a patient who is accumulating edema fluid more readily than might the sporadic intermittent mercurial program. More recent derivatives are currently being evaluated in our clinical practice. All of these agents inhibit primarily the renal tubular reabsorption of sodium and chloride, with water loss occurring secondarily: an action similar to that of the mercurials. Increased potassium excretion caused by these agents has important clinical implications. Diuresis is initiated approximately 2 hours after an effective oral dose, and continues for 6 to 12 hours thereafter. These important advances in the field of diuretic therapy have not supplanted the basic indications in the treatment of congestive heart failure, which continue to be digitalis, rest, and a reasonable reduction in the dietary intake of sodium. These first measures suffice in many instances of early cardiac decompensation. I t also follows that when diuretics become necessary the choice of drug and dosage must be tailored to the needs of the individual patient. The use of the minimal effective dose will lessen the likelihood of undesired effects and, possibly, toxicity. A schedule of diuretic administration on one or two days of each week may keep a patient free of edema, while more advanced cases may necessitate a daily diuretic regimen. An additive effect may be observed by the concomitant use of one of these agents plus a mercurial diuretic. This has been useful in some cases of resistant congestive failure and in patients approaching the refractory phase of their disease. A few instances of gratifying results in these advanced cases have also been seen when a benmthiadiazine has been combined with adrenocortical steroids or the spirolactones. The effective dose of chlorothiazide or flumethiazide is 1 to 2 gm. daily in two divided doses. This results in a significantly greater diuresis than that produced by a large single dose given once a day. If the second dose is given

Recurrent ventricular tachycardia associated with complete heart block: Observations in a patient with the simultaneous use of a single-stimulus implanted myocardial pacemaker and a “coupled-pulse generator”

Abstract Recurrent bouts of ventricular tachyarrhythmia with Stokes-Adams episodes, in the presence of a postoperative complete heart block, represents a therapeutic challenge. This is compounded when the tricuspid valve has been replaced by a Starr-Edwards prosthesis. An attempt to control the ventricular tachycardia with an implanted myocardial pacemaker, at a fixed rate of 74 per minute, failed to abolish the arrhythmia. Temporary control of the ventricular ectopic focus with the additional use of the coupled-pulse generator was recorded. Some of the difficulties encountered in the clinical use of the new technique of paired stimulation and the hazard of complete heart block in tricuspid valve replacement should be emphasized.

The Weltmann serocoagulation band in myocardial infarction

Abstract The serocoagulation test of Weltmann has been compared with other diagnostic and prognostic blood studies in coronary occlusion with myocardial infarction. It compares favorably with these procedures. With large infarctions a marked “shift to the left” in the coagulation band occurs, so that it is an index of degree of infarction. Healing of the infarction can be followed by the progressive change in the coagulation band. In certain conditions the sedimentation rate may be altered by other, coexisting causes. The Weltmann test is not altered in such a manner, and reflects either the healing phase or early exudative or destructive phase. It can serve both as a diagnostic and prognostic laboratory aid to the clinician.