Iatrogenic coronary artery stenosis following coronary stenting.

We present 6-month follow-up of 435 patients undergoing stent deployment. Forty-four patients were referred because of myocardial ischemia related to the stented artery. In six of these patients (14%), the stented vessel revealed a new proximal lesion separated from the stented portion, which warranted further intervention. It is felt that these new lesions are related to the stenting technique as a result of local trauma induced from the guiding catheter.

Symptomatic coronary disease for 20 or more years: clinical aspects, angiographic findings, and therapeutic implications.

Clinical, angiographic, and therapeutic aspect of coronary artery disease of long duration (exceeding 20 years) is reviewed in 50 patients (study group) and compared to a control group of 100 consecutive patients with coronary artery disease of shorter duration. All were referred because of symptomatic coronary artery disease. The study group had a greater incidence of clinically evident extracardiac vascular disease (28% vs 4%) (p less than 0.01). Transmural infarction was more frequent in the study group (64% vs 45%). Triple-vessel and main left disease was observed respectively in 90% and 28% compared to 36% and 7% in the control group (p less than 0.01). Twenty-nine percent of collaterals were jeopardized in the study group compared to 13% of collaterals in controls (p less than 0.01). Abnormal left ventricular ejection fraction (p less than 0.05) was found in 50% of the study group compared to 28% of controls (p less than 0.01). Medical therapy was recommended for 36% of the study group with 11 of 18 (61%) considered inoperable, whereas in 39% of the control group medical therapy was continued, with 9 of 39 (23%) considered inoperable (p less than 0.01) Surgery or coronary angioplasty was recommended in 64% of the study and in 61% of the control group. No patient in the study group was considered a candidate for coronary angioplasty, whereas in 20% (12 of 61) of the control group coronary angioplasty was recommended. Patients with coronary artery disease for over 20 years have severe coronary artery disease, with one in four having main left disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Aberrant main left coronary artery in a patient with unstable angina.

A patient with significant obstructive coronary artery disease in an anomalous left main coronary artery arising from the right coronary artery is reported. The combination of this coronary anomaly with main left atherosclerotic disease is noteworthy and presented no surgical technical problem.

Functional and anatomic correlates of markedly abnormal stress tests.

The functional state and coronary anatomy of 120 patients evaluated primarily because of a markedly positive ischemic exercise stress test (greater than 2 mm ST depression) is presented. Twenty-seven patients were asymptomatic (group A), 36 patients (group B) had type I angina (Canadian classification) and 57 patients (group C) had angina with only minor limitations (type II angina). All patients underwent exercise stress testing (Bruce protocol) within 2 months of cardiac catheterization. No significant intergroup differences were observed in exercise variables including time of onset of ischemia, maximal heart rate achieved, rate-pressure product, duration of exercise or mean change in blood pressure. Two patients in group A had normal coronary arteriograms. Comparison of the remaining asymptomatic patients in group A with patients in groups B and C revealed no significant differences in the number of coronary arteries involved, main left coronary artery disease, coronary score or the frequency of collateral circulation. In group A, 18% of collateral vessels were in jeopardy compared with 52% in groups B and C (p less than 0.05). Triple vessel disease was present in 57% and left main coronary artery disease in 16% of the total group. The only exercise variable useful in identifying patients with severe coronary disease was an abnormal exercise blood pressure response. This study indicates that a markedly ischemic stress test, regardless of the functional state of the patient, identifies patients, including those without symptoms, who have severe coronary disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Left bundle branch block: a predictor of poor left ventricular function in coronary artery disease.

Clinical, coronary arteriographic, and hemodynamic studies were performed in 55 patients with left bundle branch block (LBBB) and coronary artery disease and were compared with 110 patients consecutively matched for age and sex with ischemic heart disease but without LBBB. No significant differences were found in duration of symptoms or frequency of prior myocardial infarction, hypertension, or diabetes mellitus; however, the LBBB patients had a significantly (p less than 0.001) higher frequency of congestive heart failure (38.2% vs 11.8%) and cardiomegaly (63.6% vs 25.5%). An evaluation of severity of the coronary disease on the basis of subtotal vs total obstructive lesions, number of vessels involved, total coronary score, and individual coronary arteries involved revealed no significant differences between the groups. The LBBB patients had significantly (p less than 0.001) greater impairment of left ventricular function as reflected by the end-diastolic volume (107 +/- 43 vs 79 +/- 30 ml/m2), ejection fraction (0.35 +/- 0.19 vs 0.59 +/- 0.18), and frequency of an abnormal contractile pattern (91% vs 61%). Evaluating the LBBB patients on the basis of the QRS width and axis revealed no significant intragroup differences in clinical profile, severity of coronary disease, or left ventricular dysfunction. A prolonged PR interval (greater than or equal to 0.20 second) was associated with more severe coronary artery disease and an enlarged heart. This study indicates that coronary artery disease associated with LBBB identifies patients with severe left ventricular dysfunction.

Atrial transport function in coronary artery disease: relation to left ventricular function.

