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Vasoconstriction of normal coronary arteries has been reported after intracoronary (i.c.) administration of acetylcholine (Ach) in cardiac transplant patients and has been related to early endothelial disfunction; the clinical correlates of this response are still unknown.We infused graded i.c. concentrations of Ach in 32 pts with angiographically smooth coronary arteries 1 to 3 years after heart transplantation. Changes in diameters of the proximal and middle segments of the left anterior descending coronary artery were measured by quantitative coronary angiography (automatic edge detection).The response to Ach ranged from +44% to -58%; at linear regression analysis it was significantly related to the plasma levels of cyclosporine (r = -0.39, p.05) and triglycerides (r = -0.42, p.02) but not to vessel diameter, recipient and donor age, time after transplantation, hypertension, cholesterol levels, number of acute rejection episodes and previous cytomegalovirus infections.In heart transplant pts with angiographically normal coronary arteries i.c. Ach may reveal endothelial disfunction which is associated with high cyclosporine and triglycerides plasma levels. Whether this response may predict an earlier development of coronary disease remains to be elucidated.

Primary pulmonary hypertension is an uncommon but serious disease that often results in debilitating symptoms and early death. One approach to treatment has been to attempt a reduction of pulmonary artery pressure and vascular resistance by using vasodilator drugs with conflicting results in several studies. The aim of this study is to review the ten-years (1978-1988) experience of vasodilator therapy for primary pulmonary hypertension at our institute. In this period 7 patients, 5 women and 2 men, mean age 38.4 years (range 15-66) met clinical and hemodynamic criteria for primary pulmonary hypertension. At diagnosis 3/7 patients were in NYHA class III and 2/7 in class II. Diagnosis was confirmed by open lung biopsy in one case. Mean pulmonary artery pressure was 66 +/- 17 mmHg, mean value of pulmonary vascular resistances was 22.5 +/- 11 U.W. and of cardiac index 1.8 +/- 0.58 l/min/m2. Twelve different vasodilator drugs were tested during right heart catheterization in a non randomized manner. Various vasodilators were usually tested in the same patient (2 or more drugs in 6 patients). Only one patient did not tolerate acute therapy because of development of a persistent systemic hypotension. Hemodynamic responses to nitrates showed a general reduction in pulmonary artery pressure and pulmonary vascular resistances with marginal changes in cardiac index. Calcium channel-blocking agents elicited different responses in similar patients with favorable, little, no or adverse effects in pulmonary hemodynamics and sometimes a significant decrease in systemic vascular resistances. Also hydralazine showed favorable hemodynamic results in few cases but exacerbated pulmonary hypertension in others.(ABSTRACT TRUNCATED AT 250 WORDS)

We compared the effects of cold pressor test and mental stress on coronary hemodynamics in 16 patients with coronary artery disease. The patients were divided into 2 groups according to the clinical characteristics of chest pain. Group I included 5 patients complaining of angina at rest associated with transient ST-segment changes, while Group II comprised 11 patients with stable exertional angina. In all patients coronary arteriography disclosed a proximal left anterior descending artery disease. Thermodilution measurements of the great cardiac vein flow, the venous efflux from the territory supplied by the left anterior descending artery, were obtained during cold pressor test and, after return to control conditions, during a mental arithmetic stress, consisting of serial subtractions of a two-figure number from a four-figure number. Coronary resistance of the anterior region was calculated as the quotient of mean arterial pressure and the great cardiac vein flow. In both groups of patients heart rate, mean arterial pressure and the great cardiac vein flow increased significantly during cold pressor test as well as during mental stress. During cold pressor test, coronary resistance of the anterior region increased in all patients of Group I (p less than 0.05), but did not change significantly in Group II patients. During mental test, coronary resistance of the anterior region increased in 3 patients and decreased in 2 patients of Group I (p:NS), while a significant decrease in coronary resistance of the anterior region was found in all patients of Group II (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Although restenosis after percutaneous transluminal coronary angioplasty (PTCA) may have morphologic characteristics which are not similar to the original stenosis, it is unknown if a different morphology is also associated with a different clinical presentation. Eleven consecutive patients with angina and single vessel disease had a recurrence of symptoms and restenosis within 6 months of successful PTCA. Seven patients (group I) complained of spontaneous angina before PTCA and had a positive hyperventilation test, while 4 patients complained of exercise-induced angina and had a negative hyperventilation test (group II). In group I restenosis was associated with the same clinical presentation as before PTCA and the hyperventilation test was positive in 6 patients. The angiographic morphology of restenosis was changed in 4 patients. In group II restenosis occurred with the same clinical presentation as before PTCA, the hyperventilation test was negative in 3 patients while the angiographic morphology of restenosis was unchanged in only 1 patient. Although morphology of restenosis is different from the original stenosis, clinical presentation associated with restenosis is generally the same as before PTCA. The response to vasoactive stimuli is independent from the morphology of the lesion.

