bluuebunny/crossref_metadata_2025 huggingface dataset:
Differentiation between left circumflex and right coronary artery occlusions: Studies on ST‐segment deviation during percutaneous transluminal coronary angioplasty
Authors: Hiasa Y. , Morimoto S. , Wada T. , Hamai K. , Nakaya Y. , Mori H.
Published: February 2009

To distinguish between acute occlusion of the right coronary artery (RCA) and the left circumflex artery (LCx) by electrocardiography, we studied ST‐segment deviation during balloon inflation in percutaneous transluminal angioplasty. The composite electrocardiographic criteria based on ST‐segment deviations increased the diagnostic specificity: that is, the finding of inferior infarction (ST‐segment elevation in leads II, III, aVF) without lateral infarction (ST‐segment elevation in leads V5, 6) was highly suggestive of RCA occlusion (sensitivity and specificity: 35 of 43 cases, 81.4%; and 33 of 36cases, 91.7%), whereas ST‐segment elevation in leads V5,6 (LCx: 23 of 36 cases; 63.9%, RCA: 5 of 43 cases; 11.6%) or isolated ST‐segment depression in leads V2‐4 (LCx: 9 of 36 cases; 25.0%, RCA: none of 43 cases) was highly suggestive of LCx occlusion. These results indicated that the composite electrocardiographic criteria were useful in predicting the artery involved in acute myocardial infarction, although any single criterion was not sensitive or specific enough to differentiate right from left circumflex coronary artery occlusion.
Apical hypertrophic cardiomyopathy presenting with sustained monomorphic ventricular tachycardia and electrocardiographic changes simulating coronary artery disease and left ventricular aneurysm
Authors: Wilson P. , Marks A. , Rastegar H. , Manous A. S. , Mark Estes N. A.
Published: February 2009

A 52‐year‐old male presented with sustained monomorphic ventricular tachycardia as the initial manifestation of apical hypertrophic cardiomyopathy. The electrocardiogram during normal sinus rhythm showed a pattern of an old anterior wall myocardial infarction with aneurysm formation. Cardiac catheterization documented angiographically normal coronary arteries. Apical hypertrophic cardiomyopathy was documented at cardiac catheterization and by echocardiogram and Doppler studies. Monomorphic ventricular tachycardia was reproducibly initiated and terminated during electrophysiological studies and antiarrhythmic drugs failed to control the tachycardia. At the time of implantation of a cardioverter defibrillator, left ventricular apical biopsy revealed pathologic findings characteristic of hypertrophic cardiomyopathy.
Hypertrophic cardiomyopathy: Prognosis with medical or surgical therapy
Authors: Blanchard D. G. , Ross J.
Published: February 2009

Over the past 30 years, knowledge of the natural history and effects of therapy in patients with hypertrophic cardiomyopathy has expanded greatly, but progress has been hampered by its variable patterns of expression. Many but not all patients show symptomatic improvement with medical treatment. Chronic beta blockage does not appear to affect long‐term survival, whereas results with calcium channel blockade by verapamil have been encouraging; however, they await confirmation, and verapamil may be hazardous in some patients with severe left ventricular (LV) outflow tract obstruction and elevated LV end‐diastolic pressure. Reported beneficial effects of amiodarone on survival also require further study. Surgical therapy has become the treatment of choice for medically refractory patients with proven outflow tract obstruction. In several centers, the operative risk is low, and long‐term follow‐up demonstrates prolonged symptomatic relief. It is hoped that work currently underway will provide more definitive information on the long‐term effects of the role of calcium channel blockers, antiarrhythmic medications, and the long‐term effects of surgical therapy on survival of patients with this disorder.
Cross‐sectional area index of left ventricular myocardium as a risk factor influencing early and late postoperative survival in aortic regurgitation
Authors: Okamura K. , Mitsui T. , Hori M.
Published: February 2009

Late cardiogenic death after aortic valve replacement in aortic regurgitation is still a most important unresolved problem. We studied how the extent of cross‐sectional area index (CSAI) relates to early and late cardiogenic deaths after aortic valve replacement (AVR) in aortic regurgitation with normal coronary artery. Forty‐one patients were classified into two groups: Group I having CSAI >20 cm2/m2 (18 patients), and Group II, in whom CSAI was <20 cm2/m2 (23 patients). All preoperative factors in patients with CSAI ≥ 20 cm2/m2 showed poor values compared with patients with CSAI <20 cm2/m2 with a statistical difference of 63 ± 6 versus 56 ± 4% in cardiothoracic ratio, 72 ± 9 versus 64 ± 8 mm in diastolic dimension, 54 ± 9 versus 43 ± 7 mm in systolic dimension, 25 ± 7 versus 32 ± 6% in fractional shortening, 326 ± 60 versus 209 ± 63 ml/m2 in end‐diastolic volume index, 177 ± 52 versus 81 ± 29 ml/m2 in end‐ systolic volume index, and 47 ± 14 versus 58 ± 5% in ejection fraction (mean ± SD). In Group II, there were no postoperative cardiac deaths and no patient was subjected to intra‐aortic balloon pumping (IABP). In contrast, in Group I, 17% died from postoperative low output syndrome and 33% were subjected to IABP. Concerning late deaths, there was no cardiac death in any CSAI patient with <20 cm2/m2; however, 22% of the patients with CSAI ≥20 cm2/m2 died from cardiac causes. Survival at the end of the ninth year showed 78 ± 10 % in CSAI < 20 cm2/m2 in contrast with the poor results of CSAI ≥ 20 cm2/m2 as 38 ± 16% (p<0.05). Thus, we conclude that AVR in aortic regurgitation should be scheduled before CSAI levels reach 20 cm2/m2, and if the operation is to be performed in patients with CSAI above 20 cm2/m2, cautious observation and medication should be the rule in order to avoid late cardiogenic deaths.
What a clinician needs to know about the mechanisms of action of antiarrhythmic drugs
Authors: John Camm A. , Janse M. J.
Published: February 2009

