Selective Coronary Arteriograms Research Articles

First selective coronary arteriogram.

To the Editor: I enjoyed reading Dr Ryan’s superb recount of the historical development of coronary arteriography,1 but I wish to make a comment on its chronology. Dr F. Mason Sones, Jr, of the Cleveland Clinic performed the first selective coronary arteriogram on October 30, 1958.2 The selective right coronary arteriogram photographed by Sones on October 30, 1958, was inadvertently obtained during an aortic root injection in a 26-year-old patient with rheumatic heart disease,3 when the catheter whiplashed into the ostium of the right coronary artery. Although the performance of this selective coronary arteriogram was unintentional, it was the first direct injection of a contrast agent into a coronary artery (Figure). Cine frame from the first selective coronary arteriogram recorded by F. Mason Sones, Jr, on October 30, 1958. …

The coronary angiogram and its seminal contributions to cardiovascular medicine over five decades.

The selective injection of contrast media into the right coronary artery of a middle-aged male by Dr F. Mason Sones, Jr, on October 30, 1958 (Figure 1) introduced a new era in cardiovascular medicine that was to revolutionize our understanding and management of the cardiac patient for the remainder of the twentieth century.1,2⇓ As the first reliable in vivo marker for the presence of obstructing coronary lesions, the coronary angiogram not only provided objective evidence to support or refute the clinical diagnosis of angina pectoris but, quite importantly, led to our first studies of the natural history of patients with coronary artery disease (CAD). The purpose of this article is to underscore the crucial role this particular technology played in contributing to the epochal events and discoveries that have characterized the march of progress in the field of cardiology over the past 50 years. Figure 1. Cine frame from the first selective coronary arteriogram taken by F. Mason Sones, MD, on October 30, 1958. Reprinted with permission from J Am Coll Cardiol. 1998;31:89B–96B. Sones’ decision to undertake selective visualization of the coronary artery in his patient undergoing catheterization to evaluate mitral regurgitation was, in some measure, the result of a serendipitous event that occurred in his laboratory 2 days earlier. This has been described in detail elsewhere by Dr Willis Hurst3 and entailed a power injection of 40 to 50 cc of contrast media that was intended to be delivered into the aortic root of a patient with aortic regurgitation. Under 10 kg/cm2 of pressure, the catheter whiplashed into the ostia of the right coronary artery, and an estimated 30cc of 90% Hypaque (Nicomed) was selectively delivered as a bolus into the coronary artery before the injection could be aborted. A former fellow of Sones’, Dr …

A review of coronary arteriography- and contrast media-induced ventricular fibrillation.

Since the first animal coronary arteriogram in 1933 there have been many innovations in techniques and contrast media. From 1933 through the late 1950s the procedures used involved nonselective aortic injections and the use of acetylcholine to slow the heart. The first selective coronary arteriogram in animals was performed by West, Kobayashi & Guzman in 1958 (45) and in 1959 Guzman & West (7) observed ventricular fibrillation with some media but not others. In 1967 Judkins (14) described the catheter designs for right and left coronary catheterizations that we still use today. In the 1970s and 80s many authors observed the ionic monomeric contrast media reduced plasma calcium causing fibrillation and myocardial depression. Supplementation of ionic media with calcium was shown to moderate these adverse effects. Almen's vision of low osmolality contrast media and the creation of metrizamide (1) stimulated the rapid development of monomeric and dimeric nonionic contrast media. The ionic dimeric medium ioxaglate also provided low osmolality. Digital frame grabbers and computers lead to the development of digital subtraction angiography and new applications of arteriography, frequently using dilute media. Unexpectedly, during prolonged right coronary arteriography in animals, dilute nonionic media were found to produce increased fibrillation as compared to dilute ionic media. The addition of sodium to nonionic media significantly reduced the incidence of fibrillation. Animal studies with the nonionic medium iodixanol supplemented with sodium and calcium (Visipaque) have demonstrated minimal incidences of fibrillation and myocardial depression.

