Digoxin did not reduce overall mortality, but it reduced the rate of hospitalization both overall and for worsening heart failure. These findings define more precisely the role of digoxin in the management of chronic heart failure.

SUMMARY Physiologic changes in the circulatory system caused by performing the Valsalva maneuver are blunted or absent in patients with congestive heart failure. Previously there has been no noninvasive method for examining cardiac chamber size during this maneuver. M-mode echocardiography was used to evaluate possible changes in cardiac chamber dimensions in 12 normal subjects (group I) and 15 patients with cardiovascular disease (group II). In group I, the left ventricular end-diastolic dimension decreased 11.2% (±1.5%) and the end-systolic dimension 9.5% (±1.32%), with a fall in stroke volume of 29%. The left atrial (LA) dimension decreased 30%.THE VALSALVA MANEUVER, raising intrathoracic pressure against a closed glottis ("forced expiration"),1 and the Mueller maneuver, reducing intrathoracic pressure behind a closed glottis ("forced inspiration"),2 have been used in the investigation of cardiovascular hemodynamics and autonomic nervous system function.2 4 Both produce marked hemodynamic changes, resulting in widespread alterations in the central and peripheral circulation. Disease states alter these responses.5 The echocardiogram permits the noninvasive determination of an internal dimension of the left atrium, aorta, and left ventricle. We investigated the echocardiogram during the Valsalva and Mueller maneuvers in normal volunteers and in patients with heart disease to determine the change in cardiac chamber size that such maneuvers might produce and the correlation of this change with abnormalities of cardiovascular function. MethodsTwenty men and seven women were studied. Group I was composed of 12 normal subjects (age range 21 to 58 years, mean = 32) who had no history of cardiovascular or other disease. These subjects were chosen from a group of 24 volunteers because they had satisfactory ventricular and atrial echograms throughout the Valsalva maneuver. Group II consisted of 15 patients (19 to 65 years, mean = 47) admitted to Vanderbilt University Hospital for cardiac evaluation and included patients with ischemic heart disease, aortic stenosis, mitral regurgitation, mitral stenosis and one with severe hypertension. These patients (excepting the hypertensive patient) underwent cardiac catheterization within one week of the study described below. Their The Valsalva and Mueller maneuvers were calibrated using a standard mouthpiece connected in parallel to a graduated manometer and a Statham transducer. The manometer displayed the positive or negative pressure generated by the patient and was placed in view of the patient so that he could maintain the desired pressure. The pressure generated was recorded on the echocardiogram (via a pulse amplifier) or the time during which it was maintained was marked by a separate observer using a marker channel on the strip chart recorder. All subjects were thoroughly instructed and practiced each maneuver several times. Movement and tension of the thoracic and abdominal musculature were observed to ensure valid performance.Left atrial diameter was measured as an...

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Some 23 years have passed since the suggestion was first made that the symptoms of constrictive pericarditis might yield to surgical treatment (Volhard and Schmieden, 1928). This interval has ripened judgment on the effects of this therapeutic procedure, and it is now opportune to pass opinion on the value of the operation and on other aspects of the condition, especially its atiology, distinctive physical signs, and the meaning of certain cardiographic and cardioscopic appearances. These are described in the light of our experience with 30 patients who have undergone surgical treatment.The series was made up of 26 males and 4 females. The youngest patient was 11 years of age and the oldest 63; there were 6 in the second decade, 7 in the third, 3 in the fourth, 6 in the fifth, 7 in the sixth, and 1 was over sixty years of age. AETIOLOGY AND PATHOLOGYWhite (1935) and Harrison and White (1942), reporting on the progress of 1500 patients with rheumatic heart disease, found among them no instance of constrictive pericarditis. In one of our patients mitral stenosis was found side by side with constrictive pericarditis (Jackson, 1950). This one example does not justify the view that constrictive pericarditis is a rheumatic condition, and we have regarded the association as fortuitous in this patient. Apart from the rarity of mitral stenosis in constrictive pericarditis-one reported case and one in our series-the relative sex incidence of 26 males and 4 females, opposes the suggestion that the pericardial condition may have a rheumatic origin in that mitral stenosis is much commoner in women. A history of rheumatic fever was obtained in two patients only. Acute pericarditis occurred in five, and in four of them it preceded the development of signs of constriction by only a matter of months; in the fifth the attack of pericarditis happened 23 years before.We bring evidence from our cases to support the view that constrictive pericarditis is the outcome of a tuberculous infection. In four there was active tuberculosis in a close relative and in a fifth, in the family where the patient lodged; in a sixth case the patient's father had a deformed spine from Pott's disease. Involvement of the pleura was common and four gave a history of pleurisy, though in none was it proved bacteriologically to be tuberculous in nature; there was a large effusion on the right side in four cases. Pleural thickening was met with on the right side in seven,'on the left in one, and on both sides in six. Evidence of tuberculosis was found in four patients who did not undergo operative treatment and for that reason are not included in this series; in one there was fibrosis of lungs and in another active pulmonary tuberculosis; tuberculous glands were confirmed at biopsy in a third, and in a fourth there was tuberculous infection of the elbow joint. In another three patients, treated surgically and therefore included in this series, there was substantial evidence that tuberculosis had caused the infection: in one dissemination of tuberculosis in t...