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1. 1. In twenty-seven patients with acute coronary insufficiency and in twenty-four patients with acute myocardial infarction, electrocardiograms and mean spatial vectors of QRS and T have been described and compared. 2. 2. Acute coronary insufficiency is a common clinical entity, at least half as common as acute transmural myocardial infarction. 3. 3. The diagnosis of acute coronary insufficiency may be made with reasonable accuracy and implies an area of subendocardial necrosis which is anterior in location three times as frequently as posterior. 4. 4. The mean spatial vector of QRS, being a composite figure, shows little change in myocardial infarction, and, of course, in coronary insufficiency. 5. 5. The mean spatial T-vector shift is greater in acute myocardial infarction than in acute coronary insufficiency. The maximum shift occurs earlier, on the third day in acute coronary insufficiency, and considerably later in myocardial infarction. 6. 6. In acute myocardial infarction, anterior in location, there is a close correlation between the degree of shift of the mean spatial T vector and the severity of the illness. Thus in this situation the degree of shift of the T vector appears to be a measure of the extent of myocardial injury. 7. 7. Complete electrocardiographic recovery occurs more frequently in acute coronary insufficiency; also the attainment of a stable electrocardiogram occurs earlier than in acute myocardial infarction. 8. 8. Vector-electrocardiography is of real value in acute coronary insufficiency and in acute myocardial infarction; it is a semiquantitative yardstick for the more detailed appraisal of the degree of myocardial injury and the amount of recovery.

Observations on bacterial resistance to antibiotics in 64 patients with bacterial endocarditis are reported. Streptococcus endocarditis is contrasted with staphylococcus endocarditis as regards course, bacterial resistance to antibiotics, and mortality. The management of bacterial resistant patients is stressed and particular emphasis is placed upon the role of the newer antibiotics such as aureomycin.

1. (1) Seven patients with mitral insufficiency and giant V waves in the wedged pulmonary artery position have been studied. 2. (2) The systolic peak of the V (or regurgitant) wave approximated the systolic peak of the right and main pulmonary artery pressure curves. 3. (3) Pulmonary arteriolar resistance was found to be normal or reduced. 4. (4) A consideration of the hemodynamic data favors the concept that in mitral insufficiency a retrograde transmission of the V wave may occur and that it results from an increase in the tone of the pulmonary vascular system without an increase in the pulmonary vascular resistance.

1.1. A series of cases exhibiting the combination of pulmonary stenosis and a defect permitting a left to right shunt is described. The series includes examples of the combination of pulmonary stenosis with atrial septal defect, transposed pulmonary veins and ventricular septal defect, respectively. 2.2. The clinical features of the cases were in general those of mild or moderate pulmonary stenosis. It is thought that electrocardiographic and radiologic findings may suggest the presence of an accompanying septal defect. 3.3. Atrial septal defect with left to right shunt occurred in the presence of mild or moderate pulmonary stenosis and a normal left to right atrial pressure gradient. These findings are contrasted with those in pulmonary stenosis with right to left shunts. 4.4. A shunt through transposed pulmonary veins may occur in the presence of severe pulmonary stenosis. 5.5. Cases of ventricular septal defect and pulmonary stenosis appeared to fall into two groups; those with slight to moderate elevation of right ventricular pressure and those in which the right ventricular and systemic pressures were similar. 6.6. The surgical implications of these combined lesions are discussed.

W ITH EXPECTED advances in the technics of hypothermia and artificial heart-lung machines, surgical exposure and closure of interventricular septal defects has become a more feasible and common procedure. Thus it seems worthwhile to re-examine our knowledge and diagnostic ability of a condition which promises to become of increasing importance as definitive corrective therapy becomes available. With this in mind, the authors reviewed cases of interventricular septal defect which had been studied in the Cardio-Respiratory Laboratory of Cedars of Lebanon Hospital in the preceding twelve months. The six cases which form the basis of this report were reviewed and the cardiac catheterization, electrocardiographic, and vectorcardiographic findings were correlated.

Six consecutive patients studied by angiocardiography or aortography ranging in age from 1½ to 68 years were checked by a direct-writer type of electrocardiograph during the procedure. The clinical entities consisted of pulmonary stenosis, coarctation of the aorta, aneurysm of the ascending aorta, ventricular septal defect (2 cases), and atrial septal defect associated with complete transposition of the great vessels. Following angiocardiography immediate T-wave depression was noted. This was followed within three minutes by the development of short bursts of ventricular tachycardia lasting up to 27 minutes after dye injection. A different and much less spectacular picture followed aortography. None of these cases showed visible distress.

