Citations

The present study presents pertinent clinical and pathologic findings in 20 cases of ruptured mitral chordae tendineae encountered at the Mayo Clinic between 1934 and 1958 inclusive. Mitral insufficiency results from the rupture of chordae tendineae, the severity being related to the number of chordae ruptured. The resulting heart disease may be severe and may progress to cardiac decompensation and death. Bacterial endocarditis was the major etiologic factor in rupture of the chordae tendineae in this study.

An anatomicopathologic entity of the tetralogy of Fallot with an additional finding of an accessory flap of tricuspid valvular tissue is described. In the 3 cases reported in this paper, the outstanding hemodynamic finding was a right ventricular systolic pressure that was significantly greater than the systemic systolic pressure. The hemodynamic findings were explained by the fact that the accessory tricuspid flap partially closed the large ventricular septal defect. The clinical picture was similar to that of either severe pulmonary stenosis with an intact ventricular septum or severe pulmonary stenosis with a small ventricular septal defect and a right-to-left shunt at the ventricular level.

This has been a summary of the clinical patterns in certain types of cerebrovascular disease with emphasis on occlusive disease. Knowledge concerning these categories is important in studying the results of various therapeutic technics and in selecting the correct treatment for some subdivisions where effective therapy exists.

From March 1955 to April 1959, 174 patients with ventricular septal defect and 124 patients with ventricular septal defect associated with pulmonic stenosis were referred from the Section of Pediatrics of the Mayo Clinic for open intracardiac repair. Forty-eight of these 298 patients had complete heart block at some time following operation. Eighteen of the patients with heart block died in the immediate postoperative period, 18 had reversion to normal sinus rhythm, and 12 were discharged from the hospital with complete heart block. Three of these 12 patients died subsequently. Two died presumably as a direct result of complete heart block and a third died following a second open cardiac operation. Of the 9 surviving patients, 3 have had serious bradycardia or periods of asystole and 6 have no symptoms from heart block. One of 3 surgical technics was employed for all the patients in this study with variation in incidence of block with the use of each technic. Other factors that might relate to the incidence of heart block are discussed. The management of the patient with complete heart block both in the immediate post-operative period and after dismissal from the hospital is described.

Bilateral determinations of the blood pressures were made nonsimultaneously and simultaneously by the indirect method under basal conditions on 447 patients. In this group 26.6 per cent of the paired measurements by the nonsimultaneous indirect method exhibited systolic differences of 10 mm. Hg or greater and 15 per cent exhibited diastolic differences of this magnitude, whereas only 5.3 per cent of the measurements by the simultaneous indirect method had systolic differences and only 4 per cent had diastolic differences of this degree. This indicates that bilateral determinations of blood pressure must be performed simultaneously on patients being examined for possible inequalities of blood pressure. Bilateral differences in blood pressure obtained by the simultaneous indirect and simultaneous direct methods in 14 normal subjects and 53 selected patients were compared. In the normal subjects, 3 of the 42 paired indirect measurements and none of the paired direct measurements in either the radial or brachial arteries had systolic differences of 10 mm. Hg or greater, and none of the diastolic differences were of this level. In the 53 selected patients, 10 per cent of the indirect and 6 per cent of the direct measurements of systolic blood pressure differed by 10 mm. Hg or more and 8 per cent of the paired indirect measurements of diastolic blood pressure and less than 1 per cent of the paired direct measurements differed by this amount. These differences in bilateral blood pressures were characterized by their inconstancy and lack of agreement with subsequent measurements when studied by both the indirect and direct methods, which apparently separates them from those due to altered hemodynamics from pathologic conditions of the aortic arch or its tributaries. Bilateral differences of blood pressure are of clinical importance when they are great and are reproducible by the direct as well as by the indirect methods, as illustrated by a patient encountered in this study. In addition, 1 case of extreme obesity and 1 of advanced arteriosclerosis were reported. Both patients were found to have pseudohypertension, which was detected in this study. A slight increase in the incidence of bilateral differences in indirect blood pressures was found in a group of patients whose blood pressures were measured while they were in the supine and then in the sitting position. A slight increase in the incidence of bilateral differences was found at higher levels of blood pressure by comparing the blood pressures of nonhypertensive and hypertensive patients and of hypertensive patients before and during treatment with antihypertensive drugs. Bilateral inequalities of blood pressure did not appear to be related to the age or sex of the subjects. Likewise, differences in circumferences of the arm or right or left-handedness did not appear to influence these inequalities, and there was no marked side dominance for differences found. Bilaterally simultaneous, indirect measurements of blood pressure should be carried out on patients with hypertension who will be treated with antihypertensive drugs. Bilateral direct measurements may be used to verify the existence of inequality of blood pressures detected by the indirect method and to determine the correct pressure to be followed. This is particularly important in patients being screened for pheochromocytomas, since such differences may produce false-positive results.

In a pathologic collection of 722 congenital heart lesions we have observed 10 cases in which a ventricular septal defect was associated with obstruction to normal left ventricular outflow. These cases are presented in the framework of a classification relating hemodynamics to the position of the obstructing lesion and the size of the ventricular septal defect. One additional case observed clinically and at operation is also reported to make more nearly complete the classification of the anatomic arrangements in which the common denominators are ventricular septal defect and obstruction to normal ventricular outflow.