Transthoracic ultrasonic visualisation of coronary aneurysm, stenosis, and occlusion in Kawasaki disease

OBJECTIVE—To determine the sensitivity and specificity of our transthoracic echocardiographic technique using high frequency (7.5 MHz) transducers for identification of the presence and type of coronary artery disease in patients with Kawasaki disease.
DESIGN—The results of the prospective echocardiographic study in each of seven segments of the four major coronary arteries were compared with the selective coronary angiograms.
SETTING—Kitasato University Hospital.
SUBJECTS—60 patients with Kawasaki disease, ranging in age from 8.0 months to 22 years (median, 6.0 years).
RESULTS—Adequate echocardiographic images were obtained in 397 (95%) of 420 coronary segments. Coronary angiography showed the presence of coronary aneurysms in 87 segments and stenosis or occlusion in 28. The overall sensitivity and specificity of cross sectional echocardiography for correctly identifying coronary aneurysms were 95% and 99%, respectively; for correctly identifying coronary stenosis or occlusion the values were 85% and 98% for the right coronary artery, and 80% and 97% for the left anterior descending coronary artery. Agreement on the presence or absence of coronary aneurysms and obstructive lesions on echocardiograms between the two observers was 1.0 and 0.98, respectively.
CONCLUSIONS—Echocardiography may provide a non-invasive means of identifying the presence and type of coronary artery disease in patients with Kawasaki disease.


Keywords: Kawasaki disease; coronary artery aneurysm; coronary artery stenosis; echocardiography     

Restrictive pericarditis

BACKGROUND—Pericardial thickening is an uncommon complication of cardiac surgery.
OBJECTIVES—To study pericardial thickening as the cause of severe postoperative venous congestion.
SUBJECTS—Two men, one with severe aortic stenosis and single coronary artery disease, and one with coronary artery disease after an old inferior infarction. Both had coronary artery bypass grafting surgery.
METHODS—Magnetic resonance imaging (MRI), Doppler echocardiography, and cardiac catheterisation.
RESULTS—Venous pressure was raised in both patients. MRI showed mildly thickened pericardium, and cardiac catheterisation indicated diastolic equalisation of pressures in the four chambers. Jugular venous pulse showed a dominant "Y" descent coinciding with early diastolic flow in the superior vena cava, and mitral and tricuspid Doppler forward flow proved restrictive physiology. The clinical background suggested pericardial disease so both patients had pericardiectomy. This proved the pericardium to be thickened; the extent of fibrosis also involved the epicardium.
CONCLUSIONS—Although rare, restrictive pericarditis (restrictive ventricular physiology resulting from pericardial disease) should be considered to be a separate diagnostic entity because its pathological basis and treatment are different from intrinsic myocardial disease. This diagnosis may be confirmed by standard investigational techniques or may require diagnostic thoracotomy.


Keywords: restrictive pericarditis; pericardial disease     

Randomised comparison of coronary stenting with and without balloon predilatation in selected patients

BACKGROUND—The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon.
OBJECTIVE—To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study.
PATIENTS AND DESIGN—All patients < 76 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of > 3.0 mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60 patients.
RESULTS—Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (p = 0.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65) ml v 157 (62) ml (p < 0.001), respectively. No major adverse cardiovascular events had occurred by 30 days.
CONCLUSIONS—The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.


Keywords: coronary artery angioplasty; stent; coronary artery ultrasound     

Comparison of peripheral endothelial dysfunction and intimal media thickness in patients with suspected coronary artery disease

