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Instantaneous coronary arterial phasic blood flow velocity was measured in 21 patients (8 with coronary artery disease) after amyl nitrite inhalation. Measurement was made with use of a Doppler ultrasonic flowmeter catheter positioned at the ostia of the coronary arteries. In all cases, there was an appreciable increase in diastolic coronary arterial phasic blood flow velocity within 10 seconds. Flow velocity increased from 50 to 216 percent over control values after administration of amyl nitrite. Subjects with marked obstructive coronary artery disease had decreased peak coronary arterial phasic blood flow velocity responses when compared with control subjects. Atrial pacing to heart rates attained with amyl nitrite alone resulted in no appreciable increase or decrease in coronary arterial phasic blood flow velocity, thus showing that increase in the latter was not dependent on this action of the drug. Furthermore, increase occurred before appearance of the arterial hypotensive effect of amyl nitrite. The presence of an increase in coronary arterial phasic blood flow velocity after administration of a drug with demonstrable coronary vasodilating action strongly suggests that one of the important attributes of nitrites is their ability to increase coronary arterial blood flow.

Summary Serial electrocardiograms and Frank vectorcardiogramswere recorded from a 59-year-old male with unstable complete left bundle branch block (LBBB) and intermittent left anterior hemiblock (LAHB). Biplane timed vectorcardiograms demonstrated that abnormal frontal plane left axis deviation was present during both types of conduction. It is suggested that coexisting main stemLBBB combined with LAHB and left bundle bifascicular block can account for these findings. Under the latter circumstances, complete LAHB and partial left posterior hemiblock may appear electrocardiographically as “complete” LBBB with left axis deviation.

Summary Utilizing His bundle electrography, catheter induced complete heart block was documented distal to the main His bundle in two subjects with pre-existent bundle branch block. In the first patient, concealed retrograde A-V nodal conduction was manifested by unexpected failure of atrial depolarizations to result in His deflections. The second subject demonstrated a similar phenomenon, but altered A deflection polarity and fluoroscopic monitoring indicated probable “pseudo concealed retrograde A-V nodal conduction” secondary to recording catheter movement. This report represents the first description of 1) catheter induced complete heart block with simultaneous concealed retrograde A-V nodal conduction and 2) His bundle electrographic demonstration of complete heart block secondary to catheter induced trauma of the left bundle branch in a subject with complete right bundle branch block.

By means of the Doppler ultrasonic flowmeter catheter, phasic aortic blood flow velocity and simultaneous aortic pressure, right atrial pressure, and Lead II of the electrocardiogram were measured in 7 normal subjects and 8 patients with heart disease during right atrial pacing. At pacing rates between 110 and 170 per minute, type I, second-degree atrioventricular block appeared. The increase in peak aortic blood flow velocity was generally proportional to the preceding cycle length and inversely related to the P-R interval. These variations were more pronounced during shorter Wenckebach periods. The first beat of a period always manifested a greater peak flow velocity than did the last beat. Short cycle lengths with less ventricular diastolic filling resulted in diminished aortic systolic flow velocity, with reduction up to 80 per cent. The changes in flow velocity paralleled the changes in aortic pressure. Compared with similar pacing rates at 1: 1 conduction, the aortic peak flow associated with the first ventricular complex following a dropped beat increased 40 per cent. The conclusion is that Wenckebach periods cause cyclic changes in aortic blood flow velocity, related to diastolic filling and to the length of the P-R interval.

Left ventricular blood flow velocity was recorded in 32 conscious human subjects with the Doppler ultrasonic flowmeter catheter. There are three major left ventricular flow velocity patterns in man: (1) Inflow tract blood velocity is characterized by a predominant diastolic wave related to left ventricular filling succeeded by a smaller systolic component, (2) Midcavity blood flow velocity is triphasic in nature, and (3) Outflow tract blood velocity is manifested by a major systolic wave, resulting from left ventricular ejection. These flow velocity wave-forms parallel the major hemodynamic events occurring at each anatomic site. It is concluded that such study is of value for characterizing blood velocity in the left ventricle of conscious man.

Excerpt Phasic renal artery blood flow velocity was measured in 23 patients, utilizing the Doppler ultrasonic flowmeter telemetry system. The catheter tip containing the transmitting and receiving ...

