Download Human Heart Weight at High Altitude

Human Heart Weight
at
High Altitude
By HERBERT N. HULTGREN, M.D.,
AND
HARRY MiLLER, B.A.
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SUMMARY
The weight of the right ventricle, left ventricle, and septum determined in 98 hearts
of high altitude (12,300 feet) residents in Peru and in 86 hearts from sea level in the
continental United States revealed that right ventricular hypertrophy is no greater
at high altitude than at sea level in the stillborn-newborn infant heart. Right ventricular
weight relative to total heart weight at high altitude exceeds that at sea level beginning
about 30 days after birth and reaches a plateau at 56 days. Thereafter the degree
of relative right ventricular hypertrophy changes only slightly through the adult years.
No evidence was found of postnatal atrophy of the right ventricle either at sea level
or high altitude nor of septal hypertrophy accompanying the right ventricular hypertrophy in high altitude. The degree of right ventricular hypertrophy was moderate
and variable, and corresponded to the moderate, variable pulmonary hypertension
previously demonstrated in high altitude residents. Since total heart weights are
similar at high altitude and sea level and since high altitude subjects have a smaller
body size, the heart weight/body weight ratio is probably greater in the high altitude
subject.
ADDITIONAL INDEXING WORDS:
Pulmonary hypertension
Ventricular hypertrophy
hood. The technique of dissection employed
permits determination of the weight of the
free wall of the right and left ventricles after
separation from the septum and, therefore,
differs from the technique employed by AriasStella and Recavarren-8 in which septal
weight was not determined.
PROLONGED EXPOSURE to high altitude
is associated with a moderate degree of
pulmonary hypertension. This has been demonstrated by direct pressure measurements in
Peru and in continental United States.'-3 Indirect evidence of pulmonary hypertension
manifested by hypertrophy of the right ventricle was first demonstrated in Peruvian natives by Rotta4 in 1955. Further studies were
carried out by Campos and Iglesias.5 Recently Arias-Stella and Recavarren6 7 reported
their observations of ventricular weights in 114
hearts from high altitudes in Peru compared
to 127 hearts obtained at sea level. All age
groups were represented. Moderate right ventricular hypertrophy was found in all high
altitude age groups after approximately 3
months.
This paper reports additional studies of heart
weight at high altitude from infancy to adult-
Methods
The method of dissection was originally described by Muller.9 Fresh hearts were fixed from
1 to 6 weeks in 10% buffered Formalin. Prior to
fixation the atria were opened, blood and clots
were washed out, and the heart chambers were
loosely packed with cotton. Following fixation
and after washing for several hours in tap water,
the great vessels, atria, valves, epicardial fat,
and coronary vessels were removed by sharp
dissection. The right ventricle was first separated
from the septum by a sharp scalpel. The plane
of the cut was made parallel to the plane of the
surface of the septum. The left ventricle was
separated from the septum in a similar manner.
The free wall of each ventricle and the septum
were weighed to the nearest 0.10 g. The relative
weight of the right ventricle was expressed as a
percentage of the total ventricular mass (RV/T).
To determine if septal hypertrophy was present
when left ventricular hypertrophy was not present, the weight of the septum was expressed as a
From the Department of Medicine, Cardiology Division, Stanford University School of Medicine, Palo
Alto, California.
Supported by Research Contract DA-49-193-MD2274 from the Surgeon General's Office and a grant
from the San Mateo Heart Association.
Circulation, Volume XXXV, January 1967
207
HULTGREN, MILLER
208
Results
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percentage of the weight of the left ventricle
(S/LV). No systematic study of total heart
weight to body weight ratios was made. All dissections were performed by the two authors, and
after dissection all segments were compared to be
sure that a uniform technique had been employed.
It was noted that even easily discernible differences in the line of separation between the
septum and free ventricular walls resulted in
only slight differences in the RV/T and S/LV
ratios or weight of the individual segments.