Vaughan Williams' classifications of antiarrhythmic drugs are briefly discussed, including the fact that these drugs are classified based upon their effects on normal cardiac cells; that more and more subclassifications need to be introduced; that many drugs have actions belonging to different classes. A plea is made not to consider just one effect of an antiarrhythmic drug—that is, its effect on conduction velocity only or on refractory period only, but to evaluate its effect on wavelength, the product of refractory period and conduction velocity. Experimental studies on atrial arrhythmias induced by electrical stimulation in chronically instrumented dogs have shown a very good correlation between wavelength and type of arrhythmia induced. The predictive value of wavelength was much greater than that of refractory period alone or conduction velocity alone. It is emphasized that drugs that shorten wavelength especially at rapid rates may exhibit dangerous proarrhythmic effects.
Annular subaortic aneurysm resulting in sudden death
Authors: Normann Sigurd J.
Published: February 2009

A subvalvular aneurysm in a 34‐year‐old black woman developed beneath the left coronary cusp of the aortic valve and extended in the epicardium between the aortic root and left atrium. She was asymptomatic until she expired suddenly from myocardial ischemia caused by compression of the circumflex coronary artery by the aneurysm. A review of the literature reveals 13 reports of subaortic and 58 submitral aneurysms but only two instances of myocardial infarction secondary to coronary artery compression by spontaneous subvalvular aneurysms in either the subaortic or submitral position.
Emergency coronary revascularization using polytetrafluoroethylene conduits in a patient in cardiogenic shock
Authors: Hartman A. R. , Vlay S. C. , Dervan J. P. , Lawson W. E. , Mannisi J. , Anagnostopoulos C. E.
Published: February 2009

There is growing awareness that a particular subset of patients with coronary artery disease who need surgical revascularization do not have autologous vein or internal mammary artery available or surgically applicable. The polytetrafluoroethylene graft has had limited use in aortocoronary bypass procedures. We describe a case of cardiogenic shock secondary to severe coronary artery disease and aortic stenosis, where the use of this synthetic graft contributed to a successful outcome. Angiographic patency was documented at 3 months follow‐up. Our experience, plus a review of the literature, supports the use of polytetrafluoroethylene grafts during aortocoronary artery bypass to salvage infarcting or ischemic myocardium, when traditional autologous bypass conduits are not available or applicable.
Subendocardial arteriovenous malformation in a patient with unstable angina
Authors: Kemme D. J. , Rainer W. G.
Published: February 2009

A variety of arteriovenous abnormalities of the heart have been previously described. Arteriovenous malformations are uncommon developmental abnormalities documented in almost every organ of the body. A subendocardial arteriovenous malformation in a patient with unstable angina is described which we believe to be the first reported case.
Well‐being (quality of life) in connection with hypertensive treatment
Authors: Dahlöf C.
Published: February 2009

Quality of life is often considered to equate how the medical treatment is subjectively perceived by the patient, but ought to include the total impact of the disease/treatment on the patient's emotional, physical, and social well‐being. Recently, a proposal for a generally applicable definition of quality of life in health care was put forward. This definition includes general well‐being, health, and welfare (external factors), as three fundamental components, and the definition is based on both objective and subjective judgments. General well‐being is exclusively an expression of the individual's subjective experience and is based on his or her own qualitative evaluation of well‐being in relation to condition, treatments, and experiences. Health is according to the proposed definition, judged both objectively (signs) and subjectively (symptoms). Apart from health and well‐being, there is also reason to include objectively registrable factors at the welfare level (external factors) such as the consumption of medicines, number of days in hospital, length of sick leave, need of in‐home care, etc. This review is an attempt to elucidate the effects of antihypertensive pharmacotherapy on the patient's general well‐being. The topic will be discussed from several points of views (e.g., aims of antihypertensive treatment, occurrence of symptoms in the population, compliance with prescribed treatment, symptom inventories, the concept of quality of life).
Coronary Collateral Circulation
Authors: Pellinen T. J. , Virtanen K. S. , Toivonen L. , Heikkilä J. , Hekali P. , Frick M. H.
Published: February 2009

