Terminal cardiomyopathy, splitting, and borderline personality organization.

A 63-year-old married man with idiopathic terminal cardiomyopathy was admitted to the medical service for treatment of advanced heart failure. A psychiatric consultation was requested to assist the medical treatment team in dealing with the patient's abusive behavior. The case is presented and discussed within the context of understanding the borderline personality in the medical setting.

Presentation and late outcome of myocardial infarction in the absence of angiographically significant coronary artery disease.

To determine the natural history of myocardial infarction (MI) in the absence of angiographically significant (no lesion greater than or equal to 50% diameter stenosis) fixed coronary artery disease (CAD), clinical and angiographic data and late outcome were studied in 43 such patients. The mean age was 45 +/- 11 years; 32 patients (74%) were cigarette smokers. Mild fixed CAD, present in 38 patients (88%), was more frequent in the artery supplying the MI zone (p less than 0.01). Filling defects or serial angiographic resolution of obstruction in the artery supplying the MI zone were present in 14 patients (33%). At late follow-up, 14 major cardiac events occurred in 9 patients, including revascularization in 3, recurrent MI in 6 and cardiac death in 5. Of 35 patients undergoing catheterization within 1 year of the index MI, cumulative risk of a major cardiac event was 9 +/- 4, 12 +/- 5 and 20 +/- 7% at 3, 19 and 37 months, respectively. Myocardial infarction in the absence of significant fixed CAD tends to occur in young smokers with mild CAD in the artery serving the MI zone. Superimposed intracoronary thrombus can be frequently implicated. In these patients, subsequent major cardiac events may occur more frequently than previously reported.

Coronary disease, cardioneuropathy, and conduction system abnormalities in the cardiomyopathy of Friedreich's ataxia.

Abnormalities of the heart are a frequent and possibly ubiquitous problem in patients with Friedreich's ataxia, but their pathogenesis is unclear. Postmortem findings are reported from the hearts of three patients with Friedreich's ataxia who died of congestive heart failure and atrial arrhythmias. Particular attention was paid to the following: the large and small coronary arteries, the nerves and ganglia, the conduction system, and the histological and cellular features of the cardiomyopathy. There were pleomorphic nuclei and focal fibrosis and degeneration throughout each heart including the conduction system. There were distinctive abnormalities of both large and small coronary arteries, and focal degeneration of nerves and ganglia. These observations suggest a mosaic concept for the pathogenesis for the cardiomyopathy of Friedreich's ataxia that involves the interplay of molecular faults, cardiomyopathy, cardioneuropathy, and coronary disease.

Avoidance of transverse midventricular disruption following mitral valve replacement.

From 1974 through 1977 when our hospital mortality for aortic valve replacement and myocardial revascularization was 3.5% and 1.1%, respectively, hospital mortality for mitral valve replacement (MVR) was 8.3% (13/156)--as high as 14.9% in 1976. Transverse midventricular disruption (TMD) was present in 7 of 10 patients on whom an autopsy was done and was clinically diagnosed in 3 others without postmortem examination. Transverse midventricular disruption presented as refractory myocardial failure immediately on termination of bypass or later (1 to 5 days) after an initial period of good hemodynamics. It appeared to result when volume loading or afterload pressure was returned to the untethered ventricle after MVR performed with potassium-induced, cold cardioplegia and ischemic arrest. Operative techniques were modified to preserve a portion of the mitral suspensory mechanism, to extend the reperfusion interval following cardioplegia and ischemic arrest, and to control strictly ventricular volume and pressure loading following bypass. By utilizing these methods, TMD was avoided from 1978 through 1982, and hospital mortality for MVR was 3.7% (9/241). The improved hospital mortality and avoidance of TMD did not result from patient selection. Allowing adequate time for recovery of the myocardium after cardioplegia plus ischemic arrest prior to ventricular loading, preservation of mitral suspensory function, and strict control of preload and afterload pressures have been effective in lowering hospital mortality for MVR and have eliminated TMD in a 5-year period.

Influence of left ventricular aneurysm on survival following the coronary bypass operation.

Patients having coronary bypass and aneurysm resection (N = 40) or aneurysm plication (N = 32) were compared with patients having coronary bypass without aneurysm (N = 2782). Unlike other series, the primary indication for surgery in the aneurysm patients was angina pectoris, with heart failure playing a secondary role. Multivessel disease was present in 83% of the patients with aneurysm. Total occlusion of the anterior descending coronary artery was more prevalent in the group of patients who had aneurysmectomy (75%) than in rhe group of patients who had plication (38%), and more grafts/patient could be performed in the plication group (2.6 vs 2.0). Location of the aneurysm was most often anteroapical (N = 55) and infrequently inferior (N = 6). Septal wall motion was akinetic or aneurysmal in 47% of the aneurysmectomy group, and 10% of the plication group. Postoperative requirements for inotropes or intra-aortic balloon assist was much higher in the aneurysm group (aneurysmectomy or plication) than in patients without aneurysm having bypass. Hospital mortality for aneurysm patients was 2.7% versus 1.4% in patients without aneurysms having coronary bypass. The actuarial survival rate at 42 months for all aneurysm patients was 90%. Improvement in anginal symptoms after plication and coronary bypass (96%) was more frequent than with aneurysmectomy and coronary bypass (76%) and this was attributed to larger viable muscle mass and greater revascularization. Although two-thirds of patients having surgery for aneurysms had improvement in heart failure symptoms after operation, 30% of those having aneurysmectomies and 35% of those having plications said they were unimproved after surgery. However, this could be explained by the finding that a significant number (35% of the aneurysmectomy and 45% of the plication group) were in heart failure Class I prior to operation. Hospital mortality has been progressively reduced and late survival increased by the surgical treatment of left ventricular aneurysm, primarily through early operation at a time when coronary bypass can be used as an adjunct to aneurysm resection or plication.

