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Twenty-one consecutive Black African patients with severe pure mitral stenosis were evaluated hemodynamically. It was found that advanced mitral stenosis presents itself in Kenya at a very young age (22.9 ± 9.6 years, mean ± S.D.), with all but three patients under thirty. Left ventricular angiography demonstrated significant impairment of left ventricular function with 50% of patients having abnormally low valves (mean ejection fraction 0.50 ± 0.11). This diminished ejection fraction was related primarily to diffuse hypokinesia and an increased end-systolic volume. There was a significant deterioration of ejection fraction with increasing age which could not be correlated to increased severity of mitral stenosis or pulmonary hypertension. It is proposed that the diffuseness of the myocardial involvement and its progression with age in a young population without coronary artery disease represents the resoltuion of the acute inflammatory process of rheumatic fever in diffuse fibrosis of the myocardium and/or an occlusive vasculitis.

Summary The medical problems encountered during the care of patients undergoing mitral and multiple valve replacement have been discussed. Included are remarks regarding particular problems which have been encountered at the University of Oregon Medical School, and the philosophy which has evolved here regarding the care of these patients. The discussion includes some aspects of the preoperative evaluation, preoperative medical care, and the role of internist during surgery. Postopertive medical management is considered at length, with special reference to complications.

Digitalis augments the contractility of the normal and the failing heart. In nonfailing cardiac disease the positive inotropic action is not translated into increased cardiac output, largely due to increased vascular resistance and decreased cardiac filling. Digitalization does not affect ventilation or cardiac output during physical exercise, and has been shown to reduce the postexercise oxygen debt in patients with enlarged hearts not in failure. In experimental animals, digitalis prevents depression of cardiac function by anesthesia and by anoxia and hemorrhagic shock. There is also evidence that treatment of the overloaded but nonfailing heart may delay or reduce the increment in cardiac hypertrophy. The experimental evidence indicates that digitalis would rarely be harmful in patients with cardiomegaly without overt congestive heart failure, and may have definite prophylactic value when stress is anticipated.

An analysis of the postoperative course in twenty-eight patients who had complete correction of tetralogy of Fallot is presented. Pertinent preoperative findings are summarized and the operative procedure is briefly described. During or following surgery, seven patients had a syndrome of low cardiac output, which was lethal in four. Factors which may have contributed to the development of this state are discussed. The operative mortality rate was 14 per cent. One patient died during re-operation for persistence of the ventricular septal defect; the over-all mortality rate was 18 per cent. Congestive heart failure developed in 42 per cent of surviving patients. This was transient in some and had a more protracted course in others. All patients recovered and late improvement was impressive. Possible mechanisms for this incidence of heart failure are presented. The ultimate result from surgery was considered excellent in the majority of cases. It is concluded that total correction is feasible in most patients with tetralogy of Fallot, with an acceptable surgical mortality.

Responses to infusions of isoproterenol and methoxamine and to acute administration of ouabain have been studied in 17 patients with aortic insufficiency. Cardiac output was consistently increased and left heart filling pressures were reduced with isoproterenol. Forward stroke volume and the effective emptying ratio of the left ventricle both increased. These effects were related to increased inotropy, decreased impedance to left ventricular outflow and a diminished regurgitant volume. Methoxamine caused a marked rise in left heart pressures but the cardiac output remained unchanged or fell, the result of augmented systemic resistance with no associated direct inotropic effect. Ouabain caused no gross hemodynamic alterations, as has been noted previously in patients not in heart failure. These findings suggest that isoproterenol might be of considerable use in the clinical management of patients with aortic regurgitation. Methoxamine would be disadvantageous as a vasopressor drug in such patients, and perhaps in all situations requiring vasopressor therapy. The role of cardiac glycosides in treating patients with cardiac dilatation but without overt heart failure is questionable.