The occurrence and influence of coronary collateral circulation and obstruction of the supplying coronary arteries on left ventricular contractility, prevalence of myocardial infarction, and bicycle exercise ergometer test were studied in a random sample of 286 patients with angiographically documented coronary artery disease. Collaterals appeared increasingly in all three main coronary arteries with grade of obstruction. The highest prevalence of collaterals occurred in stenosis of the right coronary artery (60%), followed by the left descending artery (45%); they occurred least in the left circumflex artery (21%) (p<0.001). The frequency of intra‐arterial collateral circulation was 42%, 11%, and 12%, respectively (p<0.001). With total occlusion of the left anterior descending coronary artery, 22% of the patients had nor‐mokinetic anterior and apical left ventricular wall when collaterals were present. More often, the inferior wall showed normal contraction with total occlusion of the right coronary artery and collaterals [52%, p<0.001 compared with left anterior descending artery (LAD)]. The prevalence of inferior myocardial infarction was 39%, with collateral circulation to the totally occluded right coronary artery. The respective prevalence of anterior infarction and total occlusion in the left coronary artery was 58% (p<0.02). The presence or absence of collaterals had no obvious influence on ST‐segment response during bicycle ergometer test. In triple‐vessel disease, peak work capacity was better when collaterals to LAD were not jeopardized (427 kpm) than when jeopardized (321 kpm) (p.<0.02).
Stress‐induced changes in blood pressure and left ventricular function in mild hypertension
Authors: Lindvall K. , Kahan T. , De U. , Östergren J. , Hjemdahl P.
Published: February 2009

Left ventricular function was studied by M‐mode echocardiography at rest and during a mental arithmetic stress test and a cold‐pressor test in 14 patients with mild hypertension and in 14 matched normotensive subjects. The elevation of blood pressure at rest in the hypertensive group (154 ± 4/87 ± 3 vs. 120 ± 3/66 ± 3 mmHg in the control group) was due mainly to a higher cardiac output (6.0 ± 0.3 vs. 5.0 ± 0.3 L/min), which was related to elevations of stroke volume and heart rate (73 ± 2 vs. 66 ± 2 beats/min). Venous plasma catecholamines were similar in the two groups. Mental stress induced cardiac output‐dependent increases in blood pressure in both groups; systemic vascular resistence tended to decrease. The relative increases in diastolic and mean arterial blood pressure were smaller in the hypertensive group (15 vs. 26% and 15 vs. 21 %, respectively), which exhibited signs of a reduced cardiac compliance, possibly related to a left ventricular hypertrophy. Mental stress elevated venous plasma adrenaline similarly in the two groups; effects on noradrenaline were small. The cold‐pressor test increased blood pressure similarly in the two groups, largely due to increased systemic vascular resistence; plasma noradrenaline responses were also similar. Mental stress appears to elicit a differentiated sympathetic nerve activation pattern resembling the hypothalamic defense reaction. Mild hypertension seems to be associated with increased arousal and cardiac activation at rest. However, an attenuated blood pressure reactivity to mental stress may reflect reduced stroke volume responsiveness, which is related to structural changes, as heart rate reactivity tended to be enhanced in mild hypertension.
Subepicardial aneurysm of the left ventricle: Report of a case and review of the literature
Authors: Vossenberg F. , Amidi M. , Kormos R. , Labuda M. J.
Published: February 2009

A case of subepicardial aneurysm is reported and 16 other cases found in the literature are reviewed. Although the subepicardial aneuryms are distinct from true and false aneurysms, their propensity for rupture is similar to false aneurysm. The incidence of this aneurysm is increasing due to the use of thrombolytic therapy in myocardial infarction. Early invasive diagnostic test is leading to its more frequent discovery.
Acute occlusion of left main coronary artery without ventricular damage
Authors: Prachar H. , Dittel M. , Enenkel W.
Published: February 2009

We report a patient with acute occlusion of left main coronary artery with only a small increase of cardiac enzymes but without electrocardiographic signs of acute myocardial infarction. Normal global and regional left ventricular function could be documented angiographically. Damage of myocardium was prevented by extensive collateral circulation from a large dominant right coronary artery.
Developing a rational management strategy for angina pectoris after coronary bypass surgery: A clinical decision analysis
Authors: Mills Roger M. , Kalan Jay M.
Published: February 2009

Long‐term follow‐up of patients undergoing coronary artery bypass graft surgery indicates that as many as 50% eventually experience recurrent angina pectoris. Rational management of these individuals requires an understanding of the natural history of coronary bypass grafts, the risks and benefits of both reoperation and angioplasty, as well as a structure within which to integrate these data. This report reviews the literature and employs formal decision analysis to develop a strategy for management of recurrent angina. Our analysis supports the strategy that patients experiencing recurrent angina within 3 years alter surgery should undergo prompt angiographic re‐evaluation and angioplasty if anatomically suitable. Symptoms beginning more than 6 years after surgery should be managed medically, reserving surgery for refractory symptoms.
Electrocardiography and postextrasystolic potentiation: Utilization of the two methods to predict postrevascularization segmental myocardial function
Authors: Cooper M. W. , Mitchell R. , Lutherer L. O. , Lust R.
Published: February 2009

