Cyanosis following right pneumonectomy: importance of patent foramen ovale.

A patient with chronic lung disease became cyanotic following right pneumonectomy for cancer. He was found to have right-to-left shunting through a patent foramen ovale in the absence of pulmonary hypertension, and he improved remarkable after surgical therapy. This case vividly illustrates the subtlety with which acquired right-to-left shunting may appear in the setting of chronic hypoxemia. The frequency of patent foramen ovale in the general population (20 percent) and the ease and efficacy of treatment for this lesion underscore the need for general awareness of this potential problem in the chronically or critically ill.

Behavior of serum myoglobin during cardiac catheterization: concise communication.

We have studied 28 patients undergoing coronary angiography by the Judkins technique to determine whether serum myoglobin (MG) might be useful as an indicator of myocardial injury during routine cardiac catheterization and coronary angiography. MG was measured immediately before and after the procedure, and 4 hr later. The study population failed to show a rise of MG outside the normal range in spite of angina, hypotension, or severe coronary disease. Four patients premedicated with intramuscular pentobarbital (positive control) showed a consistent rise, with a range 1.5--3 times normal (p less than 0.001). We conclude that injury to myocardial or peripheral tissues occurring during coronary angiography does not raise myoglobin in venous blood above normal levels in the absence of myocardial infarction or preoperative intramuscular injection. Myoglobin, therefore, provides a useful test for the exclusion of myocardial infarction following coronary angiography.

Comparative accuracy of electrocardiographic and vectorcardiographic criteria for inferior myocardial infarction.

Numerous criteria for the diagnosis of inferior wall myocardial infarction by electrocardiogram (ECG) and vectorcardiogram (VCG) have been published, but they have not been subjected to a systematic, independent evaluation. Accordingly, we studied 146 patients undergoing cardiac catheterization; 63 were normal and 83 had a history of infarction, a significant right coronary lesion and an inferior wall motion abnormality (inferior infarction group). No ECG or VCG criteria were considered in the designation of the two groups; rather, three sets of ECG and VCG criteria were evaluated for this purpose. Specificity was excellent (98-100%) and sensitivity was poor (4-34%) by all three sets of ECG criteria, but the 1949 ECG criteria of Meyers et al. are the least sensitive (4%, p less than 0.001). Specificity (90-100%) and sensitivity (82-84%) were very good by all three VCG criteria. The VCG criteria of Starr et al. gave no false-positive results in our normal group. Because of enhanced sensitivity, the overall accuracy of the VCG was higher than that of the ECG for the diagnosis of inferior infarction (90% vs 62%, p less than 0.001). We conclude that more recent ECG criteria for the diagnosis of inferior wall myocardial infarction are highly specific, but insensitive compared with VCG criteria.

Electrocardiographic aspects of acute left anterior hemiblock induced by exercise.

The intraventricular conduction time was measured during rest, exercise, and recovery in five patients who developed acute left anterior hemiblock during exercise-induced myocardial ischemia. The A QRS shifted from 58 +/- 17 degrees at rest to -66 +/- 11 degrees during exercise (p less than 0.001). The intraventricular conduction time at rest was 86 +/- 4 ms and increased to only 90 +/- 4 ms during left anterior hemiblock. Our observations suggest that the intraventricular conduction time is not always prolonged during left anterior hemiblock, particularly if this conduction abnormality is acute.

Surgical treatment of anomalous left coronary artery from pulmonary artery: follow-up in teenagers and adults.

To determine which method of surgical therapy might be optimal for patients with anomalous left coronary artery from the pulmonary artery (ALCAPA), a follow-up study was performed. Twenty-nine teenagers and adults who had ALCAPA diagnosed during life at age 13 years or older were identified mainly by literature search. Recent follow-up was obtained on all. Thirteen treated by ALCAPA ligation alone (Group A), were followed a mean of 9.2 years postoperately (range 1 to 15 years). There was no operative mortality. Three Group A patients died suddenly; a mean of five years (range 2 to 7 years) postoperatively. Sixteen patients treated by simultaneous ALCAPA ligation and saphenous vein graft (SVG) from aorta to left coronary artery (Group B) were followed a mean of five years (range 0 to 11 years) with one intraoperative death and no late mortality. Using the generalized Wilcoxon test for single censored samples, there was no significant difference in survival at any postoperative year when comparing both Groups A and B. The late appearance of sudden death in three Group A patients and no late deaths in Group B patients suggests that ligation and SVG, or its equivalent, may be the therapy of choice.

Medullary sponge kidney and renal-leak hypercalciuria. A link to the development of parathyroid adenoma?

The pathogenesis of the association of medullary sponge kidney and hyperparathyroidism from parathyroid adenoma remains obscure. This unusual case of medullary sponge kidney and secondary hyperparathyroidism due to renal-leak hypercalciuria gives insight into a possible mechanism for the occurrence of medullary sponge kidney with parathyroid adenoma. Suppressible hyperparathyroidism due to renal calcium wasting could represent an intermediate stage in the development of unsuppressible parathyroid hormone secretion. Thus, parathyroid adenoma occurring with medullary sponge kidney may represent a consequence of disordered renal calcium excretion rather than a primary abnormality.

Anomalous origin of left coronary artery from pulmonary artery. Case report and review of literature concerning teen-agers and adults.

An adult with angina was found to have anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Review of the literature regarding this anomaly in teen-agers and adults disclosed only 25 cases diagnosed during life. Eighteen additional cases of ALCAPA in this age group have been diagnosed post mortem. In this report, we will review the management of teen-agers and adults in whom ALCAPA was correctly diagnosed during life. We shall also describe the eighth case of successful aorta-left coronary artery grafting with the saphenous vein in this age group. This case brings the total in the literature to 44. Of those patients offered surgical therapy, 13 underwent successful ligation of the anomalous artery. Saphenous vein grafts were employed in 8. Five did not undergo ligation or saphenous vein grafting. There was one death. It would appear that saphenous vein grafting is the definitive means of surgically correcting ALCAPA, because it restores the dual coronary circulation.