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The change in ejection fraction during exercise is frequently employed as a measure of left ventricular functional reserve in patients with aortic regurgitation. However, little information is available about its relation to invasive measurements of cardiac performance. Therefore, simultaneous hemodynamic measurements and supine exercise blood pool scintigraphy were performed in 14 patients with severe, asymptomatic or minimally symptomatic aortic regurgitation associated with cardiomegaly but preserved left ventricular function at rest. Their hemodynamic measurements at rest were normal and their exercise capacity was excellent.When the patients were categorized into those patients whose ejection fraction increased or did not decrease by more than 0.05 (Group 1) and those whose ejection fraction decreased by more than 0.05 (Group 2), important differences were apparent. Echocardio-graphic, radionuclide and hemodynamic measurements at rest in the two patient groups were similar, but Group 1 exhibited a greater increase in cardiac index during supine exercise (2.8 ± 0.4 to 10.0 ± 1.8 versus 2.7 ± 0.5 to 6.9 ± 1.0 liters/min per m2; p < 0.005) and a lesser increase in pulmonary capillary wedge pressure (13 ± 4 to 19 ± 7 versus 12 ± 4 to 31 ± 8 mm Hg; p < 0.01). The severity of regurgitation decreased during exercise in all patients, but end-diastolic volume decreased and end-systolic volume decreased or was unchanged in Group 1, whereas end-diastolic volume was unchanged and end-systolic volume increased in Group 2. In the patient group as a whole, the change in ejection fraction correlated closely with the exercise-induced increase in cardiac index (r = 0.81, p < 0.001) and significantly, though less closely and in an inverse manner, with the increase in pulmonary capillary wedge pressure (r = −0.69, p < 0.01). Thus, the exercise ejection fraction response during supine exercise is a useful indicator of left ventricular reserve in aortic regurgitation and correlates well with invasive exercise hemodynamic measurements.

We studied the exercise ejection fraction response in 56 patients with chronic aortic insufficiency. All had left ventricular dilatation but preserved resting ejection fraction and minimal or no symptoms. The exercise ejection fraction increased by 0.05 units or greater in 18 (32%) patients (group I), remained within 0.05 units of the resting value in 18 (32%) patients (group II), and fell by 0.05 units or greater in 20 (36%) patients (group III). There were no significant differences among the groups in left ventricular end-diastolic dimension, end-systolic dimension, or fractional shortening by echocardiography or in resting left ventricular volumes and ejection fraction by radionuclide angiography. Left ventricular end-systolic wall stress was significantly higher in group III than in either group I or group II (89 +/- 20 vs 70 +/- 18 and 69 +/- 17 X 10(3) dyne/cm2; p less than .005). At peak exercise there were no differences among groups in systolic blood pressure. However, end-systolic volume increased from 65 +/- 28 to 77 +/- 36 ml/m2 in group III and fell from 50 +/- 21 to 28 +/- 18 ml/m2 in group I during exercise. Thus, at peak exercise end-systolic volume was nearly three times greater in group III than in group I. Although stress could not be determined directly during exercise, the directional changes in its determinants suggest that it also would have been higher in group III patients. A highly significant inverse correlation was present between the ejection fraction response and the change in end-systolic volume (r = -.87, p less than .0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Gated magnetic resonance imaging (MRI) provides excellent anatomic evaluation of the heart, but its capability for assessing cardiac physiology is less clear. Accordingly, regional left ventricular (LV) wall thickening was evaluated by multiphasic transverse images in 37 patients with a variety of myocardial diseases and in 9 normal subjects. Angiography and 2-dimensional echocardiography (2-D echo) were used for comparison. End-diastolic and end-systolic wall thickness, absolute systolic wall thickening and percent systolic wall thickening were determined in 7 regions. Mean systolic wall thickening in normal subjects was not significantly different among the regions. However, there was considerable individual variation in wall thickening, ranging from 18 to 100%. Patients with LV hypertrophy (n = 4), amyloid cardiomyopathy (n = 1), constrictive pericarditis (n = 5), and hypertrophic cardiomyopathy (n = 3) had absolute and percent systolic wall thickening within normal limits. Infarcted segments in patients with ischemic heart disease (n = 17) had reduced absolute and percent systolic wall thickening, often combined with diastolic wall thinning, whereas mean percent systolic wall thickening in adjacent normal myocardial regions was higher than in normal volunteers (p less than 0.001). In patients with coronary artery disease, MRI had a sensitivity and specificity of 93% in detecting regional wall motion abnormalities. Because sagittal images were not acquired, inferior wall motion abnormalities were not assessed by MRI due to parallel wall sectioning in transverse images.(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging (MRI) was conducted with use of the spin-echo technique (0.35 Tesla) in 22 patients with a variety of congenital and cardiovascular anomalies and in 16 normal volunteers. Electrocardiographic (ECG) synchronization of the data acquisition produced transverse, parasagittal, and coronal tomograms that were used to define size and relationship of the great vessels and internal cardiac structures. MRI findings were corroborated by angiography and sector-scan echocardiography. In most patients the diagnosis had been established before the MRI study. MRI detected all of 11 abnormalities at the level of the great vessels, all of six atrial septal abnormalities, and 10 of 11 ventricular septal defects. Images of poor quality resulting from patient motion were obtained in the one instance in which a small ventricular septal defect was not imaged. Of two patients with Ebstein's anomaly, the displacement of the tricuspid leaflets was shown in one patient but was not evident in another. Complex anomalies such as double-outlet right ventricle, uncorrected L-transposition, single atrioventricular valve, single ventricle, and common ventricle were clearly shown by MRI. Initial experience with MRI has indicated the effectiveness of this technique for defining great vessel and internal cardiac anatomy in patients with congenital heart disease. This is accomplished without the use of contrast media and is thus a completely noninvasive technique for cardiovascular diagnosis.

