Joseph H. Yahini

Subaortic Stenosis (Discrete Form)' Classification and Angiocardiographic Features

The angiocardiographic features of 18 cases of discrete form subaortic stenosis (DSAS) are analyzed and four classifications defined: Type I, a thin membranous diaphragmatic stenosis; Type II, a fibrotic ring stenosis; Type III, a fibromuscular additional tissue stenosis; and Type IV, a tunnel-like stricture of the left ventricular outflow tract. This classification allows the distinction of DSAS from muscular hypertrophic stenosis with which it is often confused. Due to the concomitant finding of aortic insufficiency, the types of DSAS are better recognized if selective thoracic aortography as well as selective left ventriculography are performed.

PAROXYSMAL ATRIAL FIBRILLATION IN WOLFF-PARKINSON-WHITE SYNDROME SIMULATING VENTRICULAR TACHYCARDIA.

Abstract Five proven and one suspected case of Wolff-Parkinson-White syndrome with paroxysmal attacks of atrial fibrillation simulating ventricular paroxysmal tachycardia are described. They lend support to the assumption of others that in young and otherwise healthy adults an irregular ventricular rate of 240/min. and above, with good general state during the attack, is practically diagnostic of the Wolff-Parkinson-White syndrome. The electrocardiogram recorded during the attack is characteristic enough to permit accurate diagnosis even if tracings taken during sinus rhythm are not available. It shows principally, a grossly irregular ventricular rate exceeding 240/min., with wide QRS complexes merging gradually into complexes of normal configuration and no discernible P waves. This arrhythmia predominates in male subjects. As pointed out previously by others, these cases raise the possibility that some cases described as ventricular paroxysmal tachycardia in young healthy adults may actually be cases of Wolff-Parkinson-White syndrome. Rational therapy during the attacks should begin with oral or parenteral quinidine or procaine amide; if this fails, digitalis may be added without concern.

Pulmonic stenosis: A clinical assessment of severity∗

Abstract The clinical, phonocardiographic, electrocardiographie, vectorcardiographic and tele-oroentgenographic findings in thirty-four patients with proved pulmonic stenosis with a normal aortic root are analyzed and points of reference enabling assessment of the severity of the stenosis are presented and tabulated. Patients with mild stenosis (right ventricular systolic pressure below 50 mm. Hg) present no effort incapacity. Characteristic findings include an early systolic click, an early peak of the systolic murmur, a normal pulmonic closure and an aortopulmonic interval between 0.04 and 0.06 second. The height of R in lead V 1 does not exceed 15 mm. The vectorcardiogram shows either clockwise or counter-clockwise direction of inscription of the QRS loop in the horizontal plane and a posterior deviation of T between +60 and +90 degrees in this plane. The cardiothoracic ratio is normal. Patients with moderate stenosis (right ventricular systolic pressure between 50 and 100 mm. Hg) show little effort incapacity if any, and have a soft and delayed pulmonic closure (aortopulmonic interval between 0.05 and 0.10 second) ; the height of R in lead V 1 does not exceed 23 mm.; the direction of inscription of the QRS loop in the horizontal plane is always clockwise and the posterior deviation of T in this plane between +75 and +122 degrees. The cardiothoracic ratio is still within normal limits. Patients with severe stenosis (right ventricular systolic pressure above 100 mm. Hg) show increasingly severe effort incapacity. The systolic murmur has a late peak and overrides the aortic closure whenever the right ventricular systolic pressure exceeds the systemic pressure. The pulmonic closure is not heard but may be recorded (aortopulmonic interval between 0.06 and 0.14 second). An increased fourth heart sound is common. The electrocardiographic findings include “pulmonary” P waves and T wave inversion beyond lead V 1 . The vectorcardiogram shows marked posterior deviation of the T loop in the horizontal plane (between +80 and +170 degrees). The cardiothoracic ratio is increased. The different methods of examination are compared; the reliability of the phonocardiogram and the value of careful auscultation alone as a gauge of the right ventricular systolic pressure and in the bedside selection of the operable patients are stressed.

Congenital pericardial defect

Congenital pericardial defect was first described over 400 years ago by Columbus (quoted from Ellis, Leeds and Himmelstein, 1959). Chang and Amory, in 1965, referring to previous publications from 1961 (Chang and Leigh) compiled 112 cases from the medical literature, including their own recent one. The present case report, together with three other recent ones (Baker, Schlang and Ballenger, 1965; Rogge, Mischkin and Genovese, 1966; Varriable, Rossi and Grace, 1967), brings the total number of published cases to 116. Up to the last decade the majority of instances described were observed incidentally at autopsy or during various surgical procedures. In the last decade, however, with the increasing awareness of the lesion, radiological investigations have been the means of detecting such cases. Recognition of this anomaly is of importance because the resulting radiologic appearance may simulate different serious pathological conditions. Two types of congenital pericardial defects have been described in the ...

Atrial septal defect and constrictive Pericarditis

Abstract A case of atrial septal defect complicated by constrictive pericarditis is described. Phonocardiograms showed wide and “true” fixed splitting of the second sound. It is stressed that the clinical diagnosis of atrial septal defect is not hindered by the presence of constrictive pericarditis, even though the presence of constrictive pericarditis may be confused with congestive heart failure, with or without tricuspid insufficiency.

Electrocardiographic changes during daily work and acute exercise in permanent inhabitants of hot areas

Abstract Electrocardiographic changes seen during daily work or after a hike under different conditions of hydration in young and healthy permanent residents of hot areas on 189 working days and in 71 walking experiments are described. Even at rest, there was a slight increase in heart rate which paralleled the rise in ambient temperatures. The rise in heart rate after daily work or after 2 hours of walking was most marked in subjects under a restricted intake of water, was less marked in subjects under free intake of water and was least marked in those under forced intake of water. An increase in the QT TQ ratio, prolongation of the corrected Q-T interval, and a decrease in the magnitude of the ventricular gradient were observed in subjects working or walking under restricted intake of water. These changes were less marked in subjects under free intake of water and were least marked in those under forced intake of water, independent of the changes in heart rate. The possibility that the electrocardiographic changes observed can be related to the decrease in the venous return as a result of dehydration and/or to a transient relative coronary insufficiency is discussed.

Unusual effects of chronic myocarditis

Abstract A case of chronic myocarditis complicated by extensive pulmonary fibrosis is presented. The chronic inflammatory process, predominantly located in the left ventricle, raised the diastolic pressure of this chamber, contributed to a remarkable distention of the fibrotic left atrium and of the right heart. The case was completely studied by angiocardiography and right and left heart catheterizations. The lack of a mitral gradient had excluded mitral stenosis. However, the lack of left ventricular dilatation, at least from a clinical point of view, had been held against the diagnosis of myocarditis. Autopsy disclosed an extensive chronic myocarditis and a process of chronic fibrosis of the lungs. The extreme dilatation of the left atrium, the severe elevation of the left atrial pressure, and the proportionate increase of right ventricular pressure ruled against a significant contribution of the pulmonary process to the right ventricular overload (possibly because several areas of the lungs were less involved). Thus, it is evident that the finding of a “plateau” level of pressure behind the left ventricle, similar to that caused by rigidity of the left ventricular wall, does not exclude chronic myocarditis. The pulmonary and myocardial process is tentatively explained as the result of an old viral infection.

Synchronization and accrochage in the presence of incomplete heart block

Abstract An electrocardiogram presenting first and second degree A-V block, “concealed conduction” and “skipped P waves,” suggesting the presence of auriculoventricular synchronization, is described.