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BACKGROUND: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created. RESULTS: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation. CONCLUSIONS: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation. ispartof: ANNALS OF THORACIC SURGERY vol:114 issue:3 pages:758-+ ispartof: location:Netherlands status: published

Background The ease of implantation of the rapid deployment (RD) and sutureless valves has contributed to the adoption of anterior right thoracotomy (ART) approach for aortic valve replacement (AVR). Aim of the study This study evaluates the safety and haemodynamic performance of minimally invasive AVR through ART using the RD valves. Methods This is a retrospective, single-center review of a total of 50 consecutive patients who received RD-AVR through ART. Results The median age of patients was 75 years (interquartile range [IQR]: 69-80), and median Euroscore II was 5.1 (IQR: 2.4-7.5). ART RD-AVR was successfully performed in all cases with no conversion to sternotomy, paravalvular leaks or need for valve explantation. The mean size of the implanted valve was 23.2 ± 2.3 mm. In-hospital mortality was 2%. The mean and maximum pressure gradients across the aortic prosthesis were 10 mm Hg (IQR: 9-12) and 19 mm Hg (IQR: 16-23). Conclusions Rapid deployment aortic valve replacement can be safely performed through anterior right thoracotomy wit excellent haemodynamic performance and low postoperative complications rate.

Case Presentation A 27-year-old man from Eritrea presented to the ED complaining about a progressively worse blunt chest pain in the anterior right hemithorax. Chest pain started 4 years ago and was intermittent. During the last 6 months, symptoms got worse, and the patient experienced shortness of breath in mild exercise. For this purpose, he visited another institution, where a chest radiograph was performed ( Fig 1 ). He was advised to visit a pulmonologist for further evaluation, with the diagnosis of a loculated pleural effusion in the right upper hemithorax.

A 72-year-old man was referred to a chest X-ray due to persistent coughing, intermittent dyspnoea and atypical chest pain. The radiology report mentioned a 4 cm inhomogeneous opacity at the anterior right lower lung field ([figure 1A][1]). Subsequently, a CT scan of the thorax and upper abdomen

Electrode placement in electroconvulsive therapy (ECT) has a major impact on treatment efficacy and cognitive side effects. Left Anterior Right Temporal (LART) is a lesser utilised bilateral montage which may produce more optimal clinical outcomes relative to standard bitemporal ECT. In this study we used computational modelling to explore how stimulation effects from LART and two novel variants (LART - F3 and LART - Frontal) compared to the more common bilateral placements of bitemporal and bifrontal ECT. High resolution finite element human head models were generated from MRI scans of three subjects with Major Depressive Disorder. Differences in regional stimulation were examined through parametric tests for regions of interest and subtraction maps. Compared to bitemporal ECT, LART - Original resulted in significantly greater stimulation of the left cingulate gyrus (hypothesised to be associated with treatment efficacy), and relatively reduced stimulation of the bilateral hippocampi (potentially associated with cognitive side effects). No additional clinical benefit was suggested with the novel LART placements compared to the original LART. The original LART placement is a promising montage for further clinical investigation.

OBJECTIVES The purpose of the present study was to analyse the effects of working posture, physical balance and work accumulation on shifts in plantar pressure in dental hygienists, by measuring REBA, which evaluates working posture, and plantar pressure, which evaluates physical balance. METHODS This study was conducted on 24 dental hygienists currently working in dental clinics. The ergonomic assessment method of the Rapid Entire Body Assessment was used to evaluate working posture in the dental hygienists, and a Gait Analyzer was used to measure plantar pressure. RESULTS The subjects' mean REBA score was 4.96 ± 1.04 points, and 87.5% of the subjects showed poor working posture, with a REBA score of at least four points. Among subjects with a REBA score of four points or more, seven of the eight parts of the sole of the foot showed significant differences in plantar pressure between the right and left feet (P

Purpose During the last decades, it has been established that there are numerous individual anatomical variations of the arterial blood supply in human liver. In the present study, we examined the liver vascularization of an intrahepatic cholangiocarcinoma patient. Methods For surgical planning, an enhanced CT scan was performed and a three-dimensional model of liver vascularization constructed. Results The patient was diagnosed as a Michel’s type VII hepatic artery variation. An accessory right hepatic artery arose from the superior mesenteric artery and had distributed into the right anterior liver to provide the blood supply of segments V and VIII, which was more medial than the territory of the right hepatic artery coming from the proper hepatic artery. At the same time, an accessory left hepatic artery originated from the left gastric artery. Conclusion We present a case in which an accessory right hepatic artery provided a territory more medial than a right hepatic artery coming from the proper right artery.

