CONGENITAL HEART DISEASE—Comments Regarding Incidence and Natural History

The incidence of congenital heart disease is approximately 1 per cent of all live births. Approximately 60 per cent of patients who die of congenital heart disease do so at less than two years of age. Very few patients with such lesions live beyond 45 years at the very most. In about 70 per cent of patients who are born with cardiac anomalies, the lesions are either of kinds that are already being operated upon successfully or for which operations are now being attempted and often are helpful.     

CARDIAC CATHETERIZATION IN ADULT CONGENITAL HEART DISEASE—A Preliminary Report

The diagnosis of uncomplicated ventricular septal defect and uncomplicated patent ductus arteriosus presents few hazards. Differential diagnosis of atrial septal defect and of transposed pulmonary veins is technically more difficult. The complex nature of most types of cyanotic congenital heart disease requires the combined use of catheterization, determination of circulation times, ventilation studies, and possibly angiocardiography.Reports of eight cases in which cardiac catheterization was carried out illustrate the common forms of acyanotic and cyanotic heart disease and the factors in diagnosis.     

RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE—Incidence in California

The statistics quoted in this and other published reports appear to substantiate the impression that rheumatic fever in California, although still an important public health problem which varies widely from one locality to another, is of lower incidence and perhaps of more benign character than in most other parts of the United States. It also appears that in California aortic insufficiency may be of higher relative incidence and occurs more frequently as a clinically diagnosable sequel of rheumatic fever than does classical mitral stenosis. Congenital defects of the heart constitute a large proportion of the cases of organic heart disease in children and young adults in this state.     

PULMONARY HEART DISEASE—A Panel Discussion

Abruptio placentae, in its severe form, causes the most hazardous type of third trimester bleeding. The severe grade may be accompanied by systemic effects, some of which are potentially lethal. A knowledge of these, as well as a system of grading the severity in terms of maternal risk, is essential to an understanding of therapy. Cases should be graded in severity from I to III on the basis of clinical factors. A delay in delivery, in Grade III, may result in an increased incidence of serious maternal complications. In Grade II, immediate cesarean section has reduced the fetal mortality rate.In managing Grade III premature separation of the placenta, the following steps should be carried out: (1) Laboratory study, including blood cross-matching and determination of plasma fibrinogen; (2) vaginal examination to confirm the diagnosis and to rupture of the membranes; (3) indicated therapy of systemic effects with fresh whole blood and fibrinogen, before considering any operative delivery; (4) election of a mode of delivery which will terminate the pregnancy in less than about six hours after onset of separation; this will frequently be cesarean section; (5) careful attention to postpartum care to avoid shock and renal failure.In Grade II, the same principles of therapy obtain. If the fetal heart tones are present, however, and vaginal delivery is not imminent, immediate cesarean section is justified. Complete conservatism, with vaginal delivery, is recommended in Grade I.     

ANTICOAGULANT THERAPY IN HEART DISEASE—A Summary of the Literature

Considerable experience by many independent workers with the use of anticoagulants in the treatment of certain types of heart disease has shown that such therapy reduces significantly the incidence of thromboembolic complications and, largely through this effect, the morbidity and mortality rate from heart disease of these types.This is certainly established in acute coronary occlusion with myocardial infarction and in those instances of rheumatic heart disease with auricular fibrillation in which repeated embolic phenomena have occurred. The case for the administration of the anticoagulants in congestive heart failure is less secure, although there is no doubt that the number of thromboembolic complications is reduced by use of them.The administration of the anticoagulants requires considerably more exacting attention than does the administration of the majority of therapeutic agents in use commonly today. Hence, it is suggested that the use of anticoagulants in heart disease be restricted to those instances in which the indications are clear and facilities are compatible with the efficient and safe use of the drug, whether Dicumarol or heparin.     

CONGENITAL CARDIAC DEFECTS—Indications for Surgical Repair

The optimum ages for the operative repair of the various congenital defects have not as yet been definitely established. With certain exceptions, it has generally been the authors'' preference to delay elective operations until after the age of 18 months. In the usual case, the optimum age for the closure of septal defects is believed to be three to five years. Operative relief of stenosis of the aortic or pulmonic valves, however, is related entirely to the extent of the obstruction, age not being a factor. Although the surgical treatment of coarctation of the aorta is probably best delayed beyond the period of infancy, it is the authors'' belief that in the presence of extreme hypertension, cardiomegaly or cardiac failure, early resection of the aortic block should be accomplished. As to the treatment of tetralogy of Fallot, the authors'' policy is to delay operation until such time as definitive repair becomes less hazardous. Patients with severe symptoms, however, are given the benefit of some form of operative relief as soon as possible. Whether this is palliative or corrective depends upon the characteristics of the individual case.Definitive diagnostic studies are of great aid in assessing the urgency of operative intervention. The fact that approximately one-third of the patients dealt with required operation at less than 18 months of age suggests that, in selected cases, these studies should be performed early in infancy.     

