Robert S. Eliot

CHOLESTEROL EMBOLISM: A MULTIPLE-SYSTEM DISEASE MASQUERADING AS POLYARTERITIS NODOSA.

Abstract The clinical picture and necropsy data of 2 cases of cholesterol embolism, clinically masquerading as polyarteritis nodosa, are described. In 1 case, the correct diagnosis was made during life by biopsy of the skin. The clinical entity of cholesterol embolism is defined as the rupture of intimal atheromas of the aorta causing impaction of cholesterol crystals in small arteries of many organs and a characteristic picture of sudden obliterative arteritis primarily throughout the lower half of the body. Some of the specific clinical features are (1) the abrupt onset of scattered intense pains in the legs and feet with subcutaneous and muscular nodules or gangrene despite, in some cases, paradoxically normal peripheral arterial pulses; (2) abdominal pain with nausea and vomiting suggesting pancreatitis and/or gastrointestinal or splenic infarction; (3) arterial hypertension thought to be secondary to impairment of renal function; (4) livedo reticularis or cyanosis of the legs and lower trunk within a few days after the onset of pain and hypertension; (5) less commonly, neurologic symptoms and possible funduscopic demonstration of retinal emboli; (6) laboratory evidence of neutrophilic leukocytosis, transient eosinophilia, markedly increased sedimentation rate, hematuria, albuminuria, azotemia and melena; and (7) a biopsy showing cholesterol crystal emboli. Although some of the features suggest a state of hypersensitivity, recognition of the distinctive pattern found in our 2 cases may allow the clinician to differentiate cholesterol embolism from polyarteritis nodosa. Final diagnosis rests upon the biopsy showing the characteristic histologic changes. A new gradation of the histologic changes into four stages of evolution is suggested.

CONGENITAL ANEURYSM OF THE LEFT AORTIC SINUS. A RARE LESION AND A RARE CAUSE OF CORONARY INSUFFICIENCY.

AN aneurysm restricted to the left aortic 1A.t sinus is extremely rare. Aneurysms of an aortic sinus most often involve the right (related to the right coronary artery) or the posterior (noncoronary) sinuses. The left aortic sinus may participate with the other two in aneurysmal dilatation, such as occurs in the Marfan syndrome. Described in this communication is an aneurysm that involved the territory of the left aortic sinus in a patient with a congenitally bicuspid aortic valve. The purposes of this report are to demonstrate that an aneurysm may occur in this region and to indicate that by displacing and compressing the left coronary artery, the aneurysm was responsible for coronary insufficiency and myocardial infarction.

Cor Triatriatum Review of the Surgical Aspects with a Follow-up Report on the First Patient Successfully Treated with Surgery

A follow-up report on the first patient with cor triatriatum to undergo successful surgical treatment is presented. A second procedure was necessary 9½ years later because of stenosis of the initial surgically created orifice in the anomalous diaphragm. A review and ananalysis have been made of 17 cases from the literature reporting successful operations for this lesion. Total excision of the accessory septum utilizing cardiopulmonary bypass is presently the appropriate surgical treatment of this entity. Preoperative and postoperative hemodynamic data are discussed. Recognition and correction of this defect are emphasized in order to avoid permanent pulmonary vascular changes attended by a relatively fixed cardiac output.

Coexistent mitral and aortic valvular atresia

Abstract Fourteen specimens of an uncommon form of congenital cardiac disease, coexistent mitral and aortic atresia, were reviewed grossly and histologically. The anomaly occurred more often in boys than in girls. Death usually occurred within a period of three days after birth. Although short, the life span depended upon the type and size of the interatrial communication. In those patients who had no true atrial septal defect, the egress of blood from the left atrium, in the presence of a normally developed atrial septum, occurred through a peculiar form of acquired interatrial communication. It consisted of a herniation and prolapse of the valve of the foramen ovale into the right atrial cavity. Although the left ventricle was blind and therefore was excluded from hemodynamic significance, it still contained a blood clot in several instances. This gave evidence of persistent communication between the left ventricle and the coronary circulation by way of myocardial sinusoids; this was proved histologically. Anatomic details which might aid in the location of the hypoplastic left ventricle are described. The most commonly associated anomaly was coarctation of the aorta. The condition may be misdiagnosed as common ventricle with or without persistent truncus arteriosus. Identification of the landmarks in the single functioning ventricle will establish this to be the right ventricle. Careful dissection of the great vessels will reveal a hypoplastic ascending aorta, in addition to the widely patent pulmonary trunk. Such observations exclude the diagnosis of persistent truncus arteriosus. The left ventricle may be identified as a tiny slit lying to the left of the anterior descending coronary artery and below a dimple in the floor of the left atrium.

