Search

The authors report a rare case of atresia of the left main coronary artery in an adult patient, symptomatic for effort angina. At coronarography, the left main coronary artery was not found; instead, the arteries of the left coronary tree were filled via a single collateral vessel arising from the ostium of the right coronary artery and ending in the trunk of the left anterior descending artery. All left arteries had very narrow calibres, almost hypoplastic, while the right coronary artery had a normal calibre. All the principal arteries had important stenoses. The patient underwent complete cardiac revascularization, and, sixteen months later, is free from angina. Rest and stress myocardial scintigraphy, control coronary angiography and Doppler analysis of internal mammary artery flow demonstrated normal myocardial perfusion, adequate blood flow through the grafts and good runoff in the native vessels. Hence, the authors conclude that such patients should be referred for coronary artery revascularization, since surgical results are good and the small calibre of the left coronary arteries is no contraindication.

Preoperative assessment of calcifications is important in order to choose the correct surgical approach for mitral valve disease. To test the accuracy of echocardiography (ECHO) in the semiquantitative analysis of mitral valve (MV) calcifications we preoperatively echo-studied 66 patients, who were to undergo MV replacement of rheumatic disease. Echocardiograms were performed using a standardized method, recorded on videotape and analyzed by two independent observers. Areas of calcification were identified as dense conglomerate echoes which were brighter than those of adjacent internal structures. After removal, the MVs were evaluated by means of inspection (I), direct radiography (X-ray) and quantitative calcium extraction--EDTA spectrophotometry--(QCa). In the three methods ECHO, I and X-ray, MV calcifications were graded as absent (group 1), mild (group 2) nodular (group 3) and diffuse (group 4). Using the chi square test, no significant differences were found between the three methods, or between ECHO and X-ray, or between ECHO and I, while I grading was slightly lower than X-ray grading (P less than 0.002). Using variance analysis, no significant differences were found in QCa in the three methods within group 1 and 4, whereas significant differences were present within group 2 (P less than 0.002) and group 3 (P less than 0.001), due to the lower sensitivity of I. On the base of the observed distribution of QCa in the removed MVs, the following QCa values: a) less than 20 mg, b) 20-80 mg, c) greater than 80 mg, were considered as the selection criteria for a) absent or mild, b) nodular and c) diffuse calcifications respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of cardiac fibroma in a three years old child successfully operated on is presented. The tumor was localized on the interventricular septum and was provoking an obstacle in the outflow of the right ventricle. The preoperative diagnosis was formulated by angiocardiography. A year after the operation, the hemodynamic control showed that he interventricular pressures were normal. The problems and the importance of an early diagnosis are emphasized in patients affected by cardiac fibroma. Surgical indication, technical aspects related to the operation, the immediate and more long-term results from surgical operation of this kind of pathology, with reference to the data taken from the literature, are discussed.

Controlled crushing of the intimal plaque and of the underlying vessel wall are the determinants of transluminal dilatation of coronary stenoses. The technique of angioplasty has been recently modified in many laboratories, by the use of new catheters and dilatation policies. Data from the NHLBl Registry indicate a 59% primary success rate, being 29% and 12% respectively the failures due either to inability to cross or to dilate the stenosis. A retrospective analysis of successful procedures has highlighted factors that positively affect the results: recent onset of the angina, lack of calcifications, iterative ballooning at high pressures and the experience of the angiographer. Main complications were angina becoming unstable (5.7%) and acute coronary occlusion (4.4%); an emergency bypass operation had to be done in 6.3% of the cases, whereas myocardial infarctions scored 4.4% and hospital deaths less than 1%. Preliminary results of Centro De Gasperis concern 18 attempts to dilate LAD stenoses: primary success rate was 44% with a failure rate of 39% and 17% regarding inability to cross or only to dilate stenosis, respectively. The above results are less favorable than those reported in NHLBl Registry and very much less than those reported by selected laboratories; they are however acceptable in view of the suboptimal characteristics of the materials used and the limited experience of the team.

83 patients who underwent resection of postinfarction aneurysms involving the anterior wall of the left ventricle were studied to identify possible determinants of operative outcome, long-term survival and long-term improvement. The indications for aneurysmectomy (either isolated or combined with direct revascularization) were congestive heart failure, angina or life-threatening arrhythmias; six patients were asymptomatic at the time of surgery. Operative mortality rate was 14.4% (11.5% for patients operated more than 60 days following myocardial infarction). The over-all survival rate, at a mean follow-up of 31.5 months (range 2 to 82 months), was 74.39%; 80.88% of patient discharged from hospital, exhibited clinical improvement. Mean values of ejection fraction and excess ejection fraction were significantly higher in the group of operative survivors (31.28 +/- 8.26% and 0.17 +/- 0.08 respectively) than those of surgical deaths (20.25 +/- 8.37% and 0.08 +/- 0.06) (p less than 0.005); the coronary score was significantly lower in the group of survivors (6.81 +/- 2.35 vs 8.33 +/- 2.29) (p less than 0.025). Presence of arrhythmias increased operative mortality (33.3% vs 11.2%, p = 0.05), as did a low cardiac output, impaired contraction of the postero-lateral wall and mitral regurgitation. Long-term survival and improvement were not related to anyone of preoperative parameters taken into consideration: however, a higher percentage of clinical improvement was observed when myocardial revascularization was associated to aneurysmectomy (85% vs. 67.7%).

