Echocardiographic observations of calcium in operatively excised stenotic aortic valves.

Qualitative and quantitative 2-dimensional (2-D) echocardiographic methods were developed to define the anatomic and physiologic significance of valvular calcium in aortic stenosis (AS). Qualitative methods assigned etiologic diagnoses by matching patterns of calcium with anatomic criteria. Quantitative techniques measured echodensities from superimposed short-axis views of calcium. Fifty-five pathologic specimens procured from surgery were photographed and radiographed. Etiologic diagnoses were assigned from gross examination and radiodensities were planimetered. Echocardiographic and anatomic diagnoses were compared. Sensitivities for diagnosing the most common etiologies, congenitally bicuspid and degenerative, were 58% and 100% and specificities were 100% and 76%. Calcium tended to be heaviest in congenitally diseased valves and lightest in those with degenerative disease (p less than 0.2) and showed propensity for the right cusp in all etiologies except for those with degenerative disease. Correlation of echodensities to radiodensities was 0.82. The relation of calcific echodensities to orifice area was curvilinear; beyond a level of calcium, further deposits did not reduce the orifice more. A systematic echocardiographic examination of calcium in stenotic aortic valves can give a correct etiologic diagnosis in most patients and identify the severely narrowed orifice.

Recent trends in the management of life-threatening ventricular arrhythmias.

An edited summary of an Interdepartmental Conference arranged by the Department of Medicine, UCLA School of Medicine, Los Angeles. William M. Pardridge, MD, Associate Professor of Medicine, is Director of Conferences. This study was supported in part by grants from the Public Health Service; the National Institutes of Health (HL-23970, 1978-1981); the Medical Research Service of the Veterans Administration, and the American Heart Association, the Greater Los Angeles Affiliate.

Atypical echocardiographic and angiographic presentation of a postoperative pseudoaneurysm of the left ventricle after repair of a true aneurysm.

Subsequent to the repair of a true aneurysm from the posteromedial-basal aspect of the left ventricle, a 58 year old man developed a draining wound at the site of the sternotomy. Two-dimensional echocardiography revealed recurrence of the aneurysm at the site of the previous aneurysm repair. This aneurysm had a wide neck and looked similar in appearance to the previous true aneurysm. However, at surgery the patient was found to have a ventricular pseudoaneurysm with a cardiocutaneous fistula.

Early valve replacement in active infective endocarditis. Results and late survival.

In the past 14 years, 42 patients with active infective endocarditis underwent early valve replacement for severe congestive heart failure, major prosthetic dehiscence, intramyocardial abscesses, sepsis, or major embolization. Blood cultures were positive in 40 patients and the valve tissues were positive in two others. All patients received antimicrobials for from 1 to 4 weeks. Drug addiction was noted in 24%, urinary tract manipulation in 7%, dental work in 5%, contaminated prosthesis in 2%, and unknown cause in 62%. Organisms were predominantly staphylococcal (43%) and streptococcal (41%); the remainder were gram-negative (9%) or fungal (7%). The aortic valve was involved in 72%, mitral in 14%, tricuspid in 7%, and both aortic and mitral in 7%. By the New York Heart Association (NYHA) functional classification, 90% (38/42) were in Class III or IV. Operative mortality was 10% (4/42) and all four patients had preexisting renal failure necessitating dialysis. No predominant organism correlated with early deaths. In aortic valve replacement (30 patients), operative mortality was 7%. Postoperatively, 95% (35/37) were Class I or II with one lost to follow-up. Subsequent reoperation was required in five patients (13%) for recurrent endocarditis, with an operative mortality of 20% (1/5). Late death occurred in 45% (17/38). Overall probability of survival was 0.53 at 5 years. For isolated aortic valve involvement, the 5 year survival was 0.58. Survival for native valve involvement was 0.58 and for prosthetic endocarditis, 0.55. This study shows that after at least 1 week of antibiotics, early operation in patients with active endocarditis has an acceptable operative mortality. Clinical improvement is excellent in 95% and more than half survived 5 years or longer.

Hemodynamic effect of myocardial revascularization in the impaired ventricle.

The hemodynamic effect of myocardial revascularization with saphenous vein grafts (mean 3.3 per patient) was analyzed 1 year after operation in 111 patients. Operations were performed using one continuous period of aortic cross-clamping with hyperkalemic cardioplegia for distal anastomoses in 84% of patients; 16% had arrest with topical and systemic hypothermia for myocardial protection. Group I (N = 18) had normal ventricles (ejection fraction [EF] greater than 50%; left ventricular end-diastolic pressure [LVEDP] less than or equal to 12 torr); Group II (N = 64) had ischemic ventricles (EF greater than 50%, LVEDP greater than 13 torr); and Group III (N = 30) had abnormal ventricles (EF less than 50%, LVEDP greater than 13 torr). Hemodynamic measurements were obtained before and 1 year after operation. Fifteen of 18 patients (83%) in Group I did not show significant hemodynamic changes, but in three EF decreased by greater than or equal to 10% and LVEDP increased by greater than 10% over preoperative levels. In Group II, EF was unchanged or slightly better in 89% (57/64) and worse in seven patients. Improvement in cardiac index (p less than 0.01) and LVEDP (p less than 0.001) was significant. Worsening of EF in 10 of 82 patients in Groups I and II was attributed to graft closure and/or poor myocardial protection. In Group III, significant improvement in cardiac index (p less than 0.001), EF (p less than 0.001), and LVEDP (p less than 0.01) was also noted. A subset of nine patients with EF less than or equal to 35% showed postoperative improvement in 56%. Of the remaining 20 patients with an EF of greater than 35% to less than 50%, half had greater than or equal to 20% improvement in postoperative EF. Operative mortality was 3.3% (1/30) for Group III. Late mortality was 1.5% (1/64) for Group II and 10% (3/29) for Group III. Significant improvement was noted postoperatively in 67% (57/85) of all patients who had preoperative treadmill tests (p less than 0.001). This study shows that myocardial revascularization significantly improved left ventricular performance in most patients with ischemic and abnormal ventricles. Previous studies that fail to show improvement may be related to incomplete revascularization and/or poor myocardial preservation. These data, therefore, justify the need for revascularization of the impaired ventricle.

