Reappearance of anterior QRS forces after coronary bypass surgery. An electrovectorcardiographic study.

This report describes the reappearance of anterior QRS electrical forces in six patients after direct coronary arterial bypass surgery. Each patient had severe coronary artery disease including a segmental stenosis of the left anterior descending artery. Revascularization was performed by direct anastomosis of the left mammary artery to the left anterior descending coronary artery and saphenous vein bypass of other stenotic coronary arteries. Preoperative electrocardiograms and vectorcardiograms showed patterns of anterior wall myocardial infarction with absent or diminutive anterior QRS forces. In each case, postoperative studies demonstrated the regeneration of anterior QRS forces within 10 days of operation. Although these patients represent a small percent of those with a preoperative pattern of infarction who undergo coronary revascularization, the findings demonstrate that electrically silent areas of myocardium may be altered and are not always synonymous with myocardial cell death. Chronic myocardial ischemia may in certain instances produce electrocardiographic and vectorcardiographic patterns of myocardial infarction that may be reversible upon reestablishment of perfusion to ischemic areas.

Black/white differences in risk factors for arteriographically documented coronary artery disease in men.

Although the leading cause of death among black men in the United States is coronary artery disease (CAD), risk factors have not been well documented in black populations. Therefore, possible racial differences in the relation of several characteristics to the extent of CAD were assessed in 4,722 white and 169 black men who underwent arteriography. Associations between an occlusion score (ranging from 0 to 300), reflecting the severity of CAD, and levels of total and high-density lipoprotein (HDL) cholesterol, triglycerides, cigarette smoking, alcohol intake, relative weight, systemic hypertension and diabetes mellitus were examined. Most risk factors were significantly related to the extent of CAD in both races, but lipid levels showed stronger associations with CAD among blacks: correlations between CAD and total cholesterol were 0.16 (whites) vs 0.29 (blacks) and associations with HDL cholesterol were -0.22 (whites) vs -0.49 (blacks). In addition, at adverse levels of certain risk factors, blacks had more extensive CAD than did whites: mean occlusion scores were 148 (whites) and 238 (blacks) at HDL cholesterol levels less than 30 mg/dl. As assessed by multiple linear regression, however, only triglyceride levels were differentially related to CAD between whites (beta = 0) and blacks (beta = 0.47), p less than 0.01 for racial contrast. These results document the importance of risk factors in black men and indicate black/white differences in the relation of triglycerides to CAD.

Nonsurgical removal of foreign body from right heart. A new percutaneous approach.

A new method is described for the nonsurgical removal of foreign bodies from the right heart. By means of the percutaneous Seldinger Technique, endoscopic forceps were passed throught the internal jugular vein to remove a fragment of polyvinyl catheter from the right atrium of a patient who had had heart surgery. The procedure is atraumatic and can be performed on patients who are critically ill and those who recently have had surgery.

The "bad" left ventricle. Results of coronary surgery and effect on late survival.

Between 1968 and 1971, 252 patients with severe ventricular malfunction underwent revascularization surgery. By means of single-plane ventriculography, the ventricle was divided into six segments, three anteriorly and three inferiorly, and ejection fractions were calculated. Patients were classified into four groups according to these observations. Results were assessed in regard to relief of angina, graft patency status, surgical mortality rate, and survival as determined by actuarial life-table analysis. These results were then compared to over-all medical and surgical experience contained in the Milwaukee Cardiovascular Data Registry as well as to other reported series of medical treatment for similar degrees of coronary artery disease and impairment of left ventricular function. Comparison between the surgical and medical series suggests improved survival and improved quality of life in the surgically treated patients. Thus many patients with severe ventricular malfunction, especially if associated with angina, can be reasonably considered candidates for surgery.

Trends during 25 years of coronary artery bypass operation at St. Luke's Medical Center in Milwaukee, Wisconsin.