The results of aortic valve replacement with the Starr-Edwards prosthesis are reviewed in 86 patients. The total early and late mortality rate was 24 per cent. This fell to 13 per cent in 1964, and can be expected to decline further. Nearly all survivors are greatly improved by surgery. Detailed follow-up of 6 months to 3 years is available in 50 patients. All but one had symptoms prior to operation, and hemodynamic study preoperatively demonstrated gross abnormalities in most. Sixty-six per cent became asymptomatic, whereas mild limitation to exercise persisted in another 40 per cent. Angina pectoris disappeared in 32 of 34 instances. Sixty-eight per cent had a normal or only slightly enlarged heart after operation. Electrocardiographic evidence of left ventricular hypertrophy disappeared in 58 per cent. Postoperative hemodynamic studies usually demonstrated some mild residual hemodynamic abnormality, probably attributable to irreversible myocardial damage resulting from long-standing left ventricular hypertrophy and/or dilatation. Postoperative complications included regurgitation around the prosthesis, which was rarely of hemodynamic consequence, bacterial endocarditis (rare), traumatic hemolytic anemia (rare), and systemic arterial embolization. Thromboembolism remains the major unsolved problem of aortic valve replacement, and anticoagulant drugs have not been proved to be of value in preventing this. Indications for aortic valve replacement are discussed in terms of the current mortality rate and incidence of complications, the proved clinical and hemodynamic benefits, and the natural history of the various types of aortic lesions. All symptomatic patients with aortic stenosis, and all Class III or IV patients with aortic regurgitation are candidates for surgery. In addition, surgery is recommended in relatively asymptomatic patients with aortic stenosis who have a transvalvular peak systolic gradient of more than 70 mm. Hg, and in those with aortic regurgitation if there is gross cardiac enlargement, angina pectoris, or abnormal left heart dynamics. The possibility of underestimating the hemodynamic severity of a mixed aortic valve lesion was discussed.

In a double-blind, randomized test, long-term prophylactic anticoagulant therapy after acute myocardial infarction did not reduce mortality rate or complications. More treated patients required hospitalization than patients not receiving anticoagulant drugs. Patients continuously entered the study between 1956 and 1967. The average period at risk was about six years. All patients received six weeks of anticoagulant therapy for initial episodes of infarction, and, time and circumstances permitting, for recurrent myocardial infarctions.

A ball-valve prosthesis for aortic replacement has been described which, while it is similar to the mitral ball valve in terms of materials and construction, is quite different in sewing margin and internal geometry. Implantation is greatly facilitated by the flexibility of the prosthesis in terms of external diameter, and by the availability of a full set of varying sizes for obtaining a proper fit. Widening of the aortic root by patch grafting has not been necessary. Long-term survival has been achieved in the dog, and early clinical results are most promising. While the selection of the ideal aortic valvular replacement must await further experience with all types of prostheses, continued evaluation of the ball valve in the aortic position, in carefully chosen patients, is indicated.

The occurrence of right bundle-branch block and varying degrees of altered ventricular conduction in a group of cases of ventricular septal defects repaired by direct closure is presented. The development of abnormal conduction is correlated with the location of the ventricular septal defects and the relationship of the conduction tissue. The etiologic role of operative trauma to the conduction system is reviewed, and the influence of ventriculotomy alone is discounted.

1. Twenty-one infants with various forms of congenital heart disease leading to congestive heart failure, arterial unsaturation, or a combination of both events were studied with respect to resting oxygen consumption. Comparison was made with 21 control infants considered to be of normal growth and to have normal cardiac and respiratory systems. 2. Mean oxygen consumption for infants with heart disease was 9.3±2.4 ml/min/ kg compared to 7.3±0.8 ml/mm/kg for controls. Markedly undergrown infants with heart disease (60% or less of the 50th percentile weight for age) had a mean oxygen consumption of 10.9±1.4 ml/mm/kg compared to a mean of 7.5±2.0 ml/min/kg for infants with heart disease who were greater than 60% of the 50th percentile weight for age. Relative hypermetabolism seemed to relate to the degree of undernutrition rather than to any specific clinical finding. 3. Possible mechanisms of undernutrition and of relative hypermetabolism in the infant with heart disease are discussed.