Jaundice associated with polycystic liver disease.

Jaundice is rarely encountered in polycystic disease of the liver. In the present case, pressure from tense cysts at the hilus of the liver caused a marked narrowing of the common hepatic duct and slowing of bile flow with the formation of stasis stones. Decompression of the cysts and removal of debris in the intrahepatic ducts resulted in a rapid decrease of the serum bilirubin level.

The effect on atrial and ventricular intracellular potentials, and other pharmacological actions of L9146, a non-halogenated benzo(b)thiophene related to amiodarone.

L9146 was synthesised in the hope of eliminating the unwanted side-effects of amiodarone which has been shown to be effective in the control of atrial fibrillation, flutter, and in pre-excitation syndromes such as Wolff-Parkinson-White syndrome. L9146 has pharmacological and electrophysiological effects similar to those of amiodarone. It is an antagonist of both alpha and beta adrenoceptor-mediated cardiovascular effects of a noncompetitive type. It lowers vascular resistance briefly, and causes a longer lasting bradycardia. It moderately reduces the maximum rate of depolarisation (MRD), conduction velocity, and totally suppresses ventricular pacemakers activated by high doses of isoprenaline. In addition, L9146 greatly prolongs action potential duration (APD) in atrial and ventricular muscle. In normal ventricular conducting tissue the action potential duration (APD) is shorter in the bundle of His than in the false tendons, and shorter still in the ventricular muscle. L9146 lengthened APD throughout, but particularly in the proximal portion, and even more in the muscle, so that APD became uniform. The decrement of conduction of premature action potentials was increased to the point at which slowly conducting premature AP's were eliminated altogether.

Intraoperative mapping of atrial activation before, during, and after the Mustard operation.

Thirty-eight patients with transposition of the great arteries underwent intraoperative mapping of atrial epicardium and endocardium during various stages of the operative procedure. The purpose was to determine the electrophysiological basis of the postoperative supraventricular arrhythmias associated with this operation. Comparisons were made between atrial activation patterns and times before and after each of the following stages: (1) cannulation, (2) atriotomy, (3) excision of atrial septum and coronary sinus, and (4) placement of intra-atrial baffle. The first stage produced no significant changes in atrial activation times or patterns but did demonstrate a shift of the functional pacemaker to the sulcus terminalis in 8 of 14 patients studied. Longitudinal atriotomy did not significantly lengthen atrial activation. Transverse atriotomy did not alter activation times of the His bundle but did significantly change patterns of epicardial and endocardial activation. Excision of the septum and coronary sinus always produced block in the posterior crista terminalis, and placement of a baffle worsened this block. Four patients developed nodal rhythm on the operating table and had both a posterior crista terminalis block and anterior septal block. Suggestions for modification in the surgical techniques were advanced to help prevent rhythm disturbances in paitients undergoing transvenous correction of transposition of the great arteries.

Investigations to characterize a new anti-arrhythmic drug, ORG 6001 including a simple test for calcium antagonism.

1 The compound Org 6001 (3alpha-amino-2beta-hydroxy-5alpha-androstan-17-one hydrochloride) was found in recent experiments to exhibit anti-arrhythmic activity. Evidence is presented in this paper concerning its mode of action. 2 Org 6001 was 1.8 times more potent than procaine as a local anaesthetic on desheathed frog nerve. 3 Org 6001 had no effect on the resting potential of isolated cardiac muscle of rabbit, but greatly reduced the maximum rate of depolarization tion (MRD). The action potential duration TAPD) WAS MARGINALLY PROLONGED IN ATRIAL AND VENTRICULAR MUSCLE. 4 Org 6001 preferentially shortened APD in that part of the Purkinje system in which APD is normally longer than elsewhere, so that APD

Surgical treatment of ventricular arrhythmias using epicardial, transmural, and endocardial mapping.

In 3 patients with ischemic coronary disease or primary myocardiopathy who were unresponsive to conventional and experimental antiarrhythmia therapy, surgical treatment of intractable ventricular tachycardia was performed using epicardial, transmural, and endocardial mapping techniques. An experimental canine model of acute and chronic myocardial ischemia with recurrent ventricular tachycardia was developed to refine the mapping technique for clinical use. In patients and animals alike, atrial overdrive pause pacing, premature ventricular pacing, or both were used to bring outa repeatable pattern of tachycardia. Mapping techniques distinguished the irritable focus so that surgical excision of the site of earliest activation could be performed. In addition, the mapping techniques were used in the validation following excision. The limitations of epicardial mapping alone in locating all areas of premature focus are discussed, and the need for mapping in ventricular aneurysm is demonstrated.