Morton E. Tavel

Repetitive Ventricular Arrhythmia Resulting from Artificial Internal Pacemaker

We have presented a case summary of a patient in whom several periods of repetitive ventricular arrhythmia—at times indistinguishable from fibrillation—were induced by artificial internal pacemaker stimuli falling in the T wave of a preceding cycle (the vulnerable period). Ours is the third such case to be reported and, although this repetitive response is said to be rare, the exact incidence remains to be determined. The theoretical and clinical implications are discussed and possible explanations are given for why such small artificial stimuli are capable of evoking such serious arrhythmias in certain patients. We also have suggested measures that might reduce the likelihood for this complication to arise.

Atrial myxoma: II. Phonocardiographic, echocardiographic, hemodynamic, and angiographic features in nine cases

Abstract Nine cases of atrial myxoma, seven left and two right, have been diagnosed and successfully treated in the past five years. The phonocardiographic, echocardiographic, hemodynamic, and angiographic features are discussed in detail.

Atrial myxoma. I. Clinical and pathologic features in nine cases.

Abstract During the past five years, nine cases of atrial myxoma, seven left and two right, have been diagnosed and successfully treated at this institution. Seven were female and all were Caucasian except for one Negro man. Dyspnea was the most common symptom, being present in all nine patients. Six of the nine complained of vague chest pain and syncope was present in three. Ankle edema was prominent in eight patients. Emboli, pulmonary and/or systemic, occurred in four patients. Congestive heart failure, right and/or left, was present in eight of the nine; no patient complained of hemoptysis. Four patients were found to have anemia and three noted fever. The atrial myxoma was successfully removed with the aid of cardiopulmonary bypass and all nine patients noted marked symptomatic improvement. The clinical, electrocardiographic, and pathologic features are described.

Cardiac Auscultation A Glorious Past—And It Does Have a Future!

Cardiac auscultation remains an important part of clinical medicine. The standard acoustic stethoscope, which has been useful for more than a century, cannot process, store, and play back sounds or provide visual display, and teaching is hindered because there is no means to distribute the same sounds simultaneously to more than one listener. Modern portable and inexpensive tools are now available to provide, through digital electronic means, better sound quality with visual display and the ability to replay sounds of interest at either full or half speed with no loss of frequency representation or sound quality. Visual display is possible in both standard waveform and spectral formats. The latter format is readily available and provides certain advantages over the time-honored waveform (phonocardiographic) method. Both methods, however, can and should be used simultaneously. Sound signals obtained electronically may then be subjected to objective visual and numerical analysis, transmitted to distant sites, and stored in medical records. Signal analysis shows early promise for clinical application, such as in the assessment of severity of aortic stenosis and in the separation of innocent from organic murmurs. In addition to their clinical value, these methods provide a critical vehicle for the teaching of cardiac auscultation, a method that can and should be preserved for future generations.

Congenital absence of the left pericardium. Clinical, electrocardiographic, radiographic, hemodynamic, and angiographic findings in six cases.

Until the past decade, the diagnosis of congenital absence of the pericardium, partial or complete, had rarely been made prior to postmortem examination or thoracotomy. Since 1963, the condition has been recognized during life in six patients at this institution. Of these six patients, two had partial absence of the left pericardium and four had complete absence of the left pericardium. Characteristic roentgenologic findings were present in all six patients. Associated heart lesions were not present in either patient with a partial pericardial defect. Two of the remaining four had associated heart lesions. One patient had surgical repair of an atrial septal defect. Surgical repair of the pericardial defect was not attempted in any of the six patients. Hemodynamic determinations at rest were normal in all six patients. The two patients with partial pericardial defects, however, had elevation of the pulmonary artery and left ventricular end-diastolic pressures during mild exercise in the recumbent position which suggests that this type of defect is not totally innocuous. In view of the unusual and extreme cardiac mobility in this condition, it is conceivable that a portion of the heart could herniate and transiently incarcerate through the partial defect during exercise. It is suggested that partial pericardial defects may warrant surgical repair. Small defects or complete absence of the left pericardium, however, are apparently without lethal potential and do not require surgical intervention.