Heterotopic heart transplantation: catheterization, endomyocardial biopsy, and coronary angiography of the donor heart

Follow-up after heart transplantation presently requires invasive techniques to assess graft viability and function. As the heterotopic transplant technique assumes a more important therapeutic role for patients not eligible for an orthotopic allograft, an understanding of the inherent challenges associated with management of these patients is mandatory to optimize patient care. Heterotopic transplant technique was used in 19 of 135 (14%) consecutive heart transplant procedures over a 41 month period. Invasive diagnostic procedures performed in follow-up revealed 1) adequate tissue for histologic evaluation in 140/158 (89%) biopsy procedures, 2) successful pulmonary wedge pressure measurements in 142/158 (90%) right heart catheterizations, and 3) successful coronary arteriography in 18 patients undergoing angiography (both vessels in 12 and one vessel in six patients). Thus, biopsy and surveillance procedures are feasible and productive in patients who have undergone heterotopic heart transplantation. Although heterotopic heart transplantation has become an increasingly utilized therapy for some patients with heart failure, there are no guidelines for routine biopsy and angiographic techniques in these patients. The objective of this study was to determine the feasibility of angiographic and endomyocardial biopsy procedures in heterotopic heart transplant recipients. The complete experience with heterotopic heart transplant recipients at Baylor College of Medicine and The Methodist Hospital over a 41 month period including endomyocardial biopsy, right heart catheterization, and selective coronary arteriography results were analyzed. Eighteen patients underwent 310 procedures without significant complications. Of 158 biopsy procedures, 140 (89%) yielded tissue adequate for histologic evaluation. Right heart pressures were obtained in almost all patients undergoing right heart catheterization. Pulmonary wedge pressures were obtained in 137 (90%). A rapid decrease in right heart pressures was noted following transplant; however, a gradual but significant rise in mean arterial pressure occurred. Eighteen selective coronary arteriogram procedures were performed; 12 (66%) resulted in successful cannulation of both coronary arteries. Of 12 patients followed for at least 1 year, five (40%) have developed evidence of allograft arteriopathy. The 1 and 2 year survival rates were 67% and 53%, respectively. Invasive diagnostic techniques can be performed safely and reliably and should not preclude the use of heterotopic heart transplantation in selected patients who are otherwise unsuitable for orthotopic transplantation.

Surgical treatment of the Wolff-Parkinson-White syndrome by epicardial electrical ablation

A new operation to eliminate accessory pathways—epicardial electrical ablation—is described. In a group of 201 patients without concomitant disease, the mortality rate was 0.5% and the overall efficacy of the operation for free wall accessory pathways, 98%. A retrospective clinical study of 44 unselected patients was performed to examine how safe epicardial electrical ablation is. The criteria for intraoperative effectiveness were disappearance of both the delta wave and retrograde conduction and inability to induce tachycardia. In the postoperative and follow-up periods, the following were reviewed: electrocardiograms; Holter monitor recordings (24 to 26 hours); release of the myocardial-specific isoenzyime of creatine kinase; intracardiac hemodynamics and myocardial contractility (radionuclide methods); selective coronary arteriograms and ventriculograms; mean work capacity (bicycle ergometer); diagnostic transesophageal electrical stimulation; and histology of the area of ablation. The main conclusion of this study is that epicardial electrical ablation is a highly efficient and safe operation for surgical elimination of parietal accessory pathways in patients with Wolff-Parkinson-White syndrome. Its advantages are its technical simplicity and the opportunity to review results immediately during the operation.

In vivo canine coronary artery laser irradiation: Photodynamic therapy using dihematoporphyrin ether and 632 nm laser. A safety and dose‐response relationship study

This study examined the safety and dose-response relationships of 632-nm laser irradiation of photosensitized normal coronary arteries in 27 dogs. Fifteen received 2.5 mg/kg dihematoporphyrin ether (DHE), seven received no sensitizer, and five had coronary instrumentation but no laser (sham laser procedures) at nine coronary sites--four sensitized, five non-sensitized. Laser energy of 82 to 1,640 J/cm2 was delivered via a 584 microns diffusing-tip optical fiber, providing estimated tissue fluences of 20 to 410 J/cm2. Serial electrocardiograms and selective coronary arteriograms were performed up to 1 month post laser irradiation. Histologic examination was performed of all treated sites. Tissue fluences less than 200 J/cm2 produced no permanent electrocardiographic or angiographic changes; reversible spasm occurred in 2/8 photosensitized-lased, 0/2 non-photosensitized-lased. Minor medial damage occurred in 1/8 sensitized-lased, 1/2 non-sensitized-lased, and 0/9 sham-lased sites. At tissue fluences greater than 200 J/cm2 4/7 sensitized-lased animals died prematurely--one due to immediate and irreversible coronary spasm and Q wave infarction, one due to fibrillation during 48-hour follow-up coronary angiography (normal angiograms), two with normal electrocardiograms and angiograms within one day of undetermined death; 0/5 non-sensitized-lased animals expired or had coronary spasm; and 3/7 sensitized-lased and 0/5 non-sensitized/lased had significant medial to adventitial histologic damage. Coronary irradiation at less than 200 J/cm2 appears to be safe for photodynamic treatment of atherosclerotic lesions. Pretreatment for coronary spasm is appropriate.

