Selective Coronary Cinearteriography Research Articles

Coronary Artery Surgery

Coronary Artery Surgery

The cough that resuscitated Dr. F. Mason Sones's first patient undergoing selective cine coronary arteriography

The cough that resuscitated Dr. F. Mason Sones's first patient undergoing selective cine coronary arteriography

Prinzmetal's variant form of angina as a manifestation of alpha-adrenergic receptor-mediated coronary artery spasm: Documentation by coronary arteriography

In four patients with Prinzmetal's variant form of angina, the attack was induced by the combined administration of epinephrine (0.4 to 0.5 mg, given subcutaneously at 7:30 to 8:00 A.M.) and propranolol (40 mg. given orally at 5:00 A.M.). Selective coronary cinearteriography was done before, during, and after the attack with constant monitoring of the ECG and blood pressure. Severe spasm of the right coronary artery occurred at the proximal portion in association with ST-segment elevation in Lead III during the attack and disappeared with the subsidence of the attack in all of them. These results strongly suggest that severe spasm of a large coronary artery mediated by alpha-adrenergic receptors is responsible for the attack of Prinzmetal's variant form of angina.

Left ventricular aneurysm without coronary arterial obstruction or occlusion

The most common cause of left ventricular aneurysm is severe obstruction or occlusion of a major coronary artery. Among the last 2,500 patients studied in our laboratory with selective coronary cinearteriography and left ventriculography, we found 9 with unquestionable evidence of left ventricular aneurysm and no or minimal coronary arterial obstruction. Eight of the nine patients had a history of previous myocardial infarction and classic electrocardiographic changes. We believe that in these patients coronary arterial obstruction had led to the development of left ventricular aneurysm. Later, complete or partial regression of the coronary obstruction ensued, leaving a normal or a minimally compromised vascular lumen.

Hemoglobin affinity for oxygen in the anginal syndrome with normal coronary arteriograms.

Oxyhemoglobin dissociation (OHD) curves were performed on whole blood (WB) from 20 patients with anginal pain, normal hemodynamics, and normal coronary arteries, as demonstrated by selective coronary cinearteriography. OHD curves in 19 of 20 patients, from zero to full saturation, were nearly identical to those in normal control subjects with values for P(50) (Po(2) at 50% saturation and pH 7.4) of 26.7+/-1.5 (mean+/-SD of the mean) torr (mm Hg) and red blood cell (RBC) levels of 2,3-diphosphoglyceric acid (2, 3-DPG) of 0.72+/-0.10 (mean+/-SD of the mean) M/M hemoglobin (Hb). Normal values for nonsmoking adults were: P(50), 26.6+/-1.4 (mean+/-SD of the mean) torr: and RBC 2,3-DPG, 0.81+/-0.09 (mean+/-SD of the mean) M/M Hb. Mean levels of carbon monoxide were normal at 0.14+/-0.01 (mean+/-SEM) ml/100 ml WB in 10 patients who were nonsmokers and 0.45+/-0.15 (mean+/-SEM) ml/100 ml WB in 10 smokers. In one patient, a heavy smoker with markedly elevated blood carbon monoxide levels, an abnormal leftward shift of the OHD curve was observed. This was corrected after discontinuation of smoking. In utilizing these methods, we could not detect consistent abnormalities of Hb affinity for oxygen at rest in the patients studied, which suggests that a defect in oxygen transport at rest is an unlikely explanation for the symptoms of chest pain in patients with the anginal syndrome and normal coronary arteriograms.

Coronary-to-bronchial anastomoses: an in vivo demonstration by selective coronary arteriography.

Collateral circulation from the left coronary artery to the left bronchial artery was demonstrated by selective coronary cinearteriography in chronic obstructive pulmonary disease and atrial fibrillation in vivo in the absence of congenital heart disease. Presumably, disease altering the pulmonary arterial circulation caused pre-existing interarterial anastomoses to become functional. The relationship between the patient's arrhythmia and possible “coronary steal” is discussed.

Diagnostic Accuracy of Two-Step Postexercise ECG

A total of 305 selected patients with chest pain syndromes were studied with both the two-step test and selective coronary cinearteriography. All patients were suspected clinically of having coronary artery disease. Subjects with positive responses were subdivided according to degree of ischemic R-ST depression, and those with negative responses according to immediate postexercise heart rate. Results of this study suggest that the diagnostic accuracy of a moderate stress test (such as the two-step) is greatly enhanced when postexercise heart rate, degree of R-ST depression, and presence of preexercise electrocardiographic abnormalities are considered. Retention of the two-step test as a screening procedure appears justified.

Myocardial infarction in young women with normal coronary arteriograms.