The dependability of RVA in the evaluation of TI was studied in 141 patients with congenital or rheumatic disease. In patients over age 10, angiocardiography revealed TI in 13 and was negative in 27. Eight with positive RVA had cardiac operation and TI was confirmed in seven; three not having been operated upon were probably false positives. Six with negative RVA had an operation and no TI was detected. In 20 per cent of 95 younger patients, RVA revealed TI, often believed catheter induced. RA pressure criteria commonly employed in the hemodynamic diagnosis of TI were tested. RA pressure level and contour were analyzed in 27 cases proved negative for TI by RVA and in seven proved positive by operation. An X descent shallower than Y correlated better with atrial fibrillation than with TI; X deeper than Y correlated better with sinus rhythm than with tricuspid competence. RVA can exclude TI but yields false positive studies. RA pressure contour is believed not to have the usually accepted significance.

Over one half of the deaths from all congenital malformations were due to congenital cardiovascular disease. There were 496 individuals who died of congenital cardiovascular disease in Oregon during 1957 thru 1961, and three fourths of the deaths occurred in infants under 1 year of age. More males were affected by congenital cardiovascular disease than females, but, when congenital cardiovascular disease was present, the length of survival, as measured by life span, did not differ by sex. One out of every four infants dying of congenital cardiovascular disease was of low birth weight; of these, 60% were over 37 weeks' gestation. However, there was no difference in the life span of low birth weight and normal birth weight infants who died with congenital cardiovascular disease. This would imply that the significant factor of death in these infants was the cardiac malformation rather than the low birth weight. One out of every three infants who died with congenital cardiovascular disease had malformations of other systems. Fewer deaths than expected were identified among first born. Fetal deaths were noted more frequently in the population of mothers of children with congenital heart disease than in the overall population. The parental age in this group was significantly higher than in the general population and death rates of infants with congenital cardiovascular disease increased with advancing parental age. Thirty-two percent of the infants who died with congenital cardiovascular disease had single lesions. Early diagnosis and treatment is to be stressed if mortality is to be reduced.

A fifteen year old boy, whose case is reported here, survived a myocardial infarction which was apparently related to strenuous exertion. The anatomic diagnosis, based on electrocardiographic and vectorcardiographic observations, was confirmed by coronary arteriograms which demonstrated marked narrowing of both major branches of the left coronary artery. The etiologic diagnosis of coronary atherosclerosis is suggested, primarily because of exclusion of other possibilities.

The complications in 191 consecutive transseptal catheterizations are described. These included puncture of the wall of the heart in 9 cases, with 1 death, hemopericardium observed at the time of operation, a fatal coronary occlusion from an embolus which originated in a Lehman catheter, electrocardiographic changes of coronary insufficiency, and thrombophlebitis of the right lower extremity with pulmonary embolism.

Summary This paper describes the role of digitalis in cardiac surgical patients as viewed in our hospital. Routine preoperative digitalis is given to almost all patients who are to have intracardiac surgery, whether or not cardiopulmonary bypass is to be used. The positive inotropic effect of digitalis and its action on atrioventricular conduction are discussed in relation to cardiac surgery. The use of digitalis and the means of its administration before, during and after surgery are described. Postoperative digitalis intoxication and its treatment are outlined.

A case of reversed reciprocating paroxysmal tachycardia in a patient with the WPW syndrome is reported. The tachycardia was controlled by guanethidine. The blocking of sympathetic activity, with resultant predominent vagal influence on the conduction pathways of the A-V node and the anomalous bundle, is offered as an explanation for the control of this arrhythmia.

A safe, rapid method for estimating left ventricular volume in man during the course of hemodynamic studies should prove helpful in the assessment of cardiac disease and useful in physiological research. It is the purpose of this report to present left ventricular volume measurements in man that were obtained by an indicator dilution method which employs cold as the indicator. This circulatory indicator has been studied by several workers (1-4) and has been used for left ventricular volume determinations in animals previously (5-10). The method employed was adapted from those used by Rapaport and his co-workers for left ventricular volume measurements in the dog (7) and right ventricular studies in man (11).

Mannitol infusion has significantly decreased plasma hemoglobin build-up rate in mitral and aortic valvular replacement. This occurred before hemoglobin appeared in the urine, and was unrelated to the binding of hemoglobin by haptoglobin. The mechanism by which mannitol decreases the build-up rate of plasma hemoglobin is unknown, but seems to be other than by renal excretion of hemoglobin.

