Two-dimensional echocardiographic determination of left atrial emptying volume: a noninvasive index in quantifying the degree of nonrheumatic mitral regurgitation.

Several noninvasive techniques, including radionuclide angiography and Doppler echocardiography, have attempted to measure the regurgitant volume in patients with mitral regurgitation; however, none of these techniques are entirely satisfactory. Utilizing a computerized light pen method for tracing the left atrial endocardial border during systole and diastole in two orthogonal planes (apical four and two chamber views), biplane volume determinations were calculated in 12 normal subjects and 30 patients with nonrheumatic mitral regurgitation. Left atrial emptying volume determinations were performed by subtracting the left atrial end-diastolic volume from the left atrial end-systolic volume. The degree of mitral regurgitation was visually assessed as normal (0, trivial, Group I, 12 patients), mild (1+, Group II, 4 patients), moderate (2+, Group III, 8 patients), moderately severe (3+, Group IV, 12 patients) and severe (4+, Group V, 6 patients) by contrast left ventricular angiography and also quantitatively by regurgitant fraction at cardiac catheterization. All 18 patients with moderately severe (Group IV) and severe (Group V) mitral regurgitation had a left atrial emptying volume greater than 40 ml compared with none of the normal subjects and patients with mild (Group II) or moderate (Group III) mitral regurgitation. There was good correlation between left atrial emptying volume and mitral regurgitant fraction (r = 0.85, p less than 0.01). Thus, in patients with nonrheumatic mitral regurgitation, left atrial emptying volume is useful in separating mild from severe mitral regurgitation.

Effect of collateral vessels on prognosis in patients with one vessel coronary artery disease.

The prognostic implications of coronary collateral channels were examined in 359 medically treated patients with one vessel coronary artery disease and a normal left ventricular ejection fraction (greater than or equal to 50%). There were 149 patients with isolated left anterior descending coronary artery disease (group I) and 210 patients with isolated left circumflex or right coronary artery disease (group II). Collateral channels were present in 68 patients (46%) in group I and 115 patients (55%) in group II. During a follow-up period of up to 82 months (mean +/- SD 34 +/- 18), there were 23 cardiac events (4 patients died of cardiac causes and 19 patients had a nonfatal acute myocardial infarction). Actuarial survival analysis showed that the risk of cardiac events was not related to the presence of collateral channels in the two groups. Thus, the risk of cardiac events is not related to the presence or absence of collateral channels in patients with one vessel coronary artery disease. Further, the risks of cardiac death (0.3%/yr) and nonfatal myocardial infarction (1.9%/yr) are very low in medically treated patients with one vessel coronary artery disease and a normal left ventricular ejection fraction.

One-vessel coronary artery disease. Anatomic, functional, and prognostic considerations.

Patients with one-vessel coronary artery disease (CAD) constitute a heterogenous group with regard to anatomy, pathophysiology, and prognosis. Noninvasive examination of these patients shows variation in the presence and magnitude of ST-segment depression, the presence and extent of exercise-induced thallium 201-perfusion defect, and the presence and extent of regional and global left ventricular dysfunction assessed by radionuclide angiocardiography. Further studies, however, are needed to determine whether the physiologic consequences assessed noninvasively compound the effects of coronary anatomy as defined by angiocardiography on the prognosis or whether they are independent of these effects. Percutaneous transluminal coronary angioplasty should be considered in patients with one-vessel CAD who are symptomatic or in those who have a large amount of jeopardized myocardium.

Total occlusion of left main coronary artery without angina pectoris.

A patient had total occlusion of the left main coronary artery that was proved by coronary arteriography. The patient was initially seen with clinical signs of congestive heart failure but without symptoms of angina pectoris or ECG evidence of myocardial infarction. The patient's extensive right-to-left coronary artery collaterals may have contributed to the absence of chest pain. Because of the severe left ventricular dysfunction and the absence of chest pain, the patient was treated with medical therapy. Six months after the cardiac catheterization, he was alive and well under New York Heart Association functional classification II.

Pseudoaneurysm of the left ventricle complicated by Salmonella typhimurium infection. Recognition by two-dimensional echocardiography.

A patient is described with a large posterior left ventricular pseudoaneurysm complicated by Salmonella typhimurium infection. M-mode echocardiography displayed a massive echo-free space behind the posterior left ventricular wall, and two-dimensional echocardiography specifically defined the orifice and saccular contour of the false aneurysm. These findings were confirmed by cardiac catheterization and surgery. The unusual features of Salmonella endovascular infection and the noninvasive methods to detect left ventricular pseudoaneurysms are reviewed.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva.

