Selective versus routine predischarge coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction. TIMI II Investigators.

To ascertain whether predischarge arteriography is beneficial in patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA), heparin and aspirin, the outcome of 197 patients in the Thrombolysis in Myocardial Infarction (TIMI) IIA study assigned to conservative management and routine predischarge coronary arteriography (routine catheterization group) was compared with the outcome of 1,461 patients from the TIMI IIB study assigned to conservative management without routine coronary arteriography unless ischemia recurred spontaneously or on predischarge exercise testing (selective catheterization group). The two groups were similar with regard to important baseline variables. During the initial hospital stay, coronary arteriography was performed in 93.9% of the routine catheterization group and 34.7% of the selective catheterization group (p less than 0.001), but the frequency of coronary revascularization (angioplasty or coronary artery bypass surgery) was similar in the two groups (24.4% versus 20.7%, p = NS). Coronary arteriograms showed a predominance of zero or one vessel disease (stenosis greater than or equal to 60%) in both groups (routine catheterization group 73.1%, selective catheterization group 61.3%). During the 1st year after infarction, rehospitalization for cardiac reasons and the interim performance of coronary arteriography were more common in the selective catheterization group (37.9% versus 27.6%, p = 0.007 and 28.6% versus 11.6%, p less than 0.001, respectively); however, the interim rates of death, nonfatal reinfarction and performance of coronary revascularization procedures were similar. At the end of 1 year, coronary arteriography had been performed one or more times in 98.9% of the routine catheterization group and 59.4% of the selective catheterization group (p less than 0.001), whereas death and nonfatal reinfarction had occurred in 10.2% versus 7.0% (p = 0.10) and 8.6% versus 9.0% (p = 0.87), respectively. Because the selective coronary arteriography policy exposes about 40% fewer patients to the small but finite risks and inconvenience of the procedure without compromising the 1 year survival or reinfarction rates, it seems to be an appropriate management strategy.

Prolapsed left atrium behind the left ventricular posterior wall: two dimensional echocardiographic and angiographic features.

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.

Propranolol rebound--a retrospective study.

To assess the effects of sudden withdrawal of propranolol on inpatients with coronary artery disease, 102 patients admitted for cardiac catheterization were evaluated. Criteria for inclusion in the study were angiographically documented coronary artery disease, propranolol therapy at a mean daily dose of at least 80 mg and abrupt discontinuation of propranolol therapy before catheterization. There were 55 patients (mean age 52.5) who discontinued propranolol therapy (mean daily dose 127 mg) and a control group of 47 patients (mean age 53) who continued to receive propranolol (mean daily dose 143 mg). The criteria for morbidity were death, myocardial infarction or change in pain pattern. In the withdrawal group there were no deaths, one myocardial infarction judged to be related to catheterization and only one instance of a change in pain pattern. Thus, propranolol rebound appears to occur infrequently among hospitalized patients with reduced activity.

A simplified lesion classification for predicting success and complications of coronary angioplasty. Registry Committee of the Society for Cardiac Angiography and Intervention.

In 1988, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures presented a classification of coronary lesions utilizing 26 lesion features to predict the success and complications of balloon angioplasty. Using data from the Registry of the Society for Cardiac Angiography and Interventions (SCAI) we evaluated the ability of this classification to predict success and complications. Lesion success, death in hospital, emergency cardiac bypass surgery, and major adverse events were evaluated in 41,071 patients who underwent single-vessel angioplasty from January 1993 to June 1996. Logistic models using the ACC/AHA lesion classification, vessel patency, or both, were compared. A new classification based on the interaction of the ACC/AHA classification plus lesion patency was compared with the existing ACC/AHA classification. Vessel patency, added to the ACC/AHA classification, improved prediction of lesion success (p

Double coronary arteriovenous fistula.

Coronary arteriovenous fistula is an uncommon, although not rare, congenital cardiac malformation, especially in the adult. Most such reported such cases have involved but a single coronary vessel. This report documents the second case of coronary arteriovenous fistulae involving the right and circumflex coronary vessels draining into the coronary sinus. At the present time the patient is free of definite ischemic symptoms or obvious impairment of hemodynamic function and is being followed-up medically.

Predicting aortic valve prosthesis size. A step toward better matching of patient and prosthesis.

