Diagnosis of intracardiac thrombi in mitral stenosis and left ventricular dysfunction. Use of selective coronary arteriography.

Neovascularization of the left atrial appendage on selective coronary arteriography implying left atrial thrombus occurred in five of 20 patients with mitral stenosis, and is consistent with the incidence of left atrial thrombi in mitral stenosis determined both surgically and post mortem. The presence of a thrombus was confirmed at surgery in the two patients operated on. Selective coronary arteriography with attention to the presence or absence of left atrial neovascularization is suggested for the full evaluation of mitral stenosis. The absence of left atrial neovascularization in mitral stenosis strongly suggests, but does not confirm, the absence of left atrial thrombi. Left ventricular neovascularization was not found to be a sign of left ventricular thrombi, and left ventriculography remains the diagnostic procedure of choice in assessing the presence or absence of left ventricular thrombi.

Mid-ventricular obstruction: a variant of obstructive cardiomyopathy.

In two patients with clinical and catheterization findings of hypertrophic obstructive cardiomyopathy, the level of intraventricular obstruction was found to be in the mid-ventricular area rather than at the junction of the inflow and outflow tracts. One patient died suddenly shortly after unsuccessful outflow tract myectomy. In vivo recognition of this probably rare variant form of obstructive cardiomyopathy rests mainly on the angiograhic appearance of the left ventricle and on the recording of pressures in multiple sites of the left ventricular cavity. Surgical relief of the obstruction in these patients is not likely to be obtained by a transaortic left ventricular outflow myectomy but may require either papillary muscle resection by the transatrial or transventricular approach or mid-ventricular septectomy, or both.

Partial right-sided congenital pericardial defect with herniation of right atrium and right ventricle.

In an unusual case of right-sided pericardial defect with herniation of the right atrium and right ventricle, cardiac blood pool isotope imaging is introduced as a new, noninvasive diagnostic procedure. Surgery which consisted of excision of right-sided pericardium relieved the chest pain which was the only symptom the patient had prior to surgery.

Thyrotoxicosis and lactate-producing angina pectoris with normal coronary arteries.

Three patients with thyrotoxicosis are described, in whom the presenting symptom was severe cardiac pain at rest or on effort and who were admitted to hospital with suspected or proven myocardial infarction. All patients were studied by selective coronary arteriography and left ventriculography after thyroid function tests which confirmed thyrotoxicosis. There was no demonstrable disease of the major coronary arteries in any of the patients, yet myocardial infarction and left ventricular aneurysm were shown to be present in 1, and there was definite electrocardiographic evidence of ischaemia in all 3. In addition, under stress the myocardium of all 3 patients produced lactate. It is recommended that thyrotoxicosis be seriously considered in the differential diagnosis of cardiac pain, particularly in younger women. The cause of the pain seems related to the cellular effects of thyrotoxicosis on the myocardium and current views of these effects are summarised. Of the 3 patients, 1 died suddenly 6 months after becoming euthyroid, indicating that the disease may not be as benign as expected. A guarded prognosis and continued medical follow-up are recommended when thyrotoxicosis presents with angina pectoris even when normal coronary arteries have been demonstrated.

Comparison of single and biplane ejection fractions in patients with Ischaemic heart disease.

Simultaneous biplane left ventriculography was performed in 59 patients with ischaemic heart disease. A comparison was made of the frontal (EFF), lateral (EFL), and biplane (EFB) ejection fractions. Discrepancies between the three measurements in the same patient were frequent observed. The patients were then grouped according to the presence or absence of signs of transmural myocardial infarction in the electrocardiogram or wall motion abnormalities, and the single and biplane EF data were again compared. There were 31 patients with previous transmural myocardial infarction and 37 patients with wall motion abnormalities, usually involving the anterior or inferior walls. The EFL of patients with transmural myocardial infarction or wall motion abnormalities commonly exceeded the EEF, because of frequent preservation of dorsal wall contraction visualized only in the lateral plane. Consequently, there was a significant difference between EFF or EFL and EFB for these patients. In contrast, there was close agreement EEF and EFL for patients without transmural myocardial infarction or wall motion abnormalities. It is concluded that differences frequently occur between single and biplane EF in patients with ischaemic heart disease, especially if transmural myocardial infarction or wall motion abnormalities are present. Hence, accurate assessment of left ventricular performance is greatly facilitated by simultaneous or sequential biplane ventriculography.

Hypertrophic cardiomyopathy with midventricular obstruction associated with mitral stenosis: partial relief of the obstruction by papillary muscle and trabecular resection.

A patient is reported with hypertrophic cardiomyopathy where midventricular obstruction was found in association with mitral stenosis. Partial relief of the intraventricular obstruction was obtained by extensive papillary and trabecular muscle resection in the mid-left ventricular area, in conjunction with mitral valve replacement with a porcine heterograft.