Patent ductus arteriosus with pulmonary hypertension: Results of surgical treatment

Abstracts Pathologic findings included renal artery thrombosis (3 cases) ; branch artery occlusion (1 case) ; stenosis of the main renal artery (1 case) ; parenchymal compression from perinephric hematomas (2 cases) and from subcapsular hematomas (2 cases) ; and a corticomedullary scar (1 case). Seven of 10 patients became normotensive after operation and have remained so during follow-up periods that averaged 49 months (range 4 to 144 mo.). Nephrectomy was performed in 6 patients and endarterectomy with partial nephrectomy in 1. Operative procedures on the 3 patients whose blood pressures did not return to normal included nephrectomy in 1 (who had hypertension of more than eight years’ duration), heminephrectomy in 1 and evacuation of a subcapsular hematoma in the third. Hypertension resulting from renal trauma can usually be relieved by removal of the injured kidney. The Post-Extrasystolic T Wave Change: A Carrelate of the Inotropic State. KALMANGREENSPAN, PH.D., F.A.c.c., ROBERT E. EDMANDS,M.D., JOHN FISCHER,M.D. and CHARLES FISCH, M.D., F.A.c.c., Indianapolis, Ind. The relationship between the inotropic state of the myocardium and post-extrasystolic (P-E) T wave change was studied in anesthetized dogs. Epicardial electrograms, conventional lead II electrocardiogram (ECG) and myocardial tension were recorded. The effect of variations in ventricular filling upon tension development was precluded by stretching that portion of the ventricle upon which the transducer was sewn to 150% of its resting length. Variably premature atria1 and ventricular stimuli were administered through implanted electrodes. The more premature stimuli were consistently followed by marked P-E potentiation and T wave change in the accompanying electrogram. Conversely, a premature stimulus of longer coupling was uniformly followed by P-E potentiation of lesser degree and by a T wave of smaller magnitude. A linear correlation was thus observed between the extent of P-E T wave change and the rate of P-E ventricular tension development. This P-E T wave change was not discernible in the concomitant lead II unless the contractile potentiation was marked. Similarly, mechanical alternans which reflected alternating rates of tension development, produced by rate acceleration and occurring transiently following abrupt rate change, was consistently associated with T wave alternans. These studies suggest that the post-extrasystolic T wave change, as well as T wave alternans, represents an ECG correlate of an inotropic change, ordinarily undetectable in the less sensitive surface ECG. VOLUME 21, JANUARY1968

101

Myocardial Metabolism in Complete Heart Block and Induced Tachycardia. JOHN J. GREGORY, M.D., HILTRUDMUELLER,M.D., STEPHEN M. AYRES, M.D., F.A.c.c., STANLEYGIANNELLI,JR., M.D., F.A.C.C. and WILLIAM J. GRACE, M.D., F.A.c.c., New York, N. Y. Cardiac index (CI), coronary blood flow (CBF), myocardial oxygen consumption (MV02), myocardial lactate extraction (LE) and cardiac work were determined at idioventricular, normal and fast heart rate (HR) in 14 patients with chronic complete heart block. In 6 patients (Group I), CBF was unpredictable. In 8 patients (Group II), CBF was increased linearly with HR (CBF = 1.08 HR + 25.9). MVOz and CBF were linearly related (MV02 = 0.12 CBF) since myocardial oxygen extraction remained fixed regardless of HR. CI was greatest at the normal HR in 8, at the high HR in 3, and remained constant in 3. MVO, was poorly correlated with flow work but was directly related to developed tension (TTI). Increase in MVOZ could be predicted by the HR-blood pressure (BP) index of Katz. For Group II, MVO, = 0.97 (HR X BP) + 4.01, whereas from Katz’s canine data MVOp = 0.60 X HR X BP + 6.58. In Group II per cent LE in 7 patients averaged 24 at idioventricular HR, 8 at normal HR, and 9 with fast HR. The eighth patient increased per cent LE with increase in HR. In Group I no definite trend in LE was apparent. It is concluded that heart rate and blood pressure are important determinants of MVOz in man. Pacing at normal or above normal heart rate was associated with shift in substrate utilization in some patients, thus suggesting that demands of increased heart rate were not met by adequate increase in MV02. The optimal pacing rate is a compromise between rate effects on CI and MVO,. The data suggest that certain patients should be paced at slower rates than are currently used. Patent Ductus Arteriosus with Pulmonary Hypertension: Results of Surgical Treatment. GRADY L. HALLMAN,M.D., F.A.c.c.,SARCIT S. GILL, M.D., ROBERT D. LEACHMAN,M.D., F.A.c.c., ROBERT D. BLOODWELL, M.D., F.A.C.C. and DENTONA. COOLEY, M.D., F.A.c.c., Houston, Tex. Surgical interruption of patent ductus arteriosus has become the standard treatment for this anomaly and can be accomplished with low morbidity and negligible mortality. The association of pulmonary hypertension with patent ductus makes the diagnosis more difficult, increases the hazard of operation from a technical standpoint and renders the results of surgery less predictable. This paper details our experience

Abstracts

102 with 39 patients

with patent

hypertension. “severe”

The

pulmonary

(PA) pressure

ductus

majority

hypertension

greater

than 80%

with “mild”

pressure

of systemic]

pulmonary

50 to 64 per cent

complete “moderate”

pulmonary

2 had limited tion.

exercise

hypertension

some persistent tomatic.