We have developed a simple method of predicting aortic valve prosthesis size from supravalvular aortic cineangiograms, taken in the 30 degree right anterior oblique projection, during routine diagnostic cardiac catheterization. Measurements made on the aortogram were corrected to true size by means of a 1 cm2 grid reference plate filmed at the conclusion of the catheterization. This method was utilized prospectively to predict the anulus size in 26 patients undergoing aortic valve replacement alone or as part of a more extensive procedure. The catheterization prediction of anulus size was perfectly predictive of the prosthesis size used in eight of 26 (31%) cases, within 1 mm of the prosthesis size used in 20 of 26 (77%), and within one prosthesis size in all 26 (100%) cases. Comparing the measured anulus diameter to the actual prosthesis diameter yielded r = 0.93. When both systolic and diastolic frames were available for analysis, the diastolic frame was more accurately predictive than the systolic frame (diastolic r = 0.93; systolic r = 0.88), although both yielded acceptable results. Utilization of this method has significantly altered operative plans in four patients with a small anulus. Such preoperative assessment should allow improved matching of patient and valve prosthesis and thereby yield improved long-term results in aortic valve replacement.

Congenital aortic valve anomaly. Aortic regurgitation with left coronary artery isolation.

A case is reported of aortic regurgitation resulting from a congenitally abnormal aortic valve. The left coronary cusp of the valve was small and adhered to the aortic wall, so that there was insufficient valve tissue to maintain diastolic valve competence. In addition, this rudimentary cusp completely occluded the left coronary ostium. The patient was treated successfully by valve replacement.

Determinants of cardiac performance in severe aortic stenosis.

Left ventricular (LV) myocardial function and the influence on LV pump performance of associated coronary arterial disease, of outflow obstruction and its consequences, and of altered ventricular pressure-volume characteristics were examined in a representative group of 28 adult patients with symptomatic severe aortic stenosis (valvular orifice area less than 0.50 sq cm/sq m). Eighteen patients (64%) exhibited depressed LV pump performance with levels of ejection fraction less than 0.50. In seven patients, coronary arterial disease documented by either arteriographic studies or postmortem analyses was associated with a segmental (i.e., nonhomogeneous) LV contractile disorder consistent with previous myocardial infarction. In the remaining 11 patients a homogeneous LV contractile disorder was the result of chronic outflow obstruction and its consequences. The possibility that reduced ventricular performance might be accounted for by increased afterload could not be supported by significant correlation between LV contractile characteristics (estimated from the ejection fraction and the mean circumferential fiber shortening rate) and indices of afterload (including LV systolic pressure, aortic valvular orifice area, and mean systolic wall tension). This observation suggested that myocardial hypertrophy and other consequences of longstanding obstruction to outflow played a primary role in depression of LV performance in these patients. Left ventricular end-diastolic volume was abnormal in all but three patients with depressed LV function; this increase was accompanied by a disproportionately greater increment in end-diastolic pressure, suggesting that reduced distensibility limited the ability of the ventricle to compensate for reduced contractile performance by means of the Starling mechanism.

Persistence of biologic activity after disappearance of propranolol from the serum.

In order to evaluate the duration of the biologic effects of propranolol after the drug was discontinued, we evaluated a variety of noninvasively determined hemodynamic parameters. Significant depression was found in the heart rate (18 per cent), cardiac output (13 per cent) (determined echocardiographically), and the triple product of blood pressure, heart rate, and systolic ejection time (16 per per cent) during administration or propranolol (200 mg. per day) to 9 normal volunteers. Significant depression of these parameters was present 12 hours after discontinuing the drug. By 12 hours, serum propranolol levels had returned 90 per cent toward their base line; however, at the same time, the heart rate and cardiac output had returned only 19.4 and 14.3 per cent toward their base-line values, and the triple product had returned 41 per cent toward its baseline. By 36 hours no biologic effect was seen. Thus if propranolol were discontinued 2 days prior to cardiac surgery, no significant biologic effect would remain to complicate the patient's postoperative course.

The changing status of ejection fraction as a predictor of early mortality following surgery for acquired heart disease.