Context According to evo-devo theory, the embryonic development of the nasal organ mimics its phylontogenic formation: the lateral masses of the human ethmoid bone develop by curved “onion” stacking of the endoturbinals (the horizontal bone septa of the mammalian olfactory chamber) under the impact of facial and skull-base remodeling, rather than by pneumatization of cavities communicating via ostia. Objectives To assess the frequency of the onion structure on coronal CT. Material and methods Three independent examiners performed a retrospective descriptive study of coronal CT scans taken ahead of septorhinoplasty between June 2010 and December 2012 in adult patients without history of sinonasal surgery. Results Fifty patients were included. In the anterior right and left and posterior right ethmoid, an onion arrangement of the endoturbinals was systematically found on at least 1 view, and on 60% of views taking all ethmoid compartments together. Two endoturbinals were generally involved, but a rolling-up of 3 endoturbinals was also observed, significantly more frequently in the posterior compartments (P = 0.004 on the right side, P = 0.012 on the left). Conclusion The onion structure of the lateral masses of the ethmoid can be observed on coronal CT scans. This structure confirms evo-devo theory. The ethmoid thus appears fundamentally different from the paranasal sinuses, suggesting that the pathogenesis of nasal polyposis and ethmoidectomy techniques need to be reconsidered.

We report the case of a 55-year-old woman who developed a mass in the soft tissue of the anterior right proximal thigh. Microscopic findings in the biopsy specimen supported the diagnosis of sclerosing epithelioid fibrosarcoma (SEF). This entity is part of a spectrum of lesions that includes low-grade fibromyxoid sarcoma (LGFMS) and hyalinizing spindle cell tumor with giant rosettes (HSCTGR). It shares with LGFMS occasional overlapping histopathologic features and immunopositivity for MUC4. Although FUS and CREB3L2 gene rearrangements, characteristics of LGFMS, have been found in hybrid tumors (those with features of both SEF and LGFMS) and in examples of LGFMS with relapses showing SEF morphology, it appears that EWSR1 and CREB3L1 rearrangements predominate over FUS and CREB3L2 rearrangements among "pure" SEF tumors. Recent information about SEF is briefly reviewed.

We report a case of a 4-week-old female neonate who was admitted to the hospital for a anterior right lump of the neck, perceived by his mother the day before. The mother also noticed a preferential tilting of the head towards right. He was an otherwise full-term healthy baby, with a history of instrumented delivery. There was no fever, trauma or respiratory symptoms/signs. Family history was irrelevant. On examination, the neck swelling was a small firm, partially mobile, no warm on touch and apparently painless mass, with approximately 1.5–2 cm soft tissue mass, attached to the right sternocleidomastoid muscle. There was no restriction of neck movements. Ultrasonography (USG) revealed a 13 mm …

Schizophrenia has been proposed to result from impairment of functional connectivity. We aimed to use machine learning to distinguish schizophrenic subjects from normal controls using a publicly available functional MRI (fMRI) data set. Global and local parameters of functional connectivity were extracted for classification. We found decreased global and local network connectivity in subjects with schizophrenia, particularly in the anterior right cingulate cortex, the superior right temporal region, and the inferior left parietal region as compared to healthy subjects. Using support vector machine and 10-fold cross-validation, nine features reached 92.1% prediction accuracy, respectively. Our results suggest that there are significant differences between control and schizophrenic subjects based on regional brain activity detected with fMRI.

