Walter L. Floyd

The precordial honk

Abstract Seven patients with a loud, intermittent, precordial sound have been described. The quality of the sound suggested the honking noise of a goose, and we have elected to call it the “precordial honk.” This sound may well be the same sound that McKusick 5 and Levine and Harvey 11 have called a “systolic whoop.” The patients had extensive cardiac evaluations which included complete right and left heart catheterizations with cineangiocardiography. The clinical and cardiac catheterization findings are presented, and the various mechanisms for the production of the “precordial honk” are discussed.

Percutaneous technic for cardiac pacing with a platinum-tipped electrode catheter☆

Abstract We have reported a rapid and simple percutaneous technic for initiating intracardiac pacing at the bedside utilizing a small platinum-tipped wire electrode catheter. The method is valuable and potentially life-saving, both pro-phylactically and therapeutically, in the management of Stokes-Adams disease, complete heart block and asystole, particularly when drugs prove ineffective.

Coronary arterial-left atrial fistula. Case with obstruction of the inferior vena cava by a giant left atrium.

Abstract A 64 year old man with a life-long history of known heart disease and irregular heart action presented with a continuous parasternal bruit, a massively enlarged heart and incomplete inferior vena cava obstruction. Angiocardiograms demonstrated marked distortion of all of the heart chambers, particularly the right atrium, and partial obstruction of the inferior vena cava by a large mass presumably invading the heart. Aortogram demonstrated a large anomalous branch of the right coronary artery, but it was not possible to determine angiographically the termination of the vessel. On exploratory thoracotomy, the mass distorting the heart was determined to be a giant left atrium that was presumably the result of a coronary arteriovenous fistula between the right coronary artery and the left atrium. The angiocardiographic findings are presented in detail, and the postulated factors in the development of giant atriomegaly are discussed.

Primary aortic sarcoma mimicking aortic dissection

Abstract Dissecting aortic aneurysms are often fatal and must be treated early for a favorable outcome. Symptoms and signs that suggest the diagnosis of acute dissection include chest pain, pulmonary edema, extremity ischemia, syncope, stroke, paraplegia, renal failure and sudden death.1 Conditions in which some of these findings also occur include myocardial infarction, pancreatitis, cholelithiasis, renal colic, mesenteric ischemia and embolic or hemorrhagic strokes. Recognition of these conditions is important, as they each require a different management approach. We report a case of a primary aortic tumor masquerading as an aortic dissection.

Prostate cancer with solitary parotid metastasis correctly diagnosed with immunohistochemical stains.

A case of prostate cancer in which the parotid gland was the sole site of metastatic disease is presented. Special immunohistochemical stains of the excisional biopsy allowed for rapid, accurate diagnosis and appropriately directed successful therapy.

Observations on sustained pulsus alternans during hypothermia

Abstract Twenty-two dogs were studied by simultaneous measurement of left ventricular pressure, left atrial pressure, aortic pressure, and phasic aortic flow, through the use of a square-wave electromagnetic flowmeter. The induction of hypothermia by extracorporeal cooling of blood or external ice packing resulted in reduced cardiac output and aortic pressure, bradycardia, and marked prolongation of duration of systole and isometric relaxation. In 9 dogs, selective rewarming of the sinus node during the period of hypothermia resulted in tachycardia, a fall in cardiac output and stroke volume, and the appearance of sustained pulsus alternans. During periods of ventricular alternation, prolongation of systole and myocardial relaxation resulted in the abbreviation of ventricular filling time and varying degrees of incomplete ventricular relaxation. Reversal of abnormal contraction and relaxation by rewarming of the left ventricle was accompanied by a return of stroke volume to precooled levels and disappearance of the alternation. Two dogs cooled by external ice packing developed pulsus alternans during the cooling period. In one of these animals a spontaneous slowing of the heart rate during the period of progressive reduction in heart temperature resulted in increased ventricular filling time and disappearance of the pulsus alternans. Elevation of left atrial pressure in 2 dogs with sustained pulsus alternans resulted in the disappearance of ventricular alternanation without any appreciable change in heart rate. Increased ventricular outflow resistance produced by venous-to-arterial pumping during the cooling period was accompanied by pulsus alternans in 2 animals. Reduction of outflow resistance by cessation of extracorporeal pumping was accompanied by a fall in aortic pressure, a reduction in duration of ventricular contraction, and disappearance of pulsus alternans, even though the heart rate and left atrial pressure were unchanged. Prolonged myocardial contraction and relaxation resulting in abbreviated and abnormal character of ventricular filling are considered to be prerequisites to the occurrence of pulsus alternans at physiologic heart rates in the hypothermic dog heart. However, the presence and degree of ventricular alternation is modified by other dynamic factors, such as heart rate, atrial filling pressure, and ventricular outflow resistance.