We previously reported that postextrasystolic potentiation (PESP) is a useful predictor of changes in systolic wall function (SWF) following coronary revascularization. In the current study we analyzed ECG changes related to corresponding myocardial segments to determine their correlation with PESP and SWF. We found: (1) The PESP response in a jeopardized segment was a valid predictor of improved SWF even when Q waves, ST‐segment changes, or T‐wave changes were present. (2) However, when Q waves were present in two or more of the corresponding leads, positive PESP was less likely to be observed. (3) Thus Q waves in two leads predicted the least postrevascularization improvement. (4) Segments with no corresponding Q‐wave postrevascularization usually improved SWF. (5) Furthermore, a continuum of responsiveness to PESP was found, ranging from T‐wave changes, ST‐segment changes to Q‐wave changes, indicating dissociation between electrical and mechanical events. In conclusion, the ECG together with PESP provide good predictive information relative to the efficacy of revascularization. PESP is a more valuable predictive indicator. ECG alone may be of value in that the occurrence of Q waves in two or more corresponding leads predicts a low probability of improved SWF. Further studies are indicated to investigate the dissociation between electrical and mechanical events.
Thrombolytic therapy in refractory unstable angina: The role of holter monitoring
Authors: Brunelli Claudio , Spallarossa Paolo , Ghigliotti Giorgio , Iannetti Mario , Caponnetto Salvatore , Lantieri Pasquale
Published: February 2009

We tested the safety and the usefulness of intravenous urokinase (2 million units administered over 30 min) in 44 patients with refractory unstable angina, defined as persistence of ischemic episodes during 48‐h Holter monitoring (Phase 1) despite maximal medical therapy. After thrombolysis, recurrence of ischemia was observed during a week of observation in the CCU, including two 24‐h Holter monitorings at the beginning and the end of the week (Phase 2). Seventeen patients completed the observation period without either symptomatic or asymptomatic ischemic episodes (Group A); the remaining 27 continued to manifest ischemia (Group B). No bleeding complications occurred. Within a 6‐month follow‐up, 2 patients of Group A had recurrence of unstable angina while in Group B, 19 patients had refractory angina or a major cardiac event [10 patients underwent coronary artery bypass surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for refractory angina (p>0.001), 6 other patients with refractory angina continued medical therapy, one patient had a myocardial infarction, and two patients died]. In Phase 1 the duration of total ischemia (min/24 h) was a relevant prognostic marker: higher duration correlated with adverse clinical outcome (p>0.01). In comparison to Phase 1, duration of total ischemia in Phase 2 was significantly reduced in both groups (16.9±19.6 vs. 25.4±17.7; p>.001). A percent value expressing this variation was calculated for each patient: the variation thus obtained again gave information on the clinical outcome—the greater the reduction, the lower the risk of cardiac events (p>.001). Our data suggest that (1) clinical stabilization may be obtained with the addition of urokinase to conventional treatment, (2) Holter monitoring bears prognostic information helpful in identifying patients who need further intervention.
Electrophysiologic effects of oral diltiazem before and after beta blockade
Authors: Kumar Krishna , Bajaj Rajiv , Kaul Upendra , Bahl Vinay K.
Published: February 2009

We conducted electrophysiologic (EP) studies and estimated the sinus node function and atrioventricular (AV) conduction in 10 patients with suspected coronary arterial disease (age range 35–55 years) before and during diltiazem therapy (60 mg thrice daily for 5–7 days). The effect of beta blockade (0.1 mg/kg of intravenous propranolol) was evaluated in both EP studies. The mean spontaneous sinus cycle length (SCL) and the AV nodal Wenckebach cycle lengths (AVWB) were significantly higher (p<0.05) after propranolol alone (913±131 and 504±197 ms, respectively) compared with baseline values (SCL: 827±149 ms, AVWB: 439±173 ms). Diltiazem alone failed to influence the SCL and AVWB significantly. Following the combination (diltiazem + propranolol), SCL (945 ± 147 ms) and AVWB (533 ± 148 ms) were significantly higher (p<0.05) than baseline and post diltiazem values (SCL: 840 ± 150 ms; AVWB 457 ± 103 ms). None of the other parameters (sinoatrial conduction time, corrected sinus node recovery time, AH and HV intervals, AV nodal and atrial effective refractory periods) were significantly influenced by propranolol, diltiazem, or the combination. No patient developed AV block, sinus arrest/sinoatrial exit block, or symptomatic sinus bradycardia following beta blockade after diltiazem administration. Oral diltiazem therapy alone and after beta blockade does not appear to adversely influence the sinus node function and AV conduction in patients below the age of 55 years. The combination of diltiazem and beta blocker thus appears safe in selected patients with coronary arterial disease.
Improvement of left ventricular aneurysm after myocardial infarction: Report of three cases
Authors: Iwasaki Khoichirou , Kita Toshimasa , Taniguchi Gyou , Kusachi Shoza
Published: February 2009

We report on the disappearance of a left ventricular aneurysm after myocardial infarction in three cases. Coronary blood flow was restored by spontaneous recanalization in two cases and by angioplasty in one case. When the aneurysm was observed, the findings in these cases were (1) no or limited abnormal Q wave in surface electrocardiography, (2) total or subtotal stenosis of the proximal coronary artery without adequate distal filling through collaterals, (3) no ST shift in exercise electrocardiography, and (4) decreased but not absent thallium‐201 uptake in myocardial scintigraphy. In Cases 1 and 2, respectively, 3 years and one year and 8 months after the myocardial infarction, an anginal episode occurred and the ventricular aneurysm disappeared. In Case 3, the aneurysm disappeared after coronary angioplasty. These cases suggest that even without a demonstration of reversible ischemic myocardium and/or severe stenosis without distal tilling through collaterals, the myocardium presenting a ventricular aneurysm would be hibernating. These cases were also informative about the detection of hibernating myocardium.
Doppler echocardiography versus cardiac catheterization in the evaluation of valvular heart disease: Do we have a gold standard?
Authors: Schwinger Matthew E.
Published: February 2009