TRAUMA OR STRAIN AND HEART DISEASE—Causal Relationship

Myocardial infarction and coronary insufficiency are the common conditions involved in workmen''s compensation cases based on allegations of cardiac injury. Since coronary disease tends to be a progressive process, punctuated by sudden accidents, it is difficult to determine when a given stress at work may have had a significant effect in producing an infarction. Though there are gaps in our knowledge, considerable information is available indicating the way in which effort or stress may produce a myocardial infarction.Certain states have taken steps to develop more uniformity of medical opinion regarding causal relationship of stress to heart disease, and in other ways have attempted to improve the application of workmen''s compensation laws in an attempt to provide fair and prompt compensation to those injured by their work but to discourage abuses of these laws.     

PHARYNGOESOPHAGEAL DIVERTICULA—Surgical Treatment

A series of 75 cases of pharyngoesophageal diverticula observed at the University of California Hospital between 1920 and 1955 was reviewed. In 64 cases surgical repair by either a one-stage or two-stage operation was carried out. Comparison of the results by both methods appears to justify the opinion that pharyngoesophageal diverticula should be repaired in one stage in practically all instances.     

CONGENITAL ABNORMALITIES—The Timing and Management of Surgical Reconstruction in Infancy and Childhood

The proper timing of corrective and reconstructive surgical operations for the management of congenital abnormalities in infancy and childhood is exceptionally important. Although no hard and fast rules apply, each deformity should be evaluated in the light of specific features of local and general relationship. Correlation to growth and development must be stressed as an important feature. Evaluation of the congenital abnormality in the light of its many relationships provides for a basis of better complete handling, follow-up, and ultimate result with the aim directed toward elimination of tumor threat, restoration of function and esthetic improvement.     

LIPOPROTEINS AND DIET IN CORONARY HEART DISEASE—A Five-Year Study

In a follow-up study for a five-year period of 351 patients with myocardial infarction and 119 patients with angina pectoris, the following observations were made:(a) The previously reported lipoprotein atherogenic index elevation in coronary heart disease was confirmed.(b) The prognosis in angina pectoris is strikingly and significantly worse when the lipoprotein atherogenic index is high.(c) Patients who died in the follow-up period showed significantly higher atherogenic index values than those who survived.(d) The lipoprotein atherogenic index measure is much superior to the serum cholesterol measurement as an indicator of the lipid disorder in coronary disease.(e) The low fat, low cholesterol diet is effective in maintaining chronically lowered lipoprotein atherogenic index values.(f) In patients who said they did not adhere to a low fat, low cholesterol diet, the recurrence and death rate was four times as high as in patients who stated they adhered to the diet.     

PERIPHERAL NERVE INJURIES—Early Surgical Treatment

Injuries to the major nerves of the extremities are common.Surgical treatment should be undertaken soon after injury that completely or partly severs a peripheral nerve, because permanent changes appear in muscles that are deprived of nerve supply for more than a few months. The muscular changes may prevent restoration of normal function even though actual nerve regeneration is adequate.Injuries which do not completely sever a nerve may be hard to diagnose but special methods such as electromyography are helpful.     

POST-TUBERCULOUS BRONCHIECTASIS—Indications for Surgical Treatment

Two hundred twelve of 308 post-tuberculous patients were found to have significant bronchiectasis; and in 105 of them, in whom certain symptoms or combinations of symptoms and conditions were observed, resectional operations were carried out. Good results were obtained in 81 per cent of the group. There were serious complications in 13 per cent. Three of the patients died, two after pneumonectomy, one after lobectomy plus segmental excision.     

DIVERTICULITIS OF THE COLON—Surgical Treatment

Appropriate surgical treatment of diverticulitis of the colon can result in a highly satisfactory proportion of permanent cures, with an operative mortality of 2 to 5 per cent.Colostomy is a valuable emergency procedure for the control of severe infection or the relief of obstruction but is not a satisfactory definitive treatment for the cure of diverticulitis. Definitive surgical treatment requires resection of the involved segment of colon.Three indications for surgical intervention in “uncomplicated” diverticulitis are: (1) continued or repeated attacks, (2) persistent deformity as seen by x-ray examination, and (3) persistent blood in the stools.Although a three-stage operation is usually considered a safer procedure, one-stage resections may be safely and satisfactorily employed in many instances.