Postoperative cardiac catheterizations were performed in eight patients within the first year following replacement of the tricuspid, mitral, and aortic valves with Starr-Edwards ball-valve prostheses. Two additional patients were studied who had mitral and tricuspid replacement. Before surgery the patients characteristically had distinct elevation of right and left atrial pressures, and markedly reduced cardiac outputs. Four individuals had marked pulmonary hypertension. At the postoperative catheterizations, consistent changes were an increase in cardiac output, a decrease in right and left atrial pressures, and a decrease in right ventricular systolic pressure. The last change was particularly notable in those individuals who had marked pulmonary hypertension before surgery.

HEMOLYTIC anemia has occasionally been reported as complicating various open-heart surgical procedures performed in laboratory animals1 and human patients.2 3 4 These cases have been characterized by destruction of erythrocytes through mechanical means. We have recently encountered 7 cases of acquired hemolytic anemia after aortic-valve surgery that did not appear to result solely from mechanical breakdown of erythrocytes. The association of positive serologic tests and a characteristic clinical pattern suggests a previously undescribed syndrome. The purpose of the present report is to outline the clinical nature of this state and to indicate a possible autoimmune pathogenesis for the hemolytic process. Case Reports . . .

A search of the literature has revealed the reports of only 14 cases of situs inversus of the abdominal viscera with levocardia. Eight additional cases are presented in this paper. Angiocardiography and/or heart catheterization was carried out on 6 of these and a Blalock-Taussig operation was performed subsequently on each patient. The autopsy findings in 2 instances, together with the results of special investigations in surviving patients, indicate that the malformations are of a bizarre nature. Anomalies of the venous return to the heart are particularly common and variable degrees of transposition of the great vessels are postulated.

Left ventricular end-systolic and end-diastolic volumes were measured by a thermodilution technic in four patients with idiopathic left ventricular hypertrophy. Two patients had no outflow tract obstruction at rest and the ventricular end-diastolic volumes were 90 and 107 ml. per M 2 . Two patients with idiopathic hypertrophic subaortic stenosis (IHSAS) with large gradients, had end-diastolic volumes of 69 and 67 ml. per M 2 . The lower limit of normal for this value in our laboratory is 90 ml. per M 2 . The low end-diastolic volumes in the two patients with IHSAS were associated with ventricular end-diastolic pressures of 18 and 20 mm. Hg, indicating that the diastolic compliance of the left ventricle was severely reduced. This low compliance produced a high mean left atrial pressure and a low stroke volume, due to inadequate ventricular filling. It is postulated that in some cases of IHSAS, such handicaps may be as important as outflow tract obstruction. When methoxamine was administered to two patients with IHSAS, the systemic pressure rose and the outflow gradient was lessened in both. However, in one case the ventricular enddiastolic volume rose from 69 to 79 ml. per M 2 ., and in the other it fell from 90 to 59 ml. per M 2 . Based on our data, and other studies from the literature, it is suggested that systemic diastolic pressure is an important determinant of the outflow gradient in IHSAS. A rise in systemic diastolic pressure may reduce, or even nullify, the effects of either a reduced ventricular systolic volume or positive inotropic stimulation, both of which have been shown to increase outflow obstruction. It is proposed that the gradient in IHSAS depends on a complex interplay of variables, some tending to increase the gradient, and some tending to decrease it. It may thus be difficult to predict the effect of any agent or maneuver in a given patient with IHSAS.

Abnormalities in the silastic poppets of cardiac valve prostheses have been detected with increasing frequency. Ball variance can cause serious mechanical dysfunction of the prosthesis and can result in sudden death. Contour sound spectrograms were recorded on 12 patients with ball variance confirmed by operation and 25 controls. In ball variance the frequency of the aortic opening sound at the second right intercostal space was decreased, with the peak frequency recorded being below 1,300 cycles/sec in 11 of the 12 patients. The peak frequency was greater than 1,300 cycles/sec in 24 of the 25 control patients. The remaining patient had peak frequencies in both the normal and abnormal range. The diagnosis of aortic ball variance in patients with triple valve replacement remains difficult because of the nearly synchronous tricuspid closing and aortic opening sounds. The sound spectrographic findings have been the most reliable objective evidence of ball variance in patients with Starr-Edwards aortic prostheses of the Model 1000 series.