The emergency room records of 140 patients with cardiac complaints were reviewed. The average age was 60 years. Chest pain was the most common symptom and a majority of patients with this complaint expressed fear of an acute coronary episode. Of 41 cases admitted with the initial diagnosis of myocardial infarction, only 21 had that diagnosis at the end of two weeks. Of 91 patients sent home from the emergency room, 83 were alive and well at the end of six weeks. A single patient died of acute myocardial infarction ten days after leaving the emergency room. No patient was averse to admission, and in 10 instances patients came to the emergency room equipped with personal items indicating anticipation of admission. Such studies are feasible and may elucidate further the role of the emergency room in the early care of the “coronary suspect.”

Utilizing the Doppler ultrasonic blood velocity probe, superior mesenteric artery blood velocity (SMABV) was studied in 20 subjects during cardiac arrhythmias. Normal SMABV is phasic and continuous throughout the cardiac cycle, with a substantial diastolic fraction. Atrial, junctional, and ventricular premature beats result in diminished SMABV, dependent on their coupling intervals. Atrial tachycardia, atrial fibrillation, and ventricular tachycardia can cause a marked reduction of SMABV. Termination of tachyarrhythmia is associated with an increased systolic and diastolic SMABV. It is concluded that cardiac arrhythmias can diminish SMABV, providing a basis for some cases of nonocclusive mesenteric ischemia and infarction. The Doppler blood velocity probe system is a useful technique for characterizing SMABV under normal conditions and during cardiac arrhythmias.

Serial electrocardiograms and vectorcardiograms were obtained from 10 consecutive patients who underwent combined proximal right aortocoronary saphenous vein bypass graft implantation and distal right coronary gas endarterectomy. Nine of these subjects manifested postoperative electrovectorcardiographic changes of acute inferior wall myocardial infarction. Only 1 of 13 other patients who were subjected to right bypass graft implantation without gas endarterectomy had similar findings. All 9 patients who were subjected to gas endarterectomy and who manifested postoperative patterns of infarction had a clinically uncomplicated postoperative course and were discharged on the 10th to 12th postoperative day. It is concluded that postoperative electrovectorcardiographic evidence of acute inferior wall infarction is prevalent in patients subjected to combined proximal right aortocoronary bypass graft implantation and distal right coronary gas endarterectomy. These changes may be based on physical consequences of the gas endarterectomy.

D etailed investigation has revealed that hypertrophic cardiomyopathies may be generally categorized into the obstructive andnonobstructive varieties.1’2 Asymmetric septal hypertrophy has been proposed as the unifying link between these entities,3 but there are limitations to this criterion,4 and, indeed, the disease may represent a wide spectrum of pathologic findings.5 Recent study has indicated that obstruction of the left ventricular midcavity represents an unusual but distinctive variant within this array,6’7 yet there is a dearth of descriptions concerning the noninvasive aspects of this state. We report herein unusual graphic recordings from a patient afflicted with the “hourglass” left ventricle.7 Figure 1 shows the external carotid pulse tracing and phonocardiograms from a 55-year-old man with obstruction of the left ventricular midcavity. The patient was known to have a cardiac murmur for at least 40 years and paroxysmal atrial fibrillation. An echocardiogram did not demonstrate either asymmetric septal hypertrophy or systolic anterior motion of the mitral valve.8 Auscultation revealed distinctive combinations of midsystolic or late systolic clicks and a harsh systolic ejection murmur which changed in duration during multiple examinations. The murmur was loudest at the tricuspid area, was preceded by a variable fourth heart sound, and was intensified by a voluntary execution of Valsalva’s maneuver and the upright position. At the mitral area the murmur was abruptly terminated in midsystole by a loud systolic click. The latter nonejection sound

Miconazole was administered intravenously in six consecutive patients with, active coccidioidal infection. Such treatment was associated with progressive anemia and thrombocytosis. The hematological abnormalities appeared to be dose related and potentially reversible. Bone marrow studies demonstrated erythroid hypoplasia and increased or active platelet production in three subjects. No hemorrhagic or thrombotic episodes were identified. It is suggested that careful hematological monitoring be performed in subjects undergoing systemic miconazole therapy.