The clinical and angiographic findings in 10 patients with anomalous origin of the left main (LM) coronary artery from the right sinus of Valsalva are presented. The initial course of the anomalous artery was between the aorta and the pulmonary trunk in 6 patients (5 men and 1 woman), and posterior to the aorta in 4 patients (3 women and 1 man). The best coronary angiographic projection to determine the course of the LM coronary artery in relation to the aorta and pulmonary trunk was the right anterior oblique and lateral projections, with a catheter in the pulmonary trunk as a guide. In the right anterior oblique projection left ventriculogram, an increased density at the base of the aorta was seen in all patients with posterior-to-aorta course of the anomalous artery. The blood supply to the first portion of the ventricular septum is provided by 1 or 2 descending septal branches from the anomalous LM artery, when the anomalous vessel is coursing between the aorta and pulmonary trunk. When the anomalous LM courses posteriorly to the aorta, it does not provide any septal branches. In patients with this anomaly, the blood supply to the first portion of the septum is usually provided by descending septal branches originating from the right sinus of Valsalva or from the first portion of the right coronary artery. Six of the 10 patients had severe obstructive coronary artery disease. Four of the 6 patients had significant LM coronary artery disease.

Two-dimensional echocardiographic determination of right atrial emptying volume: a noninvasive index in quantifying the degree of tricuspid regurgitation.

Contrast echocardiography and inferior vena cava ultrasonography are useful techniques in diagnosing tricuspid regurgitation (TR) but are not helpful in estimating the severity. Using a computerized light-pen method for tracing the right atrial (RA) border during systole and diastole in the apical 4-chamber view, single-plane volume determinations were calculated in 10 normal subjects (Group I), 18 patients with atrial fibrillation (AF) and no TR (Group II), 14 patients with mitral stenosis and mild TR (Group IIIa), and 8 patients with mitral stenosis and severe TR (Group IIIb). TR was quantitated as absent, mild or severe by contrast right ventriculography. The RA end-systolic volume was 36.4 +/- 13.1 ml in Group I patients, 59.1 +/- 16.8 ml in Group II patients, 76.9 +/- 55.4 ml in Group IIIa patients, and 154.6 +/- 57.3 ml in Group IIIb patients (all Groups versus Group I, p less than 0.001). The mean RA emptying volume, which equals RA end-systolic volume--RA end-diastolic volume, was 15.3 +/- 5.0 for Group I, 17.7 +/- 3.0 for Group II, 30.4 +/- 8.0 for Group IIIa, and 71.6 +/- 25.4 for Group IIIb. All 8 patients with severe TR but none of the 14 patients with mild TR had an RA emptying volume greater than 40 ml (p less than 0.001). In addition, all 28 patients in Groups I and II but only 4 of 14 patients in Group III had an RA emptying volume less than 26 ml (p less than 0.01). The mean RA pressure measured at cardiac catheterization correlated with RA emptying volume (r = 0.71, p less than 0.001). Thus, RA emptying volume is useful for separating severe TR from mild TR in patients with mitral stenosis.

Sinus bradycardia and atrial fibrillation associated with the Wolff-Parkinson-White syndrome.

Thirty-three patients with atrial fibrillation associated with the Wolff-Parkinson-White (WPW) syndrome were studied to determine the relation of sinus bradycardia and atrial fibrillation. In seven patients the sinus rate was less than 40 beats/min and sinus nodal disease was considered a cause of the periods of bradycardia. Ventricular fibrillation of functional cardiac arrest was documented in four instances. Twenty-six patients demonstrated a type A and seven a type B WPW pattern during periods of sinus rhythm. Male patients predominated. The average age was 38.5 years among patients with a type A pattern compared with 25.3 years among those with a type B pattern. The shortest R-R cycle length in this group was 130 msec during a period of atrial fibrillation. Five thousand serial microscopic sections were studied in one patient who demonstrated ventricular fibrillation. Three anomalous pathways were located in this patient with the widest tract, 380 mu, containing about 400 muscle cells. Most of the sinoatrial node was replaced by collagen elastic fibers, and there was widespread destruction of the atria with a marked increase in fibrous connective tissue. Ventricular fibrillation or functional cardiac arrest is not a rare arrhythmia in patients with atrial fibrillation associated with the WPW syndrome and may be responsible for sudden death in patients with these arrhythmias. Hence, precise electrophysiologic studies and pharmacologic or surgical management, or both, are suggested to prevent sudden death in patients with short refractory periods associated with atrial fibrillation and the WPW syndrome.

Progression of isolated aortic stenosis: analysis of 29 patients having more than 1 cardiac catheterization.

