Exertion isotope tests in coronary insufficiency. Comparison with isotopic ventriculography and myocardial scintigraphy

Very few studies have been described comparing the value of exercise myocardial scintigraphy and left ventricular angioscintigraphy. The authors designed a study comparing these two investigations with conventional exercise stress testing and coronary angiography. The isotopic investigations were carried out within 48 hours of coronary angiography. A total of 143 patients undergoing coronary angiography (35 normal, 108 coronary patients: 36 single vessel, 36 double vessel and 36 triple vessel disease) were included in this study. The lesions were located of the LAD (77 cases), left circumflex (77 cases) and right coronary arteries (62). The sensitivity and specificity of both radionuclide investigations were evaluated to assess their diagnostic value; the best results were obtained with myocardial scintigraphy (sensitivity 86 p. 100; specificity 100 p. 100); angioscintigraphy had a sensitivity of 71 p. 100 and specificity of 97 p. 100, and conventional exercise stress testing of 42 p. 100 and 70 p. 100 respectively. The sensitivity seemed to increase with the degree of stenosis; although the sensitivity of myocardial scintigraphy increased progressively, that of angioscintigraphy doubled in cases of stenosis 90 p. 100 (stenosis less than 90 p. 100, sensitivity = 37 p. 100; stenosis greater than 90 p. 100, sensitivity = 73 p. 100). The sensitivity of myocardial scintigraphy with respect to the severity of the coronary artery disease was best in cases of right coronary artery stenosis (sensitivity in cases of RCA stenosis = 74 p. 100; sensitivity in LAD stenosis = 58 p. 100; sensitivity in left circumflex stenosis = 43 p. 100). The sensitivity of left ventricular angioscintigraphy was best in LAD stenosis (RCA stenosis = 50 p. 100, LAD stenosis = 64 p. 100, left circumflex stenosis = 36 p. 100). The sensitivity of both investigations was poor in left circumflex artery stenosis even when severely diseased. The sensitivity of both investigations was better in diffuse coronary artery disease: myocardial scintigraphy (single vessel disease: 72 p. 100, double vessel disease: 92 p. 100, triple vessel disease: 94 p. 100), left ventricular angioscintigraphy (61 p. 100, 69 p. 100, and 83 p. 100 respectively). Although the association of these two radioisotopic investigations does not improve diagnostic sensitivity, it does provide more information about the localisation and extension of the coronary artery disease especially in LAD and right coronary artery stenosis. These results suggest that these investigations are complementary in the evaluation of patients with coronary artery disease.(ABSTRACT TRUNCATED AT 400 WORDS)     

Atherosclerosis in the Human Brachial Artery

Objectives. We sought to assess the prevalence of atherosclerotic lesions in the human brachial artery.Background. Many investigators have recently studied endothelial and vascular function in the brachial circulation in humans to further their understanding of coronary artery disease and early atherogenesis. However, the prevalence of brachial atherosclerosis and its relation to coronary disease have never been documented.Methods. Arterial segments from the brachial, common carotid and left anterior descending coronary arteries were obtained during autopsy in 52 consecutively examined subjects (35 men, 17 women; 21 to 79 years old, mean [±SD] age 51 ± 16) and studied by light microscopy using standard histologic techniques. Severity of the atherosclerotic lesions was categorized as fatty streaks (grade 1), fibrous plaques (grade 2) and advanced lesions (grade 3).Results. Atherosclerotic lesions of any grade were found in the brachial artery in 39 (75%) subjects, common carotid artery in 51 (98%) and left anterior descending coronary artery in 52 (100%), and the prevalence and severity of disease increased with age in all three arteries. The grade of lesion severity in the brachial and coronary arteries was significantly correlated (r = 0.41, p = 0.003), as was severity in the brachial and carotid arteries (r = 0.53, p = 0.0001) and the carotid and coronary arteries (r = 0.69, p = 0.0001). The correlation between the brachial artery and the left anterior descending coronary artery was highly significant in subjects ≤50 years old (r = 0.54, p = 0.002), but not in those ≥50 years old (r = 0.37, p = NS).Conclusions. Atherosclerosis is common in the human brachial artery and is significantly correlated with both coronary and carotid disease. These results suggest that the brachial circulation may serve as a reasonable “surrogate” for studying atherosclerosis, particularly in younger adults.(J Am Coll Cardiol 1997;29:318–22)     

