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Thirty years after ligation of the anterior descending branch of the left coronary artery
THIRTY
YEARS AFTER LIGATION OF THE ANTERIOR DESCENDING BRANCH OF THE LEFT CORONARY ARTERY SAMUEL BRADBURY, M.D.,
GERMANTOWN,
P,z.
N APRIL 18, 1909, a woman was admitted to the Pennsylvania Hospital shortly after having been stabbed in the left breast. A diagnosis of wound of the heart was made, and the operative note, after describing opening the thorax and pericardium, informs us that “the heart was beating regularly and a gush of blood was coming with each systole from a cut about one inch long. A suture of linen thread was passed through the heart muscle, closing this (cut) partially. The blood from the upper end of the wound was bright, and from the lower end, dark. The wound was seen to cross a coronary vessel, and was apparently in the middle of the right ventricle. Five or six linen SUtures closed the wound completely.” Actually, the wound crossed the anterior portion of the interventricular groove diagonally from the left above to the right below, about midway between the apex and the auriculoventricular groove, severing the descending branch of the left coronary artery. The patient was in the hospital from mid-April to mid-July, during which time she developed acute pericarditis, empyema, and lobar pneumonia ; she was finally discharged “well and strong. ” This patient reported to the Pennsylvania Hospital outpatient department October 24, 1940. She is a grandmother, and lives with the daughter, now married, whom she was nursing at the time of the accident. She takes her part in the daily housekeeping activities, climbs the stairs with impunity, and is as well and active as a 75-year-old woman could be expected to be; she presents no subjective symptoms of heart disease. Examination showed that her blood pressure was 170/85; the pulse rate was 80, the pulse was regular in rhythm but not in force, and the The left breast was smaller arteries were not particularly sclerotic. than the right, and the scar, at the inner margin of the breast, was scarcely noticeable. The cardiac apex was in the fifth intercostal space, 8 cm. to the left of the midline; it was not diffuse and no thrill was felt. The right border of the heart was not displaced. A systolic murmur was heard all over the heart, perhaps best at the base. Expansion of the bases of the lungs was unequal; it was better on the right, where there were &es. There was a drainage scar in the axilla. There was no edema of the ankles or over the sacrum.
0
Rrrc?ivcd
for
publication
IvTnwh
18, 1911. .‘jC\Y
A r’oentgenogram of the thorax, made Feb. 13, 1940, was intcrpretcd as follows : “The heart is not. enlarged; there is good pulsation, and no limitation of motion due to the previous operative intervention. The There is calcification of arch of the aorta shows marked calcification. the pleura on the left side. The left half of t.he diaphragm is slightI? elevated, but the diaphragm moves freely and cqnall~~ on respiration. ” An orthodiagram, made April 4. 1940. showed that the transverse diameter of the heart was 11 cm., with a thoracic diamet,er of 20.2 cm. lwttr Also, the heart was described as showing “JWJ- slight enlargement. of the left ventricle and of the right outflow tract.”
Fig.
1.
The electrocardiogram (Fi g. 1) showed an occasional premature beat, a rate of 88, a P-R interval of 0.14 sec., no axis deviation, inversion of T,, and low voltage of QRS in Lead III. The chest lead was normal. Such a curve is not abnormal for a person of this age, and is not tliagnostic of heart disease.
564
AMEMCAN
HEART
JOURNAL
This case was reported in 1913 (J. A. 11. A., Nov. 15, 1913), four years after the accident. At that time attention was directed to the previously reported cases of wound of the heart, with severed coronary arteries. Three of the patients died soon after operation. Three (the present patient made four) had recovered from their operations; one patient (F. T. Stewart’s first case) died of pulmonary tuberculosis and came to autopsy five years after operation. The present patient is living and comfortable, 32 years after severance and ligation of the descending branch of her left coronary artery. As nearly as we can ascertain, she has no evidence of coronary disease, and she cannot be said to have any cardiac dysfunction.
