Richard P. Lasser

The Hemodynamics of the Left Side of the Heart as Studied by Simultaneous Left Atrial, Left Ventricular, and Aortic Pressures; Particular Reference to Mitral Stenosis

At operation the hemodynamics of the left side of the heart were studied in six patients without mitral stenosis, and in eight patients with mitral stenosis, by means of simultaneous needle puncture of the left atrium, left ventricle, and aorta. This technic permits analysis of the various phases of the cardiac cycle in normal subjects and in patients with mitral stenosis. The fundamental hemodynamic expression of mitral stenosis is the presence of an elevated left atrioventricular filling pressure sure gradient, which ranged from 4 to 20 mm. Hg, and after valvulotomy fell in relation to the adequacy of the procedure.

Spatial vectorcardiography: The normal vectorcardiogram. VI

Abstract 1. 1. Vectorcardiograms have been recorded and photographed simultaneously in the horizontal, sagittal, and frontal planes in sixty-two normal children and adults. 2. 2. The horizontal plane QRS loop in normal adults is characterized by an initial deflection anteriorly to the right and is then inscribed in a counterclockwise direction to the left and posteriorly. 3. 3. The sagittal plane QRS loop in normal adults is characterized by an initial deflection anteriorly, usually superiorly, and is then inscribed in a clockwise direction inferiorly and posteriorly. 4. 4. The frontal plane QRS loop may be inscribed in a clockwise or counter-clockwise direction depending upon the axis of the QRS loop. 5. 5. The vectorcardiograms of children are usually oriented more anteriorly, inferiorly, and to the right than those of adults. 6. 6. Multiple thoracic unipolar leads can be derived from the horizontal plane QRS loop, esophageal leads from the sagittal, and standard extremity and unipolar leads from the frontal. 7. 7. The alterations of the QRS and T loops with respiration are described. 8. 8. The clinical advantages and theoretical implications of spatial vectorcardiography are discussed.

PRODUCTION OF CHRONIC ELEVATION OF LEFT VENTRICULAR END DIASTOLIC PRESSURE IN DOGS: HEMODYNAMIC AND RENAL STUDIES.

In an effort to produce a preparation for the study of sodium excretion in chronic left heart failure a graft anastomosis was created between the left subclavian artery and the left atrium in five dogs. This resulted in chronic progressive elevation of left ventricular end diastolic and left atrial pressures. Maximal left ventricular end diastolic pressures ranged between 18 and 30 mm Hg, 10 to 20 weeks postoperatively. There was only a slight rise in right ventricular diastolic pressure and no clinical evidence of right heart failure. Cardiac outputs remained within normal limits in all animals. Serial electrocardiograms disclosed the development of left ventricular hypertrophy and left ventricular hypertrophy and dilatation were observed at postmortem examination. One dog which survived with a patent shunt for more than a year had right as well as left ventricular hypertrophy but no right heart failure. Glomerular filtration rates, renal plasma flow and excretion of rapidly infused isotonic saline remained unaltered even at the highest levels of left ventricular end diastolic pressure. Although the development of left and eventually right ventricular hypertrophy, the chronic and progressive elevation of left ventricular end diastolic, mean left atrial and pulmonary arterial pressure, with only slight elevation of right ventricular end diastolic pressure, were regarded as characteristic features of isolated left ventricular failure, the propriety of this term may be questioned in view of the unaltered cardiac output and renal hemodynamics. But the observations do indicate that marked elevation of left ventricular end diastolic and presumably pulmonary venocapillary pressure, such as occur in left heart failure, do not impair renal excretion of sodium.

Reflex Circulatory Effects Elicited by Hypertonic and Hypotonic Solutions Injected into Femoral and Brachial Arteries of Dogs