Diagnostic value of exercise tomoscintigraphy with thallium 201 in patients with complete left branch block

Eighteen patients with rate-dependent (n = 5) or chronic (n = 13) left bundle branch block underwent thallium 201 exercise SPECT and selective coronary arteriography. 15 patients showed significant septal or anteroseptal perfusion defects on the exercise scintigrams, but in only 4 of them did the coronary disease involve the left anterior descending artery (LAD) (n = 3) or the left main coronary artery (n = 1). Among patients with normal scintigrams, one had right coronary artery stenosis. Test performance in detecting individual coronary artery stenosis greater than 70 p. 100 was: sensitivity 80 p. 100 (4/5) and specificity 15 p. 100. In patients with left bundle branch block, T1 201 SPECT was indeterminate for LAD disease due to reversible septal perfusion defect. We conclude that the usefulness of stress thallium 201 SPECT in patients with left bundle branch block is very limited.     

Extensive development of vulnerable plaques as a pan-coronary process in patients with myocardial infarction: an angioscopic study

OBJECTIVES: To test our hypothesis that the development of vulnerable plaques is not limited to the culprit lesions, but is a pan-coronary process, we directly observed all three major coronary arteries by angioscopy and evaluated the prevalence of yellow plaques in patients with myocardial infarction (MI). BACKGROUND: Although pathologic studies have suggested that the disruption of atheromatous plaque plays a major role in the development of acute MI, the prevalence of yellow plaques in the whole coronary arteries of patients with MI has not been clarified. METHODS: Thirty-two patients undergoing follow-up catheterization one month after the onset of MI were prospectively and consecutively enrolled in this study. The prevalence of yellow plaques and thrombus in the major coronary arteries was successfully evaluated in 20 patients (58 coronary arteries, 21 culprit lesions) by coronary angioscopy. The diameter stenosis (DS) of the culprit lesions and the maximal diameter stenosis (maxDS) of nonculprit segments were angiographically measured for each coronary artery. RESULTS: The DS of the culprit lesions and maxDS were 27 +/- 17% and 19 +/- 13%, respectively. Yellow plaques and thrombus were detected in 19 (90%) and 17 (81%) of 21 culprit lesions, respectively. Yellow plaques were equally prevalent in the infarct-related and non-infarct-related coronary arteries (3.7 +/- 1.6 vs. 3.4 +/- 1.8 plaques/artery). However, thrombus was only detected in the nonculprit segments of one (2%) coronary artery. CONCLUSIONS: In patients with MI, all three major coronary arteries are widely diseased and have multiple yellow though nondisrupted plaques. Acute MI may represent the pan-coronary process of vulnerable plaque development.     

Evaluation of vulnerable coronary plaques and non-alcoholic fatty liver disease (NAFLD) by 64-detector multislice computed tomography (MSCT).

BACKGROUND: Multislice computed tomography (MSCT) permits direct visualization of not only coronary artery stenosis but also the characteristics of plaques in patients with coronary artery disease (CAD). Also, because of its potential to be a novel risk factor for cardiovascular disease, interest in non-alcoholic fatty liver disease (NAFLD) is increasing. METHODS AND RESULTS: Participants comprised 298 consecutive patients who received MSCT to diagnose CAD. Patients with an alcohol intake exceeding 20 g/day or with a history of known liver disease were excluded from the study. Liver steatosis and 4 coronary artery findings, including remodeling lesions, lipid core plaques, calcified plaques and narrowing of lumen, were assessed. Liver steatosis was evaluated by computed tomography density of the liver and spleen. In the study, NAFLD was defined as having a liver and spleen (L:S) ratio of <1.1. The L:S ratios of patients with remodeling lesions or lipid core plaques were significantly lower than those without. NAFLD was related significantly to those findings, but there was no correlation between calcified plaques, narrowing of lumen and L:S ratios. Adjusted odds ratio of NAFLD for remodeling lesions was 2.41 (95% confidence interval (CI), 1.24-4.67; p=0.009), and those for lipid core lesions was 2.29 (95% CI, 1.15-4.56; p=0.018). CONCLUSION: NAFLD is a novel risk factor for vulnerable plaques.     