Two women, ages 34 and 36 years, suffered an acute transmural anterior myocardial infarction accompanied by typical ECG and serum enzyme changes. At the time of selective cinecoronary arteriography 29 and 57 months later, however, neither had demonstrable narrowing of any coronary artery. Both have persistent ECG changes of an anterior infarct and markedly diminished contractions of a large segment of the anterior wall and apex on left ventriculogram. Neither before nor after infarction has either patient experienced angina pectoris. Both patients are premenopausal, and neither of them has diabetes, hypertension, obesity, valvular heart disease, a lipoprotein abnormality, or a family history of premature coronary arterial disease. Both smoke cigarettes. At the time of infarction one patient was taking an oral contraceptive and the other was 11-days postpartum. The pathogenesis of the myocardial infarcts in these patients is unknown. Embolization or in situ thrombosis of a previously normal anterior descending coronary artery with subsequent clot lysis would explain the infarcts, the normal coronary arteriograms, and the absence of prior or subsequent angina.

Diastolic heart sounds and filling waves in coronary artery disease.

One hundred thirty selected patieints with chest pain syndromes were studied by apex- and phonocardiography as well as by cardiac catheterization, selective cine coronary arteriography, and cine left ventriculography. Ninety-three patients had coronary artery disease; 37 did not. Abnormal graphic studies were found in 42 patients with coronary artery disease and three patients with normal coronary arteriograms. These abnormalities correlated well with the presence of elevated left ventricular end-diastolic pressure. Third heart sounds were found less frequently than fourth heart sounds and/or abnormal apexcardiographic a waves, but when present were usually associated with a depressed cardiac index. Diagnostically, over 90% of all patients with chest pain who exhibited graphic abnormalities had significant coronary atherosclerosis. Normal graphic studies did not rule out coronary artery disease, but did indicate adequate left ventricular function since only 5% of patients with normal graphic studies had elevated left ventricular end-diastolic pressure combined with a low cardiac index.

Selective cine coronary arteriography and vectorcardiographic diagnoses: Correlative study of one hundred patients

One hundred patients were studied with cine coronary arteriography and vectorcardiograms (VCG's). Coronary artery narrowing was estimated and correlated with vectorcardiographic diagnoses of myocardial infarcts and/or fibrosis. An anatomically and physiologically derived computer model of the myocardium was used as a means of interpreting the spatial VCG with regard to the size and site of destructive lesions within 12 myocardial subdivisions. Standard VCG criteria for large myocardial infarcts as well as new criteria for identification of smaller lesions were compared with coronary arteriographic findings. Myocardial lesions were identified as “scallops” in the QRS-E loop and their size was estimated by the magnitude and duration of deviation from a smooth progression of the VCG loop. A significant statistical correlation was found between the presence of severe coronary artery disease and vectorcardiographic evidence of large myocardial infarcts. VCG diagnoses of “small” and “medium” lesions had no statistical correlation with hemodynamically significant coronary artery disease. There was no significant statistical correlation between coronary arteriographic findings and VCG localization of infarcts. This is most likely due to anatomical variation in regional arterial supply and collateral vessel formation and is supported by a previous observation that the degree of coronary arteriographic change is inconsistent with the degree of ventricular dysfunction as demonstrated by ventricular angiograms. The VCG appears to be a useful clinical adjunct in the diagnosis of severe coronary artery disease and large myocardial infarcts. However, there is no evidence that smaller lesions predicted by VCG relate to the size or location of small scars in the myocardium.

Premenopausal castration and documented coronary atherosclerosis

Twenty surgically castrated women and 65 female control subjects who presented with clinical symptoms of coronary artery disease were studied with selective coronary cinearteriography to determine the prevalence of angiographically documented coronary atherosclerosis. Our results suggest that women who have been surgically castrated for at least 5 years have no more coronary atherosclerosis than their ovary-bearing, age-matched peers, and that surgical castration does not adversely influence the risk of coronary artery disease created by coronary risk factors.

The Syndrome Associated with Mid-systolic Click and/or Late Systolic Murmur: Analysis of 32 cases

We have collected 32 patients with the syndrome associated with mid-systolic click and/or late systolic murmur attesting to its prevalence. Ballooning of the posterior leaflet of the mitral valve was visualized in the 11 patients who underwent left ventriculography. Chest pain occurred in 20 of our 32 patients, dyspnea in 16, fatigue in 15, palpitations in 13, and lightheadedness in 9. The clinical pattern was often atypical. A midsystolic click followed by a late systolic murmur was recorded in 18 patients and in eight only a click was observed. In one patient with neither click nor murmur, mitral ballooning associated with chest pain and T wave changes was silent In five patients with proved ballooning only a pansystolic murmur was heard. In 22 patients we noted T wave inversion in lead aVF. Cardiac catheterization showed a “constrictive pattern” in five patients. Selective cine coronary arteriography performed in five patients was normal. We have collected 32 patients with the syndrome associated with mid-systolic click and/or late systolic murmur attesting to its prevalence. Ballooning of the posterior leaflet of the mitral valve was visualized in the 11 patients who underwent left ventriculography. Chest pain occurred in 20 of our 32 patients, dyspnea in 16, fatigue in 15, palpitations in 13, and lightheadedness in 9. The clinical pattern was often atypical. A midsystolic click followed by a late systolic murmur was recorded in 18 patients and in eight only a click was observed. In one patient with neither click nor murmur, mitral ballooning associated with chest pain and T wave changes was silent In five patients with proved ballooning only a pansystolic murmur was heard. In 22 patients we noted T wave inversion in lead aVF. Cardiac catheterization showed a “constrictive pattern” in five patients. Selective cine coronary arteriography performed in five patients was normal.