Rapid injection of 40 ml. of 5 per cent saline into the femoral or brachial arteries of 24 dogs resulted in an average elevation of arterial blood pressure of +42/+20 mm. Hg, an increase in the heart rate of +20 beats/min., and an acceleration of the respiratory rate of +140 per cent. The response began 6 to 10 seconds after the onset of injection and lasted for 5 to 30 minutes. It occurred with the injection of hypertonic solution of saline, dextrose, and urea. The magnitude of the response was related to the degree of hypertonicity. Responses could be provoked by 10 ml. of 1.25 per cent saline. Rapid intra-arterial injection of isotonic saline, dextrose, and urea solutions, and of whole blood in volumes up to 80 ml. had no circulatory effect. Rapid injection of distilled water, 0.225 per cent and 0.45 per cent saline into the femoral or brachial arteries resulted in a slight degree of hypotension and a rise in the respiratory rate. The appearance of circulating catechol amines following the response to intra-arterial injection of hypertonic solutions was suggested by the demonstration of hypotensive response to intravenous injection of phentolamine. These responses to injection of hypertonic and hypotonic solutions in the femoral artery were abolished by section of the sciatic nerve in animals with an ipsilateral partially-transected hind limb, a preparation which left intact only the femoral artery, femoral vein, and femur. Sciatic section in the intact limb reduced but did not abolish the response. Removal of the sympathetic chain from the eleventh thoracic through the third lumbar ganglia had no apparent effect. It is concluded that the response to femoral aud brachial intra-arterial injection of hypertonic and hypotonic solutions is initiated by peripherally located “osmoreceptors” in the distribution of these arteries and is mediated via a reflex whose afferent fibers travel in the peripheral somatic nerves and enter the spinal cord without passing through the sympathetic chain. The efferent are is the sympathetic nervous system.

Chest Pain in Patients with Isolated Pulmonic Stenosis

Chest pain like angina pectoris has been described in patients with pulmonary hypertension and cor pulmonale but its origin is obscure. In this article 5 patients are reported with isolated pulmonic stenosis and chest pain. On the basis of the clinical, electrocardiographic, hemodynamic, and pathologic findings the authors conclude that the chest pain is caused by ischemia of the right ventricular myocardium due to increased work and reduced coronary flow to the right ventricle.

The use of simultaneous left heart pressure pulse measurements in evaluating the effects of mitral valve surgery

Abstract 1.1. The need for an objective method of measuring the adequacy of mitral valvulotomy by estimating the extent of residual mitral stenosis is emphasized. 2.2. Measurement of the mitral valve filling pressure gradient appears to be the best method of determining the degree of hemodynamically significant mitral stenosis. A method for recording the pressure gradient between the left auricle and the left ventricle at the operating table, by inscribing simultaneous pressure pulses in the left heart, is described. 3.3. The normal filling pressure gradient across the mitral valve approximates zero. The effect of valvulotomy on the elevated pressure gradient in mitral stenosis is to produce a fall of variable degree, depending on the adequacy of the surgical procedure. When this pressure gradient remains high after valvulotomy, relief of the obstruction can be termed inadequate. 4.4. The method is also of value in the differential diagnosis of mitral stenosis, in aiding the surgeon at the operating table to decide whether sufficient manipulation of the valve has been carried out and in determining whether recurrence of obstruction has taken place in patients previously operated upon for mitral stenosis.

Brain abscess caused by an Erwinia species: Report of a case and review of the literature

Abstract A fifty-seven year old man with a brain abscess caused by a member of the Erwinia genus is described. To our knowledge, it is the first time Erwinia has been isolated from this type of lesion. The presence in the patients serum of agglutinating antibodies against this organism but not against other Enterobacteriaceae, as well as the failure of normal serums to effect any agglutination of the strain involved, is highly indicative of systemic invasion in this patient. It now appears that although classically thought of as plant pathogens, members of the Erwinia genus under certain conditions can produce infection in man.

L-lysine monohydrochloride. A clinical study of its action as a chloruretic acidifying adjuvant to mercurial diuretics.

THE usefulness of chloruretic, acidifying agents before the administration of mercurial diuretics is well established,1 since they have been shown to enhance the intensity of diuresis after injecti...

Treatment of recurrent paroxysmal ventricular tachycardia

Abstract This case report demonstrates the therapeutic effect of the combination of propranolol and procainamide upon recurrent paroxysmal ventricular tachycardia in a 10-year-old boy. When used as a single agent, procainamide, diphenylhydantoin, and propranolol proved ineffective in suppressing the arrhythmia. The child has been in normal sinus rhythm for 20 months without side effects, while receiving a combination of propranolol and procainamide. The etiology and therapy of this condition was discussed.

Effect of alterations in systemic pressure upon oxygen saturation in patients with congenital heart disease.

The effect of alteration of systemic pressure upon peripheral arterial oxygen saturation was studied in patients with congenital heart disease. Vasodepression produced by amyl nitrite caused a fall in systemic oxygen saturation in five patients with tetralogy of Fallot, two with patent ductus arteriosus and severe pulmonary hypertension, and one with Eisenmengers complex. These changes did not occur in normals or in those with isolated puhmonic stenosis, trilogy of Fallot, or uncomplicated interatrial septal defect or patent duetus. Levarterenol on the other hand produced a rise in systemic oxygen content in one patient with tetralogy of Fallot. The use of these technics is suggested as a diagnostic aid and for the study of venoarterial shunts.