Evidence for the 'cardiac pump theory' in cardiopulmonary resuscitation in man by transesophageal echocardiography.

There are two theories to explain the mechanism of blood flow during cardiopulmonary resuscitation: The 'Cardiac Pump Theory' and the 'Thoracic Pump Theory'. We have performed transesophageal echocardiography during the resuscitation of a patient with cardiopulmonary arrest. By this method we could study the motion of the aortic, mitral and tricuspid valves and the changes in ventricular size during cardiopulmonary resuscitation in man. We demonstrated an opening of the aortic valve during thoracic compression with simultaneous closure of the mitral and tricuspid valves. During relaxation of the chest, a rapid opening of the atrioventricular valves and closure of the aortic valve was noted. Short interruption of cardiopulmonary resuscitation to test for spontaneous heart action lead to echocontrast in all four heart chambers through stasis of blood, which resolved on continuation of cardiopulmonary resuscitation. This 'washing out' phenomenon enables visualization of blood flow through the aortic valve during compression, and through the mitral valve during relaxation. These observations favour the Cardiac Pump Theory as the predominant hemodynamic principle of blood flow during cardiopulmonary resuscitation in man.

Influence of age on the survival rate of out-of-hospital and in-hospital resuscitation.

During a 9-year period 1472 cardiopulmonary resuscitations were analysed. Five-hundred seventy-two were in-hospital and 898 out-of-hospital resuscitations. Of the out-of-hospital resuscitations 495 (55.1%) patients were less than 70 years and 403 (44.9%) older than 70 years. Survival in the former group was 71 (14.3%) in the elderly group 44 (10.9%) (P < 0.1). In the in-hospital population 245 (43%) were below 70 years and 327 patients above 70 years (57%). Seventy patients (28.2%) in the former group and 46 (14.1%) in the latter group survived (P < 0.01). The statistical analysis of the out-of-hospital resuscitations indicates no significant difference in the survival rate of patients younger than 70 years compared to those above 70 years. The survival rate however for patients above 70 years in the in-hospital group was significantly worse, probably attributed to multimorbidity of the older in-hospital patients. The results in our study indicate that old age is not a determinant of prognosis or outcome after CPR.

Stent-supported angioplasty of an ostial left main stenosis following replacement of the ascending aorta with reimplantation of the coronary arteries.

We describe a patient who underwent replacement of the descending aorta with reimplantation of the coronary arteries for acute type II aortic dissection and developed iatrogenic left main stem stenosis 1 year after operation. The patient was successfully treated by stent implantation in the left main stem.

Early transition into adult roles: some antecedents and some outcomes.

The transition to adult roles usually occurs within a normative age span. By focusing on preadolescence to late adolescence using 2-wave panel data, this research seeks to develop a more informed picture of how "early" exit from the student role and "early" entry into the adult role of parent or spouse reflect factors operating prior to adolescence. The short term consequences of adult role transition on teenage status aspirations, life plans, other psychological orientations, and parental influence are also examined. Even though multiple role transition is frequently observed, only leaving school early appears to be related to preadolescent career decisions and academic performance in high school. The determinants of early transition to the role of parent or spouse do not appear to be socioeconomic origins, parental child rearing techniques or other specific influences, academic ability or performance, or preadolescent aspirations, as has generally been hypothesized in the literature. Research dilemmas and policy implications are discussed.

[Heterotaxia syndrome without congenital cardiac defects in dilated cardiomyopathy]. / Heterotaxie-Syndrom ohne kongenitalen Herzfehler bei dilatativer Kardiomyopathie.

UNLABELLED: HISTORY AND OUTPATIENT INVESTIGATION: A 61-year-old woman presented with a six-month history of chest pain and shortness of breath on normal activity. The past medical history included hypertension treated with ACE inhibitors. While still an outpatient a diagnosis was made of cardiomyopathy with left atrial and ventricular dilatation, systolic and diastolic heart failure, moderate mitral valve regurgitation and newly documented atrial fibrillation. INVESTIGATION: Right heart catheterization was carried out via the right femoral vein. The inferior vena cava was found to be on the left, none on the right. Venous inflow was via a dilated hemiazygos vein, a persistent left superior vena cava and a markedly dilated coronary sinus into the right atrium. The hepatic veins were also directly connected to the right atrium, as was shown by retrograde perfusion during a venogram. Coronary heart disease was excluded by angiography, but a right heart catheterization was not possible because of the atypical venous connections. Ultrasound examination revealed abdominal situs inversus and polysplenia. Magnetic resonance imaging of the thorax demonstrated bilateral bilobar lungs and bilateral hyparterial bronchi. DIAGNOSIS, TREATMENT AND COURSE: Heterotaxia with anomalous systemic veins and visceral defects was revealed during a diagnostic work-up, which was indicated by the finding of a dilated cardiomyopathy with chronic atrial fibrillation, moderate mitral valve regurgitation and arterial hypertension. Arterial hypertension and heart failure were successfully treated by medication. Attempts at rhythm control were unsuccessful. Safety measures were established to prevent thromboembolic complications and endocarditis. CONCLUSION: Congenital anomalies of the systemic veins in adults are often discovered incidentally, because they are usually asymptomatic. They may cause diagnostic and therapeutic difficulties in cardiology, phlebology and surgery. These anomalies may increase the risk of thrombotic and thrombembolic events. Together with polysplenia and situs inversus they are phenotypical components of heterotaxia. They may have various clinical consequences and may occur spontaneously or may be familial.