Utilizing a Doppler ultrasonic flowmeter catheter, right carotid artery blood velocity was measured during 91 coughing episodes in 16 patients. Such coughing reduced carotid blood velocity by 40 +/- 22% (control = 34 +/- 8 cm per second, cough = 20 +/- 9 cm per second, p less than 0.001). There was an insignificant low degree of corrleation between the level of simultaneously recorded mean right pressure and the percent decline of peak carotid blood velocity, suggesting that impaired venous return was not the only factor responsible for the observed changes. It is concluded that (1)coughing diminishes phasic carotid blood velocity and (2)reduced cerebral perfusion may play a role in the pathogenesis of cough syncope.

IT is common for a patient to perceive his heartbeat by hearing cardiac sounds when the side of his head is placed on a pillow at night.1 Indeed, most physicians are familiar with complaints of pre...

Apexcardiograms were performed in 68 consecutive patients who had either normal findings or coronary artery disease on cardiac catheterization. The height of the a wave in relation to the total apexcardiographic deflection (a/H) and the duration of both the rapid (RFW) and the slow (SFW) filling periods were determined in each case. The patients were classified into three gorups: I, no evidence of heart disease on catheterization; II, significant coronary artery disease with elevated left ventricular end-diastolic pressure; and III, coronary artery disease with normal filling pressure. There was a significant difference (P less than 0.001) between the SFW/RFW values (mean +/- 1 standard deviation) in control subject (group I, 2.3 +/- 0.5) and in subjects with coronary artery disease (group II, 4.7 +/- 1.6 and group III, 4 +/- 1.7). Setting the upper limit of normal for SFW/RFW at 2.8 (mean + 1 standard deviation) identified 94 percent of patients, in group II, 71 percent of patients in group III and 86 percent of all patients with coronary disease (group II plus group III). This sensitivity appeared greater than that of the a/H ratio. Only 2 of 17 patients (12 percent) without coronary atherosclerosis had an SFW/RFW ratio greater than 2.8. It is concluded that (1) the slow/rapid filling period ratio is a useful noninvasive measurement for identifying subjects with ischemic heart disease; (2) the increased values for slow/rapid filling period ratio associated with obstructive coronary lesions may be caused by impairment of early left ventricular distensibility; and (3) this ratio should be determined in patients with other forms of heart disease to determine its specificity.

Excerpt Cocaine has the peculiar quality of being both a local anesthetic and a sympathomimetic agent with powerful central nervous-system stimulant effects. In small doses cocaine can slow the hea...

Left ventricular echocardiograms and phasic instantaneous Doppler aortic blood velocities were simultaneously recorded during short paroxysms of rapid right ventricular pacing in 20 conscious subjects. Right ventricular pacing at rates of 100, 120, 140, 160 and 180/min produced stepwise reductions of mean estimates for diastolic (D) and systolic (S) left ventricular internal dimensions (LVID) along with a diminution of aortic blood velocity. Mean (X +/- 1 standard deviation) per cent decline of LVID-D, LVID-S and peak aortic blood velocities for the study group ranged from 8.9 +/- 6.1, 8.5 +/- 5.7 and 13.7 +/- 7.7 at 100 beats/min to 29.3 +/- 10.6, 25.2 +/- 10.5 and 55.2 +/- 13.1 at 180 beats/min, respectively. When LVID-D, LVID-S, and aortic blood velocity X % reductions were plotted for all heart rates there was a high degree of positive correlation (r = 0.99). Two types of abnormal septal motion were observed during rapid pacing: Type I--paradoxical septal motion at all pacing rates (n = 7, 6/7 with left coronary artery disease); Type II--hypokinetic septal motion at lower pacing rates with flat or paradoxical motion at rates greater than 140/min (n = 13, 10/13 with normal coronary arteries). It is concluded that short episodes of rapid right ventricular pacing result in reduced LVID and abnormal septal motion with the latter possibly related to septal ischemia. Such study provides insight into the untoward influence of rapid ventricular rhythms on cardiac performance.

