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Important systolic pressure gradients between the left ventricle and the arterial system were intentionally reproduced in dogs with closed pericardium, when their cardiac output was diminished and the contractile strength of the heart was maintained or increased. Pressure patterns reverted to normal when the pericardium was widely opened or when the cardiac output was increased while other factors remained constant.

excerpt Demonstration of a stenotic renal artery in a hypertensive patient has become commonplace. The assumption has often been made that the stenosis has been responsible for the hypertension. There is, however, very little information available concerning the existence of similar abnormalities in patients who are normotensive. Most of the angiograms which have been obtained in our institution (The Henry Ford Hospital) were indicated because of various manifestations of peripheral vascular disease, and this group of patients thus includes many normotensives. Among these normotensive subjects renal arterial disease of some type was found in 98 instances (32 per cent). The angiograms, clinical records, excretory urograms and, where available, isotope renograms, surgical findings, and pathologic reports of 500 patients have been studied; 409 of this number had been subjected to angiography because of a variety of vascular problems such as abdominal aneurysm, occlusive vascular disease, and various entities...

1. 1. The possibility of the creation of a venous shunt between the pulmonary vein and the superior vena cava by the use of a proximal segment of the azygos vein in patients with mitral stenosis and pulmonary venous hypertension is suggested. The effect upon cardiovascular hemodynamics of such a procedure remains to be investigated. 2. 2. That such a shunt is technically feasible in dogs by means of an end-to-end anastomosis of the azygos and pulmonary veins, using a Vitallium tube, has been demonstrated. 3. 3. In the presence of a pressure gradient such a shunt is well tolerated in normal animals and remains widely patent.

THE appreciation of renal-artery lesions as a cause of systemic hypertension began with the work of Goldblatt et al.1 in 1934. This experimental finding was immediately implicated in human hypertension with overenthusiasm and eventual disillusionment by many workers in the field. Although many nephrectomies were performed for presumably unilateral renal-artery disease only an occasional cure of systemic hypertension was reported. It now appears that the primary reason for the high failure rate of nephrectomy in these early reports was the inability to make an accurate diagnosis of renal-artery disease. The development of aortography described originally by dos Santos and his . . .

Optically recorded subclavian pulse curves obtained with a simple cup-tambour system give graphic evidence of aortic valve mobility. Differentiation between congenital subaortic stenosis and aortic stenosis was aided by the demonstration in the former of a sharp incisura accompanied by a good aortic second sound; these two features were lacking or rudimentary in the latter. Despite marked auscultatory findings, there is usually little hemodynamic impairment in subaortic stenosis.

Patients with clinically significant mitral stenosis have been demonstrated to differ from other subjects in their circulatory responses to the Valsalva maneuver. During forced expiration most patients with mitral stencsis are able to maintain systolic pressure in the brachial artery at a level equal to or greater than the resting value, whereas most control subjects cannot. Autonomic blockade does not affect the ability of patients with mitral stenosis to maintain systolic pressure, whereas it abolishes such ability, when it is present, in control subjects. The unique response of patients with mitral stenosis under autonomic blockade is attributed to the physiologic consequences of the volume of blood in the dilated left atrium.

A Valsalva-like maneuver was performed during cardiac catheterization by a normal group of individuals and a group of patients with acoustic evidence of mitral stenosis. The latter group was subdivided according to its response to the maneuver. The mild group, like the normal group, showed an "overshoot" of blood pressure and a bradycardia in the post-straining period, whereas the severe mitral stenosis group did not. The relatively undisturbed dynamics of the mild mitral stenosis group, in contrast to the marked disturbance in the severe group, was felt to be due to the amount of obstruction at the mitral valve. Additional data from the cardiac catheterizations of these patients is presented to substantiate this concept. This simple maneuver may prove to be a bedside method for the evaluation of the dynamic significance of mitral stenosis.

Summary The surgical treatment of a case of pyloric stenosis in an infant suffering from hemophilia A is described. All measures taken before and after operation to prevent bleeding are communicated in detail. The necessity of giving slow continuous infusion of whole blood or plasma, guided by estimation of AHF in the patient's blood, for approximately ten days after operation is stressed.

A 2-month-old male infant with severe pulmonary stenosis was found to have a myxoma of the pulmonary valve; the diagnosis was suggested by angiocardiography and confirmed by open-heart surgery. Previous reports indicate that myxomas of valvular origin are rare and asymptomatic, relative to mural myxomas.