In summary, we have described what may be an infrequently recognized cause of dyspnea. Patients with unexplained dyspnea and arterial desaturation out of proportion to their cardiopulmonary disease can easily and inexpensively be screened with an arterial blood gas determination while inspiring 100% oxygen. If these arterial oxygen values suggest a right-to-left shunt, an echocardiograpbic contrast study with injection of contrast into the femoral vein should be performed. If contrast crosses over from the right to the left atrium, further evaluation to define right-to-left shunting at the atria1 level is indicated.

The value of digoxin in the patient in normal sinus rhythm with chronic congestive heart failure continues to be controversial. Although many patients taking digoxin have no clinical deterioration after its discontinuance, there is a subgroup of patients (up to 30% of the total group) who demonstrate clinical deterioration on digoxin withdrawal. Patients with an S3 gallop and an enlarged left ventricle are especially likely to benefit from digoxin therapy. Furthermore, there is good evidence in patients with congestive heart failure that there is a persistent, chronic, positive inotropic effect with digoxin. Since digitalis is the only presently available, chronic, oral positive inotropic drug capable of increasing stroke volume at any given filling pressure, it should be used in patients with congestive heart failure.

Corrected transposition of the great arteries (CTGA) is a congenital malformation whereby the great arteries arise from inappropriate anatomic ventricles: the aorta from the left-sided morphologic right ventricle (RV) and the pulmonary artery from the right-sided morphologic left ventricle (LV). We present the findings in a woman who developed acute biventricular heart failure during the third trimester of her pregnancy and was subsequently found to have CTGA

Ventricular function was evaluated by the development of ventricular function curves from the vulumes stress of angiographic contrast media in 30 patients before and an average of 5 months after coronary bypass surgery. Patients were grouped according to preoperative operative indications, perioperative events, and postoperative status to determine the most important factors affecting postoperative ventricular function. Progression of lesions in the native coronary circulation correlated most significantly with a decrease in postoperative ventricular function. In 18 of 19 patients the changes in native coronary circulation were progression to complete occlusion. Seventy-three per cent of these changes were associated with a patent graft distal to the change. Patients with very ischemic ventricles as evidenced by a markedly positive stress test (greater than 2 mm. ST depression) and/or main left coronary obstruction maintained or improved postoperatively ventricular function. Increase in postoperative ejection fraction was often associated with decrease in aortic mean pressure, making it difficult to use this parameter to evaluate postoperative ventricular function.