Visualization by bidimensional echocardiography of the trunk of the left coronary artery. Affirmation of its integrity before coronary angiography

The aim of this study was to visualise and analyse the status of the main left coronary artery by 2D echocardiography before coronary angiography. Fifty two patients were studied. The recordings were performed from the left parasternal position on video cassettes and played back frame by frame for each patient, to analyse the left main coronary artery and its bifurcation. The patients had known stenosis of this vessel; there were echocardiographic abnormalities in all 10 cases; the stenosis was visualised directly in 5 patients and the vessel was considered to be abnormal in the other 5 patients. Forty two patients underwent 2D echo before coronary angiography. The echo of the left main coronary artery was considered to be abnormal in 8 patients: these results were compared with those of coronary angiography. In 33 cases there were no echocardiographic abnormalities and there were no angiographic lesions. The false positive results were due to the inability to record the bifurcation (proximal stenosis of the LAD interpreted as stenosis of the left main coronary) or to the direction of the left main coronary which is curved and thus cannot be analysed in the plane of the transducer. False negative results corresponded to slight stenosis (less than 50 p. 100). The bifurcation can be visualised in 60 p. 100 of patients with normal left main coronary arteries. It is only in these cases that the absence of significant lesions can be confirmed before coronary angiography.     

Comparison of the postoperative blood flow waveforms of the bypassing grafts in patients following minimally invasive direct coronary artery bypass

PURPOSE: To use Doppler ultrasound velocimetry to detect and compare the postoperative flow characteristics of the bypassing grafts in patients following minimally invasive direct coronary artery bypass surgery (MIDCAB). MATERIALS AND METHODS: From January 1997 to June 1999, 34 patients underwent MIDCAB with the left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) [n = 23], with the right gastroepiploic artery (RGEA) to the right posterior descending artery (RPD) [n = 3], or with the LITA with a saphenous vein graft extension to the LAD (n = 6), the diagonal coronary artery (n = 1), or the right acute coronary artery (n = 1). There were two patients with LITA to the LAD and RGEA to the RPD. Patients underwent MIDCAB due to coronary artery stenosis (100% occlusion, n = 10; 90 to 99% stenosis, n = 18; < 90% stenosis, n = 5) or unsuccessful percutaneous transcoronary angioplasty with dissection (n = 1). All patients underwent flow velocity measurement by Doppler ultrasound velocimetry in the immediate postoperative period, and at 6-month and 12-month intervals; graft flows were quantified based on Doppler velocimetric data. RESULTS: The results showed that in a patient with a totally occluded LAD or RPD, typical biphasic velocity waveforms were consistently observed. However, a delayed diastolic wave was noted in RGEA grafts. In patients with less-occluded stenotic lesions or with strong back flows, the flow velocity patterns showed biphasic waveforms but systolic reversal was observed in the area closest to the anastomotic site. CONCLUSION: The presence of an LAD or RPD stenosis proximal to the anastomotic site significantly affects the LITA or RGEA graft flow volume. The biphasic flow pattern proves that an LITA or RGEA graft transports the blood primarily to coronary arteries during the diastolic phase.     