Two-dimensional echocardiography permitted identification of a large free-floating left atrial thrombus in a patient with mitral stenosis. A specific pattern of motion afforded its recognition and differentiation from mural left atrial thrombosis and tumors. Phonocardiographic tracings revealed a non- ejection systolic click and opening snap. A gated blood pool scintigram dis closed a left atrial filling defect. Subsequent left atrial angiography and left atriotomy confirmed the non-invasive findings.

Electrocardiograms and Frank vectorcardiograms were recorded in 156 consecutive patients with total occlusion of at least one coronary artery (on arteriography) and associated left ventricular contraction abnormality (on ventriculography). The angiograms and cardiograms were independently reviewed. In the presence of single vessel occlusion, appropriate vectorcardiographic diagnosis of myocardial infarction was determined in 118 of 156 cases (76 percent) compared with a lower electrocardiographic detection rate in 77 of 156 cases (49 percent). Findings diagnostic of two coexisting infarctions were observed in 71 percent of vectorcardiograms and 37 percent of electrocardiograms in 51 patients with double vessel occlusion and two areas of left ventricular dyskinesia. The vectorcardiographic detection rate was similarly superior to the electrocardiographic rate in the presence of subtotal coronary occlusion and myocardial asynergy in single (73 percent versus 53 percent) and double (53 percent versus 28 percent) vessel disease. The incidence rate of false positive diagnoses was 3 percent for electrocardiography and 4 percent for vectorcardiography. It is concluded that the vectorcardiogram is superior to the electrocardiogram in the diagnosis of obstructive coronary artery disease and left ventricular contraction abnormality.

A 59 year old man presented with dyspnea and a new murmur of aortic regurgitation. Two-dimensional echocardiography demonstrated a to and fro motion of the intimai flap as it prolapsed into the left ventricle and was thrust into the aorta during diastole and systole, respectively. At surgery, the echocardiographic and angiographic findings were confirmed and a proximal aortic dissection was identified. Prolapse of an intimai flap from the aorta into the left ventricular outflow tract represents a new two-dimensional echocardiographic sign of aortic dissection.

immediately after it (Fig 2). It can be surmised that the early systolic sound observed in these patients may be related to max- imum excursion of the opening motion of the car- bon leaflets or turbulence created by transvalvular flow during left ventricular systole. The high fre- quency aortic closure sound is probably produced by coaptation of the leaflets and vibrations from the resonant prosthesis secondary to rapid decelera- tion of blood at end-systole. Other findings noted rji he St. Jude valvular prosthesis is a bileaflet pyro- lytic carbon device1 which is being implanted with increasing frequency. Knowledge of the aus- cultatory and phonocardiographic characteristics of artificial cardiac valves has proven to be useful in detecting their malfunction.� We describe here our observations on the phono- cardiographic features of the St. Jude prosthesis in the aortic position. Figure 1 shows the simultane- ously recorded carotid arterial pulse tracing, phono- cardiogram from the tricuspid area and lead 2 of the electrocardiogram from such a patient. The ma- jor component (M1) of the first heart sound com- plex is normal. An early systolic sound (ES) is present at the lower left sternal border. This sound is usually heard over the entire precordium, but is best recorded at the left parasternal location. The interval from the first heart sound to the opening or ejection sound ranges from 60 to 80 msec. Note that the ejection sound coincides in timing with the onset of the external carotid pulse upstroke. The aortic component (AC) of the second heart sound consists of a major high amplitude high frequency component followed by multiple lower amplitude medium to low frequency vibrations. This aortic closing sound is recorded in conjunction with the dicrotic notch of the external carotid pulse tracing. In all cases, the aortic closure sound was greater in amplitude than the opening ejection sound with an AC:ES amplitude ratio ranging from 5:1 to 8:1. Phonoechographic study indicates that the early systolic sound follows the opening point of the prosthetic leaflets by approximately 40 msec. The aortic component of the second heart sound is in- scribed at the time of ultrasonic valve closure or I 111111 I 11111111IIIIIIIIlII(IIIIl ltlJIjlIIIllII

