"Crossing balloons:" a new technique for complex angioplasty.

A new technique is described for complex percutaneous transluminal coronary angioplasty of a lesion at the bifurcation of the obtuse marginal branch of the left coronary artery, just distal to a venous bypass graft insertion. Two separate angioplasty guide wire and catheter systems were used and the coronary artery side branch was protected in a "crossing" manner.

Aortocoronary vein graft surgery in a cadaver kidney transplant recipient.

A case of Prinzmetal angina occurred in a recipient of a cadaver kidney transplant who was treated with aortocoronary vein graft. The patient had severe retrosternal chest pain associated with ST-segment elevation in the precordial leads. Coronary arteriograms disclosed two major lesions in the proximal anterior descending artery. Aortocoronary vein graft was successfully performed with no untoward effect on the renal status. The patient has been free of angina approximately two years postoperatively.

The relationship between prolapsing mitral leaflet syndrome and angina and normal coronary arteriograms.

Patients with a prolapsing mitral leaflet frequently have chest pain while their coronary arteriograms are normal. In this regard, these patients are similar to the group of patients with angina and normal coronary arteriograms. In the present study, clinical, electrocardiographic, cardiac hemodynamic, angiographic, and metabolic findings in 20 patients with a prolapsing mitral leaflet were compared to those of 16 patients with angina and normal coronary arteriograms. Except for the presence of mitral leaflet prolapse and systolic clicks, the findings were similar in both groups. We postulate that prolapsing mitral leaflet is probably related to two different mechanisms. In one the primary pathologic change is in the mitral valve (mainly myxomatous transformation), and the abnormalities of ventricular contraction are secondary to unloading of the heart because of a volume shift into the distended and enlarged mitral leaflets. In the other group, the primary pathologic change is in the myocardium, with secondary prolapse of the mitral valve. The myocardial abnormality itself is probably related to primary underlying myocardial disease or to arteriolar pathologic changes. The latter group has probably the same pathophysiologic abnormality as patients with angina and normal coronary arteriograms.

Isolated rupture of the right ventricle in a patient with acute inferior wall MI.

A case of isolated rupture of the right ventricle secondary to acute MI, presented as cardiac tamponade, is reported. The patient underwent successful emergency surgery for closure of the right ventricular rupture without aortocoronary bypass.

High risk percutaneous transluminal coronary angioplasty in the treatment of severe coronary artery disease.

We report on 27 "high risk" patients out of 171 consecutive patients undergoing percutaneous transluminal coronary angioplasty from June 1984 to August 1985. The ages ranged from 31-80 years (mean 62.7 +/- 10) years. High risk percutaneous transluminal coronary angioplasty was defined as: salvage cases (3 patients) where the patients presented in cardiogenic shock or the vessels were not bypassable; multivessel coronary artery disease (22 patients) where a large area of jeopardized myocardium was dependent on the angioplasty vessel(s); left ventricular dysfunction (7 patients) as defined by two of the three criteria: left ventricular end-diastolic volume index greater than 100 ml/m2; ejection fraction less than 30%; and left ventricular end-diastolic pressure greater than 20 mm Hg. The initial success rate in the high risk patients was 85.2%. Emergency coronary artery bypass surgery in these patients was 7.4%. There was one death in the high risk group, as one of the salvage cases died 24 hours after successful percutaneous transluminal coronary angioplasty due to severe underlying myocardial disease. In conclusion percutaneous transluminal coronary angioplasty can be successfully performed in high risk patients with a low complication rate and should be considered as an alternative to coronary artery bypass graft surgery in selected high risk patients.

Iatrogenic postoperative left ventricular outflow tract obstruction.

A 56-year-old female, who underwent aortocoronary bypass graft for occlusion of anterior descending artery is reported, who postoperatively developed a harsh systolic murmur, mitral regurgitation, and intraventricular systolic pressure gradient suggestive of hypertrophic subaortic stenosis. The above findings were due to the administration of dobutamine hydrochloride for hypotension in association with afterload reduction (intra-aortic balloon pumping) and disappeared almost immediately after left ventriculography (volume load).

Directional coronary atherectomy in women compared with men.