The hearts of native Peruvians living at high
altitudes were obtained from routine autopsies
performed at the Chulec General Hospital, La
Oroya, Peru. The residents of this area live at
an altitude of between 12,000 and 14,000 feet.
The hearts of residents at sea level were obtained from the Pathology Department of the
San Mateo Community Hospital and the Stanford Medical School. The residents of this area
live essentially at sea level (altitude, 80 feet)
and are predominantly Caucasian.
The major cause of death in each group was
acute infectious disease, usually bronchopneumonia, which occurred in 52% of the high altitude group and in 38% of the sea level group.
Trauma was the second leading cause of death
in the sea level group.
60-
The total weight and the relative weight of
the right ventricle was greater at high altitude
in children and adults (figs. 1 and 2, table 1).
WVhen the total weight of the right ventricle
was plotted against age, a steady increase in
weight was evident in both high altitude and
sea level hearts. No evidence of a postnatal
decrease in right ventricular weight was found
in either group.
In the stillborn and newborn group, the
relative weight of the right ventricle was similar at high altitude and at sea level. An increase in right ventricular hypertrophy at high
altitude compared to sea level values was first
evident at approximately 30 days; after 56
days, there was only a small increase through
the adult years (fig. 3).
Examination of figure 4 reveals a wide dispersion of RV/T values in both high altitude
and sea level hearts from all age groups. Dispersion is greater in the high altitude hearts.
There was no difference in the total weight
of the myocardium, left ventricle, or septum
-** high altitude
sea level
o---o
50-
40
R.
I...f30
1--
-p
30-
1
//
0-
stllbr
newborn
1-90
day
3-23
months
2-10
years
11-80
years
AGE
Figure 1
Total weight of the right ventricle in various age groups of residents at sea level and high
altitude (12,300 ft).
Circulaiton, Volume XXXV, January 1967
. = _f.8v+:. -sw,b.l .ze
HEART WEIGHT
209
Z high altitude
sea level
60-
I ±ISD
40-
R)T
T
;
...s....'..
20-
...........
.......
,..............
!:::::::'" ".'.
**||s6SiS
ss
,::.,..,.:.:.::
::. ::,::.=
es6
,|,',>,-,F,,,,y,,y,,@eS
.
-
.. ,..:;:.;:,
,
-=-
.
.
1-90
stiOlborn
newborn
days
I
.
2-JO
3-23
months
I
11-80
years
years
AGE
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
Figure 2
Relative weight of the right ventricle expressed as the ratio RV/T (%) in various age groups at
sea level and high altitude (12,300 ft). The brackets represent one standard deviation.
.- high altitude
- sea level
50-
40-
RYiT
30-
~~
*A
.
-
*.
.'
.
.
.
20-
I00
stillborn
newborn
6
I
I
I
5
10
I
I
I
15
20
25
41
I
30
60
90
120
AGE (weeks)
Figure 3
Graphic analysis of the relative weight of the right ventricle in infancy
altitude (12,300 ft).
between the high altitude and sea level groups
(figs. 5 and 6, table 1). The relative weight
of the septum as estimated by the ratio of
septal weight to left ventricular weight was
not increased at high altitude (fig. 7).
Although a systematic study of the ratios of
heart weight to body weight was not made,
a partial evaluation of body weight indicates
that sea level patients were heavier than high
altitude patients by approximately 67% from
birth to 18 months and by 28% in adults.
Circulation, Volume XXXV,
January
1967
at
sea
level and high
These data clearly indicate that a greater left
ventricular and septal weight in relation to
body weight was present in the high altitude
group in addition to the clear increase in the
right ventricular weight to body weight ratio.
Inspection of the RV/T values reveals nine
hearts from the high altitude group and one
from the sea level group with values greater
than 40. The data regarding these cases, including age, total ventricular mass, and cause
of death, are summarized in table 2.
