Search

Contrast agents used for cardiac angiography are different in regard to ionicity, osmolality and physiologic effects. The nonionic contrast media have been shown to have less toxic effects and a better safety profile than do higher osmolar agents. To better assess this risk, clinically stable patients undergoing cardiac angiography were stratified according to the presence of diabetes mellitus, and level of serum creatinine, and then randomized to receive either iohexol (Omnipaque 350) or sodium meglumine diatrizoate (Renografin 76). All adverse events that occurred during and immediately after angiography were tabulated. A multivariate model was used to identify patients at increased risk for adverse outcome. The 1,390 patients were randomized to iohexol (n = 696) or diatrizoate (n = 694). Significant differences were found in the number of patients with contrast media-related adverse (iohexol vs diatrizoate: 10.2 vs 31.6%; p < 0.001) and cardiac adverse (7.2 vs 24.5%; p < 0.001) events. Severe reactions and the need for treatment were more frequent with diatrizoate than with iohexol, but there was no difference in the incidence of death. The presence of New York Heart Association classification 3 or 4 and serum creatinine > or = 1.5 mg/dl predicted a higher incidence of adverse events as a result of contrast media alone. Use of iohexol is associated with a lower incidence of all types of adverse events during cardiac angiography than is diatrizoate.

Orthotopic cardiac transplantation is occasionally complicated by unexplained bradyarrhythmias. Sinus node injury as a consequence of operation or acute rejection has anecdotally been linked to the development of bradycardia early after transplantation. These arrhythmias are empirically managed by pacemaker implantation, the indications for which remain poorly defined. This retrospective study examined the 20-year experience of our institution with bradyarrhythmias after transplantation to determine the predisposing factors and indications for pacemaker implantation. Forty-one of 556 patients in our cardiac transplant program (7.4%) received permanent pacemakers between 1969 and 1989. The predominant rhythm disturbances were junctional rhythm (46%), sinus arrest (27%) and sinus bradycardia (17%). Most patients were asymptomatic (61%), and presented in the early post-transplant period (73%). Four possible predisposing factors were evaluated: (1) graft ischemic time, (2) rejection history, (3) use of bradycardia-inducing drugs, and (4) anatomy of blood supply to the sinoatrial (SA) node. No significant differences existed between patients with and without pacemakers with regard to the first 3 variables. However, after transplantation angiograms showed that prevalence of abnormal SA nodal arteries was greater in patients with than without pacemakers (p less than 0.02). Pacemaker follow-up at 3, 6 and 12 months showed persistent bradycardia (60 to 90 beats/min) in 88, 75 and 50% of patients, respectively. The most common pacemaker complication (15%) was lead displacement at time of biopsy. These results suggest that disruption of the SA nodal blood supply may be an important predisposing factor in the development of bradycardias.

Interruption of the aortic arch, studied in 10 patients, was associated with a variety of other cardiac anomalies in 8 patients and was an isolated anomaly in 2. Clinical and angiographic evaluation in the former group revealed congestive heart failure and generalized cyanosis in early infancy, pulmonary and systemic arterial hypertension and a variety of intracardiac and aortic shunt. The two patients with an isolated anomaly had clinical and hemodyanmic features not dissimilar from those of severe coarctation but interruption of the aortic arch was demonstrated on aortography. Surgical treatment was successful in four of the eight infants with associated anomalies and in both children with the isolated defect. Postoperative angiography revealed several related complications and the status of the aortic reconstruction. Clinical angiographic recognition of this lesion is important because operative intervention has been successful in an increasing number of patients.

Coronary arteriography performed in 17 patients with Prinzmetal's variant angina demonstrated high grade fixed obstructions in 9 patients (Group I) and insignificant or no fixed lesions in 8 patients (Group II). Group I consisted mostly of middle-aged or elderly men with S-T segment elevations in various sites; Group II included five younger women with S-T segment elevations in inferior electrocardiographic leads. In Group I patients, arteriography revealed a discrete high grade lesion located proximally in a major coronary artery in four patients and multivessel involvement in five patients. In Group II patients, spontaneous spasm was documented in three patients and spasm was pharmacologically provoked in two others during arteriography. The current study indicates that spasm is the responsible pathogenetic mechanism of myocardial ischemia in some patients with Prinzmetal angina and that this mechanism may be suspected from the clinical characteristics of these patients.

Coronary vascular disease in the cardiac transplant recipient has become the third most frequent cause of death or retransplantation after infection and acute rejection. A unique pattern of concentric fibrointimal thickening develops within 1 year of cardiac transplantation; however, it is relatively inapparent on routine arteriography. The disease progresses primarily in distal vasculature, leading to progressive occlusion. Angiographically discrete lesions associated microscopically with advanced atherosclerotic plaques frequently occur in the more proximal vessels often associated with thrombus. The number of rejection episodes is somewhat predictive of the development of transplant coronary disease. Annual arteriograms performed in cardiac transplant recipients have revealed several distinctive angiographic features that include clockwise rotation of the heart, presence of coronary arterial-cameral fistulae, presumably resulting from right ventricular endomyocardial biopsy specimens and collateralization of the brachial anastomosis from coronary atrial branches. It is concluded that serial angiography in cardiac transplant recipients is important in the early detection of progressive graft atherosclerosis, a process that is clinically silent until such time as overt heart failure or cardiogenic shock occurs.

A patient with Takayasu's aortitis and angina pectoris due to severe narrowing of the right and left coronary arterial ostia is described. Takayasu's arteritis produces a panaortitis, with thickening of the adventitia predominating, and an inflammatory cell infiltrate involving the adventitia, outer media and vasa vasorum. Narrowing of the coronary arteries in this disease is due to extension into these arteries of the processes of proliferation of the intima and contraction of the fibrotic media and adventitia that occur in the aorta. The distal coronary arteries usually do not manifest arteritis and are normal in caliber. Angina pectoris may be the first symptom of the disease if the coronary arteries are the initial site of severe arterial narrowing. The coronary arterial bypass graft operation is effective therapy for treating coronary arterial narrowing due to Takayasu's arteritis.

Ergonovine maleate (Ergotrate) was given to 57 patients undergoing coronary arteriography for investigation of angina occurring at rest or without provocation when routine study showed normal arteries or insufficient occlusive disease to explain their symptoms. This provocative test induced coronary arterial spasm in 13 patients, 10 of whom had definite Prinzmetal's angina. The spasm was easily reversed with sublingually administered nitroglycerin. The spasm was occlusive or nearly occlusive in nine patients, and there was associated reproduction of the chest pain and S-T elevation similar to the spontaneous episodes. One patient with Prinzmetal's angina had S-T depression rather than elevation in association with the chest pain. The other three patients without Prinzmetal's angina had focal narrowing without coronary occlusion, reproduction of the chest pain or electrocardiographic changes. Of the 44 patients who did not demonstrate coronary spasm in response to ergonovine, 29 had normal coronary arteries and 15 had various degrees of atherosclerotic occlusive disease. We conclude that cautious administration of ergonovine maleate during coronary arteriography can be safely used to elicit coronary spasm in some patients who have insufficient fixed occlusive disease to explain their symptoms.