The literature has been reviewed, and 58 autopsied cases of dissecting aneurysm of the aorta observed at the Los Angeles County Hospital over a ten year period have been carefully studied. Clinical-pathologic correlation has been attempted whenever possible, with emphasis on diagnostic features. The increasing incidence of accurate diagnosis of dissecting aneurysm has been noted, and it is hoped that this review will help solidify the clinical syndrome or syndromes of the condition and thus facilitate diagnosis in dubious instances.

1.1. Mean levels of right ventricular pressure, flow, and work, but particularly mean levels of right ventricular work, are considerably higher in congenital heart disease than in mitral stenosis. 2.2. In congenital heart disease only abnormal electrocardiograms appeared above a mean right ventricular systolic ejection pressure of 30 mm. Hg. In mitral stenosis normal or borderline electrocardiograms appeared frequently up to a mean pressure level of 60 mm. Hg. 3.3. In congenital heart disease almost all electrocardiograms were abnormal above a right ventricular work load of 1 kg. M./min./sq.M. In mitral stenosis, normal electrocardiograms often occurred at work levels above 1 kg. M./min./sq. M. 4.4. In both mitral stenosis and congenital heart disease, the pattern of partial right bundle branch block appeared at almost all levels of right ventricular pressure and work, and thus this pattern appeared to be almost as significant as the classic pattern of right ventricular hypertrophy in the detection of right ventricular hypertension and presumptive right ventricular hypertrophy. 5.5. Gross electrocardiographic differences between congenital heart disease and mitral stenosis were present in all precordial leads; this was most marked in V 3R and V 1 , where the R wave in congenital heart disease was three to four times as tall as the comparable R wave in mitral stenosis. 6.6. In congenital heart disease, the electrocardiogram is remarkably accurate (91 per cent of cases) in the detection of right ventricular hypertrophy. In this disease no definite correlation was present between abnormalities of individual waves such as the height of R or RS ratio over the right precordium and levels of pressure or work. 7.7. The electrocardiogram in mitral stenosis is less diagnostic (51 per cent of cases) in the detection of right ventricular hypertrophy. But when the electrocardiogram is abnormal, a definite correlation is present between the height of R and RS ratios over the right precordium and levels of right ventricular pressure and work. 8.8. These differences in the total electrocardiographic picture suggest fundamental differences in the genesis of right ventricular hypertrophy in the two diseases.

Six patients with acquired heart block and ventricular rates below 40 per minute were catheterized. Pertinent hemodynamic findings were: (1) elevated right atrial and right ventricular systolic pressure; (2) atrial systolic waves transmitted to both the right ventricle and main pulmonary artery successively; (3) giant atrial a waves occurring at the time of simultaneous atrioventricular systoles, but not when this occurred in or near early diastole of the preceding ventricular beat; (4) systolic pulmonary hypertension; (5) reduced mean brachial artery pressure, but elevated mean pulmonary artery pressure; (6) increased total vascular resistance of both the pulmonic and systemic circulations; (7) reduced oxygen consumption; (8) reduced cardiac index; and (9) increase of stroke index to 28 per cent or less above normal in four of the six patients. The injection of Isuprel via a catheter directly into the main pulmonary artery in two patients resulted in: (1) more rapid ventricular rate; (2) conversion to a sinus rhythm in one; (3) unaltered stroke volume; (4) increased cardiac output; (5) unaltered oxygen consumption; (6) decreased arteriovenous oxygen difference; and (7) decreased total vascular resistance in both the pulmonic and systemic circulations.

1. 1. Acquired interventricular septal defects have been discussed and two new cases presented. 2. 2. In both cases the diagnosis was confirmed by cardiac catheterization and the presence of moderate pulmonary hypertension was observed. 3. 3. The pulmonary hypertension, in the absence of congestive failure, appears to be related to the magnitude of left to right shunt and therefore should be reversible by surgical correction of the defect. 4. 4. The degree of the left to right shunt may indicate the size of the opening in the ventricular septum and is due to either single or multiple defects. 5. 5. The shunt flows and cardiac outputs in postmyocardial infarction septal defects are lower than in the post-traumatic cases. This is most likely caused by pre-existing myocardial disease present in the postinfarction group.

The selection of patients for mitral commissurotomy must be made after considering all manifestations of the rheumatic state. A conservative approach is urged and no patients should be operated upon without evidences of increasing pulmonary hypertension and right heart strain. The preparation of the patient, the management of the arrhythmias during surgery and the postoperative care are the full responsibilities of the physician. A team composed of physiologists, cardiologists and surgeons must work together.

