Anesthesia for Patients with Valvular Heart Disease

  • Carol L. Lake

Abstract

In patients with valvular heart disease, cardiovascular stability will depend on the determinants of cardiac output—namely, heart rate, preload, afterload, and myocardial contractility—as well as the cardiac rhythm and myocardial oxygen balance. In anesthetizing patients with valvular disease, the anesthesiologist must consider the pathophysiologic effects of the disease process, compensatory cardiovascular changes, and the effects of anesthetic agents and techniques on both processes. Compensatory mechanisms for the loss of forward stroke volume include:
  1. 1.

    Increased preload (Frank-Starling mechanism);

     
  2. 2.

    Ventricular hypertrophy; and

     
  3. 3.

    Increased sympathetic activity.

     

Keywords

Catheter Ischemia Diazepam Fentanyl Lidocaine 

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References

  1. 1.
    Abbasi AS, De Cristofaro D, Anabtawi J, Irwin L: Mitral valve prolapse: Comparative value of M-mode, 2-dimensional and Doppler echocardiography. J Am Coll Cardiol 2:1219–1223, 1983.PubMedGoogle Scholar
  2. 2.
    Abellman WH: Treatment of congestive cardiomyopathy. Postgrad Med J 54:477–484, 1978.Google Scholar
  3. 3.
    Abinader EC: Adrenergic beta-blockade and EKG changes in systolic click murmur syndrome. Am Heart J 91:297–302, 1976.PubMedGoogle Scholar
  4. 4.
    Adelman AG, Wigle ED, Ranganathan N, Webb GD, Kidd BSL, Bigelow WG, Silver MD: The clinical course in muscular subaortic stenosis: A retrospective and prospective study of 60 hemodynamically proved cases. Ann Intern Med 77:515–525, 1972.PubMedGoogle Scholar
  5. 5.
    Ahn A J, Segal BL: Isolated tricuspid insufficiency: Clinical features, diagnoses, and management. Prog Cardiovasc Dis 9:166–193, 1966.PubMedGoogle Scholar
  6. 6.
    Barnett HJM, Boughner DR, Taylor DW, Cooper PE, Kostuk WJ, Nichol PM: Further evidence relating mitral valve prolapse to cerebral ischemic events. N Engl J Med 302:139–144, 1980.PubMedGoogle Scholar
  7. 7.
    Bolen JL, Alderman EL: Hemodynamic consequences of afterload reduction in patients with chronic aortic regurgitation. Circulation 53:879–883, 1976.PubMedGoogle Scholar
  8. 8.
    Bonchek LI: Indications for surgery of the mitral valve. Am J Cardiol 46:155–158, 1980.PubMedGoogle Scholar
  9. 9.
    Bonow RO, Rosing DR, Mcintosh CL, Jones M, Marón BJ, Gordon Lan KK, Lakatos E, Bacharach SL, Green MV, Epstein SE: The natural history of asymptomatic patients with aortic regurgitation and a normal left ventricular function. Circulation 68:509–517, 1983.PubMedGoogle Scholar
  10. 10.
    Borgenhagen DM, Serur JR, Gorlin R, Adams D, Sonnenblick EH: The effects of left ventricular load and contractility on mitral regurgitant orifice size and flow in the dog. Circulation 56:106–113, 1977.PubMedGoogle Scholar
  11. 11.
    Boudoulas H, Reynolds JC, Mazzaferri E, Wooley CF: Mitral valve prolapse syndrome: The effect of adrenergic stimulation. J Am Coll Cardiol 2:638–644, 1983.PubMedGoogle Scholar
  12. 12.
    Bowers JR: Anesthesia and cardiomyopathies: Report of two cases. Anesth Analg 50:1013–1016, 1971.PubMedGoogle Scholar
  13. 13.
    Braunwald E, Frahm CJ: Studies on Starling’s law of the heart: IV. Observation on the hemodynamic function of the left atrium in man. Circulation 24:633–642, 1961.Google Scholar
  14. 14.