Objective—Flow associated dilatation (FAD%) and intimal media thickness are established markers of early atherosclerosis. This study aimed to compare the ability of the non-invasive measurements FAD% and intimal media thickness to predict coronary artery disease.
Methods—FAD% and intimal media thickness were determined using high resolution ultrasound in 122 patients with clinically suspected coronary artery disease before coronary angiography. Results are given as mean (SD).
Results—Patients with coronary artery disease had reduced FAD% compared with those with angiographically normal coronary vessels (3.7 (4.1) v 7.0 (3.5)%, p < 0.001), whereas intimal media thickness tended to be increased in patients with coronary artery disease (0.58 (0.35) v 0.47 (0.11)mm, p = 0.054). There was a negative correlation between FAD% and intimal media thickness (R = −0.317, p = 0.0004). Receiver operating characteristic analysis showed that FAD%  4.5% predicted coronary artery disease with a sensitivity of 0.71 (95% confidence interval 0.61 to 0.80) and a specificity of 0.81 (0.58 to 0.95). In contrast, intimal media thickness showed a positive correlation with the extent of coronary artery disease (number of vessels with a lesion  50%) (R = 0.324, p = 0.0003), without a clear cut off point.
Conclusions—In patients with clinically suspected coronary artery disease, FAD% discriminates between the presence or absence of coronary artery disease, whereas intimal media thickness is associated more with the extent of coronary artery disease.

Keywords: coronary artery disease;  endothelial dysfunction;  intimal media thickness;  flow associated dilatation     

Comparative coronary anatomy in six twin pairs with coronary artery disease

OBJECTIVE—To compare the coronary anatomy and the location of coronary lesions in monozygotic and dizygotic twin pairs affected with coronary artery disease.
DESIGN—Coronary angiographic findings were compared with respect to the distribution of coronary blood supply and the location of coronary lesions.
MAIN OUTCOME MEASURES—Distribution of coronary blood supply, diameters and length of proximal coronary arteries.
RESULTS—The lumen diameters of the left main coronary artery, the left anterior descending coronary artery, the circumflex artery, and the right coronary artery, as well as the lengths of the left main coronary artery, showed similar variability within monozygotic and dizygotic twin pairs. With respect to the dominance pattern of coronary blood supply, two of three monozygotic twin pairs differed, while all dizygotic twin pairs were concordant. Concordant and discordant locations of stenoses were found with similar frequency in monozygotic and dizygotic twin pairs.
CONCLUSIONS—The dominance pattern of coronary blood supply and the location of coronary lesions are not strictly hereditary. The high concordance of premature coronary artery disease found in monozygotic twin pairs may largely be related to factors that are independent of the macroanatomic distribution of the coronary blood supply.


Keywords: twin studies; coronary anatomy; coronary lesions     

Transferring patients for primary angioplasty: a retrospective analysis of 104 selected high risk patients with acute myocardial infarction

Objective—To investigate the feasibility of primary coronary angioplasty as a treatment option in patients with acute myocardial infarction after initial diagnosis in a local community hospital.
Setting—Referral centre for interventional treatment of coronary artery disease.
Methods—During a five year period, 520 candidates for primary coronary angioplasty were treated in our institution, 104 after transfer from a community hospital. The transferred patients and the non-transferred patients (n = 416) were compared with regard to baseline clinical characteristics, time interval from symptom onset to treatment, and clinical outcome at six months.
Results—In this setting, the influence of transportation on total ischaemic time was limited, and there was no difference in clinical outcome between the transferred and the non-transferred patients. Clinical outcome was mainly dependent on the indication for transfer.
Conclusions—Safe and expedient transportation may facilitate the more widespread use of primary angioplasty in patients with acute myocardial infarction. A large randomised multicentre trial is needed to compare the relative merits of intravenous thrombolytic treatment in a local hospital with primary angioplasty after transfer in selected high risk patients with acute myocardial infarction.

Keywords: myocardial infarction;  coronary angioplasty;  reperfusion     

Endogenous endothelin maintains coronary artery tone by endothelin type A receptor stimulation in patients undergoing coronary arteriography