BACKGROUND Lower back pain has a lifetime prevalence of 80% for people in a modern society, and in recent years, spinal stabilization movement has been highlighted as a method to treat lower back pain and an unbalanced position. OBJECTIVE The objectives of this study were to assess the trunk muscle activities in accordance with the tilt angles (10∘, 20∘, 30∘, 40∘) during trunk tilt exercises with a 3D dynamic exercise device. METHODS Active tilt mode (a self-generated active movement in the angle and direction steered by the user) was used in this study. The rotation capability enabled the investigation of the anterior (A), anterior right (AR), right (R), posterior right (PR), posterior (P), posterior left (PL), left (L), and anterior left (AL) tilt directions. EMG signals of the trunk (3 global muscles: rectus abdominis, RA, external obliques, EO, latissimus dorsi, LD, and 1 local muscle: multifidus, MF) muscles were obtained. RESULTS The MF muscle activity was higher while the anterior tilt was maintained, and the abdominal muscle activity was higher while the posterior tilt was maintained. Also, as the tilt angle increased, the activity of the muscles opposite the tilt direction increased. CONCLUSIONS The results indicate that to maintain equilibrium through posture stabilization during whole body tilting, the human body maintains a proper interaction among the body segments as well as between the body and the execution environment. Moreover, stability is maintained through the co-contraction of antagonistic and agonistic muscles. In future studies, it will be important to conduct research on improving imbalance in the trunk muscles.

A Caucasian woman aged 56 years presented to emergency room (ER) department with leucorrhoea and fever since 48 hours. She was a smoker, had no diabetes history, no prosthetic material and denied use of injected drugs. A month before, the patient had a closed inguinal trauma due to fall from height with a muscle strain of the anterior right thigh. Despite rest and analgesics, she went to ER several times because of progressive local pain and swelling. After 3 weeks, a local ultrasound scan showed a 3 cm size haematoma associated with probable rupture of obturator internus and rectus femoris muscles. On the following days, she developed fetid leucorrhoea …

Unilateral and bitemporal electrode placement has been the dominant mode of delivery in electroconvulsive therapy. We report 3 patients receiving maintenance electroconvulsive therapy where the use of dominant electrode placements was ineffective. Changing to left anterior right temporal electrode placement resulted in marked clinical improvement. This supports the limited literature on this electrode placement.

To diagnose posterior and anterior biventricular infarctions it is necessary to record from right and left thoracic and high abdominal unipolar leads. These supplementary leads are dependable, can be repeated as many times as needed and show the evolution from signs of myocardial injury to those of dead tissue (Q waves of 0.04 sec or more). This electrocardiographic evolution increases the diagnostic value of the electrical exploration, since the injury current can be observed also in other conditions. The diagnosis of right ventricular infarction can be established even in the presence of RBBB. Signs of a dead zone in the free right ventricular wall are more frequently observed in posterior biventricular infarctions than in anterior ones. In these cases, the signs of subepicardial injury are more accentuated in the right thoracic unipolar leads than in V3, indicating anterior right ventricular involvement. These signs are also observed in experimental studies made in animals. This electrocardiographic exploration opens a wide field for the diagnosis of myocardial infarction, particularly in biventricular involvement, including old myocardial scars, and in discarding signs of pericarditis manifested only by the upward displacement of the ST segment. A review of the medical literature concerning diagnosis of biventricular infarctions is presented.

The purpose of this study was to examine the usefulness of pulsed tissue Doppler imaging for diagnosing constrictive pericarditis. Motion velocities of the ventricular septum (VS) and left ventricular (LV) posterior wall along the short axis, and those of the anterior right ventricular (RV) wall, VS, and LV posterior wall along the long axis were recorded using pulsed tissue Doppler imaging in 12 patients with constrictive pericarditis, who were diagnosed by cardiac catheterization, and also in 20 normal subjects. Peak early diastolic and atrial systolic velocities (Ew and Aw, respectively) were calculated, and the time between the aortic component of the second heart sound and the peak of the early diastolic velocity (II a -Ew) was determined. The peak Ew and II a -Ew along the short and long axes were significantly higher and shorter, respectively, in the patient group than in the normal group. In the patient group, the motion velocity of the VS along the short axis showed a “backward” motion with a sharp and marked peak velocity immediately before Ew, or a biphasic early diastolic wave; a clear “downward” motion immediately after Ew was observed in the motion velocities of the anterior RV wall, VS, and LV posterior wall along the long axis. These distinctive backward and downward motions were not observed in any of the ventricular walls of the normal subjects. In conclusion, the early diastolic RV and LV wall motion velocity patterns along the short and long axes as measured by pulsed tissue Doppler imaging provide important information for the diagnosis of constrictive pericarditis.