YEARS AFTER LIGATION OF THE ANTERIOR DESCENDING BRANCH OF THE LEFT CORONARY ARTERY SAMUEL BRADBURY, M.D.,
GERMANTOWN,
P,z.
N APRIL 18, 1909, a woman was admitted to the Pennsylvania Hospital shortly after having been stabbed in the left breast. A diagnosis of wound of the heart was made, and the operative note, after describing opening the thorax and pericardium, informs us that “the heart was beating regularly and a gush of blood was coming with each systole from a cut about one inch long. A suture of linen thread was passed through the heart muscle, closing this (cut) partially. The blood from the upper end of the wound was bright, and from the lower end, dark. The wound was seen to cross a coronary vessel, and was apparently in the middle of the right ventricle. Five or six linen SUtures closed the wound completely.” Actually, the wound crossed the anterior portion of the interventricular groove diagonally from the left above to the right below, about midway between the apex and the auriculoventricular groove, severing the descending branch of the left coronary artery. The patient was in the hospital from mid-April to mid-July, during which time she developed acute pericarditis, empyema, and lobar pneumonia ; she was finally discharged “well and strong. ” This patient reported to the Pennsylvania Hospital outpatient department October 24, 1940. She is a grandmother, and lives with the daughter, now married, whom she was nursing at the time of the accident. She takes her part in the daily housekeeping activities, climbs the stairs with impunity, and is as well and active as a 75-year-old woman could be expected to be; she presents no subjective symptoms of heart disease. Examination showed that her blood pressure was 170/85; the pulse rate was 80, the pulse was regular in rhythm but not in force, and the The left breast was smaller arteries were not particularly sclerotic. than the right, and the scar, at the inner margin of the breast, was scarcely noticeable. The cardiac apex was in the fifth intercostal space, 8 cm. to the left of the midline; it was not diffuse and no thrill was felt. The right border of the heart was not displaced. A systolic murmur was heard all over the heart, perhaps best at the base. Expansion of the bases of the lungs was unequal; it was better on the right, where there were &es. There was a drainage scar in the axilla. There was no edema of the ankles or over the sacrum.
0
Rrrc?ivcd
for
publication
IvTnwh
18, 1911. .‘jC\Y
A r’oentgenogram of the thorax, made Feb. 13, 1940, was intcrpretcd as follows : “The heart is not. enlarged; there is good pulsation, and no limitation of motion due to the previous operative intervention. The There is calcification of arch of the aorta shows marked calcification. the pleura on the left side. The left half of t.he diaphragm is slightI? elevated, but the diaphragm moves freely and cqnall~~ on respiration. ” An orthodiagram, made April 4. 1940. showed that the transverse diameter of the heart was 11 cm., with a thoracic diamet,er of 20.2 cm. lwttr Also, the heart was described as showing “JWJ- slight enlargement. of the left ventricle and of the right outflow tract.”
Fig.
1.
The electrocardiogram (Fi g. 1) showed an occasional premature beat, a rate of 88, a P-R interval of 0.14 sec., no axis deviation, inversion of T,, and low voltage of QRS in Lead III. The chest lead was normal. Such a curve is not abnormal for a person of this age, and is not tliagnostic of heart disease.
564
AMEMCAN
HEART
JOURNAL
This case was reported in 1913 (J. A. 11. A., Nov. 15, 1913), four years after the accident. At that time attention was directed to the previously reported cases of wound of the heart, with severed coronary arteries. Three of the patients died soon after operation. Three (the present patient made four) had recovered from their operations; one patient (F. T. Stewart’s first case) died of pulmonary tuberculosis and came to autopsy five years after operation. The present patient is living and comfortable, 32 years after severance and ligation of the descending branch of her left coronary artery. As nearly as we can ascertain, she has no evidence of coronary disease, and she cannot be said to have any cardiac dysfunction.