The atrial contribution to ventricular stroke volume was evaluated in 50 patients with coronary artery disease and found to be related to left ventricular function. All patients underwent complete hemodynamic and angiographic studies. Angiographic volume studies were utilized to determine atrial contribution to the stroke volume, end-systolic volume and ejection fraction. In 11 patients without heart disease, atrial contribution to stroke volume was (mean value +/- standard deviation) 9.3 +/- 6 ml/m2 compared with 13.5 +/- 6 ml/m2 in the patients with coronary disease (probability [p] less than 0.05). The percent of atrial contribution to stroke volume was 20 +/- 7 and 33 +/- 11%, respectively, in normal subjects and patients with coronary disease (p less than 0.05). The combination of congestive heart failure and cardiomegaly was the only clinical aspect associated with a significantly higher (p less than 0.05) atrial contribution to stroke volume than that in the remaining patients with coronary disease (46 versus 31%). Relating the atrial contribution to stroke volume to the left ventricular end-diastolic pressure, stroke volume, end-systolic volume and ejection fraction revealed correlation coefficients of 0.30, -0.44, 0.56 and -0.64, respectively. No patient with a normal ejection fraction (greater than 0.50) had an atrial contribution greater than 40% of stroke volume. The ratio of peak left ventricular systolic pressure/end-systolic volume (mm Hg/ml) was 2.7 +/- 1.5 in patients (n = 14) with an atrial contribution greater than 40% of stroke volume compared with 5.3 +/- 3.4 in patients having an atrial contribution of 40% or less (p less than 0.01). These findings indicate that atrial contribution to stroke volume is inversely related to left ventricular function.

Atrial fibrillation--a marker for abnormal left ventricular function in coronary heart disease.

Retrospective study of 1176 patients with known coronary heart disease by cardiac catheterisation disclosed 10 patients (0.8%) with atrial fibrillation. Comparison with 25 randomly selected patients with coronary heart disease with sinus rhythm showed that atrial fibrillation correlated significantly with impaired haemodynamic function, mitral regurgitation, and abnormalities of left ventricular contraction. Atrial fibrillation is, therefore, a useful marker of extensive myocardial dysfunction.

Left atrial size and left ventricular function in coronary artery disease: an echocardiographic-angiographic correlative study.

M-mode echocardiography was used to determine left atrial size in 100 patients with coronary artery disease undergoing cardiac catheterization. Patients were divided in two groups on the basis of left atrial diameter (greater than or equal to 40 mm in 40 patients and less than 40 mm in 60). Patients with larger left atria had a higher frequency of electrocardiographic evidence of left atrial abnormality (p less than 0.01) and myocardial infarction (p less than 0.001). Pulmonary capillary wedge and left ventricular end-diastolic pressures were higher (p less than 0.005) in patients with larger left atria. An abnormal end-diastolic volume (greater than 100 ml/M2) was observed in 13 patients with enlarged left atria compared to none with normal left atrial size (p less than 0.001). Triple vessel disease was more frequent (63% vs 32%) and single vessel disease less frequent (10% vs 37%) in patients with larger left atria (p less than 0.005). Abnormal left ventricular contractile patterns were noted in 45% of patients with normal left atrial diameters compared to 80% in those with an enlarged left atrium (p less than 0.001). An abnormally low ejection fraction (less than 0.5) was observed in 25% and 80%, respectively, in patients with normal and enlarged left atria (p less than 0.001). Of 58 patients with normal ejection fractions, only 17% had left atrial diameters greater than or equal to 40 mm compared to 71% of 42 patients with abnormally low ejection fractions (p less than 0.001). Of 18 patients with left atrial diameters greater than 42 mm, only two had normal ejection fractions. The mean ejection fraction for patients with left atrial diameters less than 40 mm was 0.63 +/- 0.13 compared to 0.41 +/- 0.18 for those with diameters greater than or equal to 40 mm (p less than 0.001). The sensitivity, specificity, and predictive value for an enlarged left atrium in identifying an abnormal ejection fraction were, respectively, 71, 83, and 75%. These findings indicate that M-mode echocardiographic left atrial enlargement is a useful marker of advanced hemodynamic and angiographic abnormality in patients with coronary artery disease.

Anomalous origin of the left coronary artery: angiographic and myocardial perfusion scintigraphic correlates.

We studied a patient with an anomalous left coronary artery arising from the pulmonary artery by using conventional angiographic and myocardial imaging techniques. Myocardial imaging with radioactive 201thallium confirmed the significance of resting Q waves, and the defect in anterior perfusion coupled with the presence of thallium in the pulmonary outflow tract during exercise underscored the dynamic nature of the ischemic response to exercise in this syndrome.

Arteriography of coronary disease at clinical onset.

The coronary arteriographic anatomic findings in 491 male patients clinically symptomatic for less than six months are described. Single and multiple vessel disease was noted, respectively, in 40 and 60 percent with 6.5 percent also manifesting left main coronary disease. Our findings indicate that severe coronary artery disease is present early in the symptomatic phase and that patients presenting with initial inferior myocardial infarctions may represent a select group having an excessive frequency of severe coronary disease suitable for early angiographic detection and surgical bypass therapy.

Aneurysm of main left coronary artery.

A 57-year-old man presented with exertional chest pain, and was found to have a saccular, lobulated aneurysm of the left main coronary artery associated with severe atherosclerotic vascular disease. This is the third similar case reported and the first case of atherosclerotic origin. All symptoms were relieved by coronary artery bypass surgery.