Myocardial infarction (MI) has been reported to occur in about 15 per cent of patients following coronary artery bypass (CAB) surgery. Preoperative and postoperative electrocardiograms (ECG) were evaluated in 85 patients. Thirty-four of these patients also had pre- and postoperative vectorcardiograms (VCG). Fifteen additional patients undergoing open heart surgery were used as controls. These included aortic valve replacement (in 4), mitral valve commissurotomy (in 6), mitral valve replacement (in 1), atrial septal defect repair (in 3), and repair SVC to LA shunt (in 1). Pre- and postoperative VCG's were analyzed in three planes. The angle of each 10 msec. vector was measured. The maximal voltage was determined along each axis in each plane. Mean changes in these parameters were determined for the controls. Change exceeding two standard deviations from the control mean was considered abnormal and not explainable by trauma of open heart surgery itself. Excluding the six intraoperative deaths, 19 79 (24 per cent) had QRS changes of myocardial infarction by ECG. Changes were considered significant in the postoperative VCG if they occurred in at least two consecutive angles in one plane or in the maximum voltage in one axis. The postoperative VCG depicted MI in 34 per cent ( 12 34 ). In the absence of classic criteria for MI a significant change in VCG angle occurred in 26.4 per cent ( 9 34 ). The voltage in at least one axis changed significantly in 11.8 per cent ( 4 34 ). A change in the postoperative VCG was demonstrated in 73.5 per cent ( 25 34 ). The pre- and postoperative VCG is a sensitive method of detecting subtle changes in conduction or loss of myocardium seen in the majority of patients following CAB surgery.

Coronary arteriography was performed in 60 patients aged 35 or less with suggested coronary artery disease (CAD). Twenty patients (Group 1) had normal coronary arteries and 40 patients (Group 2) had one or more obstructive lesions. The left anterior descending artery was commonly involved followed by the right coronary and left circumflex arteries. The right coronary artery was most commonly completely obstructed. Single-vessel disease (50 per cent or greater obstruction) was found in 60 per cent of the patients, an incidence that is considerably higher than in studies of older patients. A total of 1.6 diseased vessels per patient was present. A hyperlipoproteinemia (HLP) was found in 68 per cent of Group 2 patients. Patients in Group 2 with an HLP had significantly more CAD than Group 2 patients with normal lipoproteins. The incidence of the following clinical features were not significantly different in Groups 1 and 2: typical angina, atypical angina, positive family history, smoking, hypertension, obesity, abnormal electrocardiogram, positive treadmill test, HLP, and diabetes mellitus. A fourth heart sound and a history of a myocardial infarction were significantly common in Group 2. Since almost all of the previously reported cases of myocardial infarction with normal coronary arteries have occurred in young patients, history of a myocardial infarction does not assure the presence of obstructive coronary artery lesions. It is suggested that coronary arteriography is a justifiable procedure in a young patient who presents with a clinical picture that is either compatible with or cannot be clearly distinguished from CAD.

Numerous cardiopulmonary manifestations of the acquired immunodeficiency syndrome (AIDS) have been reported. 1,2 We have previously found that dilated cardiomyopathy, pericardial effusion and pleural effusion are the most common cardiopulmonary lesions detected by echocardiography in hospitalized AIDS patients. 3 We have also noted evidence of mild to moderate pulmonary hypertension in patients with dilated cardiomyopathy and occasional patients with active Pneumocystis carinii pneumonia. 3 By necropsy studies, some AIDS patients with Pneumocystis carinii pneumonia or cytomegalovirus infection of the lung have had right ventricular dilatation in the absence of left ventricular dilatation or myocarditis. 2 Although pulmonary emboli, pulmonary infarction, venous thromboemboli and non-bacterial thrombotic endocarditis have also been demonstrated by autopsy in AIDS patients, cor pulmonale has not been reported previously.

Eighty-two patients with mitral stenosis underwent cardiac catheterization with coronary angiography. Twenty-one patients (26 percent) had coronary artery disease. Characteristics of the mitral valve area, cardiac output, pulmonary artery pressure, pulmonary vascular resistance, left ventricular end-diastolic pressure, left ventricular ejection fraction, and atypical chest pain did not correlate with findings of angina pectoris or of coronary artery disease; however, there was correlation with sex, age, and angina. Coronary artery disease occurred only after the age of 40 years and was more frequent in males with angina. Coronary artery disease could not be ruled out in patients with mitral stenosis, especially those over age 40, without coronary arteriography.

