Joseph F. Uricchio

Bacterial endocarditis following cardiac surgery.

Intracardiac surgery for rheumatic and congenital heart disease entails direct trauma to both normal and abnormal endocardium. This communication inquires into the incidence and nature of the endocardial infections that develop subsequent to this injury. On the basis of an examination of 2,263 patients operated upon for acquired and congenital heart disease during a 5-year period terminating in November 1955, bacterial endocarditis appears to be an infrequent complication of surgery, is caused by organisms not so commonly encountered in unoperated patients, and is characterized by a clinical pattern quite different from that ordinarily associated with bacterial endocarditis. The rate of attrition in this group of patients is high, and unquestionably is related to the antibiotic resistance of the unusual organisms and the severity of the basic heart disease.

ACUTE PEPTIC ULCERATION FOLLOWING CARDIAC SURGERY

Excerpt A variety of stressful stimuli when applied to a susceptible host have been recorded as provoking an ulcerative response in the gastrointestinal tract. Thus burns,1-4trauma,5-9central nervo...

Aberrant origin of left coronary artery combined with mitral regurgitation in an adult

Abstract A case of aberrant origin of the left coronary from the pulmonary artery is described in a woman who lived to the age of twenty-six. In addition, severe mitral regurgitation was present due to a dilated and partially calcific mitral valve. The clinical syndrome is reviewed and the causes for the myocardial ischemia outlined. Angiocardiography is helpful in establishing the diagnosis. Electrocardiograms may be considered pathognomonic of the syndrome only in the absence of mitral regurgitation. Surgical treatment still is unsatisfactory.

Tricuspid regurgitation masquerading as mitral regurgitation in patients with pure mitral stenosis.

panied by pulsating neck veins and liver. Partial confirmation may be provided by x-ray evidence of right atria1 enlargement and ventiicularization of the right atria1 pressure waves at the time of catheterization [I]. Although the lesion is accompanied by a systolic murmur which should be heard best at the lower end of the sternum or at the fourth left interspace, auscultation may not be helpful diagnostically The murmur often is obscured by the associated valve defects which dominate the clinical findings, or it is erroneously attributed to a non-existent lesion. This report concerns the latter problem. It records the fact that when there is marked right ventricular hypertrophy with clockwise rotation of the heart in patients with tricuspid insufficiency and mitral stenosis, the tricuspid murmur may extend toward the apex and may be mistaken for mitral insufficiency. It also examines the pathophysiologic background against which this misconception is most apt to arise. Finally, it emphasizes the importance of the error when patients are being evaluated for mitral commissurotomy, and discusses the methods by which the mistaken diagnosis may be avoided.

Clinical and hemodynamic features of advanced rheumatic mitral regurgitation: Review of sixty-five patients

Abstract The clinical and physiologic features of sixty-five patients with mitral regurgitation of rheumatic origin were studied. 1.1. A long asymptomatic period averaging 10.6 years was observed. Contrary to previous reports dyspnea, as well as fatigue, was found to be an early and constant symptom present in over 90 per cent of the patients. 2.2. In addition to the pansystolic murmur constantly present, a mid-late diastolic murmur was heard in forty-one patients (63 per cent) despite little or no mitral obstruction. A diastolic gallop sound was a very frequent finding. 3.3. Electrocardiographic evidence of left ventricular hypertrophy was found in only onethird of the patients. A normal ventricular complex was present in 50 per cent, while right ventricular hypertrophy was observed in 15 per cent of the cases. 4.4. The typical roentgenographic rinding was an enlarged left atrium with a wide sweep of barium esophagram contrasted to the localized posterior displacement seen in pure mitral stenosis. 5.5. The cardiac index was low in the group with atrial fibrillation and normal in patients with normal sinus rhythm. A large C-V wave (ventricularization) was found in the left atrial (93 per cent of the patients) and pulmonary wedge pressure curves (83 per cent of the patients). A ventricular filling gradient, when present, is confined to early diastole. In the present series, the most reliable method for the qualitative and quantitative estimation of the degree of mitral regurgitation was ventriculography employing injection of radiopaque material into the left ventricle with simultaneous serial roentgenography of the cardiac silhouette. 6.6. Sixty-four patients were operated upon for correction of the regurgitation. At surgery, the regurgitation was found to be almost invariably posterior. Calcification of the valve was noted in 31 per cent of the patients operated upon. In approximately 12 per cent of the cases Ashoff bodies in various stages of evolution were found in the biopsy specimens of the left atrium.