BACKGROUND: Most studies of changes in coronary artery bypass graft (CABG) operations are from major academic institutions. The present study evaluated changes in CABG operations since 1968 in a community hospital. METHODS: The data were from the St. Luke's Medical Center Cardiovascular Data Registry in Milwaukee, Wisconsin. Mortality rates, risk factors, overall patient risk, and surgical procedures were compared from 1968 to 1994. RESULTS: There was a dramatic decrease in 30-day mortality rates from 1968 to 1972. After 1976, mortality rates increased because of higher risk patients, but the mortality rate, adjusted for patient risk, continued to decline. Both internal mammary arteries and sequential grafts were widely used by 1972, followed by a decline in use until 1980, and then a steep increase in use from 1980 to the present. CONCLUSIONS: This study provided evidence from a community hospital that the skills of the surgical teams improved first dramatically then gradually. The pattern of adapting new surgical techniques suggested that these techniques were critically evaluated for several years after they were introduced.

Saphenous vein graft pseudoaneurysm: diagnosis by transesophageal echocardiography and magnetic resonance imaging.

Coronary cineangiography showed probable pseudoaneurysm formation at the origin of an 11-year-old saphenous vein coronary bypass graft. Transesophageal echocardiography and magnetic resonance imaging were helpful in differentiating this from aortic dissection or true aneurysm formation and assisted the surgeon in avoiding perforation of the pseudoaneurysm during sternotomy.

Restenosis after angioplasty: mechanisms and clinical experience.

The conundrum of restenosis remains the most significant challenge in revascularization techniques. This article reviews the current understanding of restenosis based upon laboratory investigations, clinical experience, and the efficacy of mechanical and pharmacologic interventions that have been attempted to prevent and/or reduce its occurrence. However, terminology really comes into play because restenosis is really the mechanism by which the body heals and is not a rapid deposition of atherosclerotic plaque.

Venospastic phenomena of saphenous vein bypass grafts: possible causes for unexplained postoperative recurrence of angina or early or late occlusion of vein bypass grafts.

Angina recurred in a 54 year old white man after multivessel coronary artery bypass surgery. Fourteen months after operation the frequency and intensity of his mixed angina increased and cardiac stress testing was positive. Repeat cardiac catheterisation showed that all the bypass grafts were widely patent; however, spasms of a vein graft to right coronary artery system were clearly seen. Treatment with calcium blocking agents and long acting nitrates abolished the symptoms during 16 months of clinical follow up.

The association of smoking with cardiomyopathy.

We investigated the possibility that smoking has an association with ventricular wall-motion abnormalities that is independent of its known association with coronary occlusion. We studied 4763 men between the ages of 35 and 74 who had diagnostic coronary angiography and ventriculography. We considered three kinds of wall-motion abnormalities: hypokinesis in one to four ventricular segments, hypokinesis in five to six ventricular segments (diffuse hypokinesis), and akinetic or dyskinetic wall motion in at least one segment. Among men younger than 55, the relative risk of diffuse hypokinesis was 2.78 (1.1 to 6.99) for heavy smokers as compared with nonsmokers. Adjusting for the degree of coronary occlusion or eliminating subjects with a history of myocardial infarction did not change this relative risk. Among men who were 55 or older the relative risk (odds ratio for heavy smokers as compared with nonsmokers) was not significant (0.55 to 2.28). Regardless of age the relative risk of akinesis or dyskinesis, adjusted for coronary stenosis, was significant: 1.84 (1.28 to 2.65) for men under 55 and 1.57 (1.12 to 2.19) for men 55 or older. These results suggest that smoking is related to both cardiomyopathy and transmural myocardial infarction and that the relationships are largely separate from the association of smoking with coronary stenosis.

Two-dimensional echocardiography in the diagnosis of left atrial myxoma.

We performed M-mode echocardiograms on 11 patients who later had left atrial myxomas removed at operations. Seven of these 11 patients were also examined with two-dimensional echocardiography. M-mode echocardiography showed the characteristic pattern of a left atrial mass entering the mitral orifice during diastole in nine of the 11 patients. M-mode echocardiographic findings were equivocal in two patients because a short tumour stalk prevented significant motion of the tumour. Cross-sectional echocardiography clearly showed a left atrial mass attached by a stalk to the interatrial septum in all seven patients examined, including one patient in whom the tumour was immobile. Three-dimensional measurements of tumour size made from orthogonal cross-sectional echocardiographic planes were within 6 mm of similar measurements made on the excised tumours.