Antioxidants and other novel cardiovascular risk factors in subjects with rheumatoid arthritis in a large population sample

OBJECTIVE: To compare antioxidants and other novel and traditional cardiovascular disease (CVD) risk factors in participants with rheumatoid arthritis (RA) and non-RA controls in a large population sample. METHODS: The Third National Health and Nutrition Examination Survey (NHANES-III) was a cross-sectional population survey in which subjects ages >or=60 underwent a musculoskeletal examination. RA subjects were defined as those who met >or=3 of 6 available 1987 American College of Rheumatology (ACR) criteria. Non-RA subjects were defined as those who met no ACR criteria. We performed univariate and multivariate analyses of the association between RA and each novel and traditional CVD risk factor in RA versus non-RA subjects. RESULTS: The sample included 5,302 subjects ages >or=60, with 131 (2.5%) RA and 4,444 (84%) non-RA participants. A total of 727 subjects were excluded. Plasma levels of antioxidants alpha-carotene, beta-cryptoxanthin, lutein/zeaxanthin, and lycopene were significantly lower in RA subjects compared with non-RA subjects in multivariate analysis adjusting for potential confounders. Compared with non-RA participants, RA subjects were more likely to have increased C-reactive protein (CRP) levels in multivariate analysis adjusting for potential confounders. RA and non-RA participants had similar prevalence of traditional CVD risk factors and previous CVD. CONCLUSION: In this large population study, RA subjects had similar prevalence of previous CVD and traditional CVD risk factors as controls. Among novel CVD risk factors, plasma carotenoid levels were significantly lower and CRP level was significantly higher in RA compared with non-RA subjects after adjustment for potential confounders. Further research should evaluate whether these differences account for the observed increased incidence of CVD in individuals with RA.     

Sudden cardiac death and arrhythmia profile in patients with single-vessel coronary disease

214 patients with single vessel disease (high grade stenosis greater than or equal to 75% or occlusion of the LAD, RCA or LCX) were followed for 1-78 months, average 51 months. Incidence of sudden death was studied in relation to coronary artery lesions, left ventricular wall motion and ventricular arrhythmias found during ambulatory ECG monitoring at the time of angiography. Incidence of sudden death was 11.1% (16/144) in LAD, 7.3% (4/55) in RCA and 6.7% (1/15) in LCX lesions. Coronary artery occlusion was associated with a significantly higher incidence of sudden death (14.6%, 18/123) than high-grade stenosis (3.3%, 3/91) (p less than 0.05). The risk of sudden death increased markedly in patients with complex arrhythmias and an occluded LAD or RCA (21.0%, 8/38; 18.2%, 2/11) compared to patients without complex arrhythmias (14.7%, 5/34; 5.5%, 1/18) (p = ns). Only one patient (1/15, 6.7%) with an isolated LCX lesion died suddenly. Our data show that the incidence of sudden death over 51 months is relatively low in patients with single vessel disease. However, LAD occlusion or RCA lesion with akinetic left ventricular areas and complex arrhythmias are independent predictors of sudden death.     

Coronary Flow Velocity Reserve After Successful Balloon Angioplasty and Directional Atherectomy

Background: To ascertain whether transesophageal echocardiography (TEE) allows for measurement of coronary flow velocity "reserve" in patients with disease of the left anterior descending artery (LAD), and to establish the flow velocity response following angiographically successful angioplasty and atherectomy. Methods: Four groups of patients were studied: normal controls (n = 15) consisted of patients without obstructive coronary artery disease, a LAD stenosis group (n = 15) consisted of patients with > 70% stenosis, an LAD postangiographically successful balloon angioplasty group (n = 12), and an LAD postangiographically successful directional atherectomy group (n = 6). Two-dimensional horizontal plane TEE was used to image the proximal left coronary arterial system. Pulsed Doppler recordings were made of proximal LAD flow velocities at rest, and following an infusion of 0.56 mg/kg IV dipyridamole. Results: The peak diastolic flow velocity ratio (hyperemic flow/baseline flow) for normal controls was 3.46 ± 0.48 (mean ± standard deviation), for the LAD stenosis group was 1.35 ± 0.26, for the balloon angioplasty group was 2.08 ± 0.45, and for the directional atherectomy group was 2.10 ± 0.82. Conclusions: We conclude that: (1) it is feasible to record with TEE Doppler, flow velocity and flow reserve in normals, in obstructive coronary artery disease, and following revascularization; (2) coronary flow velocity ratio (CFVR) is decreased in patients with LAD stenosis; (3) CFVR remains subnormal in patients with angiographically successful directional atherectomy and balloon angioplasty; and (4) that flow velocity ratios following directional atherectomy were not significantly different from those following balloon angioplasty .     