Early diastolic sound of constrictive pericarditis.

In two patients with constrictive pericarditis an absent or faint early diastolic sound became prominent with squatting, phenylephrine infusion or injection of contrast medium and was obliterated by nitroglycerin. The lability of the sound allowed correlations to be made with acute changes in the right ventricular pressure curve. By eliciting an otherwise inaudible early diastolic sound, squatting may be a useful bedside maneuver in the diagnosis of constrictive pericarditis.

The echocardiographic correlate of a systolic click appearing after open mitral commissurotomy.

An echocardiographic correlate for a post-valvulotomy mid-systolic click is described. Simultaneous echocardiographic and phonocardiographic studies demonstrated that the click was temporally related to a sudden midsystolic posterior motion of part of the mitral valve apparatus. This temporal relationship suggests that the sudden change in position of portions of the mitral valve resulted in the loud midsystolic click. In our patient the sudden leaflet movement associated with the click was apparently a localized abnormality.

Value of coronary bypass surgery. Controversies in cardiology: Part I.

The value of coronary bypass surgery has been studied carefully during the last decade. Four methods, none perfect, have been used to compare the results of such surgery with the results of medical therapy. New data are likely to be merely supportive rather than the outcome of a definitive study with a new and a acceptable experimental design. It is therefore time to analyze the available data in light of the treacherousness of the disease and to determine if a clear trend is evident. There appears to be sufficient evidence to state that properly performed coronary bypass surgery will increase coronary blood flow and relieve angina pectoris in 90 percent of patients; total relief of angina can be expected in 60 percent and partial relief in 30 percent. Compared with modern medical therapy, properly performed coronary bypass surgery appears to prolong the life of patients who have obstruction of the left main coronary artery or triple or double vessel disease. There is not adequate evidence to state that the procedure will prolong the life of patients with single vessel obstruction. However, patients with single vessel obstruction and unacceptable angina pectoris should be considered for bypass surgery (especially patients with obstruction of the left anterior descending coronary artery). In practice, at Emory University Hospital, Atlanta, bypass surgery is recommended for young people with few symptoms if compelling obstructing lesions are present and in older patients only if their symptoms require it. Medical therapy is given before and after bypass surgery. When bypass surgery is performed in an excellent fashion (operative risk 1 percent) a great deal of "controversy" about this problem vanishes.

Aortic root dissection complicating coronary bypass surgery.

Four cases are presented of aortic root dissection after aortocoronary bypass surgery in which the origin of the intimal tear was at or very near the aortic site of saphenous vein anastomosis. Two cases were documented at autopsy. In one of two cases diagnosed with aortography, the patient underwent surgical correction and survived. All patients had long-standing severe hypertensive cardiovascular disease or severe generalized atherosclerotic disease, or both. Clinical awareness of aortic dissection after coronary bypass surgery in this group of patients should make early diagnosis with successful surgical correction feasible.

Ventricular buckling: a factor in the abnormal ventriculogram and peculiar hemodynamics associated with mitral valve prolapse.

Because of intractable ventricualr arrhythmias after a near-fatal episode of ventricular fibrillation, a patient with idiopathic mitral valve prolapse was subjected to mitral valve replacement. Vector analysis and intraoperative epicardial mapping localized the ectopic focus to the region of the posterior papillary muscle. The patient is alive and well two years after surgery; chronically inverted T waves have become upright. But propranolol and diphenylhydantoin are needed to prevent arrhythmias and T wave abnormalities during standing and exercise. Preoperatively, with the onset of mitral regurgitation and a second rapid phase of prolapse, the ventriculogram was deformed by abnormal midsystolic hyperkinesis at both sites of papillary muscle insertion. Postoperatively, focal hypokinesis appeared in the same areas, implying that they had been retracted by the prolapsing valve. Preoperatively, a papillary tip could be seen entering the mitral ring while coronary arteriography showed late systolic elongation of a small vessel feeding the anterior papillary muscle, suggesting that the papillary apparatus was indeed subject to damaging stress during the abnormal basal movement. Three other persons with severe mitral prolapse (but intact chordae) have had valve repacement and developed qualitatively similar changes in the ventriculogram. Papillary speciments in two showed significant fibrosis. Indication for operation in one of these was edpisodic ventricular fibrillation, which has not recurred. A spectrum of ventriculographic abnormality associated with mitral prolapse could be partly explained by hypokinesis of the papillary loops, variably disguised by retraction stress tansmitted from the billowing leaflets, translocation of blood into the expanding valve sail, and various degrees of unloading into the left atrium. Abnormal intraventicular flow may probably result from associated prolapse of the anterior leaflet and from buckling of the papillary sties toward the mitral annulus. Unusual physical findings in the operated cases and in eight other patients define a clinically recognizable syndrome in which severe prolapse abbreviates left ventricular ejection. Liability to symptoms and to progression of disease seems high in this group.

Echocardiographic oscillating flap in aortic root dissecting aneurysm.

A patient had a history, physical findings, and chest x-ray film suggesting type I aortic dissection. This diagnosis could not be confirmed angiographically. Echocardiographic studies predicted both the presence of dissection and the anatomic findings at surgery. A regularly oscillating echo corresponding to the intimal flap was found in the false lumen. This is suggested as a new echocardiographic finding in dissecting aneurysm.