Pulmonary varix is a rare lesion consisting of aneurysmal dilatation of a pulmonary vein. Its radiologic appearance may be indistinguishable from a neoplasm, granuloma, or pulmonary arteriovenous fistula. Pulmonary angiography with follow-up through the venous phase is the only method of diagnosis. Reported herein is an illustrative case.

This case of tricuspid insufficiency due to nonpenetrating trauma involved a male patient who had received major chest trauma in an automobile accident, had a nonholosystolic murmur that increased slightly during inspiration on standing, and tranient electrocardiographic findings of right bundle branch block. Unlike findings in previous cases, the right atrial V wave was not dominant and was less than 8 mm Hg. An echocardiogram indicating right ventricular volume overload was an essential diagnostic tool that led to cardiac catheterization and definitive diagnosis.

Coarctation of the aorta is a cause of hypertension that can present dramatically in the severely ill infant or appear incidentally in the asymptomatic young adult. Coarctation is easily detected and there is good evidence that the extremely poor natural history can be altered favorably by surgical correction. The elevated blood pressure can be lowered in the majority of patients, and there is every expectation that the incidence of known complications of coarctation can be decreased. However, in about three fourths of the patients, significant residual cardiovascular defects persist, with their potential for future problems as yet incompletely defined. For this reason, patients who have undergone surgery for coarctation will need to be followed carefully for an indefinite period.

Several reports of successful correction of anomalous origin of the left coronary artery from the pulmonary artery utilizing a graft to the ascending aorta have demonstrated the feasibility of this procedure. The patient described in this report developed proved delayed occlusion of the saphenous vein graft with a fatal outcome. This was a result of intimal fibrous hyperplasia identical to that seen in adults following the placement of the saphenous vein bypass graft for treatment of atherosclerotic coronary disease.

To assess the variability of rest and exercise radionuclide ventriculography in patients with aortic regurgitation (AR), 22 patients in stable condition with chronic AR underwent radionuclide ventriculography at rest and during exercise for measurement of left ventricular volumes and ejection fraction (EF) on 2 occasions 3 months apart. For the group, there were no significant differences between the findings of the 2 studies except for a slightly lower exercise end-systolic volume on the second study. The inter-study differences and variabilities (expressed as the standard deviation of differences) for rest and exercise EF and change in EF were 0 +/- 0.04, +0.02 +/- 0.05 and +0.01 +/- 0.05, respectively. Thus, although mean differences were minor, considerable individual variability occurred, the magnitude of which was similar to that reported for other patient populations. In 3 patients who had an initial normal response to exercise (increase in EF greater than or equal to 0.05), the response became abnormal and in 2 who initially had an abnormal response, the response normalized. This variability must be considered in clinical decision-making or in research study design for patients with chronic AR.

In order to determine whether exercise performance could be improved by using alpha methyldopa to lower the resting diastolic blood pressure, a double-blind crossover study was carried out in six normotensive patients with angina pectoris. Duration of exercise, peak systolic blood pressure, and maximum heart rate were all unchanged during treatment. It is suggested that patients with angina pectoris behave much like patients with uncomplicated hypertension who do not improve their exercise performance when treated with an antihypertensive agent.

Excerpt In the last decade the use of radioactive iodine (I131) has come to occupy a place beside subtotal thyroidectomy as a definitive treatment for hyperthyroidism. The excellent results—compara...

The clinical course and laboratory findings in the case of a 45-year-old woman with corrected transposition of the great vessels and no associated defects are reported. Spontaneous systemic ventricular failure occurred at the age of 45 without obvious cause. The possibility is raised that this represents failure of the anatomic right ventricle to sustain systemic pressures for a normal lifetime. This patient is discussed in relation to present surgical techniques for correcting transposition of the great vessels which leave the right ventricle as the systemic pump.

