Coronary angiography in octogenarians: results and implications for revascularization.

PURPOSE: To determine the risks and the consequences of coronary angiography performed on octogenarians with symptomatic coronary artery disease. PATIENTS AND METHODS: In order to define angiographic findings, procedural complications, and therapeutic consequences, a retrospective evaluation was made of 115 consecutive patients with angina, aged 80 or above, who underwent coronary angiography in our institution between 1988 and 1992. RESULTS: In all, 115 patients (68 men) aged 82 +/- 2 years, 70% with unstable angina, underwent coronary angiography corresponding to 1.4% of all the procedures performed between 1988 and 1992. Three-vessel or left main coronary artery disease, or both, was found in 42% of cases, but this proportion decreased over the years. Revascularization by means of percutaneous transluminal angioplasty (PTCA) or bypass grafting followed angiography in 54% of cases. Use of revascularization has markedly increased, from 33% in 1988 to 64% in 1992 (P < 0.05), and now tends to be performed more often by PTCA. Eight patients (7%) suffered minor periprocedural complications and 8 patients (7%) died in the hospital, but none of the deaths was directly related to the diagnostic procedure itself. At follow-up (28 +/- 16 months), 68% and 44% of the survivors were free of angina after revascularization and medical treatment, respectively (P < 0.05), and there was a nonsignificant trend for better survival after revascularization. Of the survivors, 80% were able to pursue an independent life. CONCLUSIONS: Coronary angiography may be done in symptomatic octogenarians with an acceptably low complication rate. Following diagnostic evaluation, revascularization procedures are performed in an increasing proportion of patients, and despite a relatively high procedural complication rate, they result in definite symptomatic improvement.

Congenital intrathoracic left ventricular diverticulum in an adult.

A 53-year-old woman without any risk factors for coronary artery disease was found to have a congenital intrathoracic left ventricular diverticulum with a narrow long connection to the left ventricular cavity. Coronary angiography revealed normal coronary arteries. The diverticulum was resected and showed three normal cardiac layers. This is an extremely rare finding in the adult population.

[Early percutaneous coronary angioplasty in unstable angina]. / Angioplastie coronaire percutanée précoce dans l'angor instable.

The risks of complications of percutaneous transluminal coronary angioplasty (PTCA) are increased in unstable angina. Medical treatment for a few days before PTCA is widely adopted to reduce the risk of thrombosis or occlusive dissection during and after the procedure. Over the last few years, the authors have adopted a strategy of early coronary angiography completed by immediate angioplasty when possible, without waiting for the eventual benefit of aspirin or heparin therapy. Their experience from 1988 to 1995 of 853 patients treated by PTCA (151/853 or 17.7%, with implantation of a stent) for unstable angina, was reviewed. Group I comprised 402 patients treated on the day of or the day after admission. Group II comprised 451 patients treated 2 days or more after admission. Patients in Group I were younger (62 +/- 11 vs 64 +/- 12, p < 0.001), and had single vessel disease more often (61 vs 52%, p < 0.005). The success rate of PTCA was similar in the 2 groups (85.3 vs 88.2%, NS), as was the rate of complications (death, infarction or coronary bypass surgery, 9.9 vs 7.3%, NS). The length of hospital stay was significantly shorter in Group I (6.1 +/- 5.6 vs 8.7 +/- 6.9 days, p < 0.0001). With the limitations inherent to all retrospective studies, these data suggest that an early interventional approach in unstable angina has a similar success rate with no more complications than angioplasty. This approach is associated with a deferred significant decrease in the duration of hospital stay.

[Regional coronary flow in ml/min measured with conventional coronarography]. / Débit coronaire régional en ml/min mesuré à partir de coronarographies conventionnelles.

We have developed a new method of measuring absolute coronary blood flow (CBF) in all major branches of the coronary circulation using computer analysis of conventional cineangiograms. A coronary cineangiogram is obtained in any biplane projections at 50 fps and digitized into a 512 x 512 x 8 matrix. The artery is reconstructed in 3D using the x-ray projection matrices calculated from a cube filmed in the same projections. All diameters along the artery are automatically determined. The arterial volume is calculated from the 3D reconstructed true arterial length and diameters. The absolute flow is obtained by dividing the arterial volume filled by contrast medium during the first cardiac cycle following the injection by the duration of that cycle. The method was validated in vivo by comparing LAD flow measured by angiography with great cardiac vein flow simultaneously measured by thermodilution. Ten patients were studied at baseline and during pacing-induced hyperemia at 100 and 120/min. Mean flow was 52.1 ml/min (range 28-93) by angiography and 51.5 ml/min (range 11-115; NS) by thermodilution. The two methods correlated well: r = 0.82, SE = 9.8 ml/min, n = 27, p less than 0.0001. Thus, absolute CBF can be measured by computer analysis of conventional biplane coronary cineangiograms.