    Braunwald NS, Ross J, Morrow AG: Conservative management of tricuspid regurgitation in patients undergoing mitral valve replacement. Circulation 35:(suppl 1):63–69, 1967.Google Scholar
  15. 15.
    Buckberg G, Eber L, Herman M, Gorlin R: Ischemia in aortic stenosis: Hemodynamic prediction. Am J Cardiol 35:778–784, 1975.PubMedGoogle Scholar
  16. 16.
    Bulkley BH, Hutchins GM: Atrial myxomas: A fifty year review. Am Heart J 97:639–643, 1979.PubMedGoogle Scholar
  17. 17.
    Cha SD, Gooch AS: Diagnosis of tricuspid regurgitation. Arch Intern Med 143:1763–1768, 1983.PubMedGoogle Scholar
  18. 18.
    Cha SD, Maranhao V, Lingamneni R, Goldbery H: A new technique: Right ventriculography using a preshaped catheter. Cathet Cardiovasc Diagn 4:311–316, 1978.PubMedGoogle Scholar
  19. 19.
    Cleveland DC, Westaby S, Karp RB: Treatment of intra-atrial cardiac tumors. JAMA 249:2799–2802, 1983.PubMedGoogle Scholar
  20. 20.
    Cohn JN, Franciosa JA: Vasodilator therapy of cardiac failure. N Engl J Med 297:27–31, 1977.PubMedGoogle Scholar
  21. 21.
    Cortese DA: Pulmonary function in mitral stenosis. Mayo Clin Proc 53:321–326, 1978.PubMedGoogle Scholar
  22. 22.
    Crexells C, Aerichide N, Bonny Y, Lepage G, Campeau L: Factors influencing hemolysis in valve prosthesis. Am Heart J 84:161–170, 1972.PubMedGoogle Scholar
  23. 23.
    Criley JM: Prolapse mitral leaflet could be most common valve disorder. JAMA 239:687–688, 1978.Google Scholar
  24. 24.
    Criteria Committee of the New York Heart Association: Nomenclature and criteria for diagnosis of disease of the heart and great vessels. Boston, Little Brown & Co, 1979, pp 257–268.Google Scholar
  25. 25.
    Currey GC, Elliot LP, Ramsay HW: Quantitative left ventricular angiocardiographic findings in mitral stenosis: Detailed analysis of the anterolateral wall of the left ventricle. Am J Cardiol 29:621–627, 1972.Google Scholar
  26. 26.
    Desousa AL, Muller J, Campbell RL, Batnitzky J, Rankin L: Atrial myxoma: A review of the neurological complications, metastasis, and recurrences. J Neurol Neurosurg Psychiatry 41:1119–1124, 1978.PubMedGoogle Scholar
  27. 27.
    Dexter L: Pulmonary vascular disease in acquired and congenital heart disease. Arch Intern Med 139:922–928, 1979.PubMedGoogle Scholar
  28. 28.
    Dhadphale PR, Jackson APF, Alseri S: Comparison of anesthesia with diazepam and ketamine vs. morphine in patients undergoing heart-valve replacement. Anesthesiology 51:200–203, 1970.Google Scholar
  29. 29.
    Dodge HT, Kennedy JW, Peterson JL: Quantitative angiocardiographic methods in the evaluation of valvular heart disease. Prog Cardiovasc Dis 16:1–23, 1973.PubMedGoogle Scholar
  30. 30.
    Dubroff JM, Clark MB, Wong CYH, Spotnitz AJ, Collins RH, Spotnitz HM: Left ventricular ejection fraction during cardiac surgery: A two dimensional echocardiographic study. Circulation 68:95–103, 1983.PubMedGoogle Scholar
  31. 31.
    Ellison RG, Brown WJ, Yeh TJ, Hamilton WF: Surgical significance of acute and chronic pulmonary valvular insufficiency. J Thorac Cardiovasc Surg 60:549–558, 1970.PubMedGoogle Scholar
  32. 32.
    Epstein SE, Henry WL, Clark CE, Roberts WC, Maron BJ, Ferrans VJ, Redwood DR, Morrow AG: NIH conference: Asymmetric septal hypertrophy. Ann Intern Med 81:650–680, 1974.Google Scholar
  33. 33.
    Fisher M, Budnitz E: Focal cerebral ischemia and mitral valve prolapse in monozygotic twins. Arch Intern Med 143:2180–2181, 1983.PubMedGoogle Scholar
  34. 34.