Standard electrocardiograms (ECG) and Frank vectorcardiograms (VCG) were obtained in 43 consecutive patients in sinus rhythm who had echocardiographic evidence of left atrial enlargement (left atrial internal dimension greater than 4.0 cm; x +/- 1SD = 4.7 +/- 0.5 cm). High gain VCG P loop measurements for the study group were: maximal posterior magnitude, 0.11 +/- 0.03 mv; duration, 106 +/- 14 msec and ratio of maximal posterior to maximal anterior P vector magnitudes, 3.2 +/- 1.4. Thirty of 43 (70%) patients with echocardiographic determined left atrial enlargement had VCGs diagnostic of that condition. Utilizing New York Heart Association criteria for left atrial enlargement, 17 of 43 patients (40%) had ECGs which were diagnostic. Fifteen of 43 (35%) subjects manifested both ECG and VCG criteria for left atrial enlargement and only two patients had diagnostic ECGs and normal VCGs. It is concluded that analysis of high gain VCG P loops provides a 30% higher yield for the diagnosis of echocardiographically determined left atrial enlargement when compared with P wave examination on the standard ECG.

Utilizing the apexcardiogram, the ratio of total amplitude to the height of the total diastolic wave was determined. Compared with a mean (+/- 1 SD) value of 21 +/- 4% for normal subjects there were statistically significant differences in those patients with isolated aortic regurgitation (30 +/- 10%, P = 0.01), aortic stenosis (12 +/- 11%, P less than 0.025) and mitral insufficiency (14 +/- 8%, P less than 0.025). There were no significant changes of this ratio in subjects with combined aortic stenosis and insufficiency (24 +/- 9%, P less than 0.25), triple vessel coronary artery disease (19 +/- 7%, P less than 0.25) and mitral valve prolapse (23 +/- 10%, P less than 0.35). There was a trend for higher ratio values in patients with greater angiographic evidence of aortic insufficiency, but no correlation between the ratio and left ventricular end-diastolic pressure. These alterations of the apexcardiogram accord with hemodynamic findings in the presence of each respective lesion. It is concluded that this ratio is useful for the noninvasive assessment of isolated aortic regurgitation, aortic stenosis and mitral insufficiency.

Thirty-four patients in sinus rhythm with anemia due to chronic renal failure and one subject with chronic uterine bleeding were studied by means of echo cardiography. Six patients (18%) had major diastolic fluttering of the mitral valve, and in 4 others the fluttering was equivocal. No subject had auscultatory or other clinical evidence of aortic insufficiency. In the patient with uterine hemorrhage, diastolic mitral valve motion reverted to normal after blood trans fusion. It is concluded that anemia may produce diastolic mitral valve flutter ing, which is probably based on increased blood flow in this setting. Caution should be exercised in ascribing diastolic murmurs associated with uremia to aortic regurgitation when anemia is present.

Summary Phasic instantaneous left ventricular blood velocity was measured by radiotelemetry in 28 subjects with a Doppler ultrasonic flowmeter catheter during atrial pacing and induced A-V block. Type I Wenckebach A-V block with conduction ratios of 9:8 or lower generally produced a stepwise reduction of peak left ventricular blood velocity in relation to shortened R-R intervals. Longer Wenckebach periods resulted in little or no blood velocity alteration during 1:1 A-V conduction. Those beats following a blocked atrial depolarization were associated with augmented blood velocities. In three subjects, bigeminal periods of 3:2 A-V block resulted in larger peak left ventricular blood velcities when compared with 2:1 A-V block, despite indentical R-R intervals following the blocked P wave. This latter phenomenon was attributed to diastolic augmentation of left ventricular contraction following the second and hemodynamically ineffective beat during 3:2 A-V block. Three patients manifested true blood velocity alternation during second-degree A-V block and changing R-R intervals. The variations in peak left ventricular blood velocity observed during atrial pacing and A-V block are related to changing inotropic state and cycle length dependent alterations of left ventricular diastolic filling.

chocardiographicl and left ventriculographic2 data have clearly established that the auscultatory syndrome comprised of midsystolic click and late systolic murmur is based on mitral valve prolapse. During the past decade attention has been directed toward the influence of mitral valve prolapse on the external carotid pulse tracing and left ventricular apexcardi~gram.~-~ We report here aortic

A 32-year-old man with a history of ven tricular septal defect presented with systolic and diastolic murmurs and vectocardiogra phic evidence of right ventricular hyper trophy. Echocardiography demonstrated a prominent systolic bulging of the inter- ventricular septum into the right ventricle. Left ventricular angiograms indicated that the ultrasonic abnormality was based on an aneurysm of the membranous septum which produced a 35 mm Hg gradient within the right ventricle. After plication of this aneu rysm, murmur and abnormal septal protru sion were not recorded.