Definitive evaluation of valvular heart disease is traditionally accomplished by cardiac catheterization. Recent advances in Doppler echocardiography allow noninvasive assessment of valvular heart disease with a high degree of accuracy compared to the cardiac catheterization gold standard. Doppler echocardiography may occasionally yield erroneous results due to technical difficulties in the performance of the study. A number of patient related and echo‐machine related factors may also affect the Doppler measurements independent of the severity of the lesion. Thus, a discrepancy between Doppler and catheterization data is generally considered to be a failure of Doppler methods. However, catheterization data may also be flawed due to errors in the measurement of pressure and cardiac output, as well as the known shortcomings of qualitative angiography. The Gorlin equation itself suffers from several limitations, including the substitution of pressure gradient for velocity in the basic hydrodynamic equation, and the use of a constant which may not be appropriate in all circumstances. Therefore, when Doppler echocardiography and cardiac catheterization yield discordant results, both studies should be carefully reviewed and correlated with other clinical data in order to elucidate the sources of the discrepancy and ascertain the actual severity of the valvular lesion.
Antiarrhythmic and proarrhythmic properties of diazepam demonstrated by electrophysiological study in humans
Authors: Kumagai Koichiro , Yamanouchi Yoshio , Matsuo Kunihiro , Tashiro Noritami , Hiroki Tadayuki , Arakawa Kikuo
Published: February 2009

We evaluated the electrophysiological parameters before and after the intravenous infusion of diazepam (0.2 mg/kg) in 20 cardiac patients to investigate the drug's antiarrhythmic effect. Diazepam did not significantly change the arterial pressure. After the intravenous infusion of diazepam, the sinus cycle length significantly shortened from 847±132 to 747±155 ms (p>0.01). No significant change in the maximal sinus node recovery time was noted. The AH interval at the atrial pacing length of 600 ms shortened significantly from 140±40 to 127±39 ms (p>0.05). However, there was no significant change after the administration of diazepam in the longest atrial pacing rate associated with Wenckebach conduction in the atrioventricular (AV) node, effective and functional refractory periods of the AV node, HV interval, and QRS width during ventricular pacing at the cycle length of 600 ms. The atrial and ventricular effective refractory periods remained unchanged after the administration of diazepam. Six of the eight patients who showed dual AV nodal refractory period curves in the control study did not demonstrate them after diazepam administration by increasing the atrial or AV node effective refractory period. Thus, diazepam showed significant electrophysiological effects of the heart including shortening of the sinus cycle length, improvement in AV node conduction, and no significant effect on the His‐Purkinje or intraventricular conduction and refractoriness of the atrium, AV node and ventricle. On the other hand, diazepam may influence the inducibility of supraventricular reentrant tachycardia incorporating the AV node.
Malignant myxoid emboli as the presenting feature of primary sarcoma of the aorta (myxoid malignant fibrous histiocytoma): A case report and review of the literature
Authors: Tejada Eduardo , Becker Gary J. , Waller Bruce F. , Waller Bruce
Published: February 2009

Primary sarcomas of the aorta are rare vascular tumors. About 26 cases have been reported between 1973 and 1989. They are seldom diagnosed antemortem. The present report describes a patient with a myxoid malignant fibrous histiocytoma arising in the intima of the lower thoracic aorta, which was diagnosed premortem in metastatic peripheral emboli. The clinical and pathologic features of this patient along with a summary of the 29 primary aortic tumors previously reported (26 malignant and 3 benign) are discussed. Although few of these tumors have been described histologically as benign, all of them behave as malignant tumors.
Diffuse Embolization Following Percutaneous Transluminal Coronary Angioplasty of Occluded Vein Grafts: The Blush Phenomenon
Authors: Margolis James R. , Mehta Sameer , Chen Cheng‐Yun , Krauthamer Dan , Mogensen Lars
Published: February 2009

Summary: Percutaneous transluminal coronary angioplasty (PTCA) was performed on 146 saphenous vein grafts in 116 patients. In 29 patients, 31 grafts were totally occluded. Myocardial staining lasting over 5 minutes—“the blush phenomenon”—followed the opening of the occluded grafts in 9 of these patients. In 5 of these 9, enzyme release suggested infarction. A sixth patient died within a few hours of PTCA, with suspected infarction. Autopsy demonstrated diffuse and extensive distal coronary arterial embolization of grumous material, including cholesterol crystals, platelets, and fibrin. The blush phenomenon was not seen following PTCA in the remaining 20 patients with total occlusions, nor in any of the 87 patients with stenosed grafts. We have not observed the blush phenomenon following PTCA of more than 3300 coronary arteries. Of the 9 patients demonstrating the blush phenomenon, 6 had a recent history of myocardial infarction or unstable angina pectoris, compared with 4 of the remaining 20 patients with occluded grafts. We now approach occluded grafts with injection of intragraft thrombolytic agents or with atherectomy prior to PTCA. Future approaches may include atherectomy or laser angioplasty.
Prazosin in Chronic Congestive Heart Failure Due to Ischemic Heart Disease
Authors: Antani J. A. , Antani Nirmal J. , Nanivadekar A. S.
Published: February 2009