Assessing the Severity of Aortic Stenosis by Phonocardiography and External Carotid Pulse Recordings

Phonocardiograms and carotid pulse tracings were done on a group of 47 patients with all degrees of aortic stenosis and were compared with two groups of normals. Indices evaluated were pre-ejection period, left ventricular ejection time, maximum rate of arterial pulse rise, arterial half rise time (T time) and upstroke time, and timing of the peak intensity of the systolic murmur in relation to the electrocardiographic QRS and first heart sound. The indices most indicative of the presence of aortic stenosis and best correlated with its severity were the ejection time index, the maximal rate of rise of the carotid pulse and the timing of the peak of the systolic murmur. If, in a given case, all three of these indices fall outside of certain limits (ejection time index >0.42 sec, maximum rate of arterial pulse rise <500 mm Hg/sec, and Q wave to peak of murmur >0.19 sec), then severe aortic stenosis is almost invariably present.

Late Systolic Murmurs and Mitral Regurgitation

Abstract Three cases are presented of patients who had systolic murmurs confined to mid- and late systole. Evidence of functional impairment of the heart was either minimal or lacking. Two of the three patients had mid-systolic clicks which initiated their murmurs. Two patients had electrocardiographic signs suggestive of papillary muscle damage. All 3 patients underwent cardiac catheterization studies, and a mild-to-moderate degree of mitral insufficiency was observed at cineangiocardiography. We conclude from these cases, and from 4 similar cases reported recently by others, that a late systolic murmur continuing to or through aortic valve closure probably always is caused by mitral insufficiency of mild to moderate degree, which in turn probably results from papillary muscle dysfunction, damage or slackening of the chordae tendineae, or both.

Korotkoff Sounds: Observations on Pressure-Pulse Changes Underlying Their Formation

We have studied Korotkoff sounds in 10 subjects by recording pressures and sounds simultaneously through a brachial arterial needle at locations both beyond and beneath the inflatable cuff. The Korotkoff sounds coincided with a small dip and ensuing steep rise in pressure immediately beyond the distal edge of the cuff. Sound intensity paralleled not only the rate and the acceleration of this steep ascent, but also the total pressure through which it was maintained. Pressures beneath the midportion of the cuff showed a more pronounced sharp initial negative dip, usually followed by a rapid reversal and steep rise, and the sounds were also recorded here in association with these rapid pressure changes. This study supports the hypothesis that the initial Korotkoff sound is produced by rapid changes of pressure both beneath and distal to the compressing cuff, sufficient in rate to impart sonic vibrations to the vessel wall and surrounding tissues. We have attempted to explain how these rapid pressure changes are produced.

Abnormal Q waves simulating myocardial infarction in diffuse myocardial diseases

Abstract Two cases are presented in which deep QS deflections in multiple electrocardiographic leads simulated myocardial infarction. Both patients had diffuse myocardial disease; in one the cause was unknown, and in the other the condition was associated with pseudohypertrophic muscular dystrophy. It is pointed out that diffuse myocardial destruction or replacement from several causes can occasionally give rise to deep, impressive Q-wave changes.

Idiopathic Hypertrophic Subaortic Stenosis as Observed in a Large Community Hospital: Relation to Age and History of Hypertension

ABSTRACT: The character of idiopathic hypertrophic subaortic stenosis (IHSS) was studied retrospectively in a large community hospital for the six‐year period, 1968–1974. Cases were discovered by examining the records of the Cardiac Non‐Invasive Laboratory (phono‐ and echocardiography). Of the 46 cases of IHSS identified, 39 were in patients of the 50–81 age group. Thirty‐two (82 percent) of the 39 patients were women, and 25 (78 percent) of these had a significant degree of hypertension. The hypertension had been present for more than five years in 62 percent of the cases. In 84 percent of the elderly females, the cardiac murmur had been present for less than ten years, and in 65 percent for less than five years. There was no family history of IHSS. Eighteen of the 46 IHSS patients underwent cardiac catheterization which confirmed the accuracy of the cardiographic data in all cases. The results of this study indicated that IHSS is usually nonfamilial, predominates in elderly females, and tends to be acquired after a lengthy period of hypertension. Cardiographic data appear highly specific diagnostically, often rendering cardiac catheterization unnecessary. Previous studies have not clearly defined the role of hypertension in the development of IHSS, at least partly because of the highly selective nature of most series reported from referral centers. These series often contain large numbers of younger patients.