Cardiac injuries remain the most challenging of all injuries seen in the field of trauma surgery. Penetrating injury to the heart generally occurs less frequently than blunt injury and most commonly injures the large anterior right ventricle. We present an unusual, and to our knowledge a previously unreported, cause of cardiac penetrating trauma in a child, involving a hooked needle (a 15 cm long, metallic device usually used for crocheting or lacemaking). A ventricular septal defect was managed conservatively shortly after the primary cardiorrhaphy. Evaluation methods for this rare presentation and its possible surgical treatments are discussed.

The myocardium may be divided into distinct zones which act as functional units of the coronary vascular network. The basic principle of this functional systematization of cardiac blood vessels is a constant relationship between the "distributing" and the "delivering" vessels. Six arterial zones of the myocardium are identified under this scheme: anterior right ventricular, lateral left ventricular, posterior left ventricular, interventricular septal, posterior right ventricular, and atrial. The distributing vessels of functional myocardial zones are most frequently both arterial and venous. However, between the lateral and posterior left ventricular zones there is sometimes only the left marginal vein (24%) or left marginal artery (20%). Between the atrial and posterior right ventricular zones there is sometimes only the right coronary artery (52%), or only the small cardiac vein (14%) as a distributing vessel. Between the left and the right posterior ventricular zones there is sometimes an arterial and sometimes a venous distributing vessel (10%). Between the posterior and anterior right ventricular zones there is either the artery (21%) or the right marginal vein (8%) as a distributing vessel. The permanence of the six functional myocardial zones is determined not only by the arterial but also by the venous distributing vessels, and in some cases the venous vessels are the only distributing vessels between certain zones.

Objective. Impaired left ventricular (LV) mechanics in human hypertension are strongly related to LV hypertrophy (LVH). In the present study, we investigated the relationship between LV mid-wall fractional shortening (MWS) and biventricular hypertrophy in uncomplicated essential hypertensives. Methods. A total of 328 hypertensive patients categorized in tertiles of MWS were considered for the analysis. All patients underwent routine and standardized echocardiographic examinations. Biventricular hypertrophy was defined by anterior right ventricular (RV) wall thickness ≥3.1 mm/m2 in men and ≥3.0 mm/m2 in women, combined with LV mass index (LVMI) ≥49 g/m2.7 in men and 45 g/m2.7 in women. Results. Biventricular hypertrophy was found in 21% of the study population. In the lowest MWS tertile, the likelihood of biventricular hypertrophy was 1.4- and 1.9-fold greater (p

In the present research changes in electroencephalographic (EEG) power spectrum induced by semantic violations in Italian sentences were examined. Significant effects related to the sentence correctness were found only within gamma frequency range (approximately 30-100 Hz), with well-formed sentences showing higher gamma levels than sentences containing the violation. Lower gamma band (approximately 30-45 Hz) marked semantic violation at the level of the target word and did not show specific scalp topography. Instead, in addition to the same violation effect, analyses of the two upper gamma bands (upper-1 gamma: approximately 55-75 Hz; upper-2 gamma: approximately 75-100 Hz) revealed, for the word following the target, significant greater gamma levels for correct vs. incorrect sentences specifically over anterior right sites. The functional significance of gamma band and its contribution to psycholinguistic field are discussed, by highlighting its use as an additional tool, with respect to evoked potentials, for investigating linguistic network dynamics associated to sentence processing.

The effects of delayed presentation of a central theme on the comprehension and interpretation of narratives were investigated in adults with right and left hemisphere brain-damage and normal individuals. The performance of subgroups of the subjects with right and left hemisphere brain-damage also was examined. Right hemisphere brain-damaged groups with anterior and posterior lesions were significantly less accurate and identified significantly fewer central themes when central theme presentation was delayed until the end of a narrative than when the theme was presented at the beginning. Subjects with anterior right hemisphere brain-damage produced significantly more embellishments and confabulations than subjects with posterior damage and non-brain-damaged controls, regardless of theme condition. The performance of non-brain-damaged subjects and subjects with fluent and nonfluent aphasia was unaffected by the organization of the central theme in the narratives.