OBJECTIVE—To examine the contribution of endothelin type A (ET_A) receptor stimulation by endogenously generated endothelin-1 (ET-1) to the maintenance of coronary vascular tone in humans.
DESIGN—Controlled clinical study.
SETTING—Tertiary cardiovascular referral centre.
PATIENTS—14 subjects were studied, seven with normal coronary arteries and seven with coronary artery disease, mean (SEM) age, 53 (2) years.
INTERVENTIONS—After diagnostic coronary arteriography, BQ-123 (a selective ET_A receptor antagonist; 100 nmol/min) in 0.9% saline, was infused into the left coronary artery at a rate of 1 ml/min for 60 minutes. Eight control subjects received saline alone.
MAIN OUTCOME MEASURES—Blood flow velocity in the left anterior descending coronary artery, measured using a Doppler flow guidewire; coronary arteriography performed at baseline and immediately at the end of the BQ-123 or saline infusion to measure the diameter of proximal and distal left anterior descending coronary artery segments.
RESULTS—The diameter of the proximal segment increased by 6 (2)%, while that of the distal segment increased by 12 (3)% after BQ-123 (both p < 0.05 v baseline). Coronary blood flow increased from 75 (10) to 92 (10) ml/min and coronary vascular resistance decreased from 1.99 (0.36) to 1.44 (0.22) mm Hg/ml/min after BQ-123 (both p < 0.05 v baseline). The response to BQ-123 of patients with and without coronary artery disease was similar. There was no effect of saline in the controls.
CONCLUSIONS—Endogenously produced ET-1 contributes to the maintenance of basal coronary artery tone in humans by ET_A receptor stimulation. The role of ET_B receptors remains to be defined.


Keywords: endothelins; arteries; blood flow; coronary circulation; angiography     

Clinical outcome following coronary angioplasty in dialysis patients: a case-control study in the era of coronary stenting

BACKGROUND—Balloon coronary angioplasty has been reported to be ineffective in patients treated for end stage renal disease because of a high restenosis rate.
OBJECTIVE—To compare the clinical outcome following coronary angioplasty with provisional stenting in dialysis versus non-dialysis patients.
DESIGN—A case-control study.
PATIENTS—Of 1428 consecutive patients who underwent coronary angioplasty, 100 (7%) were being treated for end stage renal disease. These were compared with 100 control patients matched for age, sex, coronary lesions, presence of diabetes mellitus, and rate of coronary stenting (40%).
MAIN OUTCOME MEASURES—In-hospital and one year clinical outcome.
RESULTS—The rates of procedural success (90% v 93%), in-hospital mortality (1% v 0%), stent thrombosis (0% v 0%), and Q wave myocardial infarction (0% v 1%) were similar in dialysis and non-dialysis patients. One year clinical outcome after coronary angioplasty was similar in the two groups in terms of clinical restenosis (31% v 28%) and myocardial infarction (6% v 2%), but cardiac death was more common in dialysed patients (11% v 2%, p < 0.03).
CONCLUSIONS—Dialysis does not increase the risk of clinical restenosis after coronary angioplasty with provisional stenting. Coronary angioplasty is a safe and effective therapeutic procedure in selected dialysis patients with culprit lesions accessible to stenting. However, the one year survival is reduced in this high risk population.


Keywords: renal disease; angioplasty; stents; restenosis     

The influence of general health status and social support on symptomatic outcome following coronary artery bypass grafting

OBJECTIVES—To assess health status, level of social support, and presence of coronary artery disease risk factors before and after coronary artery bypass grafting (CABG); to assess symptomatic relief approximately 12 months postoperatively; and to examine the association between preoperative health status and recurrence of symptoms.
DESIGN—Observational study.
SETTING—Preoperatively, in hospital outpatient department (1995-1996); postoperatively, at home (1996-97).
SUBJECTS AND METHODS—Patients awaiting elective CABG were recruited one month before the expected date of operation. Preoperative assessment included severity of symptoms, coronary artery disease risk factors, short form 36 (SF-36) questionnaire, and social activities questionnaire. The presence and severity of angina and breathlessness were reported postoperatively (mean 16.4 months). Multiple regression analysis was used to identify factors associated with improved outcome following CABG.
MAIN OUTCOME MEASURE—Patient reported presence and severity of angina and breathlessness.
RESULTS—183 patients were followed for a mean of 16.4 months after CABG. Angina and breathlessness were completely relieved in 55% and 36% of patients, respectively. In patients with residual symptoms, the severity was significantly reduced (angina p < 0.001; breathlessness, p = 0.02). Patients with low SF-36 scores and low social network scores preoperatively were less likely to be relieved of symptoms (p < 0.001). Health status and social support levels preoperatively were lower than in other reported coronary artery disease patients groups. Preoperatively, coronary artery disease risk factors were higher than recommended in current guidelines: 67.4% had raised plasma cholesterol, 39.0% were hypertensive, 80% were moderately obese, and 22.9% were smokers.
CONCLUSIONS—Recurrence of symptoms exceeded other published studies. Patients' perception of general health, symptoms, and social support influences outcome.