HULTGREN, MILLER
210
Table I
Summarized Data of 184 Human Heart Weights at Sea Level and High Altitude (12,300 Feet)*
Newborn and
stillborn
weight
Mean
No.
Range
(g)
SD
Total
myocardial
RV
weight
(g)
p
Mean
No.
Range
SD
6.6
17
1.9
4.0
15.1
weight
(g)
Range
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SD
LV
weight
(g)
p
Mean
No.
Range
SD
RV/T( %)
p
Mean
No.
Range
SD
1.94
17
0.4 - 4.8
1.3
4.08
17
0.9- 4.8
1.3
2.48
18
0.5
1.0
5.5
Mean
17
15.0
5.7
SD
S/LV(%)
p
Mean
No.
Range
SD
Herrman
index*
p
Mean
No.
Range
SD
3.9
<0.2
34.5
33.3
-
40.0
17.5
29
8.1 - 22.8
3.5
4.4
29
0.9 - 6.6
1.3
5.3
29
1.0 - 9.4
1.8
18
1.4- 12.9
4.7
7.7
29
0.9 - 11.6
2.8
25.4
29
19.0
4.1
-
35.0
-
37.8
ns
28.8
17
Range
HA
ns
p
S/T(%)
6.7
18
1.4- 12.9
2.9
ns
2.31
18
0.6- 5.5
1.2
ns
1.93
18
0.4- 4.2
1.0
2.29
17
0.5
1.6
p
Mean
No.
S
1 to 90 days
SL
HA
SL
24.1 - 33.8
3.4
28.2
18
22.8 - 33.3
3.3
30.5
29
24.7
3.6
ns
17
49.4 -100.0
16.2
77.8
71.3
18
46.4 -131.3
20.9
29
51.7 -111.5
13.0
ns
1.13
17
0.87- 2.30
0.32
p
1.09
18
0.70- 1.52
0.70
<0.1
10.4
35
3.7 - 24.7
4.2
ns
3.4
35
1.2 - 7.7
1.3
>0.001
2.9
35
1.1 - 6.4
1.3
> 0.001
4.1
35
1.4 - 10.6
1.8
> 0.001
33.9
35
26.0 - 44.0
4.0
<0.001
27.8
35
21.6 - 34.6
3.1
<0.001
73.0
35
46.7 -111.1
13.8
nS
1.44
29
0.97- 1.78
0.72
1.12
35
0.75- 1.47
0.54
< 0.001
Abbreviations: SL -sea level; HA = high altitude; ns - not significant.
*The Herrman index has been calculated for comparison with other studies using this index.
Two hearts in the series, one from sea level
and one from high altitude, exhibited an extreme degree of right ventricular hypertrophy.
Report of Cases
The sea level heart with an RV/ T ratio of
42.2% was obtained from an 11-month-old Negro
child requiring several hospital admissions because of recurrent bronchitis and pneumonia since
the age of 4 months. She was below the third
percentile in weight at the time of her final hospitalization for pneumonia. She was acutely ill;
respiratory rate was 48 and heart rate was 140
per minute. Physical signs of pneumonia and
bronchitis were present. Moderate enlargement of
the liver was noted. The hemoglobin was 8.0 g%
and the leukocyte count was 20,700/mm.3 The
electrocardiogram revealed a pattern consistent
with moderate right ventricular hypertrophy with
Circulation, Volume XXXV, January 1967
HEART WEIGHT
211
4 to 23 mo
SL
2 to 10 yr
HA
SL
25.6
12
14.8 - 33.4
27.5
28
13.3 - 59.2
11.1
11.9
56.2
16
35.0 -92.3
19.8
ns
6.9
12
3.4 - 24.4
5.7
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8.2
12
5.0 - 14.5
2.6
10.3
12
6.4 - 19.2
3.9
25.5
12
18.0 - 42.2
6.3
33.1
12
25.0 - 41.2
4.1
76.8
12
43.2 -101.2
14.0
1.49
12
0.84- 1.83
0.27
9.0
28
3.1 6.6
<0.05
7.5
28
3.2 2.9
<0.1
11.0
28
5.6 3.9
<0.3
30.7
28
23.0 7.9
<0.001
27.6
28
19.4 3.9
< 0.001
68.8
35.0
15.0
12.5
16
6.3 -22.0
4.3
17.7
15
9.8 -31.0
6.3
HA
56.4
7
31 -80
18.6
ns
17.9
7
10.5 -33.0
8.1
<0.1
16.2
7
8.5 -23.0
5.5
11 to 80 yr
SL
152.2
12
64.8 -244.5
61.2
20.5
62.5
22.5
16
18.0 -30.2
3.5
35.4
33.0
15
28.0 -39.4
3.0
28
39.4 -104.8
15.0
< 0.01
1.28
28
0.40- 1.94
0.98
ns
75.0
15
53.8 -94.8
11.4
1.57
15
1.16- 1.99
0.22
an R/ S ratio of 60% in lead aVR. A chest roentgenogram revealed pneumonitis and an aberrant
right subelavian artery. The child developed cardiac arrest and died during a lumbar puncture.