Stress and the heart. Mechanisms, measurement, and management.

Unrelieved physical or mental stress and repeated episodic stress are ultimately harmful to the cardiovascular system and thus can be life-threatening. In this article, Dr Eliot describes efforts to quantify the psychophysiologic responses to stress and to identify the components of stress and its clinical consequences. He also explains the importance of controlling the real-life episodic fluctuations in blood pressure that occur daily in response to stress.

Correction of Shunt from Right Conal Coronary Artery to Pulmonary Trunk with Relief of Symptoms

A case of a small right coronary conal branch to pulmonary trunk shunt with surgical correction is reported. The patient, a 45-year-old housewife, had chest pain, labile hypertension, and intermittent left bundle-branch block with normal serum cholesterol and triglyceride levels. Selective coronary arteriography was necessary to demonstrate the abnormal communication between the conal branch of the right coronary artery and the pulmonary trunk. Symptoms disappeared after surgical correction of the shunt. Transient left bundle-branch block appeared during exercise after surgery, but the patient was improved subjectively and resumed all household chores without difficulty. Shunting of oxygenated blood away from the myocardium thereby decreasing coronary blood flow to a specific area may have been responsible for significant symptomatology.

Conditions of the ascending aorta simulating aortic valvular incompetence

Abstract Abnormal run-off of blood from the ascending aorta may result either from primary diseases of the aortic valve or from primary diseases of the ascending aorta. Primary diseases of the ascending aorta which allow abnormal escape of blood from the aorta fall into two categories. The first includes those conditions which, by virtue of the distortion or dilatation of the ascending aorta, cause the aortic valve to become incompetent. The route for abnormal escape of blood in these situations is through the aortic valve. In the second the aorta communicates abnormally with a cardiac structure or a mediastinal blood vessel. Congenital, traumatic and infectious conditions constitute the major backgrounds for this second type of functional derangement.

Sudden death and acute myocardial infarction: clues to differences in pathophysiology.

Although both sudden death and acute myocardial infarction are almost always associated with long-standing obstructive coronary artery disease, both may originate in the myocardium. Spasm has been suggested as a factor contributing to sudden death. Not all persons dying of acute myocardial infarction have narrowed coronary arteries, nor do all persons with obstructed arteries die of heart disease. The first phase of acute myocardial infarction may well involve myocardial necrosis, followed by stasis and collapse of collateral circulation and occasionally by coronary occlusion.

Clinical Significance of Left Axis Deviation

Left axis deviation is always a matter of concern since it is often seen without other apparent electrocardiographic abnormalities and the physician must decide whether or not its presence is significant to the patient. The results of an army study of 195 men with left axis deviation compared with a normal control group over a period of 22 months indicated that left axis deviation is highly suspect of associated atherosclerosis. Experience has shown a higher operative risk for the patient with left axis deviation in combination with anterolateral peri-infarction block.

PROGNOSTIC SIGNIFICANCE OF ANTEROLATERAL PERI-INFARCTION BLOCK IN SURGERY FOR AORTIC REGURGITATION.

Abstract Eighty-four patients underwent open heart surgery with ball-valve (Starr-Edwards or Magovern) replacement for pure or predominant aortic regurgitation. Of the 58 having normal axis deviation, 40 survived; all 5 having left axis deviation alone survived; of the 20 having marked left axis deviation plus anterolateral peri-infarction block, 1 survived; neither of the two having marked right axis deviation survived. No difference between patients with normal axis or left axis deviation with or without peri-infarction block was found by gross pathologic or histologic study, review of physiologic data, review of degree of coronary atherosclerosis, degree of left ventricular fibrosis, or other parameters of investigation. Five patients with aortic regurgitation had abnormal glucose tolerance tests; 3 of these had left axis deviation. It is suggested that anterolateral peri-infarction block accompanying aortic regurgitation indicates an abnormality of the myocardium which may be expressed as failure to defibrillate, poor myocardial contraction and increased irritability. Because of the absence of infarction or histologic evidence of specific abnormality, the term, anterolateral myopathic block might be more appropriate than anterolateral peri-infarction block in the individual with aortic regurgitation. The presence of this electrocardiographic abnormality in a patient with aortic regurgitation indicates an increased risk of cardiopulmonary bypass and aortic valve replacement.