Keywords: health status indicator; coronary artery bypass; social support; risk factors     

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings,mortality, and revascularisation rate? The ACRE study

OBJECTIVE—To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study.
DESIGN—Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients.
SETTING—Royal Hospitals Trust, London, UK.
PARTICIPANTS—3631 consecutive patients undergoing coronary angiography (no exclusion criteria).
MAIN OUTCOME MEASURES—Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up.
RESULTS—The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively).
CONCLUSION—The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.


Keywords: coronary artery disease; coronary angiography; coronary artery bypass graft; appropriateness of coronary revascularisation     

Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease

OBJECTIVE—To investigate the value of coronary pressure derived fractional flow reserve (FFR) measurements in supporting decisions about medical or surgical treatment in patients with angiographically equivocal left main coronary artery stenosis.
DESIGN—A two centre prospective single cohort follow up study.
INTERVENTIONS—FFR of the left main coronary artery was determined in 54 consecutive patients with angiographically equivocal left main coronary artery disease. If FFR was 0.75, medical treatment was chosen; if FFR was < 0.75, surgical treatment was chosen.
MAIN OUTCOME MEASURES—Freedom from death, myocardial infarction, or any coronary revascularisation procedure.
RESULTS—In 24 patients (44%), FFR was 0.75 and medical treatment was chosen (medical group). In the remaining 30 patients (56%), FFR was < 0.75 and bypass surgery was performed (surgical group). Mean (SD) follow up was 29 (15) months (range 12-65 months). Survival among patients at three years of follow up was 100% in the medical group and 97% in the surgical group. Event-free survival was 76% in the medical group and 83% in the surgical group.
CONCLUSIONS—FFR supports decision making in equivocal left main coronary artery disease. If FFR is below 0.75, the decision for bypass surgery is supported. If FFR is above 0.75, a conservative approach is justified.


Keywords: coronary artery disease; left main coronary artery; fractional flow reserve; coronary artery bypass     

Coronary flow reserve in the contralateral artery increases after successful coronary angioplasty in patients with spontaneously visible collateral vessels

Objective—To test the hypothesis that coronary flow reserve could increase in the angiographically normal contralateral artery after successful coronary angioplasty of an ipsilateral coronary artery.
Design—Coronary flow reserve was estimated using a Doppler flow guide wire, by giving intracoronary adenosine in the contralateral artery, before and 15 minutes after the end of angioplasty.
Setting—Tertiary referral centre.
Patients—31 patients, mean (SD) age 56 (11) years, with stable angina and single vessel disease, undergoing angioplasty of the right coronary or the left anterior descending artery.
Results—In the contralateral artery baseline average peak velocity was 21 (9) cm/s before angioplasty and decreased to 12 (6) cm/s after (p < 0.005), while hyperaemic average peak velocity was 47 (19) cm/s before and decreased to 34 (15) cm/s after (p < 0.005). However, coronary flow reserve in the contralateral artery was 2.4 (0.7) before angioplasty and increased to 2.9 (0.6) after (p < 0.05). The contralateral coronary flow reserve after angioplasty increased by 0.8 (0.4) in 11 patients with visible collaterals before angioplasty and by 0.3 (0.6) in the remaining patients without visible collaterals (p < 0.05). Blood pressure and heart rate were unchanged after the procedure.
Conclusions—Coronary flow reserve in an angiographically normal contralateral artery increases after successful coronary angioplasty of the ipsilateral artery in patients with spontaneously visible collateral vessels before the procedure.