One hundred patients, 17 to 67 years of age, had normal hearts diagnosed on the basis of complete right and left heart catheterization and coronary cineangiography. Phonocardiograms were obtained from each patient, providing an average of 17 recordings per subject for analysis; 75/100 (75%) subjects had a recordable fourth sound; 60/75 (80%) of the latter group had an audible fourth heart sound. It is concluded that recordable and audible fourth heart sounds are common findings in subjects without catheterization evidence of cardiovascular disease.

A 31-year-old woman with chronic renal insufficiency and recurrent pericarditis developed and enlarging cardiac silhouette and physical signs of cardiac tamponade. Cardiac catheterization demonstrated pericardial effusion with hemodynamic evidence of cardiac compression. At pericardial exploration, 1.5 L. of foul-smelling purulent material was removed from a distended pericardial sac. Cultures of both the exudate and pericardium revealed pure growth of Bacteroides fragiles . The patient was subsequently treated with intravenous chloramphenicol and has had an uncomplicated clinical course since that time. This represents the first reported case of cardiac tamponade secondary to culturally proved Bacteroides pericarditis in the setting of chronic renal insufficiency.

Using M-mode and 2-dimensional (2-D) echocardiography, ultrasonic features of the lonescu-Shiley valve were characterized. A number 23 prosthesis was placed in a saline-filled chamber and subjected to pulsatile flow. Production of a linear tear at the base of a cusp resulted in coarse fluttering in the open position, and there was a reduction in the anterior cusp slope. Partial detachment of a cusp from its stent produced high-amplitude low-frequency fluttering during ejection. Alteration of transducer position eliminated the abnormal echoes. Fourteen patients with aortic and 11 with mitral prostheses were studied. There was a close approximation of echographically determined values for the bare stent internal diameter, cusp excursion, and valve orifice diameter compared with the manufacturer's specifications. Random punctiform echoes were noted when the cusps opened. Cusp echoes were superimposed on stent echoes in 21% of patients, and a third cusp was detected in 29%. Two-dimensional echocardiograms of good quality were recorded in the vast majority of subjects. Cusp echoes were smooth and had a consistent motion in both the short and longitudinal axis. Multiple transducer positions were required to delineate prosthetic components with optimal clarity. It is concluded that (1) M-mode and 2-D echocardiography is useful in assessing Ionescu-Shiley valve function, (2) in vitro valve tears or detachment produces characteristic cusp fluttering, (3) careful attention to transducer positions is necessary to record high-quality valve images, and (4) these findings represent a data base for the longitudinal follow-up study of patients with the Ionescu-Shiley valve.

Phasic instantaneous left ventricular blood velocity was continuously measured by means of the Doppler ultrasonic flowmeter catheter radiotelemetry system in 68 patients with ventricular arrhythmias. Ventricular premature depolarizations reduced peak left ventricular blood velocities in relation to their respective coupling intervals, with R-R intervals less than 0.5 second producing the greatest decline. Ventricular tachycardia in 18 subjects produced a 62 per cent mean decrease in left ventricular blood velocity. In a single subject, performance of the Valsalva maneuver effected ventricular tachycardia and a concomitant marked diminution of phasic left ventricular blood velocity. These findings demonstrate the untoward influence of ventricular extrasystoles and tachycardia on left ventricular blood velocity and provide the underlying basis for reductions of blood velocity previously demonstrated in the regional circulations of man during similar arrhythmias.

he association of nonejection systolic clicks and Trnitral or tricuspid valve prolapse has been clearly established. Unusual sounding clicks or whoops have also been described in subjects with left-sided pneumothora~.~ These extracardiac transients are &ally multiple, occur throughout the entire cardiac cycle,3 and vary with the respiratory phase and poiition. Other features of pneu&othorax are clinically apparent, thereby aiding in proper