Morphometry versus densitometry--a comparison by use of casts of human coronary arteries.

Geometric and densitometric methods for quantitative coronary arteriography have generally been compared by use of phantoms simulating arteries with circular lumina ('Hole phantoms'). We have used more adequate phantoms obtained by casting disease-free and atheromatous human coronary arteries. The phantoms, filled with contrast medium, were imaged digitally (1024 x 1024 x 10 matrix) under experimental conditions simulating routine coronary angiography. The angiographic 'diameters' and the densitometric cross-sectional areas of 59 marked lumina were determined in single plane and orthogonal biplane raw images. Geometric calibration was performed by help of a 7F coronary catheter. For the densitometric calibration, we used a 'hole phantom' attached to the image intensifier. The obtained luminal areas were compared to their true values determined previously by planimetry. The mean absolute error of single plane cross-sections obtained geometrically was 1.53 mm2. Biplane imaging reduced it by a factor 2.4 to 0.64 mm2. The corresponding mean absolute errors for densitometry were 0.56 mm2 and 0.51 mm2. Single plane 'diameter' measurements appear thus of very limited value for hemodynamic conclusions. In contrast, biplane geometric quantification was not markedly inferior to single plane and biplane densitometry.

3D determination of the intravascular volume and flow of coronary arteries.

An angiographic method for measurement of absolute coronary blood flow in patients was developed. It is based on 3D-reconstruction of the left or right coronary tree from digitized biplane coronary cineangiograms. The apparatus is presently composed of a 35-mm cinefilm projector with video camera and a 512 x 512 x 8-bits image array processor controlled by a VAX-11/750 computer. First, the parameters of the two projections are determined in the form of two 4 x 3 matrices from a pair of cineframes showing a 4-cm cube bearing markers. The cube is filmed after the coronary injection, with unchanged geometric configuration. The coronary arteries of interest are then 3D-reconstructed from a pair of cineframes showing them fully opacified. This allows the intravascular volumes needed for flow determination to be computed. Preliminary measurements in 12 patients showed that flow values obtained angiographically in the left descending coronary artery correlate well with the values measured simultaneously by thermodilution in the great cardiac vein (Qangio = 0.83 x Qthermo + 16.1 ml, r = 0.87, n = 29).

3D-reconstruction of coronary arteries in view of flow measurement.

An angiographic method for measurement of absolute coronary blood flow in patients was developed. It is based on 3D-reconstruction of the left or right coronary tree from digitized biplane coronary cineangiograms. The apparatus is presently composed of a 35 mm cinefilm projector with a video camera and a 512 x 512 x 8 bits image array processor controlled by a VAX-11/750 computer. First, the parameters of the two angiographic projections are determined in form of two 4 x 3 matrices from a pair of cineframes showing a 4 cm cube bearing markers. The cube is filmed after the coronary injection, with unchanged geometric configuration. The coronary arteries of interest are then 3D-reconstructed from a pair of cineframes showing them fully opacified. This allows to compute the intravascular volumes needed for flow determination. In vitro experiments showed that the obtained volume are reasonably accurate. For the measurement of coronary flow, the concentration of contrast medium along the involved arteries is computed (in arbitrary units) from two cineframes taken one (or two) cardiac cycle after onset of the injection. This yields a 'concentration-distance' curve per artery. The volume of fluid (contrast medium mixed with blood) which flows into the arteries during this (or these two) cardiac cycle is determined by applying a concentration threshold to the obtained concentration-distance curves. Measurements performed on a constant flow model were satisfying. Preliminary measurements in 12 patients showed that flow values obtained angiographically into the left anterior descending coronary artery correlate well with the values measured simultaneously by thermodilution in the great cardiac vein (Qangio = 0.83 x Qthermo + 16.1 ml, r = 0.87, n = 29).