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Indices based on early systolic ejection rates are theoretically more sensitive to ventricular performance than indices based on the entire systolic ejection (SE) period (mean ejection phase indices-MEPI): mean systolic ejection rate (MSER), mean normalized systolic ejection rate (MNSER) and mean velocity of circumferential fiber shortening (MVcf). The volume ejected in early systole is an indicator of the early rate of ejection. Accordingly, ventricular volume changes were determined by ventriculographic analysis for each thrid of SE in ml/sec (SER), as normalized systolic ejection rate (NSER), and as percent of stroke volume (PSV). In ten normal controls all these indices were higher in the first third compared to the other thirds of SE. Seven patients with diffuse ventricular disease had depressed values in the first third of SE. Despite "normal ventriculograms and normal MEPI, eight patients with left anterior descending coronary artery stenoses (greater than 60%) also had definitely depressed ejection indices during first third of systole. Detailed wall motion analysis in this group showed anteroapical hypokinesis isolated to the first third of SE. These data show that indices based on early SER are more sensitive than MEPI (MVcf, MNSER) for detecting abnormalities in ventricular performance in coronary artery disease

The clinical, hemodynamic, and angiographic observations, as well as the surgical approach used for repair in three patients with congenitally corrected transposition of the great arteries and ventricular membranous septal aneurysms, are presented. In two of the three patients the membranous septal aneurysm caused subpulmonary obstruction, with 94 and 125 mm Hg systolic gradients. In each patient the aneurysm was demonstrated by angiocardiography, which also showed differences in size and shape with cardiac systole and diastole. Review of the previously described reports indicates that patients with congenitally corrected transposition often display various forms of pulmonary outflow obstruction and when a ventricular membranous septal aneurysm exists, a significant subpulmonary obstruction is present in most patients. The unique anatomic relationship between the pulmonary artery and a ventricular membranous septal aneurysm in patients with transposition of the great arteries with and without atrioventricular discordance explains why subpulmonary obstruction sometimes develops.

Forty-one consecutive patients, ranging in age from 41/2 to 27 years, were operated upon for complete repair of tetralogy of Fallot without an operative mortality. Postoperative catheterization of 25 patients permitted objective evaluation of the results which were, by the criteria adopted, excellent in 16 patients, good in 5, and poor in 4, including the 2 late deaths. Surgical experience has shown the necessity for extensive resection of the right ventricular outflow tract. Prosthetic patches are considered necessary for closure of most of the ventricular septal defects encountered, but are infrequently needed for reconstruction of the right ventricular outflow tract. Its use is indicated in certain patients with hypoplasia of the pulmonary annulus or artery. Age has been an important factor in patient selection. It is suggested that symptomatic patients under five years of age may benefit from a systemic-to-pulmonary arterial anastomosis before definitive correction is undertaken later in childhood.

Postoperative cardiovascular studies were carried out in eight patients with ostium primum defect and cleft mitral valve. Apical systolic murmurs were present in all patients, but in seven of them no mitral regurgitation was detected by pulmonary wedge pressure and left ventricular angiography. Surgical repair of the cleft anterior leaflet without resection of subjacent chordae tendineae, as performed in these patients, usually results in a competent mitral valve. Postoperative angiograms showed persistence of the characteristic preoperative deformity of the medial border of the left ventricular outflow tract especially in systole. As illustrated in one of these patients, subaortic obstruction occasionally complicates abnormalities of the atrioventricular valves.

Anatomically true cross-sectional ultrasonic images of the heart have demonstrated ventricular septal defects in 25 patients with this lesion as an isolated anomaly or in conjunction with other defects. In two additional patients a defect was visualized but confirmation was not obtained. Ventricular septal defects were not demonstrated in 13 other patients in whom this lesion was identified by other techniques. In these instances the lesion was not sought for, was inaccessible, or was too small to image. Defects were manifested by the septum overriding the posterior great artery, septal discontinuity immediately below the posterior semilunar valve, or a discontinuity caudal to the posterior semilunar valve. It appears that cardiac ultrasonography may be able to demonstrate most of the common larger ventricular septal defects occurring in the infracristal region of the septum.

Myocardial blood flow (MBF) per unit mass was measured in 10 patients (pts) with severe aortic stenosis (AS) and no significant aortic insufficiency, normal ejection fractions, and normal coronary arteriograms, using xenon-133 and a multiple crystal scintillation camera. MBF per unit mass was reduced in AS (53 +/- 13 mg/100g.min) in comparison to a group of seven normal control patients (69 +/- 12 ml/100g.min) (P less than 0.05). When normalized for heart rate. MBF remained depressed in aortic stenosis (0.65 +/- 0.11 ml/100 g.beat). MBF/beat was strongly related to peak left ventricular wall stress in both groups (r = 0.97). Individual values of MBF/beat were normalized for peak stress using an analysis of covarience; the adjusted mean values were 0.62 +/- 0.03 ml/100g.beat for the AS patients and 0.84 +/- 0.03 ml/100 g.beat for the control patients. There was no overlap between groups in adjusted MBF per beat. Values of MBF per beat and peak stress for a group of ten cardiomyopathy patients with depressed contractility were observed to fall close to the regression line for AS patients. The results suggest that variability in resting MBF in these AS patients is due primarily to differences in LV stress and that reduction in MBF per beat in this group may be due to reduced contractility.

Myocardial blood flow/unit mass (MBF) and the determinants of myocardial oxygen consumption were measured in seven control subjects (group I) and 15 patients (pts) with cardiomyopathy (CM), group II (group IIa-congestive CM: 10 pts; group IIb-hypertrophic CM: 5 pts). In group I left ventricular (LV) MBF was 64 +/- 8 (SD) ml/100g-min; it was significantly lower in IIa (45 +/- 15 ml/100g-min, P less than 0.01) and IIb (39 +/- 7 ml/100g-min, P less than 0.01). However, calculated total LV flow (LV mass X MBF) was increased in the two CM groups. In nine CM pts, LV MBF increased in response to atrial pacing from 41 +/- 7 to 63 +/- 13 ml/100g-min. In group IIa, calculated peak wall stress was normal (4.39 +/hortening (MVcf) was significantly reduced (0.53 +/- 0;18 vs 1.26 +/- 0.12 circum/sec, P less than 0.01). In IIb, MVcf was normal but peak stress was significantly reduced (2.80 +/- 0.75 vs 4.51 +/- 1.10 dynes/cm2 X 10(5), P less than 0.05). Multiple regression analysis based on all pts yielded, MBF - 16.9 MVcf + 9.30 Stress + 0.26 Heart Rate - 26.4 (r=0.79). The data indicate that MBF is reduced in CM patients and the regression analysis suggests that MBF in these 22 pts with normal coronary arteriograms was determined largely by heart rate, peak stress, and ventricular performance.