35.“Rheumatic activity”: A clinicopathologic correlation

Abstracts of Papers HAROLD K. TSUJI, M.D., and JOHN V. REDINGTON, M.D., Los Angeles, Calif. Since beginning the use of the open heart technic in 1958 for the surgical treatment of mitral valve disease, we have repaired the mitral valve whenever possible and replaced only the valves that were so calcified or deformed that repair was not possible. While operating on these patients, it became apparent to us that the critically ill patients with chronic failure and tricuspid insufficiency made up the majority of the patients that could die following open heart surgery. This tricuspid insufficiency in not due to rheumatic involvement of the tricuspid valve but is due to right ventricular failure and secondary tricuspid insufficiency. If the patient were to survive mitral valve surgery the tricuspid insufficiency would in due time correct itself. However, unless this is corrected at the time of surgery, the patient dies of a low cardiac output. For a period of more than a year we turned down patients for surgery if they had tricuspid insufficiency, because of the extremely high mortality. For the past four years, we have performed an annuloplasty and thereby completely corrected the tricuspid insufficiency. Since then there has been a striking improvement in the mortality of these Class IV patients, and there have been nine deaths in 24 severely ill bedridden patients who would have died without surgery. These surviving people have now returned to a normal existence. The technic of tricuspid annuloplasty was developed in our research laboratory before it was employed clinically. *34. Support of the Failing Circulation: Use of a Pump Oxygenator in Clinical Cardiac Failure, J. H. KENNEDY, M.D., F.A.c.c., N. BAILAS, M.D., P. BARNARD,M.D., N. SARAP, B.S. and J. BEYERS, B.S., Cleveland, Ohio. The authors report experience with 6 patients who were considered to be in medically-intractable heart failure and who were treated by mechanical support of the failing circulation using a disc oxygenator and heat exchanger. Two patients in severe left ventricular failure at the conclusion of open heart surgery were subjected to left heart bypass for 45 minutes following which successful defibrillation was possible. Four patients underwent partial cardiopulmonary bypass, femoral vein to femoral artery perfusion of oxygenated blood under local anesthesia being used as an emergency procedure after the usual pharmacologic measures and phlebotomy had failed to improve the patients. Of these, 2 patients who were in left heart failure were strikingly improved so far as hemodynamic observations were VOLUME15, JANUARY1965

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concerned and were discharged from the hospital improved. Two patients who were in right heart failure improved remarkably during the bypass period, but returned to their pre-perfusion state promptly following the conclusion of partial cardiopulmonary bypass and ultimately died. At present our prime indication for emergency support of the failing circulation is intractable heart failure. Activity”: A Clinicopathologic 35. “Rheumatic Correlation, EDWARD KLIBANOFF, M.D., JULIAN FRIEDEN, M.D., MARIO SPAGNUOLO,M.D. and ALVAN R. FEINSTEIN, M.D., New York, N. Y. and New Haven, Conn. Clinical and pathologic evidence of “rheumatic activity” have been correlated in 47 patients who died with rheumatic heart disease at age 30 or below. “Clinical activity” was defined by the presence of one or more major features of the Jones diagnostic criteria (exclusive of congestive heart failure) in the 6 months before death; “pathologic activity” was defined by the presence of Aschoff bodies or of cellular infiltrate (or both) in the myocardium. The review of tissue slides and the classification of clinical records were performed independently by separate observers, unaware of each other’s findings and opinions. Pathologic activity was found in 11 (92%) of the 12 patients who were clinically active, and in 19 (58%) of the 33 who were inactive; this difference is not statistically significant (X2 = 3.2; p > 0.05). Aschoff bodies occurred in 4 (330/,) of 12 patients who were clinically active and in 5 (15’%) of 33 who were “inactive”; the difference is also not significant statistically (X2 = 0.8; p > 0.3). Cellular infiltrate but no Aschoff bodies appeared in both of 2 patients whose clinical state could not be classified. Of the 20 patients who died before age 17, clinical activity was present in SO%, Aschoff bodies in 250/o, and pathologic activity in 85%. Of the 27 patients who died at ages 17-30, these percentages were, respectively, 7%‘,, 15%, and 56%. Long term steroid therapy before death seemed to have no effect on the types of pathologic findings. The results demonstrate that “rheumatic activity” is a term of nebulous distinction. Pathologic and clinical evidence of “rheumatic activity” are both most likely to occur in patients who die at a young age, but often do not occur together in the same patient. Therefore, the data acquired by clinical and by pathologic observation should be appraised separately when “rheumatic activity” is analyzed. *36.

Norepinephrine

Effects on Myoeardial

Oxy-