Keywords: coronary flow reserve; contralateral coronary artery; angioplasty     

Magnetic resonance imaging of the coronary arteries: clinical results from three dimensional evaluation of a respiratory gated technique

BACKGROUND—Magnetic resonance coronary angiography is challenging because of the motion of the vessels during cardiac contraction and respiration. Additional challenges are the small calibre of the arteries and their complex three dimensional course. Respiratory gating, turboflash acquisition, and volume rendering techniques may meet the necessary requirements for appropriate visualisation.
OBJECTIVE—To determine the diagnostic accuracy of respiratory gated magnetic resonance imaging (MRI) for the detection of significant coronary artery stenoses evaluated with three dimensional postprocessing software.
METHODS—32 patients referred for elective coronary angiography were studied with a retrospective respiratory gated three dimensional gradient echo MRI technique. Resolution was 1.9 × 1.25 × 2 mm. After manual segmentation three dimensional evaluation was performed with a volume rendering technique.
RESULTS—Overall 74% (range 50% to 90%) of the proximal and mid coronary artery segments were visualised with an image quality suitable for further analysis. Sensitivity and specificity for the detection of significant stenoses were 50% and 91%, respectively.
CONCLUSIONS—Volume rendering of respiratory gated MRI techniques allows adequate visualisation of the coronary arteries in patients with a regular breathing pattern. Significant lesions in the major coronary artery branches can be identified with a moderate sensitivity and a high specificity.


Keywords: magnetic resonance imaging; coronary artery disease; coronary angiography; computer assisted image processing     

Occlusion of Fontan fenestrations using the Amplatzer septal occluder

Objective—To evaluate the efficacy and safety of the Amplatzer septal occluder device for occlusion of Fontan fenestrations.
Subjects—Five children aged 5-10 years who had undergone a fenestrated Fontan operation.
Setting—Tertiary paediatric cardiology centre.
Methods—Each patient had right and left heart catheterisation to assess haemodynamic suitability for fenestration closure. Sizing of the defect was achieved with a balloon wedge catheter and transoesphageal echocardiography. Transcatheter occlusion of the fenestration was accomplished using a 4 mm device in three patients, and 5 mm or 9 mm devices in the other two patients. Residual shunting following occlusion was assessed using angiography and echocardiography.
Results—100% occlusion rate of the fenestration was achieved in all patients. No complications or device failures were seen during the three month follow up period.
Conclusion—The Amplatzer septal occluder device is safe, and effectively occludes the Fontan fenestration.

Keywords: Fontan circulation;  fenestration occlusion;  Amplatzer septal occluder device;  congenital heart disease     

S-Nitrosoglutathione inhibits platelet activation and deposition in coronary artery saphenous vein grafts in vitro and in vivo

Objective—To investigate platelet activation and deposition in human saphenous vein and internal mammary artery grafts following coronary artery bypass in vitro and in vivo, as well as inhibition of activation by the platelet selective nitric oxide donor S-nitrosoglutathione (GSNO).
Design—Controlled in vitro and in vivo studies.
Setting—Tertiary cardiac centre.
Patients—24 patients undergoing coronary artery bypass surgery requiring vein and artery grafts.
Interventions—In vitro: human platelet rich plasma was perfused through segments of vein and artery, with or without GSNO 10^-6 M, and the platelet count was measured in the effluent. In vivo: indium-111 labelled antibody against the platelet α granule protein GMP-140 was injected at the end of coronary bypass grafting and γ counts were compared between vein and artery grafts with or without systemic infusion of GSNO (40 nmol/min).
Results—In vitro: platelet count in perfused vein (< 70% of baseline) decreased more than in artery segments (89-94% of baseline) (p < 0.001). The platelet count was unchanged with GSNO in vein and artery segments. In vivo: γ counts were greater at all time points over vein than artery grafts (p < 0.05), and were reduced by infusion of GSNO (p < 0.05).
Conclusions—Platelet activation is greater in vein than in artery grafts in vitro and in vivo. Activation, which contributes to early vein graft failure, was inhibited by GSNO.