Summary: Oral prazosin hydrocholoride (2–20 mg/day) was administered to 38 patients with chronic congestive heart failure due to ischemic heart disease for 6–18 months. Half (19) of the patients were hypertensive and half (19) nonhypertensive. All were receiving furosemide (80 mg/day, orally) and 19 were receiving digoxin (0.25–0.5 mg/day, orally) in addition to prazosin. Clinical radiological, mechanocardiographic, echocardiographic, and biochemical observations were made initially, at peak response, and at the end of 6 months. Prazosin improved left ventricular function indexes at rest, relieved symptoms and signs of congestion, and remained effective for 6–18 months with little or no increase in dose. There was no reflex tachycardia, tension‐time indexes fell in all patients, angina was relieved in 8 patients who complained of it, and dyskinesia of left ventricular wall was corrected in 8 of 13 patients. The New York Heart Association functional class improved in all patients, but to a greater extent in hypertensive patients and in those not receiving concomitant digoxin. Mild, transient side effects occurred in 6 patients.
Outpatient Cardiac Catheterization: A Report of 3,000 Cases
Authors: Clements Stephen D. , Gatlin Sara
Published: February 2009

Summary: A total of 3000 patients have had cardiac catheterization in the Andreas Gruentzig Cardiovascular Laboratory of the Emory Clinic. The purpose of this presentation is to describe the patient population selected for this procedure and our experience with this group. The concept of catheterization as an outpatient is attractive from the standpoint of cost savings and time conservation. Safety has been questioned. We have found that this technique can be performed safely in carefully selected outpatients. Careful selection attempted to eliminate those with unstable symptoms, recent myocardial infarction, severe diabetes, and renal failure. Small catheters were used to minimize the potential for bleeding. Excellent opacification of vessels was obtained with these catheters. Despite careful screening we found 2.2% had significant left main obstruction, 10.8% had triple‐vessel disease, 16.0% had double‐vessel disease, and 23.5% had single‐vessel disease, and a similar percentage had normal coronary arteriograms. Our patients experienced ventricular fibrillation on five occasions, there were two small cerebral emboli with reversible neurologic defects, two episodes of pulmonary edema, and two episodes of severe allergic reactions. Only three patients had significant groin bleeding at home that required compression of the site. We subsequently did angioplasty on 323 patients, performed cardiac surgery (mostly coronary bypass) on 187 patients, and admitted 18.2% of the entire group. We conclude that this procedure can be done safely in this carefully designed setting and it saves time and offers cost savings. Patient selection is very important to minimize potential emergency situations and complications. The laboratory must be carefully set up and provide a close relationship with a hospital capable of attending to any unexpected emergency.
The atrioventricular plane displacement as a means of evaluating left ventricular systolic function in acute myocardial infarction
Authors: Alam Mahbubul
Published: February 2009

Displacement of the atrioventricular (AV) plane toward the cardiac apex in systole was studied quantitatively by echocardiography in 37 patients with first‐time acute myocardial infarction (MI) in order to evaluate left ventricular systolic function. The amplitude of AV plane displacement was recorded from the apex at four different sites corresponding to the septal, lateral, anterior, and posterior walls of the left ventricle from apical 4‐ and 2‐chamber views. The patients had a decreased displacement of the AV plane compared with controls which was more pronounced at the sites of infarction. The mean value of the AV plane displacement (AV mean) correlated linearly with the left ventricular (LV) ejection fraction calculated by radionuclide angiography (r = 0.87, p<0.001, SEE= 6.2). An AV mean of 10 mm or more had a high sensitivity (95%) and specificity (82%) in defining a normal ejection fraction (2 50%). A high correlation coefficient was found between LV wall motion index and the AV plane displacement. Thus, in acute MI the LV function can be assessed noninvasively using AV plane displacement.
High‐energy catheter ablation of cardiac arrhythmias: An outmoded technique in the 1990s
Authors: Cunningham David
Published: February 2009

Catheter ablation has become an accepted technique for creating complete heart block in patients with drug refractory supraventricular tachycardias. However, it remains experimental for other indications, such as ablation of accessory pathway or ventricular tachycardia. The use of high energy defibrillator discharges is associated with adverse effects which greatly contribute to the limitations of the technique. Advances in technology have led to newer methods, such as radiofrequency and low energy capacitive discharge, which hold significant advantages over the conventional high energy technique, to the extent that the use of defibrillator discharges should now be considered outmoded and potentially damaging. Radiofrequency is the technique of choice for accessory pathway ablation and modification of AV conduction, and low energy capacitive discharge is the preferred method for creation of complete heart block. There are currently no acceptably safe and efficacious catheter techniques for treating ventricular tachycardia, and more research needs to be done in this area. The potential for the success of these techniques depends to an extent on the creation of new standards of practice for catheter ablation. There has been no unbiased comparative assessment of the different techniques, and consequently no consensus exists on the preferred technique and technologies which should be used. Only within the framework of these standards can the technique achieve significant clinical utility.
Left ventricular function during transient coronary occlusion: Digital subtraction left ventriculograms during coronary angioplasty
Authors: Kitazume, Hidemasa , Kubo, Ichirou , Iwama, Toru , Ageishi, Yoshio , Suzuki, Akio
Published: February 2009