Postexercise electrocardiogram in patients with abnormal resting electrocardiograms.

One hundred and ten patients with chest pain syndromes and resting electrocardiograms demonstrating ST-T abnormalities and/or prior transmural myocardial infarctions were studied by means of the Master's two-step exercise test and selective coronary cine arteriography. Criteria for negativity were modified so that subjects with postexercise heart rates less than 110 beats/min, who did not develop significant ST-segment changes, were excluded from evaluation. Eighty-six per cent of the coronary artery disease group and 27% of the normal coronary artery group had positive postexercise electrocardiograms. Conversely, of the patients with positive results, 88% had anatomic coronary artery disease. With this degree of stress, positive responses ≧2 mm were invariably associated with multi-vessel disease. The type of pre-existing ECG abnormality did not influence either the frequency or severity of positive responses. False-negative subjects had no distinctive features relating to type of abnormal electrocardiogram, or location of vessel involvement, although most of these patients had significant disease of only one major coronary artery.

Hemoglobin affinity for oxygen in the anginal syndrome with normal coronary arteriograms

Oxyhemoglobin dissociation (OHD) curves were performed on whole blood (WB) from 20 patients with anginal pain, normal hemodynamics, and normal coronary arteries, as demonstrated by selective coronary cinearteriography. OHD curves in 19 of 20 patients, from zero to full saturation, were nearly identical to those in normal control subjects with values for P50 (Po2 at 50% saturation and pH 7.4) of 26.7±1.5 (mean±SD of the mean) torr (mm Hg) and red blood cell (RBC) levels of 2,3-diphosphoglyceric acid (2, 3-DPG) of 0.72±0.10 (mean±SD of the mean) M/M hemoglobin (Hb). Normal values for nonsmoking adults were: P50, 26.6±1.4 (mean±SD of the mean) torr: and RBC 2,3-DPG, 0.81±0.09 (mean±SD of the mean) M/M Hb. Mean levels of carbon monoxide were normal at 0.14±0.01 (mean±SEM) ml/100 ml WB in 10 patients who were nonsmokers and 0.45±0.15 (mean±SEM) ml/100 ml WB in 10 smokers. In one patient, a heavy smoker with markedly elevated blood carbon monoxide levels, an abnormal leftward shift of the OHD curve was observed. This was corrected after discontinuation of smoking. In utilizing these methods, we could not detect consistent abnormalities of Hb affinity for oxygen at rest in the patients studied, which suggests that a defect in oxygen transport at rest is an unlikely explanation for the symptoms of chest pain in patients with the anginal syndrome and normal coronary arteriograms.

Diastolic murmur caused by coronary artery stenosis.

Two patients had diastolic murmur caused by coronary artery stenosis. In both the diastolic murmur was associated with a severe, localized narrowing of the proximal left anterior descending artery demonstrated by selective coronary cinearteriography. The murmur disappeared after acute myocardial infarction involving the area of distribution by the stenosed coronary artery. Although mid-diastolic timing of the murmur combined with an accentuated first sound may lead to an erroneous diagnosis of mitral stenosis, several distinguishing features, including its response to amyl nitrite inhalation, help to differentiate. A stenosed coronary artery is a cause of diastolic murmur.

Serum Enzyme and Electrocardiographic Changes after Coronary Artery Surgery: Correlation with Selective Cine Coronary Arteriography and Left Ventriculography

The preoperative and postoperative serum enzyme determinations and electrocardiograms of 125 patients who underwent cardiac surgery were reviewed. Eighty-one patients underwent single or double internal mammary artery implantation. A patch-graft or vein-graft procedure for severe segmental obstructions was performed in 30 patients. A ventricular aneurysmectomy was performed in five patients, whereas nine underwent prosthetic valve replacement. Correlation with the electrocardiogram and serum enzyme activity was made with cine coronary arteriography and left ventriculography in 100 of 125 patients. The levels of SGOT, LDH, and CPK were found to be elevated after a variety of surgical procedures for coronary artery disease, but notable increases in the levels were attributed to acute myocardial infarction or external cardiac massage with DC defibrillation in the majority of patients. For file most part there was good correlation between enzyme responses and electrocardiographic changes. Usually, left ventriculography confirmed the diagnostic accuracy of serial electrocardiograms and enzyme determinations in the clinical recognition of acute transmural myocardial infarction.