Is imaging the left main able to rule out severe LAD stenosis?

The 5-year cardiac mortality rate has been reported to be more than 50% in patients with leftmain coronary artery (LMCA) stenosis.The purpose of this study was to visualize the LMCA using intravascularultrasound in patients who undergo interventions of the left anterior descending coronary artery (LAD).This wasdone in order to see the incidence and severity of plaque formation in the LMCA in patients with severe LADstenesis,and to address if scanning LMCA is able to rule out LAD significant stenosis or vice versa.Methods Atotal of 293 patients with intervention of the LAD stenosis were examined with intravascular ultrasound(IVUS).Theimages of 278 patients were suitable for analysis.Results Fifty-three (19%) were found to have angiographielumen reduction in the LMCA ranging from 11% to 35% (19±8%).Sixty-one patients were found to have nativecalcification in the LMCA.Atherosclerotic plaques in LMCA were detected in 211/278 (76%) patients,of which164/211 (78%) were eccentric,and 51/211 (24%) had calcium deposit.The cross-sectional plaque area rangedfrom 1.5 mm~2 to 21 mm~2 (8.4±4.7 mm~2).Area of stenusis was 34±14% (8-66%) and diameter of stenosis was21±8% (7-42%).A weak relationship concerning severity of stenosis between LAD stenosis and LMCA stenosiswas found in the 59 patients with pre-interventional IVUS examinations (r=0.47,P<0.05).ConclusionsLMCA is frequently involved with atherosclerotic lesions in patients with severe LAD stenosis.A weak relationshipdoes exist concerning the severity of stenosis between LAD and LMCA.However,IVUS for LMCA lesion is not ableto rule out lAD stenosis.(J Ceriatr Cardiol 2004;1:35-39.)     

右冠状动脉狭窄程度对左冠状动脉狭窄患者左室射血分数的影响

目的研究右冠状动脉不同程度狭窄对左冠状动脉狭窄患者左室射血分数（LVEF）的影响。方法根据左冠状动脉病变部位不同,将1 000例左冠状动脉狭窄患者分为左前降支（LAD）狭窄,左回旋支（LCX）狭窄,左主干（LM）狭窄,左前降支+左回旋支（LAD+LCX）狭窄4个系列。每个系列再根据右冠状动脉（RCA）病变程度不同分为RCA正常组（直径狭窄<50%）、RCA非闭塞组（99%>直径狭窄≥50%）和RCA闭塞组（直径狭窄≥99%）,比较分析3组间LVEF的差异。结果在LAD,LCX,LM,LAD+LCX狭窄时,与RCA正常组LVEF相比,RCA非闭塞组LVEF分别下降0.9%,0.3%,3.4%和2.8%;RCA闭塞组LVEF分别下降10.9%,3.7%,6.5%和5.2%。LAD狭窄时,RCA非闭塞组和RCA闭塞组之间LVEF有统计学差异（P<0.01）。结论右冠状动脉病变可在左冠状动脉狭窄的基础上使左室射血分数进一步下降;当左冠状动脉狭窄为闭塞性病变时,影响更为明显。     

Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study

Objective : To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background : The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods : Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results : In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions : HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES. © 2011 Wiley Periodicals, Inc.     