Factors related to progression of nonrheumatic aortic stenosis (AS) were analyzed in 29 adult patients who underwent serial hemodynamic studies over a mean of 71 months. AS was congenital in 8 patients and degenerative in 21. The patients were divided into 2 groups on the basis of the change in aortic valve area between the 2 studies. Twelve patients had a greater than or equal to 25% reduction in aortic valve area (Group I) and 17 patients had less than 25% decrease in aortic valve area (Group II). There were no significant differences between the 2 groups in age, interval between studies, cardiac output, left ventricular end-diastolic pressure, left ventricular peak systolic pressure and origin of AS (congenital or degenerative). Group I patients had significantly larger initial aortic valve areas than did Group II patients (1.3 +/- 0.9 cm2 versus 0.8 +/- 0.4 cm2, p = 0.02). Also, the initial peak transaortic pressure gradients were lower in Group I than in Group II (27 +/- 19 versus 58 +/- 38 mm Hg, p = 0.01). Group I patients had a significantly greater increase in pressure gradient and a greater reduction in cardiac output than did Group II patients (24 +/- 21 mm Hg in Group I versus -0.1 +/- 24.5 mm Hg in Group II, p = 0.01, and -1.0 +/- 1.3 liters/min in Group I versus 0.10 +/- 1.4 liters/min in Group II, p = 0.03). Thus, AS progressed in 41% of a selected group of patients who underwent repeated cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential atrioventricular pacing as a stress test. Evaluation of left ventricular function in second-degree AV heart block developing during atrial pacing.

Advanced or second-degree atrioventricular (AV) heart block pre-existing or developing during atrial pacing (AP) at low heart rates of smaller than 130 per minute, limits the value of AP to stress the left ventricle. When Wenkebach type AV block is present, the heart rate can be increased by administration of atropine before atrial pacing or by right ventricular pacing. Atropine, however, occasionally may cause serious supraventricular or ventricular arrhythmias, and high rate right ventricular pacing is not tolerated by many patients with left ventricular dysfunction because of the absence of the atrial contribution. Twenty-eight out of 101 patients with angina pectoris (27.7 percent) developed second degree AV heart block during atrial pacing studies performed for evaluation of left ventricular function. In 8 of the 28 patients, sequential AV pacing (SP) was performed successfully, with the heart rate being increased to 150-167 per minute. In 4 of the 8 patients, left ventricular dysnfunction was demonstrated during and immediately after SP. Typical angina pectoris developed in two of the four patients during SP, one of whom proved to have normal coronary arteriogram. Sequential AV pacing is an alternative method to increase the heart rate for the purpose of stressing the left ventricle when advanced degree or second-degree AV heart block pre-exists or develops during right atrial pacing. In some patients the method of SP might be preferable to administration of atropine or to ventricular pacing.

Right heart failure secondary to compression of the right pulmonary artery by a syphilitic aortic aneurysm.

A 68-year-old man presented with right heart failure due to compression of the right pulmonary artery by a syphilitic aneurysm of the ascending aorta. The diagnosis was made by cardiac catheterization and angiography and it was proven by autopsy. This complication is unusual and supports the experimental evidence that unilateral pulmonary obstruction may be responsible for the development of pulmonary hypertension.

Dissection and rupture of the ascending aorta. Unusual complications of aortocoronary bypass surgery.

This is a report concerning two cases of unusual complications, dissection and rupture of the ascending aorta, secondary to saphenous vein bypass surgery. We recommend that evaluation of patients undergoing saphenous vein bypass surgery include careful image-intensifier fluoroscopic examination during coronary arteriography. If aneurysmal dilatation of the aorta or calcification is observed, ascending aortography should be performed to better evaluate the aorta, and surgeons should be alerted to use appropriate maneuvers and techniques to minimize the risk of complications in the aortic site of the vein anastomosis. Internal mammary coronary-artery bypass should be the procedure of choice in such conditions.

Primary coronary artery dissection.

Three patients had angiographic appearance of chronic primary coronary artery dissection with features that differed from other patients with this entity studied at autopsy; they were men, greater than or equal to 40 years of age, had angina pectoris and severe coronary artery disease. The right coronary artery, which was the artery involved with dissection, had only mild atherosclerosis. Further studies are needed to determine the natural history of this angiographic finding.

Exercise myocardial scintigraphy with 201-thallium. Use in patients with mitral valve prolapse without associated coronary artery disease.

Thirty patients with angiographically documented mitral valve prolapse but without associated coronary artery disease, underwent exercise 201thallium myocardial scintigraphy. The resting ECG demonstrated ST segment abnormalities in 15 patients (50 percent). The exercise ECGs were abnormal in two patients (6.7 percent), normal in four (13.3 percent), and inconclusive in 24 patients (80 percent). Two patients (6.7 percent) had abnormal exercise myocardial scintigraphy (both patients had abnormal exercise ECGs). Two additional patients (6.7 percent) had perfusion abnormalities in the rest images that did not change with exercise. Twenty-six patients (86.4 percent) had normal scans. We conclude that the majority of patients with mitral valve prolapse have normal exercise 201thallium images in the absence of associated coronary artery disease and exercise electrocardiography is of limited value in patients with mitral valve prolapse because the results are frequently (80 percent) inconclusive.