Three patients with ball-valve prostheses were given heparin after percutaneous retrograde aortic catheterization from the femoral artery. The drug was given prophylactically in one case and because of the development of signs of systemic embolism soon after catheterization in the other two. After 3 or more days of heparin therapy, serious bleeding developed at the site of percutaneous catheter entry. The timing and incidence of this complication are in marked contrast to experience with this procedure in individuals who did not receive heparin. Preliminary experience is presented from right and left heart catheterizations in patients whose prothrombin-proconvertin times were allowed to remain in or near the therapeutic range. No hemorrhagic complications were observed.

The anatomic nature of a double aortic arch is described. Reference is made to the history of the malformation. The clinical picture and radiographic findings described by various authors are discussed. Two cases are reported which demonstrate two types of double aortic arch, One, a relatively common type, had a large right arch with a retro-esophageal component and a left descending aorta; the second, a rare type, had a large left arch with a retro-esophageal component and a right descending aorta. Further, one was an infant who had symptoms of constriction whereas the other was an adult who had no symptoms referable to the double aortic arch. Analysis is made of these cases and 47 other cases reported in the literature. This analysis reveals that: 1. There is a striking correlation between the occurrence of symptoms and the age and duration of life, but there is no correlation between the occurrence of symptoms and the type of double aortic. 2. A double aortic arch in which both components are patent throughout is more likely to produce symptoms than a double aortic arch in which one component is partially obliterated. The process of obliteration does not appear to give rise to symptoms. 3. There is considerable variation in the relative sizes of the components of a double aortic arch. The right component is usually the larger; part of the left component may be obliterated. To date, no case has been reported of obliteration of part of a persistent right Component. 4. A double aortic arch occurs more commonly with a left descending aorta than with a right descending aorta. 5. It is unusual for a double aortic arch to be associated with a malformation of the heart. The association of a double aortic arch with other vascular abnormalities is less rare. The two principal problems raised by the demonstration of a retro-esophageal vessel are discussed. The first concerns the nature of the malformation; the second concerns the advisability of operation in the given individual.

Nineteen geriatric patients with sustained, mild to moderate hypertension in addition to cerebrovascular disease were studied for 4 months by means of a double-blind crossover technique in which mebutamate was compared to an inert placebo. No significant antihypertensive effect was observed in the 19 geriatric patients treated with mebutamate (Capla). Over 40 per cent of the patients complained of drowsiness while receiving the drug. There was no evidence of renal or hepatic impairment during the period of observation.

Serial serum transaminase determinations were made before and following cardiac arrest encountered during retrograde left ventricular catheterization and successfully managed by external cardiac massage. Prompt, significant elevation of serum glutamic oxaloacetic transaminase and slight rise in serum pyruvic transaminase occurred without evidence of myocardial infarction. Skeletal muscle trauma appeared the most likely cause.

A patient who has rheumatic heart disease with predominant mitral valve involvement and who had systemic hypertension as a result of renal artery stenosis is presented. The hemodynamic changes resulting from surgical correction of the hypertension are discussed. The difficulty in interpreting pulmonary wedge or left atrial pressures in assessing the degree of mitral valve disease in the presence of systemic hypertension is emphasized.

The relationship of left atrial contraction to ventricular filling was studied in 24 patients. Eight patients had aortic stenosis, eight had mitral stenosis, and eight others served as a control group. All had normal sinus rhythm. Cineangiocardiographic volumetric determinations of the left ventricle were done throughout the cardiac cycle, and the rate of left ventricular filling before and during left atrial contraction was calculated. In the group with aortic stenosis 39% of the left ventricular stroke volume entered the ventricle during left atrial contraction; in the group with mitral stenosis 24% was contributed during left atrial contraction, and in the control patients, 26%. The rate of left ventricular filling more than doubled during left atrial contraction in aortic stenosis, while no consistent change in the rate of filling occurred during left atrial contraction in mitral stenosis and in the control group. The character of the resistance to left ventricular filling in aortic stenosis and mitral stenosis is discussed. An important contribution by left atrial contraction to left ventricular performance in aortic stenosis is suggested.

