Pulmonary edema secondary to chronic upper airway obstruction. Hemodynamic study in a child.

A 22-month-old girl with the syndrome of hypoventilation, pulmonary hypertension, cor pulmonale and pulmonary edema due to adenoidal hypertrophy is described. Adenoidectomy resulted in relief of all symptoms and signs within 24 h. Hemodynamic study using pulmonary artery catheter showed that the pulmonary artery pressure returned to normal 48 h after relief of the obstruction. The normal left ventricular end-diastolic pressure, measured throughout the period of obstruction, in the presence of severe pulmonary edema, could suggest a non-cardiogenic "low pressure" pulmonary edema. However, the highly negative pleural pressure which existed during upper airway obstruction indicated an elevation of transmural left ventricular end diastolic pressure (compared to pulmonary wedge pressure) and thus, suggested that the pulmonary edema in this syndrome is secondary to both - right and left heart failure.

Coronary angiography in a patient with mirror-image heart ("situs inversus").

A right-sided heart associated with mirror-image atrial arrangement (situs inversus) is a rare condition. The incidence of coronary arterial disease in this setting is probably similar to that in the general population. Description of coronary angiography in this condition is very rare. We have recently catheterized such a patient. The necessary approach to coronary angiography is emphasized.

[Long-term follow-up of prosthetic heart valves].

257 patients underwent single or double heart valve replacement between 1964-1986. In 141 (55%) after isolated mitral valve replacement, operative mortality was 14.8% and after 5, 10, 15 and 20 years, actuarial survival was 84%, 70%, 59% and 44%, respectively. In 70 who underwent isolated aortic valve replacement, operative mortality was 7.1% and after 5, 10, 15 and 20 years, actuarial survival was 85%, 85%, 72% and 72%. In 46 who underwent combined aortic and mitral replacement, operative mortality was 4.3% and after 5, 10 and 15 years, actuarial survival was 78%, 71% and 71%.

Salivary gland enlargement following cardiac catheterization.

Salivary gland enlargement following heart angiography is described. Previously documented salivary gland swelling was related to excretory urography or administration of iodinated tablets. We could not find any previous description of salivary gland swelling following heart angiography.

Anomalous origin of the posterior descending artery from the obtuse marginal.

We describe a patient with an unusual coronary anatomic variant in which the obtuse marginal gives rise to the posterior descending artery. The angiographic features and clinical recognition of this anomaly are reviewed.

Choice of electrocardiographic leads for recording the earliest QRS onset in noninvasive measurements.

A significant error may be introduced in intervals measured from the onset of the QRS if an electrocardiographic lead that does not record the earliest deflection is used. To ascertain to what extent the commonly used leads can be relied on to show the earliest QRS onset, 100 normal subjects and 219 patients with heart disease were studied by means of simultaneous recording of three leads: a right precordial lead chosen to show an rS configuration, lead II, and another limb lead chosen to show a qR configuration. Lead II most frequently showed a delayed QRS onset--in 34% of normal subjects and 36% of the patients. In the other limb lead the initial QRS deflection was delayed in 24% of the normal subjects and 23% of the patients. The QRS onset in the right precordial lead was never delayed in the normal subjects; however, it was delayed in this lead in 6% of the patients. The delays in each of the leads ranged from 5-20 msec. We conclude that while a right precordial lead is by far the most reliable single lead that can be used for interval measurements, simultaneous recording of a right precordial lead and a limb lead assures that recording of the earliest QRS onset in all cases.

Severe rheumatic mitral valve disease in children. Evaluation by echocardiography.

Severe rheumatic mitral stenosis with or without mitral insufficiency is virtually unseen in children in the affluent countries of the western world, but is not uncommon in developing countries. Fifteen cases of rapidly progressive rheumatic mitral valve disease in children are presented to illustrate the value of echocardiography in the diagnosis and evaluation of this lesion. Cardiac catheterization was performed in nine and simply confirmed the diagnosis made noninvasively. Our experience demonstrates that thorough echocardiographic examination in these cases frequently enables the examiner to assess the need for surgical intervention without cardiac catheterization.

Variations in blood supply to the anterior interventricular septum: incidence and possible clinical importance.

The variations of the blood supply to the anterior interventricular septum in a series of 1,089 patients are described. Special attention has been given to variations and frequency of occurrence of the septal perforators originating from the left anterior descending artery. These variations may have clinical significance in this era of coronary angioplasty and coronary bypass surgery.

Viral myocarditis simulating dilated cardiomyopathy in early childhood: evaluation by serial echocardiography.

Left ventricular dimensions and function were assessed by serial M mode and cross sectional echocardiography in ten infants and young children with heart muscle disease characterised by left ventricular dilatation and impaired systolic function presenting in congestive heart failure, severe respiratory distress, or both. The patients were followed for 8-60 months after their initial admission. The aetiology was probably viral in all cases. One patient died three weeks after diagnosis. Left ventricular size and function returned to normal in only one child; however, various degrees of improvement were found in seven others who were symptom free at follow up. This study demonstrates that serial echocardiography adequately defines this disease in infants and young children and that invasive evaluation is seldom required. Furthermore, it emphasises the fact that even in symptom free children an echocardiographic picture that is indistinguishable from dilated cardiomyopathy may persist; such patients required continued follow up.

Idiopathic dilated cardiomyopathy in pregnancy.

We report a 34-year-old woman who presented at 21 weeks with cardiac failure due to idiopathic dilated cardiomyopathy. Following refusal of pregnancy termination, she was treated conservatively with good maternal and neonatal outcome.

Systolic time intervals in adolescents. Normal standards for clinical use and comparison with children and adults.

Systolic time intervals were measured in 147 healthy 13-19-year-old adolescents to derive regression equations for clinical use in this age group and to determine to what extent they differ from those of children and adults. Stepwise regression analysis showed that heart rate was the only variable consistently and significantly related to electromechanical systole (QS2), left ventricular ejection time (LVET) and preejection period (PEP). None of the other variables tested (age, height, weight, body surface area, blood pressure, hemoglobin, hematocrit and serum electrolytes), when used alone, were relevant variables in relation to QS2, LVET or PEP. The PEP/LVET ratio in adolescents was essentially independent of heart rate, as in children and adults. The regression lines for QS2, LVET and PEP in adolescents fall between those for children and adults, indicating that there is a distinct tendency toward lengthening of all the systolic time intervals with age, independent of changes in heart rate. The PEP lengthens proportionately more than the LVET, resulting in a progressive increase in the mean PEP/LVET ratio from childhood (0.30) to adolescence (0.32) and to adulthood (0.345). The precise hemodynamic factors underlying these changes with increasing age remain to be determined.