The purpose of this report is to describe our experience with sonography in a case of pulsatile tinnitus (PT) due to a high jugular bulb (HJB).A 71-year-old woman came to our hospital with a 1-year history of right PT. A right HJB was shown on cerebral angiography, and enlargement of the right jugular blub compared with the left side was found. First, the ultrasound probe was placed on the anterior right upper neck at the anterior edge of the sternocleidomastoid muscle to identify the ipsilateral internal jugular vein (IJV) and measure the flow velocity. After the measurement, the ultrasound probe gradually compressed the skin until the flow in the IJV decreased.The patient reported that her PT decreased after the flow in the IJV decreased. We decided that the PT in this case was induced by the HJB.This technique is less invasive and convenient for the diagnosis of PT caused by an HJB.

We report a 52-year-old woman with palpitations and syncope. Holter recording revealed runs of bidirectional ventricular tachycardia, and magnetic resonance imaging showed thickening and fatty infiltration of the right ventricle with normal cardiac chamber size and no wall motion abnormalities.

Assessment of extravascular lung water is a challenging task for the clinical cardiologist and an elusive target for the echocardiographer. Today chest x-ray is considered the best way to assess extravascular lung water objectively, but this requires radiology facilities and specific reading expertise, uses ionizing energy, and poses a significant logistic burden. Recently, a new method was developed using echocardiography (with cardiac probes) of the lung. An increase in extravascular lung water-as assessed independently by chest computed tomography, chest x-ray, and thermodilution techniques-is mirrored by appearance of ultrasound lung comets (ULCs). ULCs consist of multiple comet tails originating from water-thickened interlobular septa and fanning out from the lung surface. The technique requires ultrasound scanning of the anterior right and left chest, from the second to the fifth intercostal space. It is simple (with a learning curve of10 examinations) and fast to perform (requiring3 minutes). ULC assessment is independent of the cardiac acoustic window, because the lung on the anterior chest is scanned. It requires very basic 2-D technology imaging, even without a second harmonic or Doppler. ULCs probably represent an ultrasonic equivalent of radiologic Kerley B-lines. On still-frame assessment, cardiogenic watery comets can be difficult to distinguish from pneumogenic fibrotic comets, although the latter are usually more localized and are not dissolved by an acute diuretic challenge. Functionally, ULCs are a sign of distress of the alveolar-capillary membrane, often associated with reduced ejection fraction and increased pulmonary wedge pressure. The ULC sign is quantitative, reproducible, and ideally suited to complement conventional echocardiography in the evaluation of heart failure patients in the emergency department (for the differential diagnosis of dyspnea), in-hospital evaluation (for tailoring diuretic therapy), home care (with portable ultrasound), and stress echocardiography lab (as a sign of acute pulmonary congestion during stress). In conclusion, ULCs represent a useful, practical, and appealingly simple way to image directly extravascular lung water.

Regional brain activity was measured with H(2) (15)O PET while participants attempted to complete word-stem and word-fragment retrieval cues with previously studied words. The retrieval cue manipulation was employed to gain control over the monitoring operations associated with evaluating the episodic status of alternative cue completions. These operations were more constrained for fragments, which had fewer possible completions than each corresponding stem. In one condition (zero target), during the scanning interval none of the cues could be completed with studied items, whereas in another condition (high target), 80% of cues belonged to studied items. Relative to baseline tasks, right anterior prefrontal activity was greater for stems than for fragments in the zero target condition. The target density manipulation did not modulate right anterior prefrontal activity, but was associated with increased activity in right dorsolateral prefrontal cortex. These findings are consistent with the proposal that the right anterior prefrontal cortex supports monitoring operations during episodic retrieval tasks. In addition, the findings add to evidence suggesting that the dorsolateral and anterior right prefrontal cortex make functionally distinct contributions to episodic retrieval.

Transverse stress fracture of the patella in a child is an exceptional injury in childhood. Only one case has been previously reported. The present study reports a new case of a 12-year-old boy with anterior knee pain misdiagnosed for 5 months as Sinding-Larsen-Johansson disease who developed sudden anterior right knee pain and pop while running in a soccer match. Surgery was performed. The evolution was favorable without any immobilization required and the patient achieved full recovery.