Keywords: coronary artery bypass surgery;  platelet activation;  S-nitrosoglutathione;  ischaemic heart disease     

Endoluminal vessel reconstruction by stent placement in patients with obstructive coronary artery disease who are poor surgical candidates

Objective—To investigate the safety and efficacy of endoluminal vessel reconstruction by intracoronary stenting in patients with single or multivessel disease who have been turned down for surgical revascularisation.
Design—An observational, single centre trial of consecutive patients being followed up clinically.
Setting—Tertiary referral centre.
Patients—43 patients treated between 1995 and 1996 with a clinical follow up period of at least six months.
Main outcome measures—Acute procedural success following intervention (defined as a residual stenosis of < 30% with normal antegrade flow and without acute clinical complications); major adverse clinical events (death, myocardial infarction, repeat intervention, clinical restenosis); and functional status during follow up.
Results—Acute procedural success was achieved in 39 patients. Failures resulted from a refractory no reflow phenomenon with Q wave myocardial infarction (two patients), and from subacute stent thrombosis (one patient) and saphenous vein graft rupture at stent site (one patient), both manifesting by non-Q wave myocardial infarction. During a follow up period of 17 (8) months (mean (SD)), three of these patients died. Clinical restenosis was treated by repeat percutaneous intervention in 11 patients, while 28 patients remained asymptomatic. On a Kaplan-Meier estimate, the proportion of patients without adverse clinical events at two years was 65%.
Conclusions—Percutaneous reconstruction of diseased coronary arteries in patients with single or multivessel disease turned down for surgical revascularisation may be considered as a valuable treatment option. On follow up, more events seem to be encountered than after elective de novo stenting of discrete coronary lesions. This is probably related to higher clinical restenosis rates.

Keywords: coronary artery disease;  stents;  restenosis     

Factors affecting splanchnic haemodynamics in Crohn's disease: a prospective controlled study using Doppler ultrasound

Background—Current knowledge on splanchnichaemodynamics in Crohn's disease is limited.
Aims—To investigate which features of Crohn'sdisease affect splanchnic haemodynamics, and to establish whetherportal vein (PV) and superior mesenteric artery (SMA) blood supplyreflects clinical or biochemical activity of Crohn's disease.
Methods—Seventy nine patients with Crohn'sdisease and 40 controls were evaluated by Doppler ultrasound (US). Themean velocity of PV and SMA flow, the volume of blood flow of the PVand SMA, and the resistance index of SMA were studied. A series ofclinical, biochemical, and US variables including Crohn's diseaseactivity index, serum C reactive protein concentrations, diseaseduration and its anatomical location, smoking habits, abdominalcomplications, and current medical therapy, as well as the maximumbowel wall thickness as measured by US, were determined. The relationbetween PV and SMA blood flow and these variables was assessed byunivariate and multivariate analysis.
Results—Patients with Crohn's disease hadsignificantly higher PV and SMA flow and a lower SMA resistance indexthan controls. Stepwise multiple regression analysis identified bowelwall thickness and location of the disease as the main predictivevariables of both PV and SMA blood flow variation, accounting for 36%and 45% of their variability, respectively. No relation was foundbetween splanchnic haemodynamics and disease activity.
Conclusion—A hyperdynamic mesenteric circulationdoes exist in Crohn's disease; however splanchnic blood flow does notreflect the clinical or biochemical activity of the disease, but seems to be linked more to other Crohn's disease characteristics, such asmaximum bowel thickness and anatomical location.

Keywords:Crohn's disease; Doppler ultrasound; splanchnicblood flow

     

Ten year follow up of patients referred for coronary artery bypass grafting from a single district general hospital

Objective—To determine the status of patients 10 years after referral for coronary artery bypass graft (CABG) surgery.
Design—Retrospective analysis of case notes from all patients referred between 1 April 1981 and 31 March 1985. Full information gathered from hospital notes, GP records, and Registrar General for Scotland.
Setting—District General Hospital, West Lothian, Scotland.
Patients—102 patients referred for CABG during study period. Cardiac surgery was undertaken in Brompton Hospital, London, Royal Infirmary, Edinburgh, and Western Infirmary, Glasgow.
Results—At 10 years after operation 32 patients had died (27 cardiac, five non-cardiac causes). Full data were not available for five patients. Of the 65 remaining patients 24 had no angina, 13 had had a repeat procedure (CABG or angioplasty), and 28 had angina.
Conclusions—Long term benefits of CABG surgery is disappointing. Further steps are required to reduce progression of disease in this population.