Forty-five patients having saphenous vein aortocoronary bypass surgery were studied prospectively by pre- and post-operative hypoxemia and graded exercise electrocardiography. The stress electrocardiographic results were correlated with the degree of symptomatic relief and the angiographic evidence of graft patency and the distribution and evolution of coronary occlusive disease. Forty-one of the total group of 45 patients (91 per cent) and 32 of 34 (94 per cent) with one or more documented open grafts had excellent or good symptomatic improvement. Incongruously, five of seven patients with closed grafts also had significant clinical improvement. Functional improvement was documented in 53 per cent of patients after aortocoronary bypass surgery, in terms of postoperative reversal of the preoperatively positive stress ECG or persistance of a negative stress ECG, together with the achievement of significantly greater mean maximum exercise and heart rate. All of these patients had one or more patent saphenous vein bypass grafts. Forty-seven per cent of the patients failed to display objective evidence of improvement: post-operatively the stress ECG either remained positive, or became so, and, collectively, the group was unable to significantly increase the mean maximum exercise level or heart rate, in comparison to that achieved before surgery. Only 65 per cent of these subjects had one or more patent bypass grafts. Stress electrocardiography and quantitation of the maximum work and heart rate achieved by exercise provide accurate assessments of the relief of myocardial ischemia produced by myocardial revascularization. In this study, when the post-operative stress ECG was negative and the patient was able to achieve significantly greater exercise and heart rate, the probability of patency of one or more bypass grafts was virtually certain. On the other hand, when the postoperative stress ECG was positive and little or no increase in exercise and heart rate was possible, there was high probability of graft occlusion or significant residual coronary disease.

Left ventricular end-diastolic volume (EDV) was measured by thermodilution in 30 patients with heart disease. Those with little physiologic abnormality varied in their response to exertion. In some, EDV decreased while forward stroke volume (FSV) was maintained or increased. In others, EDV and FSV rose during exercise. Patients with aortic insufficiency usually had a decrease in EDV with exercise, whether FSV increased or decreased. In patients with other lesions, FSV and EDV tended to vary together. Changes in EDV and left ventricular end-diastolic pressure with exercise were usually not in the same direction, and the factors which may explain this unexpected finding are discussed. It is concluded that end-diastolic pressure, as usually measured in the left ventricle during cardiac catheterization, will not reliably describe EDV or its changes with exercise.

The potential advantages of an ultra-low frequency ballistocardiograph are presented.

The hemodynamic response to supine exertion was studied by left heart catheterization in 23 Functional Class II and III subjects with isolated aortic regurgitation. The resting cardiac index was normal in most patients but rose insufficiently with exercise in 11. The 12 subjects with a normal cardiac index during exercise usually had elevated left ventricular end-diastolic pressures, while those with a low cardiac index usually had normal pressures. The difference was statistically significant. The explanation for this unusual finding is not clear from the data but might be forthcoming if similar studies employing quantitative angiocardiography were performed.

The cardiac output and blood volume were measured preoperatively and sequentially during the early postoperative period in 45 patients undergoing cardiac valve replacement. Most patients showed a prompt, highly significant increase in cardiac output. Those with uncorrected valvular disease, even though apparently trivial, had lower cardiac outputs. The blood volume was sharply reduced from the preoperative level in almost every patient. When this was associated with low cardiac output, replacement of the blood volume deficit was usually accompanied by a prompt increase in cardiac output. Failure to respond in this way occurred only in patients with residual valvular lesions or myocardial disease.