The influence of gender on the procedural outcome of directional coronary atherectomy (DCA) is controversial. This study of 373 consecutive patients (418 lesions) undergoing DCA demonstrates that the procedural success rate of DCA is significantly lower in women compared with men (72.7 vs. 82.9%, p = 0.011). Women have significantly smaller coronary arteries than men (2.5 mm vs. 2.7 mm, p = 0.028) and were older than men (66 vs. 61 years, p = 0.0001). Multivariate analysis identifies small coronary vessel size rather than female gender per se as an independent predictor of poor procedural outcome. Procedural success rates in women with coronary vessel size > or = 2.5 mm is significantly higher (92.2%) than in women with coronary vessel size < 2.5 mm (73.1%), and parallels that in men with vessel size > or = 2.5 mm (89.3%). Inability to engage the ostium of the coronary artery adequately with the guiding catheter and to cross the lesion with the atherectomy device is significantly more common in women compared with men. Major ischemic complication rates are similar in women and men (8.5 vs. 8.7%). Groin complications are significantly more common in women compared with men (13.5 vs. 2.9%). We conclude that procedural success rates in women may be improved by careful patient selection, with particular attention to small vessel size. DCA is best performed in vessels > 2.5 mm in diameter.

Use of angioplasty guidewire for technically difficult angiography.

A new technique for negotiating severe vessel tortuosity or stenosis is described whereby a PTCA guidewire is initially used to cross the tortuosity or stenosed area. After introduction of a long-tipped Sones catheter over the PTCA wire and past the stenosis, the latter is exchanged for the usual 0.035-in guidewire. The Sones catheter is then removed and angiography proceeds as usual.

Angioplasty of tortuous left internal mammary artery: description of a new technique.

Angioplasty of the distal anastomosis site of a markedly tortuous left internal mammary artery (LIMA)--anterior descending artery is described. Tortuosity of LIMA was negotiated using the Tracker-Seeker catheter guidewire system. Angioplasty was then performed using the conventional technique.

Exit block: a new technique for difficult side branch angioplasty.

Angioplasty of a stenosis at the origin of a diagonal branch was initially unsuccessful because of the straight course of the anterior descending artery and a sharp bend at the diagonal branch. Therefore, in a second attempt, the anterior descending artery was blocked by inflating a balloon distal to the diagonal branch, thereby facilitating the passage of guidewire and balloon into the diagonal branch.

Ergonovine provocative testing: description of a "double catheter technique".

Since coronary arteries should be immediately accessible during ergonovine provocative testing (EPT), a double catheter technique is described. Using the catheter sheath technique from the right and left femoral arteries, right and left Judkins' catheters are introduced into each femoral artery. Selective coronary cineangiography during EPT is thus rapidly performed without the delay of exchanging catheters. Should coronary arterial spasm occur during the test, nitroglycerin can be administered into the coronary artery without delay.

Comparison of ejection fraction and zonal mean velocity of myocardial fiber shortening.

To determine the extent of cardiac involvement until a diminished ejection fraction (EF) is present, zonal mean velocity of circumferential fiber shortening (Vcf) was measured from the left ventriculogram in 36 patients. The longitudinal axis (apex to mid-point of the aortic valve plane) in right anterior oblique view was divided into four equal parts by three perpeendicular chords. Zonal Vct and percent shortening along the proximal, middle and distal chords were measured. The results of this study indicate that a normal EF is frequently associated with a reduced Vct in one or even two zones. A reduced EF is generally accompanied by a diminished Vct in all three zones of the heart. In addition, a close correlation was found between zonal Vct and percent shortening. Hence the latter, which is much simpler to measure, can be instead of Vct Ejection fraction as a measure of myocardial performance is not as sensitive as Vct, especially in hearts with asynchrony of contraction.

Spontaneous variations in atrioventricular conduction in pre-excitation.

Atrial pacing in a patient with a Wolff-Parkinson-White syndrome pattern showed unusual variability in AV nodal conduction time. Changes in the AV nodal conduction time occurred predominantly at paced rates in excess of 100/min and consisted of abrupt or gradual decreases in the AH interval. Such decreases resulted in unexpected normalization of the QRS pattern. In addition, pacing also revealed evidence of block in the accessory pathway. Such changes in atrioventricular conduction may account for the known variability of the QRS pattern in patients with the WPW syndrome. Further, they may also explain the benign clinical course in this patient.