    Fowler NO, van der Bel-Kahn JM: Operations on the mitral valve: A time for weighing the issues. Am J Cardiol 46:159–162, 1980.PubMedGoogle Scholar
  35. 35.
    Frank S, Braunwald E: Idiopathic hypertrophic subaortic stenosis: Clinical analysis of 126 patients with emphasis on the natural history. Circulation 37:759–788, 1968.PubMedGoogle Scholar
  36. 36.
    Gaffney FA, Bastran BC, Lane LB, Taylor WF, Horton J, Schutte JE, Graham RM, Pettinger W, Bloomquist CG: Abnormal cardiovascular regulation in the mitral valve prolapse syndrome. Am J Cardiol 52:316–320, 1983.PubMedGoogle Scholar
  37. 37.
    Gault JH, Covell JW, Braunwald E, Ross J: Left ventricular performance following correction of free aortic regurgitation. Circulation 42:773–780, 1970.PubMedGoogle Scholar
  38. 38.
    Goldman L, Caldera D, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE: Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297:845–850, 1977.PubMedGoogle Scholar
  39. 39.
    Goodwin JF: Congestive and hypertrophic cardiomyopathies. Lancet 1:731–739, 1970.Google Scholar
  40. 40.
    Goodwin JF, Hollman A, Cleland WP, Teare D: Obstructive cardiomyopathy simulating aortic stenosis. Br Heart J 22:403–414, 1960.PubMedGoogle Scholar
  41. 41.
    Gorlin R, Gorlin SG: Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves, and central circulating shunts. Am Heart J 41:1–29, 1951.PubMedGoogle Scholar
  42. 42.
    Gorlin R, McMillan IKR, Medd WE, Matthews, MB, Daley R: Dynamics of the circulation in aortic valvular disease. Am J Med 18:855–870, 1955.PubMedGoogle Scholar
  43. 43.
    Gottdiener JS, Borer JS, Bacharach SL, Green MV, Epstein SE: Left ventricular function in mitral valve prolapse: Assessment with radionuclide cineangiography. Am J Cardiol 47:7–14, 1981.PubMedGoogle Scholar
  44. 44.
    Herr RH, Starr A, Pierie WR, Wood JA, Bigelow JC: Aortic valve replacement. Ann Thorac Surg 6:199–218, 1968.PubMedGoogle Scholar
  45. 45.
    Hilgenberg JC, McCammon RL, Stoelting RK: Pulmonary and systemic vascular resistance responses to nitrous oxide in patients with mitral stenosis and pulmonary hypertension. Anesth Analg 59:323–326, 1980.PubMedGoogle Scholar
  46. 46.
    Hsu HO, Hickey RF, Forbes AR: Morphine decreases peripheral vascular resistance and increases capacitance in man. Anesthesiology 50:98–102, 1979.PubMedGoogle Scholar
  47. 47.
    Ingram RH, Szidon JP, Skalak R, Fishman AP: Effects of sympathetic nerve stimulation on the pulmonary arterial tree of the isolated lobe perfused in situ. Circ Res 22:801–815, 1968.PubMedGoogle Scholar
  48. 48.
    Jeresaty RM: Mitral Valve Prolapse. New York, Raven Press, 1979, pp 19–37.Google Scholar
  49. 49.
    Johnson LW, Grossman W, Dalen JE, Dexter L: Pulmonic stenosis in the adult: Long-term follow-up results. N Engl J Med 287:1159–1163, 1972.PubMedGoogle Scholar
  50. 50.
    Johnson RA, Palacios I: Dilated cardiomyopathies of the adult. N Engl J Med 307:1051–1058, 1983.Google Scholar
  51. 51.
    Josephson ME, Horowitz LN, Kastor JA: Paroxysmal supraventricular tachycardia in patients with mitral valve prolapse. Circulation 57:111–115, 1978.PubMedGoogle Scholar
  52. 52.
    Judge TP, Kennedy JW, Bennett LJ, Wills RE, Murray JA, Blackmon JR: Quantitative hemodynamic effects of heart rate in aortic regurgitation. Circulation 44:355–367, 1971.PubMedGoogle Scholar
  53. 53.
    Hancock EW: Aortic stenosis, angina pectoris, and coronary artery disease. Am Heart J 93:382–393, 1977.PubMedGoogle Scholar