Summary A case of congenital atresia of the aortic orifice, with widely patent foramen ovale and ductus arteriosus, and hypoplastic left auricle, ventricle, and ascending aorta is presented and the pathogenesis discussed.

The patients presented at this time demonstrate that the association of mitral stenosis with tricuspid valve disease represents an operable state. Thoughtful consideration of the history and careful physical examination will usually indicate the presence of tricuspid disease. Hemodynamic studies in such patients, with attention to the atrioventricular pressure gradient in early diastole, will aid in arriving at a decision regarding the operability of the tricuspid lesion. The operative mortality and morbidity are high in this type of patient but the probability of improvement warrants operative therapy.

In 109 patients with suspected aortic stenosis a direct arterial pressure pulse tracing and the response to the Valsalva maneuver were recorded prior to and following intra-arterial administration of Priscoline. The majority of the patients revealed a normal pulse contour which was accompanied by a normal, intermediate, or pathologic Valsalva response. Stenotic pulse contour was usually associated with pathologic Valsalva response. Administration of Priscoline diminished both the secondary pressure rise during the straining phase and the overshoot in patients who exhibited normal Valsalva response. Pathologic Valsalva response was not altered by the drug. In patients with intermediate Valsalva response Priscoline either modified the response toward normal or had no appreciable effect. In the majority of the patients with a normal resting pulse contour and an intermediate Valsalva response, Priscoline either provoked a stenotic pulse contour and the Valsalva response remained unaltered, or the pulse contour remained normal and the Valsalva response changed to normal. The recording of pulse contour and Valsalva response before and after Priscoline is thought to be of diagnostic help in doubtful cases of aortic stenosis.

As long ago as the middle of 1949 it had been demonstrated by the senior author that any blunt dilating mechanism applied within the stenotic aortic orifice would, upon expansion, force the separation of one or more of the fused commissures. Thus the diminutive valve orifice could be enlarged without the creation of additional insufficiency and with the restoration of such part of the original valve function as the pathologic distortion of the leaflets would permit. In other words the principles and effectiveness of such an aortic commissurotomy would be comparable to those of the similarly named operation for mitral stenosis. It has remained for us finally to develop an instrument and a technic capable of implementing these concepts, and this has at last been accomplished.

NEARLY fifty years ago the possibility of relieving the obstruction to blood flow through a narrowed mitral valve was first suggested. Subsequent attempts have been made to accomplish this.1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 The surgical technics employed in these bold but disappointing adventures have been variously described as valvulotomy and valvulectomy. Much of the discussion of the theoretical value of this procedure has been concerned with the problem whether the patient would tolerate a surgically induced mitral insufficiency better than his existing stenosis. This, however, is an oversimplification of the situation. Many factors produce the symptoms and determine the course of the disease in . . .

When the clinical findings of aortic stenosis are present and a pressure gradient is demonstrated between the left ventricle and aorta, a discrete site of obstruction, generally amenable to surgical correction, has been assumed. The fallacy of this widely held concept is emphasized by the operative and hemodynamic findings in 3 patients described.

The relatively meager roentgenologic literature on the subject of congenital esophageal atresia has dealt almost exclusively with isolated case reports. The apparent reason why more comprehensive analyses of the subject have not appeared is that, until very recently, this interesting anomaly has been universally fatal and generally regarded as a distinct medical oddity. The condition is relatively uncommon, but through various improvements in surgical technic and postoperative care it has been brought into the realm of surgically correctable abnormalities, and greater interest is being taken in the establishment of its diagnosis. Many of the diagnostic and therapeutic problems which have arisen confront the roentgenologist directly, because it is largely by his methods that the diagnosis of esophageal atresia, the recognition of its complications, and the results of surgical management are graphically recorded. It may be stated justifiably that roentgen examination is essential in the proper management of...

PYLORIC obstruction may result from the swallowing of corrosive substances. It is not generally known that this complication may occur. When alkalies or acids are taken into the mouth in sufficient concentration, the appearance of a burn about the mouth may be noted; and if these substances are swallowed, the whole alimentary tract may become involved, and marked corrosion and perforation may result. If the patient survives the immediate effects, there usually results fibrosis of the esophageal and gastric mucosa, with subsequent choking-off of the gastric glands and altered digestion. 1 If this fibrosis is severe enough, stricture results, and the severity of the stricture is dependent upon the extent and depth of the fibrosis. Cicatricial areas in a large lumen, such as the fundus of the stomach, may cause no obstruction, whereas the same amount of scarring in a narrow lumen, such as the esophagus or pylorus, may cause