Biomedical subjects
Publications and source records attributed to R J Hall.
A patient is presented in whom rupture of a bronchial artery aneurysm produced a clinical picture indistinguishable from an aortic dissection. This case emphasises the importance of considering alternative diagnoses when a patient presents with symptoms typical of a particular condition.
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Recognition of thrombosis of a Björk-Shiley aortic valve prosthesis 4 years after insertion in a patient was based upon sudden clinical deterioration, loss of prosthetic sounds, and development of new stenotic and regurgitant murmurs. Thrombotic fixation was confirmed by diagnostic alterations on the echocardiogram. All manifestations reverted to normal after successful surgical debridement of the prosthesis. Echocardiography is a valuable noninvasive adjunct in the differential diagnosis of prosthetic valve malfunction.
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Among 3,707 patients who underwent aortocoronary bypass, 302 had preinfarction angina. Coronary angiography revealed single-vessel disease in 43 patients, double-vessel disease in 81, and triple in 178 patients. Plane ventriculography showed contractility to be normal in 178 patients, fair in 88, and poor in 36 patients. Left ventricular end-diastolic pressure was normal in 203 patients, 13 to 23 mm Hg in 73, and larger than or equal to 24 mm Hg in 26 patients. Using cardiopulmonary bypass and moderate hypothermia, single coronary bypass was performed in 45 patients, double bypass in 120 patients, triple in 118 patients, quadruple in 15, and quintuple in 4 patients. Right coronary artery endarterectomy was necessary in 22 patients. The early mortality was 6.6% (20 patients) and was strongly related to poor contractility and congestive heart failure. One- to four-year follow-up data were obtained in 126 patients. Late myocardial infarction occurred in 11 patients and caused 4 late deaths; 3 unrelated deaths occurred. Ten patients experienced no benefit from their operations, 56 are completely asymptomatic, and 53 are significantly improved. Our results show that surgical intervention can improve the poor prognosis of preinfarction angina and appears to be superior to medical treatment.
In order to evaluate results of surgical repair of secundum atrial septal defect (ASD) in patients 60 years of age or older, a review was made of 16 patients who had undergone such operation between January 1964 and December 1974. Before operation eight patients were in functional classification III (New York Heart Association), seven were in class II, and one was in class I. Twelve patients had a left-to-right shunt greater than 3:1. Pulmonary artery systolic pressure was greater than 40 mm Hg in 12 patients and greater than 60 mm Hg in five. Four patients had documented paradoxical emboli and were being treated with Coumadin. Before operation all patients but one were receiving digoxin. Repair was accomplished by direct suture in two patients and Dacron patch graft in 14. No deaths occurred during the postoperative period. Postoperatively, ten patients were in class I, five in class II, and one remained in class III. The hospital stay ranged from eight to 20 days (average 11 days). Two patients died one year and another (at the age of 77) five years after surgery. The remaining 13 patients are alive and well three months to 11 years after surgery. We conclude that repair of secundum ASD in patients over the age of 60 is safe, has low morbidity, and produces considerable clinical improvement.
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In two patients with severe painful sickle cell crisis and a deteriorating clinical course, recovery coincided with large-scale exchange transfusions (6 liters). The one patient, with sickle cell beta thalassemia, achieved a 90% exchange, calculated on the sickle cell hemoglobin present before and after transfusion. The other patient, with sickle cell hemoglobin Hb A, S, and (Hb) C disease, also achieved an 80% exchange calculated on the level of HbA.S. AND C in samples before and after transfusion.
Treadmill exercise test results were studied in 93 patients with chest pain who had received digitalis therapy or had nonspecific ST-T changes in the resting electrocardiogram. Results of the treadmill test were correlated with the findings of coronary angiography. A positive treadmill result was defined as horizontal or down-sloping ST segment depression greater than or equal to 1.0 mm. Of the 40 patients with no or insignificant coronary artery disease, 15 had taken digitalis; 4 of the 15 demonstrated a positive response on the treadmill test. Of the 53 patients with coronary artery disease, 21 had taken digitalis; 15 of the 21 displayed a positive response. Among the remaining 32 not on digitalis, 20 had a positive response. The specificity of the treadmill exercise test was 96% in patients with coronary artery disease not on digitalis and whose resting electrocardiogram showed nonspecific ST changes. The specificity of the treadmill test in patients who had received digitalis was 73%. Sensitivity was 63% and 71%, respectively. By utilizing more stringent criteria in the interpretation of the treadmill exercise test (greater than or equal to 1.5 mm ST depression), among the patients on digitalis only 6.7% (1/15) with normal coronary arteries and 48% (10/21) with coronary artery disease had a positive response. With the use of the latter criterion the test was specific in 93% (14/15) of the patients and is usually indicative of coronary artery disease.
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Extensive serum lipid analyses, with specific emphasis on the concentration of serum beta and pre-beta-lipoproteins, were made on 93 patients who had a clinical diagnosis of angina pectoris and were undergoing coronary angiographic studies. Those individuals with abnormal angiographic evidence of obstructive coronary artery disease, including a group with a prior myocardial infarction, have almost uniformly elevated serum beta-lipoprotein levels when related to an arbitrary division based on the mean values for a "normal" adult population at a similar age level. Compared to serum cholesterol and serum triglycerides, the serum lipoprotein concentrations, specifically beta-lipoproteins, appear to be a more useful parameter for predicting the existence of coronary artery disease. Further studies relating clinical risk factors to coronary artery disease might be better approached by using angiography of coronary vessels rather than myocardial infarction or sudden death from coronary artery disease as an endpoint of morbid data.
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