  54. 54.
    Kelly DT, Spotnitz HM, Beiser GD, Pierce JE, Epstein SE: Effects of chronic right ventricular volume and pressure loading on left ventricular performance. Circulation 44:403–412, 1971.PubMedGoogle Scholar
  55. 55.
    Kerber RE, Isaeff DM, Hancock EW: Echocardiographic patterns in patients with the syndrome of systolic click and late systolic murmur. N Engl J Med 284:691–693, 1971.PubMedGoogle Scholar
  56. 56.
    Kirklin JW, Pacifico AD: Surgery for acquired valvular heart disease. N Engl J Med 288:194–199, 1973.PubMedGoogle Scholar
  57. 57.
    Kirschbaum M, Germon P, Maranhao V, Cha SD, Lemole G: Ventricular function before and after mitral valve replacement. J Thorac Cardiovasc Surg 82:752–757, 1981.PubMedGoogle Scholar
  58. 58.
    Klein RC: Ventricular arrhythmias in aortic valve disease. Am J Cardiol 53:1079–1083, 1984.PubMedGoogle Scholar
  59. 59.
    Kolibash AJ, Bush CA, Fontana MB, Ryan JM, Kilman J, Wooley CF: Mitral valve prolapse syndrome: Analysis of 62 patients aged 60 years and older. Am J Cardiol 52:535–539, 1983.Google Scholar
  60. 60.
    Kopman EA: Intravenous verapamil to relieve pulmonary congestion in patients with mitral valve disease. Anesthesiology 58:374–376, 1983.PubMedGoogle Scholar
  61. 61.
    Kopman EA: Relief of pulmonary congestion by sublingual nitroglycerin in patients with mitral valve disease. Anesth Analg 58:143–144, 1979.PubMedGoogle Scholar
  62. 62.
    Kotler MN, Mintz GS, Panidis I, Morganroth J, Segal BL, Ross J: Noninvasive evaluation of normal and abnormal prosthetic valve function. J Am Coll Cardiol 2:151–173, 1983.PubMedGoogle Scholar
  63. 63.
    Krantz EM, Viljoen JF, Schermer R, Canas MS: Mitral valve prolapse. Anesth Analg 59:379–383, 1980.PubMedGoogle Scholar
  64. 64.
    Kuhn H, Breithardt G, Knierim H-J, Kohler E, Losse B, Seipel L, Loogen F: Prognosis and possible presymptomatic manifestations of congestive cardiomyopathy. Postgrad Med J 54:451–459, 1978.PubMedGoogle Scholar
  65. 65.
    Laver MB, Hallowell P, Goldblatt A: Pulmonary dysfunction secondary to heart diease: Aspects relevant to anesthesia and surgery. Anesthesiology 33:161–192, 1970.PubMedGoogle Scholar
  66. 66.
    Lee SJK, Jonsson B, Bevegard S, Karlof I, Astrom H: Hemodynamic changes at rest and during exercise in patients with aortic stenosis of varying severity. Am Heart J 79:318–331, 1970.PubMedGoogle Scholar
  67. 67.
    Lee WH, Fisher J: Right ventricular diastolic disorders. Arch Intern Med 143:332–337, 1983.PubMedGoogle Scholar
  68. 68.
    Liu HY, Panidis I, Soffer J, Dreifus LS: Echocardiography diagnosis of intracardiac myxoma: Present status. Chest 84:62–67, 1983.PubMedGoogle Scholar
  69. 69.
    Lynch CL, Rizor RF: Anesthetic management and monitoring of a parturient with mitral and aortic valvular disease. Anesth Analg 61:788–792, 1982.PubMedGoogle Scholar
  70. 70.
    Maille J-G, Byrda I, Paiement B, Boulanger M: Patients with cardiac valve prosthesis: Subsequent anaesthetic management for non-cardiac procedures. Can Anaesth Soc J 20:207–216, 1973.PubMedGoogle Scholar
  71. 71.
    McIlduff JB, Daggett WM, Buckley MJ, Lappas DG: Systemic and pulmonary hemodynamic changes immediately following mitral valve replacement in man. J Cardiovasc Surg 21:261–266, 1980.Google Scholar
  72. 72.