Autopsy revealed bilateral bronchopneumonia and
evidence of moderate right ventricular failure. The
right ventricle was hypertrophied. Histological
study of the lung revealed bronchitis and bronchopneumonia. Collections of foreign-body giant
cells suggested aspiration pneumonitis. In addition, focal areas of scarring and pulmonary fibrosis were present. There were distinct abnormalCirculation, Volume XXXV, January 1967
22.0
7
8.8 -30.0
7.3
<0.5
31.8
7
23.0 -44.2
7.9
< 0.02
28.6
7
26.0 -32.2
2.0
<0.001
75.1
7
58.0 -96.0
13.1
ns
1.21
7
0.74- 1.40
0.30
<0.01
168.0
10
86 -238
43.5
ns
32.1
12
14.8 - 47.4
12.4
50.7
12
21.0 - 86.0
20.6
<0.4
23.8
15
15.0 -38.0
8.3
HA
69.6
12
29.0 -107
28.7
21.4
12
17.7 - 23.7
2.1
32.0
12
23.5 - 36.0
4.3
73.8
12
62.7 - 89.4
10.0
1.63
12
1.31- 1.84
0.14
50.0
10
25 - 83
16.3
<0.001
48.5
10
22 - 63
12.4
<0.5
75.7
10
39 -97
19.6
<0.9
29.5
10
25.5 - 40.0
4.8
<0.001
29.0
10
24.4 - 39.0
4.1
<0.05
64.4
10
54.0 - 83.3
8.5
<0.01
1.35
10
1.00- 1.58
0.55
<0.2
ities of the pulmonary vessels. Thickening of the
media was present in numerous small arterioles
as well as fibrotic intimal thickening. Pulmonary
hypertension was probably the result of pulmonary fibrosis secondary to repeated episodes
of pneumonitis.
Less information is available regarding a 1year-old Peruvian native girl who died of acute
bronchopneumonia and congestive failure. The
hematocrit was 57%. No cardiac abnormalities
were present except for a marked degree of hypertrophy of the right ventricle. Histological study
IIULTGREN, MILLER
212
62.5
I
45-
* high altitude
o sea level
*
0
.
40-
0
0-
00
0
I
C
1*16
*.
35.
8
30-
R'T
IL,
O
o
00
0
0
.
f
0
0
C
0
i:C
*-
o0
.0
25
-s
vC
C.
oo
00
e
0
00
0
0000
8
000
0
00
8
0
.
-or
0000
00
0
0
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00
00
0
0
15-
O
C
000
20-
CC
C
0
0
0
0
0
fl
stillborn
newborn
1-90
days
3-23
months
11-80
2-10
years
years
AGE
Figure 4
Graphic analysis of individual RV/T (%) values in various age groups at sea level and high
altitude (12,300 ft).