Coronary arteriography in dogs following blunt cardiac trauma: a longitudinal assessment.

The purpose of the study was to examine the effects of blunt cardiac trauma on the epicardial coronary arteries of dogs by using sequential coronary arteriographic studies. A direct impact to the anterior surface of the heart at a velocity of 12 m/sec was delivered by an air pressurized impactor in eight of ten dogs with the chest open and the pericardium intact. Selective coronary arteriograms were performed percutaneously with the chest closed starting just before trauma and repeated afterward at intervals of 3 hours, 3 days, 2 weeks, and 5 weeks. Two of ten dogs were sham operated and did not undergo impact to the heart. The coronary arteries in these two dogs remained angiographically normal throughout the study period. In dogs that underwent impact and were maintained for the entire duration of the study (seven of eight dogs), injury to the epicardial coronary arteries occurred in every instance. Injury was limited mostly to branches of the left anterior descending and right coronary arteries. The left circumflex coronary artery, which was posterior to the site of impact, was always spared. The types of injury included complete branch occlusion, partial coronary obstruction, extravasation, and in one instance, an arteriovenous fistula. In nearly all instances, these injuries became evident angiographically between 3 hours and 3 days after impact and usually were completely resolved after 2 to 5 weeks. These observations indicate that the epicardial coronary arteries may be compromised by nonpenetrating cardiac impact. The resulting coronary pathology, however, resolved within a few weeks after injury.

Relation of atherosclerosis to arterial wall shear in the left anterior descending coronary artery of man

Low fluid dynamic shear acting on the vascular endothelium has been suggested as a factor in atherogenesis. This study describes qualitatively differences of wall shear rate in the left anterior descending coronary artery (LAD) of man and relates the distribution of wall shear to that of atheromatous plaques. Selective coronary arteriograms of 21 patients without obstructive LAD diseases were reviewed. Blood velocity, and therefore wall shear in the LAD, was assessed qualitatively based upon the rate of clearance of contrast material. There was a rapid clearing of contrast material along the outer wall of the LAD as it curved around the border of the heart. A much slower clearing occurred along the inner wall, bordering the myocardium, which persisted two to six cardiac cycles after the outer wall had cleared. This suggests that velocity, and therefore shear rate, is lower along the inner wall of the LAD than along the outer wall. In 27 patients who died of noncardiac disease, an uneven distribution of atheromatous plaques in the LAD was observed histologically, with greater involvement of the inner wall. These observations demonstrate an association between the lower shear rate along the inner wall of the LAD and the site of higher concentration of atherosclerosis.

Angiocardiographic estimation of left and right ventricular volume characteristics in normal infants and children.

Left (LV) and right ventricular (RV) volume data were obtained from biplane cineangiocardiograms in 31 patients with Kawasaki disease who showed normal coronary arteries in selective coronary arteriograms. LV and RV volumes were calculated by using Simpson's rule method. Both of end-diastolic (EDV) and stroke volume (SV) were excellently expressed as a function of body surface area (BSA) with exponential relationship: LVEDV = 104.3 (BSA)1.61 ml (r = 0.93, p less than 0.001), RVEDV = 109.7 (BSA)1.68 ml (r = 0.90, p less than 0.001), LVSV = 68.1 (BSA)1.60 ml (r = 0.89, p less than 0.001) and RVSV = 66.8 (BSA)1.76 ml (r = 0.86, p less than 0.001). LV ejection fraction (LVEF) averaged 66 +/- 1% (mean +/- S.E.) and RVEF 58 +/- 1%. Both of them showed no significant correlations with BSA. The normal values of EDV and SV in infants and children can be predicted from their BSA by using the exponential equations demonstrated by the present study. Thus, these values in pediatric patients with heart diseases could be evaluated in terms of percentage of normal.