Interrelation between the extent of atherosclerosis in the thoracic aorta, carotid intima-media thickness and the extent of coronary artery disease

Intima-media thickness (IMT) of the common carotid artery and atherosclerosis of the thoracic aorta have been shown to correlate with coronary artery disease (CAD). This study compares the relation between wall changes in the thoracic aorta and the carotid arteries and the angiographic severity and extent of atherosclerotic lesions in the coronary arteries in patients with verified CAD. Atherosclerotic wall changes in the carotid arteries and the thoracic aorta were measured by B-mode ultrasonography and transesophageal echocardiography (TEE), respectively, in 37 subjects aged 65+/-10 years with angiographically verified CAD. The mean value of the common carotid IMT of the right and left sides was 0.87+/-0.21 mm. All subjects had carotid plaques. TEE detected grades II-IV atherosclerotic plaques in the thoracic aorta in 32 of the 37 (86%) patients. A significant correlation was seen between the extent of coronary artery stenosis and aortic plaques score (r=0.46, p=0.008). Mean carotid IMT was also significantly correlated with coronary artery stenosis extent score (r=0.44, p=0.007). Moreover, a significant correlation was seen between the aortic plaque score and the mean carotid IMT (r=0.39, p=0.02). In conclusion, we found a clear and significant relationship between wall changes in the thoracic aorta, common carotid IMT and the angiographic extent of coronary artery stenosis in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of the carotid arteries and transesophageal echocardiographic aortic examination in the diagnostic and prognostic evaluation of patients with suspected CAD.     

Association of Coronary Heart Disease Risk Factors with microscopic qualities of coronary atherosclerosis in youth

BACKGROUND: This study examined whether atherosclerosis in young people is associated with the risk factors for clinical coronary heart disease (CHD). Methods and Results-Histological sections of left anterior descending coronary arteries (LADs) from 760 autopsied 15- to 34-year-old victims of accidents, homicides, and suicides were graded according to the American Heart Association (AHA) system and computerized morphometry. Risk factors (dyslipoproteinemia, smoking, hypertension, obesity, impaired glucose tolerance) were assessed by postmortem measurements. Approximately 2% of 15- to 19-year-old men and 20% of 30- to 34-year-old men had AHA grade 4 or 5 (advanced) lesions. No 15- to 19-year-old women had grade 4 or 5 lesions; 8% of 30- to 34-year-old women had such lesions. Approximately 19% of 30- to 34-year-old men and 8% of 30- to 34-year-old women had atherosclerotic stenosis > or =40% in the LAD. AHA grade 2 or 3 lesions (fatty streaks), grade 4 or 5 lesions, and stenosis > or =40% were associated with non-HDL cholesterol > or =4.14 mmol/L (160 mg/dL). AHA grade 2 or 3 lesions were associated with HDL cholesterol <0.91 mmol/L (35 mg/dL) and smoking. AHA grade 4 or 5 lesions were associated with obesity (body mass index > or =30 kg/m(2)) and hypertension (mean arterial pressure > or =110 mm Hg). CONCLUSIONS:-Young Americans have a high prevalence of advanced atherosclerotic coronary artery plaques with qualities indicating vulnerability to rupture. Early atherosclerosis is influenced by the risk factors for clinical CHD. Long-range prevention of CHD must begin in adolescence or young adulthood.     

Importance of left anterior hemiblock development in inferior wall acute myocardial infarction.