The rise in left ventricular end-diastolic pressure (LVEDP) following left ventricular angiography was studied in 41 patients with coronary artery disease and in 11 “normals” to evaluate its use as a ventricular function test The response was compared to changes in the pulmonary wedge pressure obtained during exercise in 44 patients. The LVEDP rose in all cases, reached a peak two to three minutes after the left ventricular angiogram, and then slowly fell. In general, the more extensive the coronary artery disease the greater the rise in LVEDP. The most significant separation from normals occurred five minutes after the angiogram (1-vessel disease p

A 17-year-old patient is discussed who had the tachycardia-bradycardia syndrome following closure of a sinus venosus atrial septal defect. Cardiac standstill up to 7.2 seconds long occurred, but placement of a permanent demand pacemaker was avoided. This unique case demonstrates that permanent pacemaker may not always be necessary in the tachycardia-bradycardia syndrome, especially when it occurs in a young postsurgical patient.

A case of autopsy-documented fatal pulmonary hemorrhage secondary to distal pulmonary arterial rupture by a balloon-tipped catheter is presented. Possible mechanisms of pulmonary arterial tear are discussed, and safeguards against additional occurrences of this complication are suggested.

Midesophageal traction diverticula are only rarely symptomatic. Very infrequently diverticulitis1-3and spontaneous hemorrhage3,5-7have been observed to develop, and on rare occasions spontaneous perforation and fistulization with other mediastinal structures have been reported.8-20It is the purpose of this paper to report an extremely unusual case of a midesophageal traction diverticulum which formed a fistula with the superior vena cava, caused multiple septic pulmonary emboli, and terminally resulted in exsanguinating esophageal hemorrhage. Report of Case A 36-year-old white male officer was admitted to the U.S. Army Hospital at Fort Gordon, Ga., complaining of a nonproductive hacking cough, mild pleuritic chest pain, and intermittent chilly sensations, which had persisted for 5 days. Physical examination revealed no abnormality of the heart or lungs and was otherwise unremarkable except for a temperature elevation of 100.8 F. Initial laboratory studies were within normal limits and included white blood cell count and

Until sildenafil, the first effective oral agent for erectile dysfunction (ED), was introduced, only genitourinary physicians concerned themselves with this problem. Certainly cardiologists rarely asked their patients with cardiovascular disease about difficulty developing or maintaining a penile

Two patients with coarctation of the aorta initially had acute idiopathic pericarditis with anterior pleuritic chest pain as the chief complaint. A pericardial friction rub was present in both patients. Both patients died suddenly. At autopsy, they were found to have a dissecting aneurysm of the ascending aorta with extension into the pericardial space; acute pericardial tamponade was the cause of death. We recommend that when a patient with coarctation of the aorta is admitted with pericarditis, aortic dissection should be considered and appropriate diagnostic procedures undertaken. In all young patients with acute pericarditis there should be careful palpation of the femoral pulses and review of the chest x-ray film for rib notching. ( Arch Intern Med 139:108-109, 1979)

In the first 20 years of the modern era of cardiology, an enormous fund of knowledge and understanding was generated by the development and application of invasive cardiac catheterization and angiographic techniques to the problems of clinical cardiology. Coincident with the ability to evaluate the function of the heart and to visualize the form of the diseased cardiovascular system, new advances in anesthesia and surgery made it possible within a relatively few years to palliate and even, in limited situations, to cure patients whose lesions only shortly before were inoperable. Because of the complexity, discomfort, and small but substantial morbidity and even mortality, invasive examination of patients with cardiovascular disease has its limitations. This is especially true for the screening of populations for suspected disease and for sequential follow-up evaluation of patients with known cardiac disease. For these reasons, in the past decade there has been a vast increase in

Thirty-five consecutives patients with classic or definite rheumatoid arthritis underwent echocardiography to evaluate the motion of the anterior mitral valve leaflet. Adequate echocardiograms were obtained in 31 patients. All 31 patients showed normal valve motion and a normal EF slope. If meticulous technique was not observed, a falsely low value for the EF slope was obtained and a normal slope was found when the method was improved. This study shows that echocardiographic abnormalities of the anterior mitral valve leaflet rarely, if ever, occur in patients with rheumatoid arthritis, provided that careful attention to recording method is observed.