Blood velocity in the right coronary artery: Relation to the distribution of atherosclerotic lesions

Vascular endothelial injury by high shear stresses and adverse effects of low shear rates on mass transfer across the arterial wall have been suggested as factors in atherogenesis. This study describes differences in blood velocity, and therefore differences of shear rate, across the lumen of the right coronary artery (RCA) of man. Selective coronary arteriograms of 30 patients without obstructive RCA disease were reviewed. Velocity was assessed qualitatively based on the rate of clearance of contrast material. There was a rapid clearing of contrast material along the outer wall of the RCA as it curved around the border of the heart. A much slower clearing occurred along the inner wall, bordering the myocardium, which persisted 2 to 6 cardiac cycles after the outer wall had cleared. This suggests that velocity, and therefore shear rate, is much lower along the inner wall of the RCA. To determine the relation of the distribution of atherosclerotic plaques in the RCA to local blood velocity, the RCA in 17 randomly selected human subjects who died of noncardiac disease were studied histologically. There was an uneven distribution of atherosclerotic plaques in the RCA with greater involvement of the inner wall. These observations demonstrate an association between the lower shear rate along the inner wall of the RCA and the site of higher concentration of atherosclerosis.

Thallium stress myocardial imaging: An evaluation of fifty‐eight asymptomatic males

The possible value of myocardial imaging with 201thallium as a screening procedure for the detection of latent disease has not been previously shown. Fifty-eight asymptomatic men underwent exercise 201thallium imaging together with a risk score profile based on the Framingham criteria for predicting future coronary events. Six subjects (10%) developed perfusion defects compatible with myocardial ischemia. The risk score for the population with an abnormal test was 7.7 +/- 2.9%, compared to 2.0 +/- 2.2% (p less than 0.001) for those men with normal tests. Three of the subjects with abnormal scans underwent selective coronary arteriograms; all three had normal coronary arteries. During a 30-month follow-up, all individuals remained physically active and free of cardiac symptoms. Exercise myocardial imaging is not a cost-effective means of detecting coronary artery disease in an asymptomatic population and should not be used as a screening procedure.

Quantitative evaluation of vitamin E in the treatment of angina pectoris

Because of previous reports of the beneficial effect of vitamin E in angina pectoris patients, 48 patients, with both stable angina and positive (chest pain plus ishemic ST depression) maximal exercise treadmill tests, participated in a double-blind cross-over study of 6 months of vitamin E and 6 months of placebo therapy, separated by a 2 month no treatment period. All 48 patients had positive selective coronary arteriograms (75 per cent obstruction of at least a major coronary artery) and/or Q wave ECG evidence of previous myocardial infarction (Minnesota criteria). Evaluation of drug effectiveness was based on performance of serial maximal exercise treadmill tests, serial systolic time interval measurements, and daily angina diaries. No statistically significant differences between the two treatment studied. It is concluded that a large dose of vitamin E (1,600 I.U. of d-alpha-tocopherol succinate daily) for 6 months in patients with stable angina pectoris fails to increase the exercise capacity, improve left ventricular function, or reduce the frequency of chest pain.

Caliber and distribution of normal coronary arterial anatomy.

Selective coronary arteriograms of 125 patients with normal coronary arteries were reviewed to establish the caliber and distribution of normal coronary arterial anatomy. Measurements established the following normal values for coronary arterial caliber in right (R), (M), and left (L) inferior emphasis systems expressed in mm (+/-SEM): (See article). Significant differences in the caliber of right coronary arterial systems and left circumflex coronary arterial systems validate the separation of coronary arterial anatomy into right, mixed, and left inferior emphasis systems, depending upon the blood supply to the inferior wall of the left ventricle. Classification of the anatomical pattern into right, mixed, and left inferior emphasis systems is useful in the cardiac catheterization laboratory at the time of selective coronary arteriography. If the expected distribution of the coronary vessels is not found, then missing vessels must be sought out. A knowledge of the range of normal size for the coronary arterial tree should be of value in defining the severity of coronary arterial narrowing.

Esophageal Disease as a Cause of Severe Retrosternal Chest Pain

During one six-month period 11 patients were referred with a diagnosis of coronary artery disease, because of recurrent episodes of severe, prolonged retrosternal chest pain necessitating from one to seven hospital admissions per patient for "suspect myocardial infarction". In no instance was this diagnosis proved by electrocardiogram or serum enzyme changes, but 7 of the 11 patients had abnormal resting electrocardiograms. Selective coronary arteriograms were normal in 10 patients and revealed nonobstructive coronary artery disease in the 11th patient. Esophageal studies revealed hiatus hernia in 9 and mild to severe disordered motored activity of the esophagus in all 11. Acid perfusion into the esophagus reproduced the chest pain in nine patients and in the other two, the hiatus hernia was incarcerated. On direct questioning, all patients indicated that the pain was worsened by lying down and bending over, and in eight patients there was a history of pharyngoesophageal or gastroesophageal dysphagia. In this day when the problem of chest pain with normal coronary arteries is very topical, our report emphasizes the need to consider symptomatic esophageal disease in the differential diagnosis of this problem.