A 66-year-old woman presented with history of syncope, and physical signs of aortic stenosis. Echocardiography showed severe calcific aortic stenosis. Preoperative coronary arteriography revealed a double right coronary artery. Injection in the right coronary orifice resulted in selective opactfication of 2 different right coronary arteries arising separately from this sinus and coursing down the right atrioventricular groove. Neither a double right coronary orifice nor a right main trunk could be shown by arteriography. After the origin of a corms artery and a ventricular branch, the most anterior right coronary artery (Figure IA) descended toward the acute margin of the heart and terminated in a small posterior descending artery. The second right coronary artery (Figure 1B) ends with a small posterior descending artery and posterolateral branches.

A 7-year-old maJe presenting with Wolff-Parkinson-White syndrome and tachycardia was suspected by echocardiographic and magnetic resonance imaging evaluation to have an associated pericardial cyst anterior to the right atrium and ventricle. Electrophysiological evaluation demonstrated short antegrade and retrograde accessory connection refractory periods, with inducible orthodromic atrioventricular reentranf tachycardia. Surgical observation revealed a rare congenital right atrial diverticulum bridging the anterior right atrioventricular groove, with the functional accessory connection lateralized to the medial aspect of this structure. Endocardial and epicardial incisions and cryolesions placed along the anterior right atrioventricular groove initially appeared successful, but preexcitation recurred within 4 weeks postoperatively.

A case of traumatic rupture of the tricuspid chordae tendineae with severe regurgitation in a patient who previously had mitral valve replacement is presented. In this case, it is strongly suggested that a firm pericardial adhesion of the anterior right ventricular wall became a factor of the disruption of the tricuspid valve under a slight precordial blow.

A case of left parasternal systolic lift due to isolated infarction of the right ventricular anterior wall is reported. This cause of a left parasternal lift should also be considered while examining a case of myocardial infarction.

Echocardiographic motions of right ventricular anterior wall (RVAW) were investigated in 71 patients with Wolff-Parkinson-White (WPW) syndrome. According to the criteria of Rosenbaum et al the electrocardiograms were classified as type A in 35 patients and type B in 36. Sixteen type B patients exhibited abnormal RVAW motion, which was characterized by an early onset of the posterior movement before S1 andl also by a premature peak formation before S2. A small step or hump nearly coincident with S1 was observed in 10 of these 16 patients. These findings seem to suggest that both contraction and relaxation of RVAW begin earlier than normal due to anterior right ventricular pre-excitation. RVAW motion was normal in all of type A patients. Echocardiographic investigation of RVAW motion appears to be useful in non-invasive estimation of the site of pre-excitation, especially in type B WPW patients.

M-mode echocardiographic delineation of double-outlet right ventricle (DORV) has relied primarily on the demonstration of mitral-semilunar valve discontinuity--a feature that requires an interpretation of spatial anatomic relationships. Thirty-six patients with DORV were examined by wide-angle real-time two-dimensional echocardiography. Anatomic diagnosis was established by surgery in 28 patients and by angiography alone in eight. Typical two-dimensional echocardiographic features were (1) parallel orientation and origin of both great arteries from the anterior right ventricle, (2) mitral-semilunar valve discontinuity demonstrated on parasternal long-axis scans by the presence of muscular conus separation, and (3) absence of left ventricular outflow other than a ventricular septal defect. This technique also allows better recognition of spatial orientation of the great arteries and the position of the ventricular septal defect relative to the great arteries. An unexpected finding was a high incidence of atrioventricular valvular anomalies, particularly annular override or abnormal chordal attachments (straddling) (eight patients), isolated cleft of the mitral valve (two patients), and complete atrioventricular canal (five patients). Thus, these two-dimensional echocardiographic findings have allowed improved noninvasive recognition of DORV and the demonstration of associated anomalies that previously were unrecognized preoperatively.