There

Eight

and SVR,

+ll%.

hypertension

(PA

confirm

experienced with

pressure

on follow-up

and

evalua-

with “severe”

survived

pul-

operation

and the rest were

had

asymp-

were 2 late deaths.

patients

tion at varying pulmonary

who

disability,

and the

asymptomatic

One third of the 21 patients

monary

q02,

similar

(PA

to systemic

pressure

The greatest

in all patients.

repeat

after operation.

There

Pulmonary

was no persistent vascular

preoperative patients

resistance

turned to normal Observations Aortic

resistance

Previous

In the remaining was less but

7

had re-

Effect

of

ROBERT I. HAMBY,

N. Y.

studies of the hemodynamic (AI)

transiently patients

The pres-

animal.

during

The

acute

by a preformed

diagnostic

present

before

the

brachial

significant

catheter

arterial

sure without ascent

pressure

cardiac

5

The

rate.

systolic

rate of change (dp/dt) of the The dicrotic wave

The isovolumetric

quickly patients

reverted the

(CO),

less prominent.

descent of the pressure

and the ejection

output

a

and mean pres-

to a lower level and became

beats when the catheter In

was

pulse increased.

was more rapid. alterations

There

of

in the pulse pressure

in heart

The systolic and diastolic decreased

that was not Associated

pulse.

in the systolic, diastolic

and maximum

descended

murmur

were sudden alterations

pressure

any change

in 20

that was All the pa-

catheterization.

murmur

(p < 0.001) increase

and a decrease

arteria1

diastolic

or after

with the diastolic

cardiac

.41 was induced

J-shaped

held up in the region of the aortic valve. tients had an audible

to obser-

the effect of acute AI in man,

produced

catheterization.

effect of acute

have been limited

vations made in the experimental ent study will describe

pulse

contraction

time increased. to normal

time

All these

in one or two

consumption

stroke volume

results are to a great extent in animal

experiments

of dog experiments

and

to man.

of the Aortic Root.

diagnosis and treatment

an increasing

infection

controlled

and

tion, periaortic Intractable aortic

succumb

complications.

and, rarely,

University.

Surgery

of endocarditis.

to

fistula.

complications

Valve

replacement

Starr-Edwards

prosthesis

(8

was performed

in

a ball-valve also required

closure of a coronary patients

technic,

sinus-right

(90%)

normal

survived

hemodynamics

ventricular and

therapy

and important of critically

for aortic

regimens,

short-term

aspects

and

no evi-

This report

antibiotic

the use of massive

recon-

surgery

for up to three years.

and postoperative

care

partial

aorta and 1 required

Nine

surgical

ana-

with

fistula.

pre-

mentioned

in this series.

patients

dence of infection

three

were encountered

comitant

outlines

Emory

from

from the onset of the symptoms

of the ascending

have presented

at

performed

and 2 Magovern) Two

of endo-

on for acute aortic

All of the previously

tomic

to

of the aorta

endocarditis

was

weeks to nine months

case.

rupture

have been operated secondary

operative

ulcera-

secondary

and often fatal complications

Ten patients

surgery

of the

mural

failure

its

Ana-

endocarditis

perforation,

heart

insufficiency

costeroid

have to

root abscess, and aortic-cardiac congestive

placement

of patients

to

of bacterial

insufficiency

every

number only

hemodynamic leaflet

Ga.

of bacterial

corti-

in the post-

ill patients

undergoing

secondary

to bacterial

insufficiency

endocarclitis. With

aggressive

postoperative

antibiotic

management,

therapy

and

it has been

perform

early surgery

for the complications

carditis

of the aortic

root with acceptable

(lOyO) and reasonable

expectation

precise

possible

to

of endomortality

of lasting improve-

ment. The

Electrophysiological

Before after

and

After

Effects

of Countershock

Digitalis

Diphenylhydantoin

Sensitization

(DPH)

and

Desensitization.

RICHARD H. HELFANT, M.D., BENJAMIN J. SCHERLAG,

was withdrawn. oxygen

their

are the grave

in Man.

insufficiency

endocarditis,

carditis.

the

M.D., STEPHEN J. GULOTTA, M.D. and M. A. 2. HAS-

aortic

With improved

was greater

than

acute -33%

and OSLER A. ABBOTT, M.D.,F.A.C.C., Atlanta,

complications

less

SV,

M.D., F.A.c.c.,WILLIAM D. LOGAN, JR., M.D., F.A.C.C.

root include

was seen in pa-

-29y0;

of Endocarditis

tomic

on the Acute Hemodynamic

SEN, M.D., Jamaica,

Aspects

aortic

in only 3.

Insufficiency

Surgical

determined. during

CHARLES R. HATCHER, JR., M.D., F.A.c.c., N. SYMBAS,

shunt in any patients.

level in 1 patient.

pulmonary

the application

The ratio o

tients with the larger left to right shunts before operation.

These

were

obtained

-/-3.90/o; CO,

catheteriza-

was significantly

decrease

(SVR)

to those obtained

anatomic

have undergone

intervals

resistance

per cent change

AI were:

All

hypertension tolerance

vascular

The averaged

artery

Of the 7 patients

5 became

temic

had

in this group.

of systemic)

relief of symptoms.

65 to 80 y0 of systemic),

(23)

[pulmonary

only 2 deaths in the series occurred 9 patients

and pulmonary

of patients

(SV)

(qO,), and

sys-

PH.D. and ANTHONY

N.DAMATO,

M.D., Staten Island,

N.Y. THE AMERICANJOURNALOF

CARDIOLOGY