*-. high altitude
sea level
p
/ TVM
/
/,
I...
i2i
LV
years
years
AGE
Figure 5
Total myocardial weight (TVM) and weight of the left ventricle in
level and high altitude (12,300 ft).
various age groups at
sea
Circulation, Volume XXXV, January 1967
HEART WEIGHT
213
60-
high altitude
.--
-
sea
level
-50-
S.
40-
30;:i
20-
10-
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r- ]
v
stillborn '
newborn
1-90
3-23
2-10
11-80
days
months
yoers
years
l
AGE
Figure 6
Total weight of the septum (S.)
in
various
age groups
at
sea
level and high altitude (12,300 ft).
high altitude
sea
I
level
±ISD
S/V
LV
stillborn
newborn
1-90
days
3-23
months
2-10
11-80
years
yonrs
AGE
Figure 7
Relative weight of the septum expressed as the ratio S/LV in various age groups
and high altitude (12,300 ft). The brackets represent one standard deviation.
Circulation,
Volume XXXV, January
1967
at sea level
214
HULTGREN, MILLER
Table 2
Summary of Data on Hearts with RV/ T of More Than Forty Per Cent
Age
High altitude
TVM*
RVIT
(No)
Cause of
death
Unknown
Stillborn
Newborn
2.2
12.9
2 days
5.9
13.0
42.4
43.0
44.0
44.0
24.8
56.5
59.2
31.0
80.0
58.1
46.0
62.5
41.0
44.2
41.0
42.2
47 days
3
mo
1
yr
22
2
Sea level
(g)
5
mo
yr
yr
11
mo
Unknown
Bronchopneumonia
Bronchopneumonia,
dehydration
Bronchopneumonia
Bronchopneumonia
Acute bronchitis
Typhoid fever
Recurrent
bronchopneumonia
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*TVM -= total ventricular
mass.
revealed a moderate diffuse bronchopneumonia.
The pulmonary vessels incluiding the arterioles
were essentially normal. The liver showed chronic
passive congestion comnatible with right heart
failure. The pulmonary hypertension, in this patient, d'd not appear to be related to chronic
pulmonary infection or congenital cardiac dis-
uterine stimulus to the development of right
ventricular hypertrophy at high altitude. It
has been prevously shown in animals that
fetal hypoxia at high altitude is not as severe
as one might suppose, since it is diminished
by several important physiological mechan-
ease.
isms.13
Discussion
The present study has confirmed the observations of pr-vious workers that right ventricular hypertrophy is present in high altitude
residents and that this excess hypertrophy is
first evident at approximately 30 days of age.
After 56 days, little further relative right
ventricular hypertrophy occurs.
These differences between hiqh altitude and
sea level hearts are clearly reflected in th3
electrocardiogram. The pattern of "physiological right ventricular hypertrophy of infancy" is similar in both groups for 30 to
60 days after birth. In the high altitude child,
this pattern persists into childhood while in the
sea level child, the adult pattern of normal
left ventricular predominance begins to appear at this time.10-12
This study has demonstrated that, in the
newborn period, the relative weight of the
right ventricle is similar at high altitude and
sea level. Previous workers at high altitude
have not examined enough hearts in this age
group to establish this point.6 The data suggest that there is no important additional intra-
The present study did not demonstrate
postnatal decrease in right ventricular
any
weight as was observed by Muller,9 Keen,14
and Recavarren and Arias-Stella.8 Our obare in accord with those of Emery
and Mithal.15 Muller's data have been reviewed. While a 17.5% decrease in right ventricular weight was observed at 8 weeks of
age, there was during the preceding 4 weeks
no increase in septal weight and a 6% decrease in left ventricular weight (fig. 8). This
is strongly suggestive of growth failure due to
the presence of a systemic infectious disease
which was the cause of death in most of
Muller's9 cases. It does not suggest selective
servations
atrophy of the right ventricle. Keen's14
paper
does not contain adequate data for analysis.