    Meaney E, Shabetai R, Bhargava V, Schearer M, Weidner C, Mangiardi LM, Smalling R, Peterson K: Cardiac amyloidosis, constrictive pericarditis and restrictive cardiomyopathy. Am J Cardiol 38:547–556, 1976.PubMedGoogle Scholar
  73. 73.
    Mehlman DJ: A guide to the radiographic identification of prosthetic heart valves: An addendum. Circulation 69:102–105, 1984.PubMedGoogle Scholar
  74. 74.
    Mehlman DJ, Resnekov L: A guide to the radiographic identification of prosthetic heart valves. Circulation 57:613–623, 1978.PubMedGoogle Scholar
  75. 75.
    Miller DH, Borer JS: The cardiomyopathies: A pathophysiologic approach to therapeutic management. Arch Intern Med 143:2157–2162, 1983.PubMedGoogle Scholar
  76. 76.
    Mills P, Rose J, Hollingsworth J, Amara I, Craige E: Long-term prognosis of mitral-valve prolapse. N Engl J Med 297:13–18, 1977.PubMedGoogle Scholar
  77. 77.
    Mond H, Hunt D, Sloman G: Haemodynamic effects of frusemide in patients suspected of having acute myocardial infarction. Br Heart J 36:44–53, 1974.PubMedGoogle Scholar
  78. 78.
    Morganroth J, Jones RH, Chen CC, Naito M: Two dimensional echocardiogram in mitral, aortic, and tricuspid valve prolapse. Am J Cardiol 46:1164–1177, 1980.PubMedGoogle Scholar
  79. 79.
    Nery LE, Wasserman K, French W, Oren A, Davis J A: Contrasting cardiovascular and respiratory responses to exercise in mitral valve and chronic obstructive pulmonary diseases. Chest 83:446–453, 1983.PubMedGoogle Scholar
  80. 80.
    Newman GE, Gibbons RJ, Jones RH: Cardiac function during rest and exercise in patients with mitral valve prolapse. Am J Cardiol 47:14–10, 1981.PubMedGoogle Scholar
  81. 81.
    Olsen EGJ: The pathology of idiopathic hypertrophic subaortic stenosis (hypertrophic cardiomyopathy): A critical review. Am Heart J 100:553–562, 1980.PubMedGoogle Scholar
  82. 82.
    Olsen EGJ: The pathology of cardiomyopathies: A critical analysis. Am Heart J 98:385–392, 1979.PubMedGoogle Scholar
  83. 83.
    Perloff JG, Ronan JA, deLeon AC: The effect of nitroglycerin on left ventricular wall tension in fixed orifice aortic stenosis. Circulation 32:204–213, 1965.PubMedGoogle Scholar
  84. 84.
    Peters MM, Hall RJ, Cooley DA, Leachman RD, Garcia E: The clinical syndrome of atrial myxoma. JAMA 230:695–700, 1974.PubMedGoogle Scholar
  85. 85.
    Pierpoint GL, Cohn JN, Franciosa JA: Congestive cardiomyopathy, Pathophysiology and response to therapy. Arch Intern Med 138:1847–1850, 1978.Google Scholar
  86. 86.
    Pierpoint GL, Talley RC: Pathophysiology of valvar heart disease. Arch Intern Med 142:998–1001, 1982.Google Scholar
  87. 87.
    Pluth JR, Ellis RH: Tricuspid insufficiency in patients undergoing mitral valve replacement: Conservative management, annuloplasty, or replacement. J Thorac Cardiouasc Surg 58:484–491, 1969.Google Scholar
  88. 88.
    Pocock W, Barlow J: Post-exercise arrhythmias in the billowing posterior mitral leaflet syndrome. Am Heart J 80:740–745, 1970.PubMedGoogle Scholar
  89. 89.
    Popp RL, Winkle RA: Mitral-valve prolapse syndrome. JAMA 236:867–870, 1976.PubMedGoogle Scholar
  90. 90.
    Price HL: Myocardial depression by nitrous oxide and its reversal by Ca++. Anesthesiology 44:211–215, 1976.PubMedGoogle Scholar
  91. 91.
    Procacci PM, Savran SV, Schreiter SL, Bryson AL: Prevalence of clinical mitral-valve prolapse in 1169 young women. N Engl J Med 294:1086–1088, 1976.PubMedGoogle Scholar
  92. 92.
    Rapaport E: Natural history of aortic and mitral valve disease. Am J Cardiol 35:221–227, 1975.PubMedGoogle Scholar