SUMMARY To elucidate the abnormalities in ventricular activation sequence in human left bundle branch block (LBBB), epicardial mapping was performed in five patients, ages 52–58 years, undergoing coronary bypass surgery, and the results were compared with similar data published from patients without conduction defect. Three patients had chronic and two patients intraoperative LBBB. ECGs during LBBB revealed a QRS duration of 130–160 msec and a mean QRS axis of −15° to +45. Epicardial mapping revealed 1) anterior right ventricular (RV) epicardial breakthrough (5–26 msec after QRS onset), normal in site in all patients, but abnormally early in timing relative to QRS onset in three patients with chronic LBBB, and earlier compared with preoperative maps in two patients with intraoperative LBBB; 2) normal location of latest RV epicardial activation in four of five patients, but abnormally late occurrence of this event 100, 108 and 110 msec after QRS onset in three of five patients; 3) absence of discrete left ventricular (LV) epicardial breakthroughs in all patients; 4) slow transseptal epicardial activation (crowded isochrones) from right to left, with anteroseptal crossing preceding inferoseptal crossing; 5) activation of the anterolateral left ventricle before the inferior LV epicardium; 6) more widely spaced isochrones, implying more rapid conduction, over the LV free wall epicardium; and 7) location and timing of latest LV epicardial activation in an abnormal site, and abnormally late relative to QRS onset (113–140 msec, mean 124 msec) in all patients. This event occurred a mean of 20 msec before the end of the QRS in the five patients. In conclusion, with normal axis, human LBBB is associated with initiation of ventricular activation closer to anterior RV recording sites than is normal activation, slow leftward transseptal activation, a generally anteroinferior orientation of LV activation, and probable engagement of the distal LV Purkinje system during the latter part of the QRS.

Abnormal systolic direction of contrast flow toward the transducer within the right ventricle was demonstrated on M-mode echocardiograms in patients with ventricular septal defect (VSD) and left-to-right shunt. The usefulness of this new technique was tested in 30 patients with VSD proved at catheterization and in 300 control subjects. In all subjects, 2-dimensional (2-D) visualization of the defect, 2-D negative contrast effect and M-mode demonstration of positive contrast within the left ventricular (LV) cavity were also performed. Sensitivity and specificity for each technique and each hemodynamic subgroup of patients were determined and compared. A sensitivity of 100% for the diagnosis of VSD by anterior right ventricular (RV) systolic direction of contrast trajectories was achieved in 20 patients with relatively small VSDs and mild to moderate elevation of RV pressure (RV-LV pressure ratio 60%) and mean pulmonary to systemic blood flow ratio of 1.7. Sensitivities of 2-D echocardiography, 2-D negative contrast technique and positive LV contrast appearance on M-mode echocardiography were 63%, 71% and 53%, respectively. Sensitivity of 100% for systolic anterior direction of contrast trajectories was also calculated in 6 patients with RV-LV pressure ratios from 61 to 80% and mean pulmonary to systemic blood flow ratio of 2.7. Sensitivities of 2-D echocardiography, 2-D negative contrast technique and positive contrast appearance in the LV cavity by M-mode echocardiography were 75%, 60% and 86%, respectively. In 4 patients with systemic or nearly systemic RV pressure, sensitivity of systolic anterior direction of RV contrast trajectories decreased drastically, to only 67%. In contrast, sensitivities of 2-D echocardiography and positive contrast appearance in the LV cavity on M-mode echocardiography increased to 100% for both techniques. This method of identifying anterior systolic RV contrast trajectories direction was useful for detecting VSDs with left-to-right shunt in adults in whom other echocardiographic methods may be inadequate.

Unilaterally brain damaged patients were asked to judge the correctness of familiar melody lines. Sixty per cent of these items contained either pitch, rhythm, tempo, or phrasing errors. With respect to the detection of pitch errors, right anterior patients performed significantly worse than all other groups; right central patients exhibited an intermediate level of difficulty; all left brain damaged (aphasic) groups were nearly flawless. For the detection of rhythm and phrasing errors, control, left anterior and left posterior groups did well while right anterior, right central and left central groups did poorly. Results suggest that the anterior right hemisphere may be critical in the processing of pitch components of music; the right hemisphere in general may be important in maintaining the internal auditory representation of musical material, essential for detecting violations in performance.

