One hundred patients were evaluated 12 to 43 months after saphenous vein bypass surgery. The rate of progression of obstructive disease in the native vessels and changes in collateral circulation were analyzed in detail. Fifty-five per cent of preoperatively patent vessels showed progression proximal to the site of graft insertion, 40%, proximal to patent grafts; there was distal progression in only 7% of grafted vessels. The progression rate for nongrafted vessels was 14%. Patent grafts were associated with a high rate of disappearance of collaterals to the grafted vessels, while occluded grafts were associated with preservation of collaterals or appearance of new collaterals. Progression of obstructive disease in the native circulation and changes in collaterals did not prevent symptomatic improvement (93% of patients were symptomatically improved).

In 14 subiects with severe cardiogenic shock the characteristic findings before treatment were hypotension, low cardiac output, and increased central venous pressure, with normal values for total peripheral resistance. Oliguria, lactic acidosis, hypocapnia. and hypoxemia also were present. These changes were interpreted as reflecting acute heart failure in association with a peripheral vascular response which was inadequate to maintain normal blood pressure. Isoproterenol caused a decrease in venous pressure and an increase in cardiac output. In most cases this was sufficient to increase blood pressure, despite slight reductions in peripheral vascular resistance. In a few cases, however, the inotropic effect of the drug was so small that the reduction in vascular resistance caused a further fall in arterial pressure. Metaraminol caused elevation of

Thirty-eight patients with a mean age of 53.2 years (19 to 75 years of age), who were receiving doxorubicin (D) for malignant disease, were studied in order to determine the relationship between functional and morphologic myocardial changes at different dose levels. Serial patient evaluations included physical examination, chest x-ray, electrocardiogram (ECG), endomyocardial biopsy (EMB), and rest-exercise gated nuclear angiography (GNA), at doses of D ranging from 144 to 954 mg/m2 (mean, 426 mg/m2). Physical examination, chest x-ray, and ECG proved to be insensitive predictors of D cardiotoxicity. Correlation of GNA and EMB in 31 patient evaluations, exclusive of known heart disease, did not reveal any false-positive angiograms, and all abnormal GNAs were associated with abnormal biopsies. Use of stress GNA uncovered six abnormal ventricles which could have been missed with a rest GNA alone. It has been suggested that: (1) GNA is a reliable monitor of D therapy; (2) an exercise study should be performed when the rest ejection fraction is normal, but is unnecessary when the rest EF is abnormal; (3) all patients with a resting ejection fraction of less than 45%, exclusive of other cardiac disease, should have D discontinued; and (4) endomyocardial biopsy is useful in assessing D cardiotoxicity in patients with other possible causes of an abnormal GNA.

Right ventricular (RV) performance during supine bicycle exercise was evaluated by gated equilibrium nuclear angiography in 19 clinically well children with d-transposition of the great arteries (d-TGA), 6.4 +/- 2.7 years after Mustard's operation. Comparisons were made between rest and peak exercise. The mean resting ejection fraction was 44 +/- 12% (range 30-75%) and was unchanged at peak exercise. Eight children had a normal ejection fraction response, whereas 11 children had either no increase or a decrease in ejection fraction. Relative end-diastolic volumes decreased from resting values in all patients who had an abnormal ejection fraction response. Among patients whose ejection fraction increased, the end-diastolic volume increased in three, decreased in four and was unchanged in one at peak exercise. Heart rate increased 84% (range 52-135%) and systolic blood pressure increased 16% (range 0-28%) at peak exercise. There was no correlation between exercise response and age at surgery or interval since surgery. These data indicate that clinically well children after Mustard's procedure may have abnormal right ventricular function under stress, raising concerns about the ability of the right ventricle to function as the systemic ventricle.

Thirty-five patients with atrioventricular (AV) discordance underwent repair of major intracardiac defects. Ventricular septal defect (VSD) was the most frequently encountered lesion, present alone or in combination with other lesions in 86% of these patients. Pulmonary stenosis (51%) and tricuspid insufficiency (37%) were the other lesions encountered.

HUCKELL, VICTOR F. M.D., F.R.C.P. (C); STANILOFF, HOWARD M. M.D., F.R.C.P. (C); FEIGLIN, DAVID H. M.B.B.S., F.R.C.P. (C); FLINTOFT, VIRGINIA R.N.; MORCH, JOHN E. M.D., F.R.C.P. (C) Author Information