The aim of this study was to investigate the clinical and angiographic importance of left anterior hemiblock (LAHB) during acute inferior myocardial infarction (AIMI) by comparing patient groups with and without LAHB after AIMI. One hundred seventy-two patients (141 men and 31 women) between 28 and 84 years of age (mean 55 +/-10 years) with AIMI were included in the study. Patients were divided into 2 groups according to electrocardiogram (ECG) criteria: group I comprised 25 patients in whom ECG pattern characteristic of LAHB developed, group II comprised 147 patients without this pattern. According to the electrocardiogram, patients were placed in group I if the mean QRS axis was deviated to the left < 30 degrees in the frontal plane with the following pattern: increased S-wave voltage and decreased R-wave voltage in leads II, the appearance of a deep S-wave in lead II, and a terminal positive R-wave in lead aVR. Coronary angiography was performed within 2 weeks. A coronary stenosis was considered if the vessel diameter was narrowed by > 50%. The dominant coronary artery was classified as right or left or balanced. The left ventricular ejection fraction (LVEF) was calculated from left ventriculography. The mean age of the patients in group I was significantly higher (58 vs 54 years, p = 0.007), while the risk factors were similar in both groups. Left anterior descending (LAD) and multi-vessel coronary artery disease (CAD) were found to be significantly higher in group I compared with group 11 (80% vs 38%, p=0.0001; 84% vs 52%, p=0.001, respectively). The mean LVEF was found to be lower in group I (51% vs 56%, p=0.04). Peak creatine phosphokinase MB (CKMB) values were not different (216 vs 162 IU/L, p = 0.09). The frequency of left dominant or balanced coronary artery was determined to be higher in group I (44% vs 17%, p = 0.018). LAHB development during AIMI can be an indicator of LAD lesions, multivessel coronary artery disease, and impaired left ventricular systolic function.     

Evaluation of coronary lesions in biventricular inferoposterior infarction

Fifty-two patients with primary transmural infero-posterior infarcts underwent right heart catheterisation on admission to hospital and coronary angiography between the 7th day and 4th month after onset of symptoms. The patients were divided into two groups A (N = 34) with signs of right ventricular dysfunction on admission indicating biventricular infarction, and B (N = 18) without right ventricular dysfunction classified as isolated LV infarction. No significant differences were observed between the two groups with respect to: global and regional LV function; the incidence of single, double and triple vessel disease; the incidence and location of right coronary artery thrombosis; the incidence and location of lesions of the left coronary tree (LCA, LAD, Cx); the extent of coronary disease (Gensini score); the dominant artery (right coronary/circumflex), the frequency and quality of revascularisation of distal vessels. The only significant differences were the higher incidence of severe lesions (90 p. 100) of the right coronary and circumflex arteries and of stenosis of the first large septal branch of the LAD artery in Group A (p less than 0.05). These results show that the indications for coronary angiography in biventricular inferior infarction are no greater than those in mono LV inferior infarction. This supports experimental data on the physiopathology of RV infarction which demonstrates that except in cases of proximal thrombosis of the right coronary artery, the possibilities of revascularisation from the left coronary tree are limited.     

Relationship between ventricular gradient and the impairment of wall motion of the left ventricle in coronary artery disease

Fifty patients with or without coronary artery disease were studied. Twelve of them showed no coronary artery obstruction, while 38 demonstrated obstruction of the left anterior descending artery (LAD). Of the latter 38, 16 had obstruction at LAD alone, 6 at LAD and right coronary artery (RCA), 8 at LAD and left circumflex artery (LCx) and 8 at LAD, RCA and LCx. Vectorcardiography, selective coronary cineangiography and left ventricular cineangiography were undertaken in all subjects. The vectorcardiogram (VCG) was recorded on a magnetic tape and QRS area vector (Aqrs), T area vector (At) and ventricular gradient (G) were calculated by micro-computer. From left ventriculogram (LVG) "score" was computed to express the grade of impairment of the wall motion. Correlations between various vector-cardiographic parameters and this score were examined. The score correlated significantly (p less than 0.001) with azimuth of Aqrs (r = -0.545), azimuth of At (r = 0.661), magnitude of G (r = -0.705), azimuth of G (r = 0.533), G/Aqrs (r = -0.645), spatial angles between Aqrs and At (r = 0.591) and between max R and max T (r = 0.595) and X component of G (r = -0.758). These results suggested the usefulness of ventricular gradient to grasp the grade of coronary artery disease.     

Regression of coronary artery dimensions after successful aortic valve replacement.