30 patients with a previous myocardial infarction who had undergone diagnostic conventional left ventriculography and coronary arteriography had left ventriculography also performed by digital subtraction angiography after intravenous injection of contrast medium; the mean interval between the two investigations was 2.3 days. The conventional and the digital subtracted left ventricular images were computer-processed; global ejection fraction (obtained by the volumes calculated with the Dodge method) and segmental wall motion (from a quantitative analysis performed according to the Stanford method) were compared. We found a close correlation for the ejection fraction obtained by the two techniques (r = 0.89, p less than 0.01); absolute values proved to be slightly higher in the digital subtraction angiography. Segmental wall motion was significantly correlated too (p less than 0.05 for all the segments of the ventricular silhouette but for the one corresponding to the base of the heart). Digital intravenous angiography provides an accurate and less invasive method to evaluate left ventricular function.

The prevalence of right ventricular failure after orthotopic heart transplantation, evaluated in 196 patients, was 11.7%, as assessed by the presence during the first postoperative month of right atrial pressure10 mm Hg. Two deaths, related to refractory right ventricular failure, were observed within the first month, both in subjects with preoperative pulmonary arteriolar resistances5 Wood Units. The haemodynamic profile after heart transplantation showed a significant decrease (P0.01) and an early normalization of pulmonary arterial pressure, pulmonary wedge pressure and pulmonary arteriolar resistances, while right atrial pressure slowly decreased until the third month. In a long-term analysis of survival (death within 1 year) the probability of death was significantly related to the values of right atrial pressure and cardiac index during the first month after heart transplantation. Otherwise, the presence of elevated values of right atrial pressure did not show a significant correlation with the echocardiographic right ventricular end-diastolic diameter nor with the presence of right bundle branch block. The careful selection of patients referred for the cardiac transplantation (mean value of pulmonary arteriolar resistances in the evaluated subjects was 2.5 +/- 1.5 Wood Units) improves the probability of avoiding the appearance of severe right ventricular failure in the postoperative period in most cases. The best predictor of right ventricular failure remains to be clearly identified.

To investigate the incidence of myocarditis, 30 patients, with unexplained congestive heart failure, underwent endomyocardial biopsy. For each case three to five samples were examined on light and electron microscopy. Inflammatory infiltrates and injury to adjacent myocytes consistent with myocarditis were detected in 3 of the 30 cases (10%). Changes attributable to cardiomyopathy were found in the remaining 27 cases. Two of the three patients with biopsy-proven myocarditis were treated with prednisone and azathioprine. Their control biopsies six months later showed interstitial fibrosis and absence of inflammatory infiltrates. They clinically improved but hemodynamic and angiocardiographic patterns failed to show the expected improvement. The third patient affected by myocarditis died two weeks later.in our series of patients with unexplained congestive heart failure, the incidence of biopsy-proven myocarditis resulted low (10%). The results of the immunosuppressive treatment in two patients with myocarditis were unconclusive. Therefore the effectiveness of such therapy should be confirmed in a larger number of patients.