Eleven patients had right heart catheterization an average of 13 mo after total correction of tetralogy of Fallot, and the procedures were then repeated an average of 7 years postoperatively. In the intervening time there was generally no important change in the pressure gradient between the right ventricle and pulmonary artery or in right ventricular systolic pressure. Mean right atrial pressure tended to fall with time. Arteriovenous oxygen difference at rest was lower at the second study, and the resting cardiac output was generally normal. One patient with a persistent ventricular septal defect had progressive hemodynamic deterioration between the two studies. Exercise performance up to 10 years postoperatively was also assessed. The relationship between oxygen consumption and cardiac output was usually normal, but exercise magnified the right heart's filling pressure abnormalities. In the absence of an easily demonstrable ventricular septal defect, right heart hemodynamics were either stable or improved up to 10 years postoperatively. The exercise response of cardiac output was usually normal at moderate work loads.

Femoral artery occlusion occurred in 7 of 533 patients undergoing percutaneous femoral artery catheterization (1.3 per cent). Of the total group, 113 patients had predominant mitral stenosis, and 5 of these developed femoral occlusion (4.4 per cent). Unusually small iliofemoral arteries were found in 5 of the 6 patients who required thrombectomy. In addition, 2 had atheromatous narrowing and 2 had pre-existing emboli. The 5 patients who underwent thrombectomy within 12 hours had good functional results. Individuals with mitral valve disease, weak peripheral pulses, low cardiac output or previous arterial obstruction appear predisposed to arterial occlusion after catheterization. Large catheters, prolonged procedures, extensive catheter manipulation and excessive pressure to control bleeding should be avoided. Persistent signs of ischemia during a 6 hour observation period after catheterization are an indication for early arterial exploration.

A total of 16 patients with heart disease of various types underwent peritoneal dialysis for severe and often intractable, cardiac failure. The average amount of fluid removed was 6 liters. Most patients had immediate improvement of symptoms and signs of fluid overload, 12 entered periods of remission, and four were improved enough to undergo corrective surgery, with survival of three. An average weight loss of 6 kilograms occurred during dialysis and 4 kilograms more in the next 2 weeks. Serum sodium and chloride levels were depressed initially and returned toward normal in most patients. The average predialysis sodium and chloride levels were 126 and 86 mEq. per liter, increasing to 136 and 97, respectively. Total blood volume (TBV) was greatly expanded beforehand and decreased with therapy in all 9 patients so studied. The average decrease was from 139 to 109 ml. per kilogram. Cardiac index (CI) was low in all and increased significantly in 6 of 8 patients so studied, the average changing from 1.4 to 1.9 L. per minute per square meter. The decrease in TBV, increase in CI, and sustained clinical improvement were closely associated. There were no definite complications, although in one instance, excessive vascular volume depletion may have contributed to hypotension, oliguria, and death. It is concluded that hypertonic peritoneal dialysis is an effective method for the treatment of severe heart failure with sodium dilution.

Injection of sublethal doses of diphtheria toxin in dogs resulted in the following changes: (1) a significant decrease of extracellular fluid volume and an increase of intracellular fluid volume, as demonstrated both by tracer dilution methods and by muscle biopsy methods; (2) an increase of intracellular sodium in muscle; (3) a fall in cardiac output, oxygen consumption, and stroke volume, while heart rate and right atrial pressures tended to increase; and (4) a marked fall in glomerular filtration rate.

Red blood cell survival was determined in patients with aortic valvular disease, postoperative patients with aortic valvular ball-valve prostheses and postoperative patients with multiple ball-valve prostheses. The red blood cell survival was reduced in the majority of patients in each group when compared with the red blood cell survival from a normal control group. A detailed analysis of the survival curves suggested that in many patients there was more than one population of red blood cells. The first population displayed rapid random destruction. This population was not present in normal persons in the control group. The second population showed the usual decline in radioactivity due to random destruction and loss of the red cell label due to elution. The shortened red blood cell survival in some patients was due to a large percentage of the first population of randomly destroyed red blood cells, in other patients to an accelerated rate of destruction of the usual single population of cells while others had a combination of the two mechanisms. A mechanism of mechanical hemolysis due to increased intracardiac turbulence was suggested as a cause for the shortened survival. When the turbulence was increased by a leak around the aortic or mitral valve prosthesis the red blood cell survival was found to be further decreased. In some cases this reduction in survival was enough to produce hemolytic anemia. The Coombs antiglobulin test was positive in three patients. The suggestion was made that the development of autoantibodies to red blood cells was secondary to increased destruction of red blood cells.