Hydrogen-sensitive, platinum-tipped electrode in the diagnosis of left to right shunts: Practical application☆

Abstract A new technic, utilizing a hydrogen-sensitive, platinum-tipped wire electrode introduced percutaneously via a No. 18 Cournand needle into the brachial vein and flow-directed into the right heart chambers and pulmonary artery, has greatly simplified the detection of left to right intracardiac shunts. The position of the electrode is identified by intracavitary electrocardiographic monitoring. Electrical potential, created by contact of inhaled hydrogen with the platinum tip, produces characteristic electrocardiographic deflections when left to right shunts are present. Two hundred and four catheterizations in 182 patients screened for possible left to right shunts yielded 86 positive, 115 negative and 3 equivocal shunt curves. Fifty-three instances have been confirmed by conventional cardiac catheterization technics or surgery, or by both. No definite false positive curves were obtained other than from the easily identified pulmonary wedge position. In 5 patients false negative curves were obtained from the proper chamber; however, in each instance positive curves were recorded from one chamber distally. This technic can be performed as an outpatient procedure in 15 to 30 minutes without discomfort except for venipuncture. Minor complications observed were brief supraventricular arrhythmia (3), multiple extrasystoles (2), transient difficulty in electrode dislodgment (2), and intracavitary knotting (2). No major complications have occurred. Caution is expressed regarding proper grounding of all electrical equipment to prevent electrically induced ventricular fibrillation. The potential hazard of a knot in the wire electrode embracing a papillary muscle or chorda tendinea suggests the need of ready access to an experienced cardiac surgeon. The procedure presents a simple, reliable and reasonably safe method for determing left to right shunts, both preoperatively and postoperatively, and often obviates the need for major catheterization.

Exercise in the Physical Examination of Peripheral Arterial Disease

Excerpt Atherosclerotic peripheral arterial disease, a prevalent and disabling condition, has received considerable diagnostic and therapeutic attention in recent years. In the lower extremities th...

Postoperative use of the hydrogen-sensitive, platinum-tipped electrode: Detection of residual left to right shunts☆

Abstract Seventy-seven patients submitted for surgical correction of left to right cardiac shunts were studied postoperatively by the hydrogen-sensitive, platinum-tipped electrode technic. The series was composed of atrial septal defects (51 patients), ventricular septal defects (20 patients) and a miscellaneous group (6 patients). Positive hydrogen electrode studies indicating persistent postoperative shunting were observed in 5 atrial septal defects (10%), 9 ventricular defects (45%) and 3 of the miscellaneous group. In this series, surgical closure of atrial septal defects was quite successful (90%), the results being better for secundum (94%) than for primum defects (60%). Operative closure of ventricular septal defects was less successful (55%) for either uncomplicated defects (60%) or those complicated by pulmonic stenosis (53%). In each of 8 patients results obtained from electrode studies were confirmed by catheterization or by further surgery. Twentytwo patients whose atrial defects were considered closed retained the split of the pulmonic second sound; therefore, this sign does not necessarily indicate a persistent shunt. It is concluded that the hydrogen-sensitive, platinum-tipped electrode technic offers a simple, sensitive and accurate method for evaluating operative success in the repair of various left to right cardiac shunts.

The Practical Application of the Hydrogen Sensitive Platinum Tipped Electrode in the Diagnosis of Left-to-Right Shunts.

Excerpt A new technique, utilizing a hydrogen-sensitive, platinum-tipped wire electrode introduced percutaneously by a no. 18 Cournand needle into the brachial vein and flow directed into the right...