Evolution in the treatment of patients with acute myocardial infarction has taken us, within a brief period of less than 40 years, from impotent observation to aggressive invasive intervention designed to open suddenly occluded coronary arteries. The attack on the patient with acute myocardial infarction, requiring sophisticated catheterization facilities and personnel immediately available at all times, takes on many of the attributes of battlefield evacuation, complete with helicopters and pseudo-MASH units. The concept that led to this approach was the resuscitation of the idea that thrombus over a plaque was the most important mechanism of sudden obstruction in transmural myocardial infarction. Chazov et al 1 in the Soviet Union were the first to demonstrate fibrinolysis by intracoronary streptokinase. Rentrop et al 2 stimulated general interest in intracoronary thrombolysis. Later, Schroder et al 3 demonstrated that the occluded coronary artery could be opened by intravenous streptokinase. The first randomized, controlled study

HYPERTENSION is a disease affecting 23 million Americans—a public health menace of great magnitude. We have the means to control hypertension in the great majority of patients, and there is convincing evidence that such control will reduce morbidity and mortality. With such knowledge and capability, why do we still have 50% of hypertensives unaware that they have the disease, while many others are not on adequate treatment (or any treatment). 1 Where lies the fault? With the patient, the doctor, or both? The National Heart and Lung Institute (NHLI) has undertaken to coordinate a National Program of Information and Education to educate the public and alert the medical profession to the problem of "hidden" hypertension. As part of this program, the NHLI contracted with Louis Harris and Associates to conduct a survey of current public awareness and knowledge of high blood pressure. The survey was carefully designed and carried out

THE ELECTROCARDIOGRAPHIC "camel-hump" sign of Osborn,1a term first proposed by Harvey, is generally considered specific for hypothermia.2However, we recently saw a patient who had such a finding resulting not from hypothermia but from massive cerebral injury, indicating that this sign is nonspecific. To our knowledge, this is the second instance of central nervous system disease resulting in the camel-hump wave3(or, more accurately, dromedary wave) and the first with postmortem confirmation. Report of a Case An 8-year-old boy sustained a severe head injury when struck by a motorcycle while riding his bicycle. His growth and development had been normal. On admission, he was deeply comatose, and the pupils were fixed, dilated, and unresponsive to light; no papilledema was present. The blood pressure was 122/80 mm Hg and the pulse was 140 beats per minute and regular. There were left temporal ecchymoses and lacerations of the

In Reply.— Dr Thase is quite correct in pointing out that chronic anxiety disorders have been commonly described in patients with CMS. Whether the underlying mechanism that causes the mitral valve apparatus prolapse also is responsible in some way for the psychological problems that the patients have or whether these common problems are unrelated is still not clear. There is intriguing evidence of elevated production of catecholamines or increased sympathetic nervous system activity or responsiveness, but so far this has not been unequivocally associated with the anxiety symptoms that the patients have. 1,2 Procacci et al, 3 in studying the entire female population of an air force base, identified all women with the auscultatory click, murmur, or both and found that the symptomatology of palpitations, dizziness, weakness, and chest pain were as common in the group without the auscultatory findings as those with the findings. Whether there is a causal

This multiauthored book is the 24th in the Hahnemann Symposia series and offers a thorough examination of the problem of atherosclerosis and coronary heart disease. The book is written in 51 chapters arranged into seven sections: pathogenesis, pathology, pathophysiology, angina pectoris: diagnosis, angina pectoris: treatment and prognosis, myocardial infarction, myocardial infarction: treatment and prognosis. This logical organization enhances the systematic development and presentation of the latest information available on this most important of all problems in cardiology. The seventh Hahnemann Symposium was also devoted to coronary heart disease. A comparison of these works provides a measure of progress and lack of it made in the decade separating the publication of these books. Our concepts of the pathogenesis of atherosclerosis have the visage of old age, characterized by a paucity of new ideas that have been presented and represented for the last 70 years. Contrasted with this is the contribution to

By far the most frequent pathologic condition preceding myocardial infarction is coronary atherosclerosis. Because the great majority of patients who are first seen with acute myocardial infarction have atherosclerotic coronary artery disease, there is usually little thought given to other causes, except in children where congenital coronary anomalies are considered. However, there are multiple other conditions, albeit far rarer than atherosclerosis, that can result in clinical acute myocardial infarction, and a classification of these other conditions, an anatomic-pathophysiologic one, was developed from illustrative material from the files of the Armed Forces Institute of Pathology. This classification is an inclusive listing of all conditions, however unusual, that can result in acute myocardial infarction.