Fourteen patients underwent right heart catheterization 5 to 86 months after pericardiectomy for constrictive pericarditis. Twelve had preoperative catheterizations, all with findings typical of constrictive pericarditis. All patients showed marked hemodynamic and symptomatic improvement after operation. Three patients had persistent mild elevation of right heart and pulmonary artery pressures; one of these had a low cardiac output. Two other patients developed pulmonary hypertension with exercise, and one man showed an inadequate increase in cardiac output with exercise. Twelve patients were asymptomatic postoperatively and two had exertional dyspnea. Patients with incomplete pericardiectomy over the ventricles had abnormal hemodynamic results, while decortication of the atria and venae cavae made no difference in the postoperative findings. A left anterolateral thoracotomy incision provided adequate exposure for pericardiectomy, and continues to be the incision of choice at this hospital. Younger patients and those who progressed from recognized acute pericarditis to pericardial constriction more frequently had normal results at cardiac catheterization after operation. Certain preoperative liver-function tests correlated well with the postoperative hemodynamic findings. The role of myocardial disease in producing residual hemodynamic abnormalities remains unresolved. It is concluded that excellent clinical results and normal hemodynamic findings can be achieved by pericardiectomy in most patients with constrictive pericarditis.

Despite increased awareness of atrial myxoma, the lesion remains a diagnostic challenge, largelydue to a highly variable clinical picture. Some unusual manifestations of atrial myxoma are illustrated by 6 cases. The relatively slow growth of left atrial myxoma was demonstrated in a 15 year old boy thought to have mitral insufficiency from birth and by a 10 year period of observation in a 63 year old woman. The woman also had co-existent mitral stenosis. Coexistent congenital heart disease was found in a 73 year old man thought to have severe lung disease with arterial unsaturation. Cardiac catheterization showed a right to left shunt through an atrial septal defect due to a right atrial myxoma obstructing the tricuspid valve. Angiocardiography demonstrated the above lesions, as well as left atrial myxomas in 2 patients with clinical findings of mitral valve disease. A fatal complication occurred during transseptal catheterization in a woman believed clinically to have mitral stenosis. Occlusion of the mitral valve by a left atrial myxoma occurred when the catheter entered the left atrium above the tumor. The importance of angiography in the diagnosis of atrial myxoma is stressed, and the avoidance of transseptal catheterization in suspected cases is emphasized.

Electrocardiography was carried out during hypoxemia and graded exercise tests before and at intervals between 2 and 20 months after attempts to revascularize the heart by internal mammary artery implantation in 44 patients with angiographically documented coronary disease and angina pectoris. Eleven patients had single vessel disease; the right coronary was involved in seven of these patients. Thirteen patients had single vessel implants, employing the left internal mammary artery in 11 patients and a saphenous vein graft from the aorta in two. Thirty-one patients had double internal mammary artery implantation accompanied by gastroepiploic arterial implantation in four. Fifty per cent of the patients were symptomatically improved after surgery, the best results occurring in two patients with isolated anterior descending coronary disease. Of the 34 patients having postoperative coronary and mammary arteriography, 15% showed improvement which could be ascribed to mammary revascularization; 24% had limited myocardial revascularization and no symptomatic improvement; 29% had patent implants without development of collateral vessels, and the implanted vessels were occluded in 32%. Eleven of the 34 (32%) had fair or good symptomatic improvement in the absence of revascularization. The results of postoperative stress electrocardiography correlated closely with the findings on postoperative coronary and mammary angiography. The stress tests were persistently positive after operation in 83% of the patients having angiographically confirmed implant occlusion or nonrevascularization. The stress ECG response was reversed, becoming negative postoperatively, in five cases of angiographically proved significant revascularization. Thus, stress electrocardiography provided objective evidence of improvement in a small number of patients with limited coronary disease who developed good collateral circulation and correlated with the lack of revascularization in the majority even in those subjectively improved.