Selective cine coronary arteriography: an improved technic.

Selective cine coronary arteriography: an improved technic.

The value of exercise tests in patients with abnormal resting electrocardiograms

Resting int’racardiac pressures and cardiac output were normal. Response to exercise demonstrated an increase in st#roke volume and cardiac output by 370/,, and the left ventricular end-diastolic pressure increased only slightly, while the left vemricular dp/dt, increased moderately. It now appears possible to reverse episodes of acute rejection, if they are detected early, in the majority of cases. In our patients, no evidence of myocardial ischemia or late funct.ional impairment of the transplanted heart has been demonstrat.ed. The Value of Exercise Tests in Patients with Abnormal Resting Electrocardiograms PETER F. COHN, MD/HARVEY G. KEMP, MD and RICHARD GORLIN, MD, FACC Boston, Massachusetts To investigate the usefulness of exercise tests in patients with abnormal resting electrocardiograms, 60 subjects who had undergone selective coronary cinearteriography were exercised with the standard double Master’s two step test and their electrocardiographic responses compared with their coronary anatomy. These subjects were suspected clinically of having coronary artery disease uncomplicated by other forms of heart disease; they were not receiving digitalis or beta adrenergic blockers, and had resting electrocardiograms demonstrating stable minor or major ST-T abnormalities and/or evidence of old transmural myocardial infarction. Subjects presenting with conduction disturbances and arrhythmias in the resting electrocardiogram were not included in this study. The exercise tests were interpreted as positive when the S-T segment showed an initial or further depression of at least 1 mm. No negative tests were included if post-exercise heart rate was less than 110 beats/min. Result,s are as follows : 44 Patients 16 Patients With Coronary Without Coronary Artery Disease Artery Disease Master’s test positive 35 (30%) 4 (25%) Master’s test negative 9 (20%) I2 (75%) ConverseIy, of the subjects with positive tests, 90% had anatomic coronary artery disease ; of the group with negative tests, 500/, had coronary artery disease. Subjects with three vessel disease had 90% positivity; those with two vessel disease, 75% positivity; and those with one vessel disease, 0%. Of the subjects with S-T segment depression of 2 mm or more, 96 percent had anatomic coronary artery disease. The anterior zonal leads were clearly more sensitive than the inferior ones in showing electrocardiographic abnormalit,ies. No fatalities or serious complications were observed. Abnormal Heart Sounds and Apexcardiographic A Waves in Patients with Coronary Artery Disease PETER F. COHN, MDjPANTEL S. VOKONAS, MD/RICHARD WILLIAMS, MD MICHAEL V. HERMAN, MD and RICHARD GORLIN. MD, FACC Boston, Massachusetts Despite numerous reports of an increased incidence of abnormal heart sounds and apexcardiographic A waves in patients wit,h coronary artery disease, correlations of these clinical findings with both hemodynamic and anatomic data have been lacking. Forty subjects underwent cardiac catheterization, selective coronary cinearteriography and left ventriculography, and were found to have coronary artery disease uncomplicated by other forms of heart disease. They were also studied with the phonocardiogram (PCG) and/or apexcardiagram (ACG) to document the presence or absence of a third or fourth sound or abnormal A wave. Results are shown in the table at right. The vast majority of patients with abnormal PCG-ACG studies had either three vessel disease, abnormal ventriculograms or elevated left ventricular end-diastolic pressure. Conversely, no subject presenting with normal PCGACG studies had combined three vessel disease, abnormal left ventricular motion study, and elevated LVEDP. Of the three PCG-ACG parameters, the abnormal A wave was the most sensitive single index of an elevat,ed left ventricular end-diastolic pressure and of an abnormal ventriculogram, but was one third less reliable than all three parameters taken together. No accurate prediction of three vessel disease could be made from any single parameter. 22 Subjects 18 Subjects With Without PCGACG PCGACG Abnormalities Abnormalities Three vessel disease Abnormal ventriculogram Left ventricular end-diastolic pressure above 12 mm Hg All of the above Cardiac index below 3.0 liters/min 36% 34%

SELECTIVE CORONARY ARTERIOGRAPHY

SELECTIVE CORONARY ARTERIOGRAPHY A SPOT FILM ROENTGENOGRAPHIC TECHNIQUEFRANK R. BEGG, M.D., MOHAMMED A. KOOROS, M.D. and DON L. FISHER, M.D.Audio Available | Share

Selective cine coronary arteriography in patients with complete heart block

Selective cine coronary arteriography in patients with complete heart block