  93. 93.
    Reitan J A, Wright RG: The use of halothane in a patient with asymmetrical septal hypertrophy: A case report. Can Anaesth Soc J 29:154–156, 1982.PubMedGoogle Scholar
  94. 94.
    Rivero-Carvallo M: Signo para el diagnostico de las insufficiencias tricuspideas. Arch Instit Cardiol (Mex) 16:531–540, 1946.Google Scholar
  95. 95.
    Robin E, Thorns NW, Arbulu A, Ganguly SN, Magnisalis K: Hemodynamic consequences of total removal of the tricuspid valve without prosthetic replacement. Am J Cardiol 35:481–486, 1975.PubMedGoogle Scholar
  96. 96.
    Saint John Sutton MG, Saint John Sutton M, Oldershaw P, Sacchetti R, Paneth M, Lennox SC, Gibson RV, Gibson DG: Valve replacement without preoperative cardiac catheterization. N Engl J Med 305:1233–1238, 1981.Google Scholar
  97. 97.
    Saka DM, Marz GF: Management of a parturient with cardiac valve prosthesis. Anesth Analg 55:214–216, 1976.PubMedGoogle Scholar
  98. 98.
    Schlant RC, Nutter DO: Heart failure in valvular heart disease. Medicine (Baltimore) 50:421–451, 1971.Google Scholar
  99. 99.
    Selzer A: Present status of prosthetic cardiac valves. Arch Intern Med 143:1965–1967, 1983.PubMedGoogle Scholar
  100. 100.
    Semb BKH: Surgical considerations in the treatment of cardiac myxoma. J Thorac Cardiouasc Surg. 87:251–259, 1984.Google Scholar
  101. 101.
    Shappell SD, Marshall CE: Ballooning posterior leaflet syndrome: Syncope and sudden death. Arch Intern Med 135:664–667, 1975.PubMedGoogle Scholar
  102. 102.
    Shine KI, DeSanctis RW, Saunders CA, Austen WG: Combined aortic and mitral incompetence: Clinical features in surgical management. Am Heart J 76:728–735, 1968.PubMedGoogle Scholar
  103. 103.
    Sill JC, White RD: Valvular heart disease, cardiovascular performance, and anesthesia, in Tarhan S (ed) Cardiovascular Anesthesia and Postoperative Care. Chicago, Year Book Medical Publishers, 1982, pp 181–226.Google Scholar
  104. 104.
    Simon H, Krayenbuehl HP, Rutishauser W, Preter BO: The contractile state of the left ventricular myocardium in aortic stenosis. Am Heart J 79:587–602, 1970.PubMedGoogle Scholar
  105. 105.
    Stott DK, Marpole DGF, Bristow JD, Kloster FE, Griswold HE: The role of left atrial transport in aortic and mitral stenosis. Circulation 41:1031–1041, 1970.PubMedGoogle Scholar
  106. 106.
    Tinker JH, Tarhan S: Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses: Observations in 180 operations. JAMA 239:738–739, 1978.PubMedGoogle Scholar
  107. 107.
    Tyberg TI, Goodyer AVN, Hurst VW, Alexander J, Langou RA: Left ventricular filling in differentiating of restrictive amyloid cardiomyopathy and constrictive pericarditis. Am J Cardiol 47:791–796, 1981.PubMedGoogle Scholar
  108. 108.
    Urschel CW, Covell JW, Graham TP, Clancy RL, Ross J, Sonnenblick EH, Braunwald E: Effects on acute valvular regurgitation on the oxygen consumption of the canine heart. Circ Res 23:33–43, 1968.PubMedGoogle Scholar
  109. 109.
    Vincent WR, Buckberg ED, Hoffman JIE: Left ventricular subendocardial ischemia in severe valvular and supravalvular aortic stenosis. A common mechanism. Circulation 49:326–333, 1974.PubMedGoogle Scholar

Copyright information

© Springer-Verlag New York Inc. 1985

Authors and Affiliations

  • Carol L. Lake
    • 1
  1. 1.University of Virginia Medical CenterCharlottesvilleUSA

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