Twenty-six patients with Wolff-Parkinson-White (WPW) syndrome were studied by echocardiography. They were classified into the following WPW types: anterior right ventricular pre-excitation (Type I) - six patients; posterior right ventricular pre-excitation (Type II) - six patients; posterior left ventricular pre-excitation (Type III) - fourteen patients. Twenty-three patients were in WPW at the time of study. Four patients with Type I WPW had abnormal systolic motion of the interventricular septum: three paradoxical and one flat. Patients with Type II and Type III WPW had no septal motion abnormalities related to pre-excitation. Three patients had intermittent WPW, Type III; in all three only minor changes in normal septal motion were apparent on WPW beats. Associated cardiac abnormalities were evident in six patients: two mitral prolapse (one Type II WPS and one Tpe III); one idiopathic hypertrophic subaortic stenosis (Type III); one congestive cardiomyopathy (Type III); one hypertrophic nonobstructive cardiomyopathy (Type I); and one atrial septal defect (Type II). We conclude that abnormal interventricular septal motion may occur with Type I WPW abnormality. Other abnormalities are detectable by echocardiography in a high proportion of WPW patients, but do not appear to be associated with any single Wolff-Parkinson-White type.

An anteriorly positioned lower pole of the right kidney is often unappreciated on physical examination. Yet, on review of a large number of abdominal sonograms, more than 12% of the patients had a right kidney with a lower pole sufficiently anterior in position so as to lie at the same depth as the anterior surface of the liver. In a group of patients referred for ultrasound evaluation of hepatomegaly, 20% proved to have a normal liver and an anteriorly positioned lower pole of the right kidney.

The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force or the Department of Defense. *Lieutenant Colonel, U.S. Air Force, D.C.; Fellow, Maxillofacial Prosthetics. **Colonel, U.S. Air Force, D.C.; Assistant Chairman for Maxillofacial Prosthetics. acrylic resin and are designed to accurately direct the external radiation source. Positional stents are used to move or displace tissues out of the field of radiation. This clinical report outlines a technique used in the fabrication of a radiographically detectable intraoral positional radiation stent using a visible light-cured resin (Triad, Dentsply International Inc., York, Pa.). A 64-year-old white man was referred from radiation therapy for a radiation stent that would position the mandible and tongue out of the primary field of radiation. The patient had a 2 x 4 cm lesion of the soft palate extending from the uvula into the anterior right tonsillar pillar with central ulceration. A biopsy demonstrated invasive squamous

The technic of cinerecording the fluoroscopic image and the electrocardiogram simultaneously has been described in a previous report (1). Briefly, this technic consists of recording in slowed motion on 35-mm. film the fluoroscopic image with an optically superimposed electrocardiogram. The Philips roentgen image-intensifier tube2 with 5-inch fluoroscopic screen is used in conjunction with the Bell and Howell “Eyemo” 35-mm. camera. Early in 1957 we began using this method for studying cusp movement of calcified aortic and mitral valves. Location of the calcification is determined under fluoroscopy, and the patient is so manipulated that the best view of the valve is obtained. The anterior right oblique position has been found to furnish the best view of the valves. With the patient positioned, a shield with a 2-inch circular window is slipped into place between patient and fluoroscopic screen, with the window over the valve area. Minor adjustments in the patient's position are then made. With the windowed ...

Echocardiography, because of its ability to detect intracardiac structures in a noninvasive manner, has been increasing in importance as a cardiologic diagnostic tool. The ultrasonic diagnosis of pericardial effusion has stimulated much of the interest in echocardiography in this country. With this technique pericardial fluid is recorded as a relatively echo-free space between the posterior left ventricular epicardium and the posterior pericardium. Anterior fluid is seen as a similar echo-free space between the anterior right ventricular wall and the anterior chest wall. Although the examination is fairly simple and frequently can be performed in a few minutes, the examiner must be aware of technical details, especially with respect to direction of the transducer and control settings on the echograph. In addition, it may be difficult to obtain satisfactory echocardiographic recordings in some patients, such as those with marked pulmonary emphysema. However, these few limitations are overshadowed by the many advantages of a harmless, sensitive, bedside examination for pericardial fluid. Thus, in many institutions echocardiography is becoming the examination of choice for the detection or exclusion of pericardial effusion.