BACKGROUND. The effect of regression of myocardial hypertrophy on coronary artery dimensions was evaluated in patients with aortic valve disease who underwent valve replacement. METHODS AND RESULTS. Cross-sectional area (CSA) of the three major coronary arteries (left anterior descending [LAD], left circumflex [LCx], and right coronary artery) was determined by quantitative coronary arteriography in 15 patients with aortic valve disease before and 38 months (range, 14-113 months) after successful aortic valve replacement. Twelve normal subjects served as controls. Left ventricular (LV) angiographic mass was calculated according to the method of Rackley. CSA of the left coronary artery was larger in aortic valve disease than in controls (LAD, 15 versus 8 mm2, p less than 0.001; LCx, 14 versus 6 mm2, p less than 0.001). After valve replacement, CSA of the left coronary artery decreased (LAD, 12 mm2, p less than 0.05 versus before surgery; LCx, 11 mm2, p less than 0.05 versus before surgery) but remained significantly larger than in controls. CSA of the right coronary artery in patients with aortic valve disease was not different from controls. LV muscle mass was significantly increased in aortic valve disease patients before (364 g) and after (250 g) valve replacement compared with controls (135 g). The appropriateness of coronary artery size with respect to muscle mass was evaluated by normalizing CSA of the left coronary artery (LAD + LCx) per 100 g of LV muscle mass (mm2/100 g). This index amounted to 11 mm2/100 g in controls, to 8 mm2/100 g in preoperative patients (p less than 0.05 versus controls), and to 10 mm2/100 g in postoperative patients with aortic valve disease (p = NS versus controls). CONCLUSIONS. In patients with aortic valve disease, CSA of the proximal LAD and LCx is increased, but this increase is not sufficient to keep CSA per 100 g of LV mass within normal limits. The postoperative decrease in muscle mass is associated with a decrease in the size of LAD and LCx, whereas the size of the right coronary artery remains unchanged. In contrast to the preoperative state, the residually hypertrophied LV myocardium after aortic valve replacement is supplied by an enlarged but adequately sized LAD and LCx.     

Evaluation of flow in the left anterior descending coronary artery but not in the left internal mammary artery graft predicts significant stenosis of the arterial conduit

OBJECTIVES: The purpose of this study was to evaluate which Doppler-derived flow index best predicts new distal left anterior descending coronary artery (LAD) stenosis in patients with left internal mammary artery (LIMA) graft. BACKGROUND: The LIMA flow measurement has been proposed to assess graft function, but it may be misleading in case of new distal LAD stenosis and/or competitive flow from native LAD. Distal LAD coronary flow reserve (CFR: hyperemic/baseline peak flow velocity ratio) may be more appropriate. METHODS: The LIMA and distal LAD flow was measured by transthoracic Doppler echocardiography in 96 patients undergoing diagnostic/therapeutic coronary angiography, 7 +/- 4 years after cardiac bypass surgery. The LIMA flow indexes (systolic-to-diastolic peak velocity ratio [SDPVr] >1, diastolic time velocity integral fraction [DTVIf] <0.5, and CFR <2) and LAD CFR <2 were used to predict > or =70% new LAD stenosis. RESULTS: The LAD CFR <2 predicted new LAD stenosis, found in 21 of 77 patients without competitive flow from native LAD, with significantly higher diagnostic accuracy (98%) than LIMA flow indexes (SDPVr >1 = 61%, DTVIf <0.5 = 69%, and CFR <2 = 72%). The LIMA flow indexes were abnormal in 17 of 19 patients with competitive graft flow, but only 5 had graft restriction, and none had significant LAD stenosis. In a multivariate model of new distal LAD stenosis prediction, competitive flow from native LAD reduced the predictive role of LIMA but not of LAD CFR. CONCLUSIONS: In patients without competitive flow from native LAD, LAD CFR is more accurate for the detection of LAD stenosis than LIMA CFR. In patients with competitive graft flow, abnormal LIMA flow patterns and blunted LIMA CFR do not reflect downstream LAD flow as LAD CFR does.