The Pulmonary Component of the Second Sound in Right Ventricular Failure

Sound within the pulmonary artery was measured in 24 patients to determine if right ventricular failure modifies the amplitude of the pulmonary component of the second sound (P2). The amplitude of P2 in eight patients with right ventricular failure secondary to pulmonary hypertension (2610 ± 370 dynes/cm2) did not differ from P2 in eight patients with pulmonary hypertension not accompanied by right ventricular failure (3120 ± 710 dynes/cm2). In both groups, the amplitude of P2 exceeded control subjects (520 ± 70 dynes/cm2) (P \u3c .001 and P \u3c .01, respectively). The maximal rate of development of the pressure gradient across the closed pulmonary valve was higher in patients with right ventricular failure (580 ± 100 mm Hg/sec) than in control subjects (150 ± 30 mm Hg/sec) (P \u3c .001) and maximal negative dp/dt was also higher in patients with failure (750 ± 70 mm Hg/sec vs 190 ± 20 mm Hg/sec) (P \u3c .001). The maximal rate of change of the diastolic pressure gradient correlated linearly with maximal negative dp/dt (r=.89). These observations indicate that P2 is accentuated in patients with right ventricular failure secondary to pulmonary hypertension. The accentuation results from the augmented rate of development of the diastolic pressure gradient, which reflects an augmented right ventricular negative dp/dt. Therefore, an accentuated P2 remains valid as a clinical sign of pulmonary hypertension whether or not right ventricular failure occurs

Assessment of the Orifice Area of Bioprosthetic Valves by Orifice-View Roentgenography

Orifice-view angiography permits us to visualize en face the orifice of the aortic or mitral valve. The radiopaque annulus of bioprosthetic valves assists in permitting the angiographer to position the patient exactly, so that the valve can be seen as if looking directly into the orifice. Orifice-view angiography of porcine bioprosthetic valves has been useful in assessing the size and configuration of the valve orifice. It can reveal a failure of leaflet opening that would indicate degeneration, even when hemodynamic measurements remain equivocal

Intracardiac Phonocardiography in Subaortic Stenosis

The purpose of this study is to explore the value of intracardiac sound recordings for the verification of subaortic stenosis. Intracardiac sound was measured in ten patients with subaortic obstructions. Seven had idiopathic hypertrophic subaortic stenosis, two had a subvalvular membrane, and one had a subvalvular tunnel. In each patient, a systolic murmur was recorded within the left ventricle distal to the obstruction. The murmur was of lower amplitude distal to the aortic valve, and it was of even lower amplitude or absent proximal to the obstruction. In the presence of entrapment, no intraventricular murmur occurred although an apparent subvalvular pressure gradient was observed. The identification and localization of the maximal intensity of a systolic murmur in the ventricular outflow tract may assist in the verification of a subvalvular obstruction and help distinguish between artifactual pressure gradients and gradients indicative of subvalvular stenosis

Dysfunction of Mitral Ball Valve Prosthesis

Three case histories of patients with malfunctions of Smeloff-Cutter mitral ball valve prostheses are presented here - one underwent successful replacement. The clinical diagnosis was made by observing a marked variation in the A2OC interval and intermittent absence of the opening click. Phonocardiograms were diagnostic in all three cases. while echocardiograms and even angiograms did not uniformly diagnose prosthetic valve dysfunction. Periodic phonocardiographic evaluations may be helpful in early detection of the prosthetic valve dysfunction. Once the diagnosis is established, immediate surgical treatment is imperative to prevent sudden death

Subvalvular aortic stenosis associated with dynamic outflow tract obstruction: A case report

Hemodynamic and angiographic findings are described in a 27-year-old patient, who had undergone surgical operation for subvalvular membranous aortic stenosis. Left ventriculography revealed persistence or regrowth of the subvalvular fibrous ring, and hemodynamic data revealed associated dynamic obstruction of the left ventricular outflow tract. The authors emphasize the importance of uncovering associated dynamic obstruction by provocative maneuvers and use of Beta blockers

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)

Although considerable improvement has occurred in the process of care for patients with ST-elevation myocardial infarction (STEMI), room for improvement exists (1–3). The purpose of the present guideline is to focus on the numerous advances in the diagnosis and management of patients with STEMI since 1999. This is reflected in the changed name of the guideline: “ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction.” The final recommendations for indications for a diagnostic procedure, a particular therapy, or an intervention in patients with STEMI summarize both clinical evidence and expert opinion (Table 1).To provide clinicians with a set of recommendations that can easily be translated into the practice of caring for patients with STEMI, this guideline is organized around the chronology of the interface between the patient and the clinician. The full guideline is available at http://www.acc.org/clinical/guidelines/stemi/index.htm

Left Atrial Myxoma with an Atrial Septal Defect: Report of a case

A case of a left atrial myxoma presented unusual features including (1) association with an atrial septal defect, (2) attachment of the myxoma to the posterior wall of the left atrium, (3) probable paradoxical pulmonary embolization from the left atrium, and (4) probable ball valve effect of the myxoma in the atrial septal defect

Painless dissecting aneurysm of the thoracic aorta: Report of eight cases masquerading as gross aortic insufficiency, severe hypertension, myocardial infarction and mediastinal enlargement.

In a review of 68 patients with dissecting thoracic aorta aneurysm (DTAA), eight patients (11.7%) were found to have painless dissection. Three of the eight patients presented with gross aortic insufficiency (Al). Angiography on a fourth patient, who had severe hypertension, showed Type III DTAA. Three other patients had either dilatation of the ascending aorta or a possible mediastinal mass, according to chest roentgenograms. One patient received treatment for suspected myocardial infarction with cardiogenic shock. A high index of suspicion in patients with unexplained Al, severe hypertension and a mediastinal mass or dilatation of the ascending aorta, coupled with the early use of angiographic studies, will assist in establishing the diagnosis and decide the most appropriate management