Recavarren and Arias-Stella8 studied only
17 hearts in the appropriate age group and
inspection of his graph reveals that the apparent decrease in right ventricular weight at
10 weeks is due to four heart weights. When
the data of Emery and Mithal15 (32 hearts)
and Recavarren and Arias-Stella8 (17 hearts)
plotted with the data from the present
study (total 155 hearts), no evidence of a
are
Circulation, Volume XXXV, January 1967
HEART WEIGHT
215
8-
7.0~
~
--
~
6-
E
J.,
.e
or
.0
~
J.,
~
~
~
~
~~0~~~~~~.
.0
.1~~~~~R
I-
5-
~~
,___
CD
:t
A.-.-o
4-
~
~
~~~-l
~
,1
r
00
3Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
_
A'
6
I
.
I
1.
1.
i
I
4
3
2
1
f
L
24
AGE (week.)
Figure 8
Mean weights of left ventricle, septum, and right ventricle at
20-
various age groups
from Mall'r.9
o N=61
0 N=85
/816-
IM-
0
1416
?
0
12-
:1:
:k
i
10-
°
0
oo00:000
.o
ii:
0
8-
.0
0
*
0
0o*
0
o0
0
to
0
0
o
o
0
000
0
0
.0
0
-,-''0
0 0
6-
0
0
.0 0
0
0
01,p-o
00
00
0
0
0
0
0
0
0
0
4A
2-
u-
*;
a
.
stillborn O
newborn
5
10
I5
20
25
30
60
90
120
AGE (weeks)
Figure 9
Graphic analysis of weight of the right ventricle in infants and children at sea level in
the present study and from Emery and Mithal15 and Recavarren and Arias-Stella.8 Right
ventricular weight in the present paper has been adjusted to be comparable to that obtained in
other studies (RV weight = RV + S).
Circulation, Volume XXXV,
Januwry
1967
2HULTGREN, MILLER
216
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postnatal decrease in right ventricular weight
is seen (fig. 9*).
The wide dispersion of the degree of right
ventricular hypertrophy in both high altitude
and sea level hearts has been noted in previous human and animal studies. W Individual variations in dissection technique cannot account for the observed differences since
even gross differences in technique cannot
result in the dispersion of values noted. The
dispersion is probably due to variations in
pulmonary artery pressure. Hemodynamic
studies of high altitude residents have demonstrated moderate variations in resting pulmonary artery pressure and wider variations
during exercise.1-3 The degree of variation in
such values at sea level is less than at high
altitude.2
Dispersion of RV/T values and pulmonary,
artery pressures at high altitude are paralleled
by a similar degree of variability in the electrocardiogram. In 20% of high altitude residents, the electrocardiogram may be normal
but in the remainder, abnormal patterns compatible with mild-to-severe hypertrophy are
present.10 Pryor and his workers17 suggested
that the high altitude electrocardiogram was
best correlated with the pulmonary artery
pressure during exercise, but their data demonstrate only an approximate relationship.
The amount of anatomic right ventricular
hypertrophy observed at high altitude is usually moderate and corresponds to an increase of
51% in the total weight of the right ventricle.
This is comparable to the observed moderate
degree of pulmonary hypertension present at
high altitude.1-3 Similar pressures, right ventricular weights, and electrocardiographic features are present in sea level cases of pulmonary emphysema.'8 In cardiac disease with
severe pulmonary hypertension at sea level
RV/ T ratios of as high as 62% have been observed in our laboratory.'"
In both cattle and lambs the weight of the
*To
compare right ventricular weights with those
reported by Emery and Mithalla and Recavarren and
Arias-Stella,8 we have added to the weight of the free
wall of the right ventricle half of the weight of the
septumi for each heart weight plotted on the graph.
right ventricle is proportional to the pulmonary
artery pressure.20' 21 Hence the relative weight
of the right ventricle may be used as a rough
indication of the height of the pulmonary artery pressure. Comparison of the response
of man and different animal species to high
altitude can therefore be assessed.