Percutaneous Transfemoral Coronary Arteriography; Prevention of Morbid Complications

During a six-year experience involving 3,089 selective coronary arteriograms (99 percent by the percutaneous transfemoral method), modifications of technique have reduced the incidence of morbid complications. Modifications have involved guidewire technique, systemic heparinization, attention to spontaneous catheter back-bleeding after guidewire removal, and caution in approaching sever main left coronary artery lesions.

The vectorcardiogram in prolapsed mitral leaflet myocardopathy

The vectorcardiograms (VCG) of 87 cases of prolapsed mitral leaflets syndrome were analyzed with reference to clinical, electrocardiographic and catheterization data. A total of 36.8% of electrocardiograms and 72.4% of vectorcardiograms displayed abnormal T changes. T loop changes included abnormal T vector directions, wide QRS-T angles and increased T vector magnitudes. Abnormal QRS loops were seen in 30 (34.5%) VCG. All thirty-two patients with chest pain had normal selective coronary arteriograms. It is believed, therefore, that these primary T vector abnormalities are not ischemic and that they are related to some myocardial changes of unknown etiology.

A Case of Congenital Coronary Artery Fistula Involving Bilateral Coronary Artery Branches

A case with coronary artery fistula, in which branches of both right and left coronary arteries were communicating to the pulmonary artery, was reported. The selective coronary arteriograms revealed also a small caliber of the left circumflex coronary artery beyond the branching point of the fistulous vessel and preponderance of the right coronary artery.

Diagnosis of obstructive coronary disease by maximal exercise and atrial pacing.

The reliability of graded maximal exercise treadmill testing and right atrial pacing in diagnosing significant obstructive coronary artery disease was evaluated in 74 consecutive patients referred to a cardiac unit with chest pain consistent with angina pectoris. The results of maximal exercise testing and right atrial pacing, with regard to the presence or absence of the patient's characteristic chest pain or discomfort and ischemic ST segment depression, were compared with the findings determined by selective coronary arteriography. Ischemic ST segment depression was defined as a downward displacement of one full mm or more of a horizontal or downward sagging ST segment. Forty-nine of the 74 patients studied were found to have significant coronary arteriographic obstruction, i.e., greater than 75% obstruction of one major coronary artery. The occurrence of the patient's characteristic chest pain or discomfort during maximal exercise testing or right atrial pacing is an excellent indicator of the presence of obstructive coronary artery disease, since all of the 41 patients developing their characteristic pain on maximal exercise testing had coronary arteriograms positive for obstructive coronary disease (no false positives), and 46 of 47 patients with characteristic chest pain on right atrial pacing had selective coronary arteriograms positive for obstructive coronary disease. When present, one mm ST depression during maximal exercise treadmill testing also reliably indicates arteriographic obstructive coronary disease (26 of 27 patients). However, the presence or absence of ischemic ST depression during right atrial pacing is a particularly unreliable indication of the presence or absence of arteriographic obstructive coronary disease: 15 of 25 false positive tests, and 13 of 49 false negative tests.

The Apexcardiogram in Patients with the Syndrome of Midsystolic Click and Late Systolic Murmur

@ate systolic waves have been noted in apexcardiograms recorded from subjects with idiopathic hypertrophic subaortic stenosis,' primary myocardial disease1 and coronary artery disea~e.~ This report describes similar abnormalities of the apical impulse noted in two patients with midsystolic clicks, late systolic murmurs and documented prolapse of mitral valve leaflets. This latter diagnosis was based on left ventriculography. Furthermore, convex deformities of the left ventricular cavity were noted during systole in these subjects. Selective coronary arteriograms were normal in both patients and coexisting hypertrophic subaortic stenosis was ruled out by continuous cavity and transvalvular pressure measurement during isoproterenol administration and catheter provoked premature ventricular contractions.

Radiographic anatomy of the coronary collateral circulation.

The selective coronary arteriograms of 100 patients with coronary disease were studied with large films and 35 mm. cinefilming.The examinations were analyzed for the presence of anastomoses and the preferential pathways of the collateral flow.We found that all anastomoses described in postmortem studies could be demonstrated with selective coronary arteriography, if a significant stenosis is present, and if proper equipment is used.