The purpose of this study was to focus on the clinical and angiographic characteristics of 113 patients with crescendo angina (Group I) as compared to 187 patients with angina of new onset (Group II), selected from a series of 474 consecutive subjects, admitted to our clinic between January 1976 and July 1983 because of recurrent episodes of spontaneous angina, who underwent cardiac catheterization and coronary angiography within one month of hospitalization. Group I patients showed a greater incidence of prior transmural myocardial infarction (p less than 0.01), arterial hypertension (p less than 0.01), multivessel disease (p less than 0.01) and a lower value of left ventricular ejection fraction (p less than 0.01) than Group II patients. In the latter group of patients anginal episodes were more frequently associated with S-T segment elevation than with S-T segment depression (p less than 0.001), while the opposite was found in patients with crescendo angina. Survival curves up to five years showed that medically treated patients with crescendo angina had a worse long-term prognosis than patients with unstable angina of new onset (p less than 0.01). On the contrary no difference was found between the surgically treated patients of the two groups. Our data suggest that the more diffuse involvement of the coronary tree associated with a more depressed left ventricular function may result in an unfavorable long-term prognosis in patients with crescendo angina as compared to those with unstable angina of new onset. Such a difference between the two groups was abolished by surgical treatment.

The purpose of this study was to evaluate the hemodynamic benefits of atrioventricular (A-V) sequential pacing. 30 pts implanted with DDD pacemakers underwent M-mode, B-mode and Doppler echocardiography. In each patient, left ventricular (LV) stroke volume was assessed by measuring the time-velocity integral of mitral inflow in the following modes and rates: VOO at 70 ppm or at the minimum stimulation rate and at 120 ppm; DOO at the same rates with different A-V delay (100, 150, 200, 250 and, whenever possible, 300 msec). The increase in stroke volume obtained with dual chamber pacing at the optimal A-V delay was 45 +/- 25% at 75 ppm and 29 +/- 14% at 120 ppm (p less than 0.05 75 vs 120 ppm). This increase was significantly higher in pts with than in pts without LV hypertrophy (respectively: 51.9 +/- 20.4 vs 36.9 +/- 20.8% at 75 ppm, p less than 0.05 and 33 +/- 13.4 vs 25.4 +/- 14.5% at 120 ppm, p = 0.08). Concerning the A-V delay, we noted that at 75 ppm stroke volume was significantly higher in DOO than in VOO with any A-V delay ranging +/- 100 msec from the optimal one; at 120 ppm the hemodynamic benefit of DOO pacing was observed only when the programmed A-V delay was the optimal one or very near to it. In conclusion, atrio-ventricular sequential pacing allows a significant increase in LV stroke volume over single chamber ventricular pacing both at 75 and 120 ppm. Programming the optimal A-V delay is absolutely necessary to obtain this hemodynamic benefit at the higher stimulation rate.

Aim of this study was to evaluate the factors affecting the duration of the recovery time (RT) after a positive exercise stress test and to define its relationship with the extent of coronary artery disease (CAD).We studied 109 consecutive patients with a positive exercise test and proven coronary disease.RT was neither related to the severity of CAD, nor to exercise duration, rate-pressure product at the end of the exercise and maximum ST segment depression. A significant linear relationship was found between RT and the time of ischemia during exercise (IT) (r = 0.66, p.001). This relationship was analyzed separately in patients (pts) with advanced (Group I) and in pts with less severe CAD (Group II). The regression line of the data showed a similar slope but a higher y-axis intercept in Group I than in Group II (p.05). The RT/IT ratio was in fact significantly higher in Group I than in Group II (3.0 +/- 1.3 vs 1.7 +/- 0.7, p.0001). Discriminant analysis was performed to predict the presence of advanced CAD: using the RT/IT ratio instead of RT correct classification rate of the model increased from 81.4 to 86.7%, predictive accuracy from 73.7 to 85.3% and true negative rate from 85.3 to 87.4%.These results suggest that the normalization of the recovery time by time of ischemia during the test provides a simple and useful index for the prediction of the extent of coronary artery disease.