Biomedical subjects
Publications and source records attributed to A S Gooch.
A patient is described who developed high-output congestive failure following surgery to a lumbar disc. Diagnosis of arteriovenous fistula was suggested by the signs of high-output state and a continuous bruit heard over the low back scar. Confirmation was demonstrated by abdominal aortography. Corrective surgery resulted in resolution of congestive failure.
During routine coronary cinearteriography, a large, right atrial myxoma was detected in a patient with angina pectoris. It was clinically unsuspected and was found at surgery to extend partially into the left atrium.
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Because previous attempts to diagnose and quantitate tricuspid regurgitation (TR) by angiography have been unreliable, 60 patients with mitral or combined mitral and aortic valve disease had right ventriculography using a special preshaped catheter. A clinical diagnosis of TR was confirmed in 45% of the patients with moderate and severe TR. A pansystolic murmur increasing in intensity with inspiration, a pulsatile liver, and a prominent CV wave in the jugular veins when present together were specific for severe TR but were seen in only 30% of the patients with severe TR but were seen in only 30% of the patients with severe TR (3+ or 4+). Ventricularization of the right atrial pressure contour was specific for severe TR but was seen in only 40% of the patients with severe TR. A normal right atrial mean pressure (RAP) did not exclude TR, but a rise in RAP or an unchanged RAP with deep inspiration was seen in all patients with TR. Similar findings were observed in two patients with severe pulmonary hypertension who had no TR. There was no relation between the magnitude of this rise in RAP, the degree of pulmonary hypertension, and the severity of TR. The use of a special preshaped catheter tends to avoid the induction of premature beats, and right ventriculograms with a preshaped catheter may be useful in diagnosing TR.
Post-myocardial infarction aneurysms are often accompanied by persistent ST segment elevations. To determine whether or not these ST segments regress following successful surgery for left ventricular aneurysms, serial electrocardiograms were studied in 74 patients and compared to changes of heart size and NYHA Functional Class. The mean postoperative follow-up period was 18.2 months (range 3 to 52 months). The mean precordial sigma ST elevation preoperatively was 5.27 mm. and 4.71 mm. after surgery (P less than 0.025). For the highest ST segment of an individual lead, the mean values were 1.9 mm. before surgery and 1.88 mm. postoperatively (P less than 0.1). Although clinical improvement occurred in 66 (89.2 per cent) by NYHA class and x-ray evidence of improvement was seen in 46 (62.2 per cent), a degree of ST elevation remained in all cases and was less elevated in only 19 (25.7 per cent). After surgery for left ventricular aneurysm, ST segments tend to remain elevated with little apparent relation to reduction of heart size or clinical improvement.
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In 26 patients with mitral valve prolapse, ventricular function was evaluated by mean velocity of circumferential fiber shortening (MVCF) as measured along the basilar, middle and apical axes. Significantly increased rates of MVCF were found in patients with mitral prolapse along the basilar axis (1.75 +/- 0.23 circ/sec) and middle axis (2.09 +/- 0.34 cir/sec) (P less than 0.025 and P less than 0.05, respectively). Patients with mitral valve prolapse and regurgitation demonstrated a significant increase in MVCF along the basilar axes (1.72 +/- 0.15 cir/sec) (P less than 0.05). Asynergy apperars to have a negative effect on the MVCF along the middle axis. The MVCF was found not to be related to clinical findings, symptoms or electrocardiographic changes. The mechanism for the increase in MVCF in patients with mitral valve prolapse remains unsettled.
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To detect transient arrhythmias or conduction disturbances, 200 patients with the symptoms of palpitations, syncope or dizziness, and patients with coronary heart disease, angina pectoris, arrhythmias or conduction disturbances on resting 12-lead electrocardiogram, were studied by submaximal treadmill exercise and portable Holter recording. Thirty-nine patients (19.5%) had arrhythmias on the resting 12-lead ECG, 136 patients (68%) showed arrhythmias either on treadmill or Holter recording or both. Eighty-nine patients (44.5%) showed arrhythmias on exercise, while 123 patients (61.5%) had rhythm or conduction disturbances on Holter recording. Twenty-two patients (11%) had arrhythmias only on treadmill walking, while 68 (34%) had arrhythmias only with the Holter. In six patients different arrhythmias was noted by each method. Although the Holter recording technique affords a higher yield of recording transient arrhythmias than did exercise testing, both methods are useful and complementary in evaluating the ambulatory patients suspected of having rhythm or conduction disturbances.
Right ventriculography was used to assess the tricuspid valve in 61 patients with systolic murmur-click syndrome. Systolic murmurs were present in 47 cases, and 32 had clicks. Mitral valve prolapse was present in 52 patients. Late systolic prolapse of the tricuspid valve was demonstrated in 32 patients (52.4%). In 9 cases, prolapse involved the tricuspid valve alone. In the systolic murmur-click syndrome, prolapse may involve either or both of the atrioventricular valves.
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To study the effect of exercise on atrial flutter the electrocardiogram was recorded continuously before, during and after low level treadmill walking in twenty-two ambulatory patients. Atrial flutter rates increased during exercise testing in four patients. Improved A-V conduction with consequent higher ventricular rates occurred during exercise in thirteen subjects. One patient, with 4:1 conduction at rest, continued with 4:1 block throughout exercise testing, was believed to be over-digitalized. During the recovery period after exercise, ten patients transiently developed periods of Wenckebach A-V block. Walking exercise induced 1:1 conduction in six patients and was promoted by the following circumstances: 1) atrial rates of 250/min or less; 2) inadequate dosage of digitalis; and 3) the administration of quinidine. For the patient with chronic atrial flutter, treadmill testing provides a simple method for demonstrating the range of changes of A-V conduction and for deriving implications for appropriate drug therapy.
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