Several reports in the literature and our experience prior to 1974 support the thesis that operative risk in patients with acquired heart disease and poor ventricular function (as assessed by a biplane ejection fraction [EF] less than or equal to 0.40) was very significantly increased over the risk in patients with normal ventricular function. These results led to disagreement in the literature regarding the advisability of surgery in patients with poor ventricular function. Various EFs from less than 0.31 to less than 0.50 were suggested as contradicting elective surgery, while more aggressive groups recommended surgery in all patients with angina. Precise comparison of the results reported by different groups was not always possible because of the common reliance on single-plane right anterior oblique ventriculograms, which tend to underestimate EF and overestimate operative risk. Using biplane ventribulograms for accurate estimation of EF, we have demonstrated a significant reduction in 30-day operative risk to a clinically acceptable 3 percent (1/32) for single valve replacement and aortocoronary surgery patients with poor ventricular function (EF less than or equal to 0.40) during 1974. Considering the high risk of medically treated patients with reduced ventricular function, these results support further evaluation of surgical palliation for patients with valvular or coronary heart disease and reduced ventricular function.

Isolated partial anomalous venous connection: a congenital defect with late and serious complications.

The cases of 3 patients with partial anomalous pulmonary venous return with intact atrial septum are reported. The 2 adult patients had evidence of severe pulmonary artery hypertension with markedly increased pulmonary vascular resistance indicating advanced pulmonary vascular obstructive disease. This confirms earlier limited observations and emphasizes the potential for this congenital lesion to develop late, serious complications. In view of this potential, surgical repair of the anomaly should be considered whenever it is found. Descriptions of a successful operative approach are included.

Thrombolysis and intervention in acute myocardial infarction: an overview.

The use of thrombolytic agents in acute myocardial infarction (AMI) has been extensively studied for the past decade and a half and has become the standard of care for most patients presenting early in the course of AMI. Despite this general acceptance, there remains controversy over the choice of thrombolytic, the use of adjunctive anti-platelet and anti-thrombotic agents, the proper role for PTCA, especially direct PTCA, and the potential role for new interventional devices. The intent of this article is to examine in turn each of these areas, reviewing selected data from relevant trials. In so doing we shall develop an overall concept for reperfusion in AMI to quide our ongoing efforts at resolving our remaining therapeutic challenges.

Spontaneous left anterior descending artery to right ventricular fistula.

We report a very unusual case of a spontaneously acquired left anterior descending to right ventricular fistula. We believe that this spontaneous occurrence was the result of hemodynamic changes that occurred between the first and second catheterizations.

Ruptured chordae tendineae. Its association with systemic lupus erythematosus.

A case of systemic lupus erythematosus (SLE) was complicated by ruptured chordae tendineae. The mechanisms responsible for severe cardiac dysfunction in SLE are discussed.

Single left coronary artery with origin of the right coronary artery from distal circumflex.

We report two very unusual cases of agenesis of the right coronary ostium with continuation of the left circumflex artery as the right coronary artery. The recognition of the anomaly in the first case lead to a better understanding of this finding in the second case, which translated into shorter procedure time, less contrast volume, and fewer catheter manipulations.

Angina pectoris. Diagnosis and treatment.

The physician who understands the pathophysiology of angina pectoris can apply rational therapeutic measures based on an appreciation of the determinants of myocardial oxygen supply and demand. Most patients with angina secondary to coronary atherosclerosis can be treated conservatively using a systematic approach that includes correction or removal of underlying causes or precipitating factors and the judicious use of sublingual nitroglycerin. In patients with more resistant angina, use of oral or topical nitroglycerin or sublingual isosorbide dinitrite as well as propranolol can be advised. Aortocoronary bypass surgery can offer significant improvement in carefully selected patients with frequent angina poorly controlled by medical therapy. The most important consideration in the treatment of angina is protection of coronary blood flow reserve by primary prevention of the atherosclerotic process itself. All individuals from families prone to coronary artery disease should be evaluated for alterable risk factors, the most important being cigarette smoking, hypertension, and hypercholesterolemia. Considering the high risk of unheralded sudden death in previously asymptomatic patients with coronary atherosclerosis, angina can, in a sense, be considered a fortunate harbinger of coronary stenosis, identifying candidates for secondary preventive measures aimed at retarding the progression of vascular disease. More importantly, angina serves as an index for detecting families at high risk of coronary artery disease, in whom early application of primary prevention may afford a more promising outlook.

Management of cerebrospinal fluid.

In traditional practice, doctors order tests and the laboratory performs them. A series of tests are requested before the results of any of the tests are known. The authors of this paper examine the interface between the clinicians and the laboratory. They produce a cost effective and clinically useful routine for handling spinal fluid. They bring to their practice an excellent example of quality assurance which is genuine, improves practice and is not "busy work." The editor heard Dr. Albright present this material and urged him to make it available to North Carolina doctors.