IN OUR evaluation of patients with cirrhosis of the liver we have been studying the "wedge" pressure in the hepatic vein. A team of the medical and surgical service has now had an opportunity to observe this pressure in the hepatic vein during portacaval surgical procedures. A simultaneous measurement of these pressures makes possible an exact evaluation of the hepatic vein wedge pressure as a diagnostic procedure. Up until this time, no correlation with the actual pressure in the portal vein has been reported. In 1951 Myers and Taylor1and Friedman and Weiner2determined the wedge pressure in the hepatic vein of animals and correlated this with the portal vein pressure. Wedge hepatic vein pressures in man have been reported by Myers and Taylor * and by Paton, Reynolds, and Sherlock.4We have used their technique of introducing a nylon catheter into an arm vein and passing this

A method is described for the graphic registration of cardiac thrills. A thrill is defined as a chest wall vibration of sufficient intensity to be recognized by tactile sensation.

Six patients with mitral stenosis, 3 with pulmonic stenosis, and 1 with pulmonary hypertension are presented. All had isolated right ventricular hypertrophy and all had deep S waves in V 1 , V 2 , or V 3 . In 3 cases the voltage of R in V 1 was less than 0.5 millivolt. In 3 cases R/S ratios in V 1 of less than 1.0 were present. Vectorcardiograms showed characteristic features and illustrated the reasons for the electrocardiographic findings.

A case of combined pulmonic and mitral stenosis with cardiac catheterization studies is presented. A modification of the formula for calculating pulmonic valvular resistance is discussed. The importance of calculating cardiac output on the basis of the systolic ejection phase is noted. The pulmonic valvular resistance by this modified formula was 210 dynes seconds cm. -5 The pulmonary vascular resistance was 250 dynes seconds cm. -5 The pulmonic valvular resistance tended to protect against the development of pulmonary edema, much as a high pulmonary vascular resistance protects against pulmonary edema. The right ventricular output, which was 1.6 L. per minute, was limited by the pulmonic stenosis. Other mechanisms that might mechanically limit right ventricular output are significant tricuspid stenosis or limb tourniquets. In situations of impending pulmonary edema, any one of these factors that decrease right ventriccular output may be advantageous.

1. 1. A vectorcardiographic study of thirty-four patients with congenital heart disease and mitral stenosis is reported. All patients had cardiac catheterization and none except one had left ventricular hypertrophy. 2. 2. With increasing right ventricular work, there is an increased rightward and anterior deviation of the horizontal plane loop and of the spatial vectorcardiogram to the right anterior inferior octant in both lesions. 3. 3. There is a better correlation between the vectorcardiogram and right ventricular work than between the electrocardiogram and right ventricular work. 4. 4. The vectorcardiogram shows the pattern of right ventricular hypertrophy clearly. The electrocardiogram is usually reliable only in the classical pattern of right ventricular hypertrophy but not when incomplete right bundle branch block is present. In nine patients with incomplete right bundle branch block, the vectorcardiogram clearly shows that this lesion also represents right ventricular hypertrophy, thus confirming previous studies in congenital heart disease and extending them to patients with mitral stenosis as well. 5. 5. The vectorcardiogram may serve as a gross quantitative estimate of the degree of right ventricular hypertrophy, especially in congenital heart disease.

A one year study evaluating anticoagulant drugs as an adjunct in the management of congestive heart failure has been carried out on 300 patients. Depo-Heparin and dicumarol were the drugs employed. The effect of anticoagulant therapy upon the incidence of thromboembolic complications and mortality has been studied.

1.1. Four cases of Eisenmenger's complex are reported and the results of cardiac catheterization are discussed. Right ventricular hypertrophy, pulmonary hypertension, high ventricular septal defect and overriding of the aorta were demonstrated. 2.2. The practical and theoretic difficulties of demonstrating overriding of the aorta by cardiac catheterization are discussed.

This report is concerned with the need for prophylactic measures to reduce the incidence of potentially dangerous arrhythmias induced during cardiac catheterization. The experience of this catheterization team will be presented, and suggestions for increasing the safety of routine cardiac catheterizations will be made.

1. 1. Five patients with myocardial infarction and prominent or tall R waves in Leads aV R and/or V 1 are reported. 2. 2. Vectorcardiographic studies revealed that the spatial vector loop was in the right superior anterior octant in three patients, right superior posterior octant in the fourth patient, and left superior posterior octant in the fifth patient. The horizontal plane vector loop was strikingly displaced to the right in four of the five patients. 3. 3. The development of tall R waves in Leads aV R and V 1 is shown in two patients. 4. 4. Evidence is presented that these prominent R waves occur in either antero- or posterolateral wall myocardial infarction and that the infarct must be large in ratio to the remaining myocardium. 5. 5. The spatial vectorcardiogram clearly explains the reason for the prominent R waves and the concept of cardiac rotation need not be involved.