The same dissection technique has been
employed in six animal species living at similar altitudes in Peru. The degree of relative
right ventricular hypertrophy observed in
these animals is compared to the human studies
reported in this paper (fig. 10). The human
responds to high altitude with a similar degree of right ventricular hypertrophy to that
seen in lambs and pigs, but with less hypertrophy than occurs in rabbits and guinea pigs.
Two hearts with an extreme degree of right
ventricular hypertrophy have been described
in detail. In one instance, there was evidence
of recurrent infectious pulmonary disease and
abnormalities in the pulmonary vessels. Such
a factor cannot be completely excluded as
being responsible for severe degrees of right
ventricular hypertrophy which are out of the
usual range. The use of hearts from patients
free of any present or past history of pulmonary disease would eliminate this problem.
Septal hypertrophy does not accompany
right ventricular hypertrophy at high altitude.
This is consistent with observations of right
ventricular hypertrophy in disease at sea level
where septal hypertrophy only occurred when
right ventricular hypertrophy was severe.-Arias-Stella and Recavarren" have demonstrated that at high altitude the outflow portion of the right ventricle tended to be more
hypertrophied than the inflow portion. Absence of septal hypertrophy therefore indicates that only the free wall of the right
ventricle is hypertrophied and not the adjacent septal portion.
An increase in the ratio of heart weight
to body weight appears to be present at high
altitude which is not due to right ventricular
hypertrophy alone but involves to a lesser extent the septum and free wall of the left ventricle. Several factors may be responsible for
a higher ratio of heart weight to body weight
Circulation, Volume XXXV, January 1967
HEART WEIGHT
217
I
Im
40-
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SPECIES DISTRIBUTION
*
STILLBORN - NEWBORN
Figure 10
Comparison of the degree of right ventricular hypertrophy expressed as a percentage increase
over sea level values in six animal species and humans at high altitude. R = rabbits;
GP = guinea pigs; D = dogs; S = sheep; L = lambs; P = pigs; and * = stillborn and newborn
humans.
at high altitude. Increased blood volume,
greater physical activity, and a smaller amount
of adipose tissue should be considered.
Acknowledgment
The authors wish to thank the following, whose
cooperation made this study possible: Arthur Lack,
M.D., San Mateo Community Hospital, California; Alvin Cox, M.D., Stanford Medical Center, California;
and Emilio Marticorena, M.D., Chulec General Hospital, Peru.
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Circulation, Volume XXXV, Jana4ry 1967
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Ancient Fatalism
An old legend tells of a merchant in Bagdad who one day sent
his servant to the market.
Before very long the servant came back, white and trembling,
and in great agitation said to his master:
"Down in the market place I was jostled by a woman in the
crowd, and when I turned around I saw it was Death that
jostled me.
She looked at me and made a threatening gesture.
Master, please lend me your horse, for I must hasten away to
avoid her.
I will ride to Samarra and there I will hide, and Death will not
find me."
The merchant lent hin his horse and the servant galloped
away in great haste.
Later the merchant went down to the market place and saw
Death standing in the crowd.
He went over to her and asked,
"Why did you frighten my servant this morning?
Why did you make a threatening gesture?"
"That was not a threatening gesture," Death said.
"It was only a start of surprise.
I was astonished to see him in Bagdad, for I have an appointment with him tonight in Samarra."
-PETER MARSHALL: Rendezvous in Samarra. In John Doe,
Disciple. McGraw-Hill Book Co., Inc., New York, 1963, p. 219.
Circulation, Volume XXXV, January 1967
Human Heart Weight at High Altitude
HERBERT N. HULTGREN and HARRY MILLER
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Circulation. 1967;35:207-218
doi: 10.1161/01.CIR.35.1.207
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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