AUSCULTATORY sounds of a late systolic murmur, with or without a preceding nonejection click, have been generally recognized since the late 1950s to result from abnormal movement of the mitral valve apparatus during systole. Although the mitral valvular origin of these sounds was suspected before, it was only after left ventricular angiography showed the late systolic murmur to result from mitral insufficiency, which was secondary to the abnormal billowing of the mitral leaflets into the left atrium, that the true nature of these auscultatory findings was recognized. The patient with a nonejection click, with and without a systolic murmur, has been described in the literature under a wide variety of names (Table 1). With the demonstration by echocardiography of the abnormal posterior systolic movement of both aortic and mural leaflets of the mitral valve, it has been possible to identify noninvasively the patients with an abnormally prolapsing mitral valve, even

Chung has written a very good book on cardiac arrhythmias. He has organized the information in the classical way, starting with a basic chapter on anatomy, electrophysiology, and the effect of arrhythmias on hemodynamics, and then proceeds systematically through the arrhythmias by site of origin. There are comprehensive chapters on Wolff-Parkinson-White syndrome, parasystole, atrial dissociation, electrical alternans, and aberrant conduction. The book concludes with special categories of arrhythmias such as those associated with electrolyte disturbances and acute myocardial infarction, and summary chapters on differential diagnosis of tachyarrhythmias and management of arrhythmias. Reading the book cover-to-cover was much like walking through a "zoological garden" of arrhythmias. In chapter after chapter, one encounters the commonest of arrhythmias along with the rarest and the "only-twice reported" arrthymias, usually described both times by Chung himself. The outstanding characteristic of this book, distinguishing it from some of the other texts on arrhythmias, is the profuse

The Second National Conference on Prosthetic Heart Valves was held on May 30 and 31 and June 1, 1968, in Los Angeles. Participating in this meeting were many of the physicians who have contributed to the remarkable development of prosthetic valves. The communications presented have been compiled under the editorship of Lyman A. Brewer, III; they document the tremendous advances made since the first conference on prosthetic valves for cardiac surgery held eight years earlier. They also highlight the very real problems that await solution. The book is divided into five sections: (1) "Valve Structure and Testing"; (2) "Materials and Myocardial Function"; (3) "Clinical Experience"; (4) "Results and Complications"; and (5) "Valve Grafts." The chairman of each section often makes pithy comments after the presentations. The subject of prosthetic valves is reviewed exhaustively. There are several good articles on in vitro and in vivo testing of artificial valves; emphasis is

Textbooks in medicine suffer from the fact that information is accumulating so rapidly that by the time of publication, the newest theories and treatments have already been superseded by even newer ones. The physician interested in the "latest thinking" on a subject, therefore, frequently turns to the latest review in the journal literature. This objection is less applicable to textbooks of electrocardiography where a comprehensive, organized, step-by-step review of the subject is necessary for the novice to learn the practical skill of electrocardiographic interpretation. Friedman has reworked and expanded his Outline of Electrocardiography into a practical textbook of electrocardiography which presents the subject from the vectorial approach, first discussing the standard 12-lead ECG and then relating this to the vectorcardiogram. The text, in a well-organized manner, goes through basic electrocardiographic theory in several chapters and then discusses the classic abnormalities recorded by the ECG. A short discussion of the theoretical

One of the greatest advances in the treatment of cardiac disease in the last 15 years has been the development of practical and clinically successful prosthetic valves. In this monograph, Sauvage and his coauthors have reviewed in detail the structural mechanics and hydraulics of the normal and diseased aortic valve with a view towards understanding the necessary requisites for developing a satisfactory prosthetic replacement. By measurement and experiment, the mathematics are developed that illustrate how marvelously well the design of the normal aortic valve suits the function it serves. Because of the beauty and simplicity of the natural aortic valve, first attempts at developing a prosthetic valve were directed at duplicating the central flow, mechanically perfect design. These attempts have been frustrated by the lack of a material that will withstand the interminable (60 × 60 × 24 × 365 × 3 score and 10) flexing without fatigue and failure.