Keywords: coronary artery bypass surgery;  repeat procedure;  survival;  audit     

A prospective study of oesophageal function in patients with normal coronary angiograms and controls with angina

Aims—To compare the incidence of oesophagealabnormalities and their correlation with chest pain in patients withnormal coronary angiograms, and in controls with angina.
Patients—Sixty one patients with normal coronaryangiograms (NCA group) referred to a single cardiac centre betweenMarch 1990 and April 1991; 25 matched controls with confirmed coronary artery disease (CAD group).
Setting—Cardiac referral centre and oesophagealfunction testing laboratory.
Main outcome measures—Oesophageal manometry,provocation tests, and 24 hour ambulatory pH monitoring.
Results—Simultaneous contractions were morecommon (6.7% versus 0.8%, p<0.01), and the duration of peristalticcontractions was longer (2.9 versus 2.4 seconds, p<0.01) in the NCAgroup than in the CAD group. There were no group differences in theamplitude of peristaltic contractions, and none had nutcrackeroesophagus. Ten (16%) patients with NCA and no patients with CAD haddiffuse spasm (p=0.03). Twenty one (34%) patients with NCA, and five(20%) patients with CAD had abnormal gastro-oesophageal reflux(p>0.05). There was no significant difference between the groups inthe number of patients whose pain was temporally related to pH events. Particular chest pain characteristics, or the presence of additional oesophageal symptoms, were not predictive of an oesophageal abnormality.
Conclusion—Oesophageal function testscommonly implicate the oesophagus as a source of pain in patients withnormal coronary angiograms. With the exception of simultaneouscontractions during manometry however, the incidence of abnormalitiesand in particular the correlation of pH events with chest pain are ascommon in patients with normal coronary angiograms as in controlswith angina. The oesophagus may often be an unrecognised source of painin both groups of patients.

Keywords:oesophageal function; coronary artery disease; chest pain

     

Evidence of partially preserved endothelial dilator function in diseased coronary arteries

OBJECTIVE—To examine the effects of substance P (endothelium dependent vasodilator) and glyceryl trinitrate (endothelium independent vasodilator) on epicardial coronary arteries in patients with normal coronary angiograms and patients with coronary artery disease.
DESIGN—Intracoronary infusions of normal saline, the receptor mediated nitric oxide stimulant substance P (5.6 and 27.8 pmol/min each for five minutes), and glyceryl trinitrate (250 µg bolus) were given in 24 patients with coronary artery disease and stable angina, and in nine patients with normal angiograms. The diameter of proximal and distal coronary segments was measured by computerised quantitative angiography
RESULTS—Proximal segments of patients with coronary artery disease dilated less than those of patients with normal angiograms in response to 27.8 pmol/min substance P (mean (SEM): 7.9 (1.3)% v 15 (2.3)% respectively, p < 0.01). The proximal segments of diseased arteries also dilated less than those of "normal" arteries in response to glyceryl trinitrate (10.2 (1.6)% v 18.4 (2.9)%, respectively, p < 0.01). The responses of distal segments to substance P and glyceryl trinitrate were similar in the two patient groups. There were correlations (all p < 0.001) between the coronary diameter after substance P and after glyceryl trinitrate in normal proximal segments (r = 0.94) and normal distal segments (r = 0.64), in diseased proximal segments (r = 0.95) and diseased distal segments (r = 0.89), and for coronary stenoses (r = 0.93).
CONCLUSIONS—Proximal segments of patients with coronary disease dilated less than the proximal segments of "normal" patients in response to substance P and glyceryl trinitrate. The response to substance P is substantial and closely correlated with the response to glyceryl trinitrate in both "normal" patients and those with coronary disease. This suggests that although the proximal segments of diseased coronary arteries have a reduced capacity to dilate in response to direct stimulation of smooth muscle cell relaxation, they retain much of their endothelium dependent vasodilator function.


Keywords: endothelium; nitric oxide; coronary artery disease; glyceryl trinitrate