Robert J. Marshall

Mitral Valve Disease Complicated by Left-to-Right Shunt at Atrial Level

The clinical features and the changes in hemodynamics are described before and after operation in two patients with mitral valve disease associated with left-to-right shunt at atrial level.The first patient had severe rheumatic mitral stenosis, which masked the associated moderateshunt. Since the interatrial communication was small, there was a moderate gradient in pressure between the two atria. Thus, the finding of an elevated left atrial or pulmonary artery wedge pressure in a patient with mitral stenosis and an increase in the saturation of blood at atrial level does not eliminate the possibility of a small interatrial communication.The second patient had severe mitral regurgitation due to a structurally abnormal valve with ruptured chordae tendineae, and had also functional pulmonary and tricuspid valve regurgitation. These lesions also masked the associated large left-to-right shunt. Electrocardiographic and angiocardiographic criteria were used to exclude the possibilities of persistent atrioventricular canal defect and of left ventricle-right atrium shunt.After operation, cardiac catheterization demonstrated a return of the hemodynamic changes toward normal in both patients. There was also a striking clinical improvement.In both, the interatrial communication was situated in the fossa ovalis. It appeared to be a foramen ovale that had become patent due to stretching of the walls of the left atrium, rather than a true atrial septal defect. Although left-to-right shunting may occur through a patent foramen ovale in infants with mitral or aortic valve atresia, we are unaware of previous hemodynamic or surgical evidence of a similar phenomenon developing as a consequence of severe mitral valve disease in adults.

Left Ventricular Function After Cigarette Smoking by Chronic Smokers: Comparison of Normal Subjects and Patients With Coronary Artery Disease

Twenty normal subjects and 25 patients with coronary artery disease underwent systolic time interval analysis before and after rapidly smoking two cigarettes. A slight increase in heart rate and arterial pressure was seen in both groups. In patients with coronary artery disease, preejection period/left ventricular ejection time ratio increased; in normal subjects it decreased. Left ventricular performance is diminished after cigarette smoking among subjects who have preexisting significant coronary artery disease.

CHRONIC OBSTRUCTION OF THE SUPERIOR VENA CAVA DUE TO HISTOPLASMOSIS. A HEMODYNAMIC AND ANGIOGRAPHIC CORRELATION.

Selective angiography and indicator-dilution curves were employed to illustrate the fuctional anatomy of the collateral circulation in two patients with chronic obstruction of the superior vena cava. In both, clinical and laboratory evidence favored an etiologic diagnosis of histoplasmosis.In case 1, the transit time via the main collateralvenous pathway, which comprised the left superior intercostal, accessory hemiazygos and azygos veins, was found to be a little greater than 25 seconds.In case 2, the superior vena caval obstruction was incomplete, but there was an associated severe narrowing of the right pulmonary artery. Distortion of the indicator-dilution curves provided evidence for an increased bronchopulmonary anastomotic circulation to the right lung.These observations illustrate how radiographic and hemodynamic technics may usefully be combined to assess the effects of acquired diseases of the major blood vessels.

Dynamics of the Collateral Circulation in Patients with Subclavian Steal

The occurrence of retrograde blood flow in the ipsilateral vertebral artery of patients with proximal occlusion of the subclavian or innominate artery has been amply demonstrated by selective angiography. However, since flow artifacts may be induced by the physical or chemical effects of injections of contrast media, it was thought desirable to employ a different method for physiologic demonstration of the reversed flow.In the first case, cardio-green dye was injected into the innominate artery and a dilution curve was recorded from the left brachial artery. The early appearance of the dye (6 seconds) proved that a short circuit existed between the arterial injection and sampling sites, and confirmed the authenticity of the reversed vertebral flow shown in previous angiograms.In the second patient, who had symptoms of cerebral ischemia during exercise of the left (affected) arm, dye injected into the left carotid artery did not appear early in the brachial artery of the resting left arm. When it was injected during a period of intense hyperemia of the left arm, a fraction of the dye did appear early. This confirmed that, when the demand of the arm increased, blood was shunted to it not only from the vertebral-basilar system but also from the carotid system.The importance of anatomic factors was evident in another case in which absence of the anticipated retrograde flow was explained by the fact that the vertebral artery arose directly rectly from the aorta and did not communicate with the affected subclavian artery.These observations illustrate how radiographic and hemodynamic technics may usefully be combined to assess the effects of acquired diseases of the major blood vessels.

Chronic Atrial Flutter in Brothers with the Marfan Syndrome

Chronic atrial flutter was found in two teenage brothers with classical features of the Marfan syndrome. Since neither patient has a gross cardiovascular defect, it is postulated that the arrhythmias may be secondary to an alteration in the fine structure of the atrial myocardium.

Atypical angina pectoris

SummaryAngina pectoris generally conforms to the classical description of Heberden. It is important to recognise atypical forms of the syndrome, which are illustrated in this paper by three patients.

The hazards of untreated Addisonian anaemia.

SummaryFour cases are described in which death was due to untreated Addisonian anaemia, and one in which serious loss of sight occurred.In the absence of early diagnosis, Addisonian anaemia is still a pernicious anaemia.