SUMMARY 1) The resting cardiac output of patients with mitral stenosis is normal, and does not decrease until the onset of heart failure. 2) Pressure levels are more critical than flow levels in estimating the function of the right heart. 3) The most adequate picture of the right ventricular function is obtained from an analysis of pulmonary resistance and of the work of the right ventricle. 4) Patients who are most likely to benefit from mitral commissurotomy are those with high pulmonary artery pressures. 5) The degree of fall of the pulmonary artery pressure following commissurotomy is roughly parallel to the degree of clinical improvement in the few cases studied. 6) Patients with very low pulmonary artery pressures are not benefited by mitral commissurotomy and such low initial pressures may be present in patients with low grade rheumatic myocarditis. 7) Comparison of pre- and postoperative catheterization findings is the only critical method of evaluating results of mitral commissurotomy and should be further pursued. We wish to acknowledge the technical assistance of Mrs. Helen Obernolte, Dr. Andrew Farr, Miss Mary Mayo and Mr. Lucius Collier.

1.1. Ten proven and seven presumptive cases with atrial septal defects have been presented. 2.2. The importance of catheterization of the left auricle is emphasized, together with the differential diagnosis of atrial septal defect from transposed pulmonary veins. 3.3. A rise of oxygen content in the right atrium in comparison to the oxygen content of the superior vena cava is not necessarily present in proven atrial septal defects. 4.4. The cause for cyanosis in atrial septal defect lies primarily in the presence of a right to left shunt. 5.5. The direction of shunt is determined by the pressure gradient between the atria during the cardiac cycle. 6.6. Pulmonary vascular disease may contribute to the pulmonary resistance but is not a significant factor in the production of cyanosis.

Cardiovascular findings are described in seven children with sickle cell anemia. Clinically the following features were noted: (1) exertional dyspnea and fatigue; (2) wide fixed splitting of the second heart sound; (3) third “filling” heart sound in five of the seven cases; (4) systolic murmur of grade II intensity or louder, most prominent over the upper left sternal border; (5) roentgenographic evidence of diffuse cardiomegaly and increased pulmonary vascularity; (6) abnormal electrocardiograms in four cases. Laboratory findings of note were: (1) hemoglobins from 6.3 to 9.5 gm. per cent and hematocrit readings from 18 to 27 volumes per cent; (2) increased total blood volumes and plasma volumes in five of six patients. Right heart catheterizations in these patients revealed the following: (1) normal vena caval, right atrial, pulmonary artery and wedged pulmonary artery pressures; (2) normal or low pulmonary vascular resistances at rest and with exercise; (3) cardiac indices averaging twice normal; (4) increased stroke indices; (5) arterial oxygen unsaturation at rest and after breathing 100 per cent oxygen in all cases; (6) relatively small arteriovenous oxygen differences at rest and with exercise; (7) relatively high coronary sinus oxygen saturations; (8) an abnormal Valsalva response.

In 27 cases of endocarditis due to coagulase-positive Staphylococcus aureus, the mortality rate was 74%. The diversity of presenting symptoms and physical findings often gave little clue to the underlying illness. Failure to suspect the diagnosis early in the course of the disease may well have contributed to the high rate of mortality. The choice of the antibiotic which is most likely to prove effective is difficult to make early in the course of the disease, in view of the variable resistance of the staphylococci to antibiotics. It is recommended that a combination of antibiotics be given at the onset. The frequent repetition of blood cultures and sensitivity studies during the course of illness is of prime importance.

With the increasing incidence of primary atypical pneumonia in recent years it has become desirable to establish an etiologic diagnosis whenever possible. It is only during the past decade that this disease has come to be recognized as a definite clinical entity. Numerous reports concerning this condition are to be found in the current literature, most of which have come out of military establishments. Owen 1 reviewed the literature concerning primary atypical pneumonia and noted that over 1,750 cases had been reported from military posts since 1935. To these he added another 738 cases occurring at Scott Field during 1942. He also was able to find over 1,100 cases originating from civilian sources. It is significant that most of the reports available are concerned with epidemic outbreaks of the disease showing seasonal variations, being most frequent in the spring and late fall. Atypical pneumonia occurs in a sporadic form as

It is the purpose of this paper to review the factors related to the occurrence of rupture or perforation of the heart after myocardial infarction. Rupture of the heart has been recognized for over 300 years, and in recent times it has been the subject of thorough autopsy and clinical evaluation. The following salient facts have become established through previous investigations: 1. Such ruptures rarely occur in patients younger than 50 years of age.12. Patients who have unlimited activity after infarction occurs apparently have a higher incidence of rupture than those treated with "adequate" rest.23. Rupture associated with infarction almost universally occurs in the first few weeks following infarction; it rarely if ever occurs in an old scar.34. The chances of rupture occurring are three times greater in patients in whom hypertension persists after infarction than in those who have normal or subnormal blood