The impact of transient myocardial ischemia on left ventricular function was examined by digital subtraction left ventricular angiography. Contrast medium was injected into the right pulmonary artery before, at 60 seconds of balloon inflation, and 10 minutes after balloon deflation. A total of 69 patients completed the study. In 52 patients, the left anterior descending artery (LAD) was involved, and in 17, the right coronary artery (RCA) was the focus. Ejection fraction (EF) declined by balloon inflation and returned to baseline value after deflation of the balloon. There was tendency toward a lower EF and wider akinetic area for LAD dilatation. The linear correlation between resting EF and EF during balloon inflation suggested that the effect of momentary coronary occlusion on left ventricular function appears to be additive to preexisting left ventricular dysfunction, and resting ejection fraction is an important parameter for estimating the degree of diminished left ventricular function during myocardial ischemia.
Relationship of auscultatory fourth heart sound to the quantitated left atrial filling fraction
Authors: Homma Shunichi , Bhattacharjee, Dulal , Gopal, Aasha , Correia, Joaquim
Published: February 2009

The fourth heart sound (S4) has been associated with vigorous atrial contraction. However, the presence of S4 has not been previously correlated with quantitated left atrial filling fraction. In this study, the presence of an auscultatory S4 was compared with the Doppler echocardiographically quantitated left atrial filling fraction in 41 consecutive patients in whom S4 was judged to be present or absent according to the consensus of cardiologists. Left atrial filling fraction in patients with S4 was 49% and was significantly greater than 33% found in patients without S4 (p<0.005). Using atrial filling fraction of 35% as a dividing line, S4 had a sensitivity of 84% and a specificity of 75% for determining left atrial filling fraction ≥ or <35%. Furthermore, of 25 patients with S4, 21 (84%) had atrial filling fraction ≥35%, and of 16 patients without S4, 12 (75%) had atrial filling fraction <35%. Thus, the presence or the absence of S4 is quantitatively related to the left atrial filling fraction and appears to predict atrial filling fraction ≥ or <35% reasonably well.
Familial recurring cardiac myxoma
Authors: Herbert Haught, W. , Alexander, James A. , RichardConti, C.
Published: February 2009

A 34‐year‐old woman presented with her fourth occurrence of an atrial myxoma and a right lower lung field mass. Her surgical history was extensive. In addition to resection of three previous atrial myxomas, she had undergone resection of her adrenal glands as a teenager because of Cushing's syndrome, and a hysterectomy at age 26 revealed a myxoid leiomyoma. Family history was remarkable as a maternal uncle and daughter died from embolic complications of left atrial myxomas and her sister previously had a left atrial myxoma resected. The patient underwent uncomplicated removal of the myxoma, and resection of the lung mass revealed a granuloma. A review of typical and atypical aspects of cardiac myxomas is provided including a rare and recently described syndrome of familial cardiac myxoma associated with Cushing's syndrome, spotty skin pigmentation and other myxoid tumors.
Life‐threatening ventricular tachycardia as the presenting symptom of metastatic cardiac disease
Authors: Mager, Aviv , Strasberg, Boris , Zlotikamien, Bruria , Kaplinsky, Chaim , Sclarovsky, Samuel
Published: February 2009

We present 2 cases in whom repetitive rapid ventricular tachycardia (VT) was the initial manifestation of metastatic cardiac disease. In one patient, repetitive VT appeared during chemotherapy for stage IV paratesticular rhabdomyosarcoma which led to the diagnosis of cardiac metastases. In the other, it led to the diagnosis of malignant pericardial effusion 17 years after successful therapy for a breast carcinoma. In conclusion, in patients with present or past history of malignancy, the appearance of life‐threatening VT should raise the suspicion of cardiac metastases.
Coronary vasospasm as a potential cause of myocardial infarction and paroxysmal atrial fibrillation in a relatively young woman
Authors: Horimoto, Masashi , Igarashi, Keichi , Takenaka, Takashi , Anbo, Tomonori
Published: February 2009

Vasospasm‐related myocardial infarction in young women with normal coronary arteries has infrequently been reported and vasospasm‐related paroxysmal atrial fibrillation (PAF) has rarely been described. We present a 33‐year‐old woman with old inferior myocardial infarction and postinfarction angina at rest; the angina was accompanied by PAF and electrocardiographic ST‐segment elevation in the inferior leads. Coronary angiography revealed normal coronary arteries and intracoronary acetylcholine provoked an intense and diffuse spasm of the right and left coronary artery. The spasm of the right coronary artery was associated with PAF and ST‐segment elevation in the inferior leads. Frequently documented PAF, accompanied by chest discomfort and ST‐segment elevation in the inferior leads, was more effectively removed with isosorbide dinitrate than with disopyramide. These data suggest that coronary vasospasm is a likely cause of myocardial infarction and even PAF, although the precise mechanism leading to PAF remains unknown.
Influence of minimal angiographic visible collateral circulation on myocardial function during PTCA
Authors: Dim M. , Prachar H. , Enenkel W.
Published: February 2009