Spasm of a saphenous vein bypass graft. A possible mechanism for occlusion of the venous graft.

The phenomenon of spasm in a venous graft was documented by angiographic study of the graft. This phenomenon has not been reported previously, and, therefore, its frequency of occurrence is unknown. Spasm of a venous graft may prove to play a significant role in the early development of myocardial infarction, closure of the graft, or recurrence of angina after initially successful surgery for aortocoronary bypass when venous grafts remain patent.

Coronary artery disease confined to secondary branches of the left coronary system.

Among 3,000 patients studied by coronary arteriography during a 4-year period, 31 patients (1%) had coronary artery disease limited to a diagonal branch of the left anterior descending (15 patients), marginal branch of the left circumflex (10 patients), or to both branches (6 patients). Ten patients had 50-69% and twenty-one had greater than or equal to 70% diameter narrowing. The suitability for grafting was noted in 20 patients as judged by the caliber and distribution of the diseased branches. Collaterals were noted in seven patients. Disease was present in 28 men and 3 women (age range 38-70 years). At least one major coronary risk factor was present in 27 patients. Angina was noted in 27 patients; prior myocardial infarction was noted in 5 patients by history and in 4 by ECG. The left ventriculogram was normal in 22 patients and showed mild segmental asynergy in 9; ejection fraction was normal in all. Exercise ECGs were positive in 12 of 25 patients; exercise 201thallium scans were positive in 13. All patients responded to medical therapy. In conclusion, among the population of patients who undergo catheterization, coronary branch disease is rare. The clinical findings are indistinguishable from patients with major coronary disease. Prognosis remains benign and patients respond to medical therapy.

Exercise 201thallium myocardial scans in patients with disease limited to the secondary branches of the left coronary system.

Coronary disease (greater than or equal to 50% narrowing) confined to only the diagonal branch of the left anterior descending artery or to the marginal branch of the left circumflex artery, or both, is uncommon. Only 19 patients with disease as defined above were identified in a group of 1000 consecutive patients with an angiographic diagnosis of coronary heart disease. All 19 patients were studied because of angina pectoris and all underwent stress myocardial perfusion scintigraphy with 201Tl (201thallium) during maximal treadmill exercise testing (exercise electrocardiogram: E/ECG). Ten patients (52%) had positive E/ECG's; seven patients (36%) had positive 201Tl and 13 patients (68%) had one or both tests positive. In 12 patients, the diseased branch was small, i.e. it supplied a comparatively small portion of myocardium, and in seven patients it was determined to be large. The 201Tl test results were positive in four out of seven patients (57%) with large diseased branches, as compared with three out of 12 (25%) with small diseased branches (p: NS). Also, three out of seven patients (42%) with large diseased branches had positive E/ECG's as compared with seven out of 12 patients (58%) with small diseased branches (p: NS). Patients with branch disease may present with typical angina pectoris, however, they are rare and thus not likely to account for the majority of false-negative 201Tl test results among symptomatic patients with CHD. Approximately one-third of the patients with branch disease have positive 201Tl test results, one-half have positive E/ECG's, and in two-thirds, one or both tests are positive.

Coronary artery dissection--a case report.

Coronary artery dissection, both spontaneous and catheter-induced, is associated with a significant morbidity and mortality. The authors present a case of a middle-aged woman with spontaneous right coronary artery dissection causing inferior wall myocardial infarction and left coronary artery dissection at the time of coronary arteriography. It is suggested that emergency aortocoronary bypass surgery be performed preceded by insertion of an intra-aortic balloon in acute evolving cases where coronary anatomy is favorable to limit infarction and avert loss of life.

Aneurysm of the sinus of Valsalva: its natural history.

This case demonstrates that complications develop with aneurysm of the sinus of Valsalva. The aneurysm is diagnosed almost exclusively only after rupture. We feel that echocardiography provides a convenient means to follow cases of suspected aneurysms. A change in aortic root size may indicate imminent rupture. Fluttering of the anterior leaflet of the mitral valve would suggest aortic insufficiency, while an increase in right ventricular size coupled with paradoxical septal motion would strongly suggest a left-to-right shunt. Change in a murmur or in the aortic silhouette probably warrants cardiac catheterization. If rupture is suggested by clinical findings and corroborated by catheterization, surgery is indicated to prevent progressive cardiac failure.