The postcommissurotomy (postpericardiotomy) syndrome

Abstract The term “postcommissurotomy” syndrome should be discarded and permanently replaced with the more accurate description, “postpericardiotomy” syndrome. The clinical expression of this entity appears to be identical with the various forms of traumatic pericarditis reported in the past. The postpericardiotomy syndrome is described in 10 to 40 per cent of patients following commissurotomy for acquired valvular stenosis, and in 30 per cent of 100 consecutive survivors following open heart surgery for repair of atrial and ventricular septal defects and the relief of pulmonic and aortic stenosis. The clinical picture is one of recurrent fever and retrosternal pain described as dull or, more commonly, knifelike or stabbing, and in most patients a pericardial friction rub. The electrocardiogram often suggests pericardial changes that may disappear during periods of remission. They may also persist for weeks following resolution of the syndrome. The cardiac silhouette on x-ray examination is generally enlarged. The postpericardiotomy syndrome is a benign illness with an excellent prognosis. Therapy, for the most part, is supportive although in certain instances corticosteroids are used.

An Electrocardiographic Analysis of Sixty-Five Cases of Mitral Regurgitation

The detailed electrocardiographic analysis of a large series of patients with proved, dynamic mitral regurgitation is lacking in the medical literature. The present report intends to fill the gap and to point out and discuss some discrepancies observed between the current concepts and the results of the study.

CONGENITAL BICUSPID AORTIC VALVES: A CLINICAL AND HÆMODYNAMIC STUDY

The first description of a congenital bicuspid aortic valve was made by Giinsberg in the year 1846. The pathogenesis of this malformation has been ascribed either to fusion of two adjacent valvular edges during foetal life (Peacock, 1865) or to failure of a valvular cusp to develop (Peacock, 1866). Early publications on this subject have dealt mainly with its embryological and pathological aspects (Giinsburg, 1846; Peacock, 1865; Osler, 1866; Koletsky, 1941; Bettini, 1957), while clinical reports have been scanty and usually retrospective, the clue to a tentative intra vitam diagnosis usually being the implantation of subacute bacterial endocarditis upon a bicuspid aortic valve (Bourne, 1946; Tranchesi et al., 1954). The introduction of left heart catheterization into clinical medicine (Bjork et al., 1953) provided the opportunity of appraising the dynamics of this congenital malformation. The possibility, however, remained for some time only theoretical from lack of confirmation, either surgical or by necropsy. The difficulty has been overcome with the advent of open heart surgery which affords the opportunity for verification of the clinical diagnosis. The present report deals with the clinical, radiographic, electrocardiographic and hemodynamic data of six proven cases of congenital bicuspid aortic valves, five of which were associated with varying degrees of commissural fusion.

A MEDICAL APPRAISAL OF TRANSAORTIC COMMISSUROTOMY

Excerpt INTRODUCTION The first surgical method to correct commissural fusion of rheumatic aortic stenosis was conceived and employed by Bailey in 1950.1It was termed transventricular commissurotomy...

Combined mitral and aortic stenosis: Clinical and physiologic features and results of surgery☆

Abstract The clinical features and hemodynamic findings in 141 patients with combined mitral and aortic stenosis are presented. Dyspnea, fatigue, edema and hemoptysis were the most commonly occurring symptoms with angina pectoris, vertigo and syncope being noted less often. The mitral first sound was frequently less sharp than in isolated mitral stenosis and its characteristics were sometimes obscured by the aortic systolic murmur transmitted from the base. Hemodynamic alterations included a low cardiac index, elevated left atrial, pulmonary arterial and left ventricular systolic pressures and left atrial, left ventricular diastolic and left ventricular-aortic systolic gradients. Operative mortality by a variety of approaches was 19.2 per cent and improvement in symptoms was noted in 86.6 per cent of the survivors.