The potential protective role of angiographically visible minimal collateral circulation in diagnostic angiograms, not reaching or filling the target vessel (RENTROP class 1), on myocardial function during percutaneous transluminal coronary angioplasty (PTCA), was studied in two groups of patients undergoing elective PTCA of the left anterior descending artery (LAD). In the first study group consisting of 22 patients, influence of collateral circulation class 1 on left ventricular regional function was evaluated. In this group, 14 patients showed no angiographic collaterals and 8 patients showed collateral circulation class 1 in diagnostic angiograms. Increase of end‐diastolic and end‐systolic volume indices as well as decrease of global left ventricular function was not significantly different inpatients with and without such minimal collateral circulation. In patients without collaterals, the decrease of regional left ventricular function was significantly more pronounced in the left anterior length segment (p<0.05) and a trend was observed in the anterolateral (p = 0.059) and apical (p = 0.053) segments. In a second group, consisting of 29 patients, hemodynamic parameters were measured and, in addition to grading of collateral circulation in diagnostic angiograms, angiographically visible collateral circulation was estimated during occlusion of the LAD by injecting contrast materials into the right coronary artery. An increase of angiographically visible collaterals during the ischemic period of various degrees was documented in 26 (90%) of 29 patients. Combining patients of both study groups, increase in left ventricular end‐diastolic pressure during ischemia was significantly higher (p<0.05) in patients without collaterals on diagnostic angiography (n=34) than in patients with collateral circulation class 1 (n = 14). For all patients decrease of dP/dtmax as well as decrease of dP/dtmin during ischemia was statistically highly significant (p<0.001). No significant differences could be documented comparing patients without (n = 34) and with collateral circulation class 1 (n = 14). Our results indicate that, in the case of acute definitive vessel occlusion during PTCA, collateral circulation class 1 in diagnostic angiograms may not protect from extensive myocardial damage. Improvement of collateral circulation during ischemia caused by acute transient vessel occlusion is common, of rapid onset but in most cases of only minimal degree.
Relationship between electrocardiographic patterns and angiographic features in isolated left circumflex coronary artery disease
Authors: Shen Wei Feng , Tribouilloy Christophe , Lesbre Jean‐Philippe
Published: February 2009

The relation of electrocardiographic (ECG) patterns to clinical and angiographic features was assessed in 89 patients with isolated left circumflex coronary artery (LCx) disease (46 with and 43 without myocardial infarction). ECG abnormalities were present in 75 patients; there were isolated Q waves in 20, an abnormal R wave in lead V1 with or without inferior and/or lateral Q waves in 21, and isolated ST‐T wave changes in 34 cases. Inferior abnormalities on the electrocardiogram were similar in patients with proximal or distal stenoses of the LCx, but an abnormal R wave in lead V1 correlated with proximal LCx stenosis (p<0.01). Lateral abnormalities were more common in stenoses of the obtuse marginal branch and proximal LCx than in distal stenosis (all p<0.01). Compared with patients without myocardial infarction with or without ST‐T‐wave changes and those with infarction without an abnormal R wave in lead V1, patients with LCx‐related infarction and an abnormal R wave in lead V1 associated with inferior and/or lateral Q waves had larger left ventricular end‐diastolic and end‐systolic volumes, lower ejection fraction, higher incidence of total occlusion of proximal LCx without collateral vessels, and more cardiac events during follow‐up. This study suggests that an abnormal R wave in lead V1 associated with lateral abnormalities on the standard electrocardiogram may be clinically useful in predicting proximal LCx stenosis and identifying a subset of postinfarction patients with left ventricular dysfunction due to a large infarct size.
Exercise performance and beta‐adrenergic blockade in patients with complete heart block treated with ventricular inhibited pacing
Authors: Wikner Johan , Larsen Flemming F. , Nordlander Rolf , Pehrsson Kenneth , Åström Hans
Published: February 2009

The effect of beta‐adrenergic blockade (propranolol) on exercise performance was studied in 15 patients (12 men and 3 women, mean age 70 years) with complete heart block treated with a ventricular‐inhibited pacemaker (VVI). In a double‐blind procedure, the patients were randomly given either 0.1 mg/kg of propranolol or saline solution i.v. before a first exercise test and vice versa before a second test. The interval between the tests was 24 hours. Nine patients were in sinus rhythm, 4 patients had atrial flutter, and 2 others had atrial fibrillation. The exercise capacity was on an average 11% lower with propranolol than with placebo (p<0.001). The most marked reductions (20 and 33%) were found in the two patients with atrial fibrillation. The atrial rate in patients with sinus rhythm was significantly lower with propranolol than placebo both at rest (68 vs. 83 beats/min, p<0.001) and at maximal work load (91 vs. 141 beats/min, p<0.001). The present findings show that beta blockade has negative effects on exercise capacity in patients with complete heart block treated with VVI pacemakers. This finding should be considered in the selection of drug treatment in patients with fixed rate pacing and concomitant hypertension and/or ischemic heart disease.
Catheter balloon valvuloplasty of stenotic porcine bioprosthetic valves: Part II: Mechanisms, complications, and recommendations for clinical use
Authors: Waller Bruce , Vantassel James , Mckay Charles , Allen Marcus
Published: February 2009

During the last several years dilating balloons have been applied in the treatment of stenotic cardiac valves. This interest has been extended to stenotic porcine bioprosthetic valves. Part I of this review discusses the pathologic changes producing stenotic porcine prosthetic valves. Part II of this review describes an in vitro study of porcine prosthetic valve valvuloplasty defining the mechanisms, complications, and clinical applications. Results of this study indicate a limited and cautious role in balloon dilation of stenotic bioprosthetic valves.