Since June 1981 until July 1983, 40 percutaneous transluminal coronary angioplasty procedures in 38 patients have been performed. Results in the whole series are as follows: stenosis crossed in 33 patients (83%); balloon inflation done in 31 (78%), not done in 2 due to clinical instability induced by crossing of the stenosis; successful dilatation obtained in 25 patients (63%); emergency bypass surgery in 6 patients (15%) with 2 perioperative myocardial infarctions; no deaths. The whole series can be subdivided in two groups by the following parameters: premedication by nitrates (A) or by verapamil (B); temporal concentration of the procedures: 1/month up to February 83 (A), 3.7/month thereafter (B). Results are different in the two groups: 21 attempts in 21 patients: stenosis crossed in 14 cases (67%), balloon inflated in 12 (57%), successful dilatation obtained in 8 patients (38%), emergency bypass in 5 patients (24%). 19 attempts in 17 patients (2 vessel angioplasty in 2 patients): stenosis crossed and balloon inflated in 19 (100%), successful dilatation in 17 cases (89%), uncomplicated emergency bypass in 1 patient (5%). On the basis of personal more recent results an optimistic attitude towards the percutaneous transluminal coronary angioplasty is justified.

Clinical data, EKG and coronary angiography of 187 patients with unstable angina are given. The patients are divided into 4 groups: spontancous angina, spontaneous angina Prinzmetal's variant, "in crescendo" agina, intermediate syndrome. 103 patients were treated with pharmacological therapy only and 84 underwent aortocoronary bypass; 2 of them were operated on for acute myocardial infarction. The clinical and pathologic peculiarities of two groups are not similar and therefore the results are not comparable. There was a mortality rate of 10.3% of patients with pharmacological treatment and the incidence of non fatal myocardial infarction was 10.4%. The mortality during operation was 14.2% and the incidence of non fatal myocardial infarction was 13.1%. The spontaneous angina and Prinzmetal's variant often had normal rest EKG and a very similar coronary angiographic pattern, with obstructive lesions often localized in the proximal part of a single vessel. In 9% of cases coronary arteries were normal. The incidence of serious arrhythmias was higher in Prinzmetal's variant than in other types of unstable angina. The mortality in patients with Prinzmetal's angina was particularly high during the first period of experience (1970-1973) when the operation was performed after a few days of unsatisfactory results with pharmacological treatment; it decreased after patients underwent operation in an attenuate phase of the disease. The rest EKG of "in crescendo" angina was almost always pathologic; these cases presented obstructive lesions of 2 or 3 coronary arteries, functional impairment of left ventricle, collateral circulation. The mortality in patients treated with pharmacological therapy was higher than in other types of unstable angina. The mortality during operation, fairly high in the first period of experience, decreased in this group of patients as well, during the second period of experience.

--123 atrial pacings (AP) performed as diagnostic investigations in patients with chest pains were re-examined. By using floating catheter without fluoroscopic control, this technique is very simple to perform and free from relevant risks. The diagnostic sensibility and specificity of AP were examined in 93 patients in which a coronary arteriography was performed; these figures were compared with the corresponding values observed in 65 patients in which an adequate diagnostic exercise test (ET) was also available. The diagnostic sensibility of AP examined in 63 patients with significant coronary artery disease was 90%; the corresponding value of ET was 79%. In particular, in patients with single vessel disease, the sensibility of AP (90%) was much higher than that observed in ET (40%). The specificity of AP examined in 30 patients free from significant stenosis of the coronary arterial tree was 43%. This value was largely lower than that observed in ET (82%) in the same patients, and appears to be inadequate for validation AP as a diagnostic tool in coronary heart disease. Therefore, AP must be limited to functional, and not diagnostic, evaluation of patients in which the diagnosis of coronary heart disease can be made by other means.

100 patients with mitral prolapse syndrome (MPS) were studied with electrocardiogram, phonocardiogram, thorax radiography and echocardiogram. In 44 of the patients, the effort test and dynamic electrocardiogram were performed; 25 underwent hemodynamic examination, and 10 underwent selective coronarography. The most frequent symptomatologies were palpitations and vertigo; the most-registered electrocardiographic alterations were ventricular extrasystoles and altered electrical repolarization in the inferior seat. The symptomatic patients with rhythm disturbances showed reduced work capacity (RWC) with aggravation of the effort arrhythmias. The phonocardiogram showed variability of the phonoauscultatory reports, not only from patient to patient, but also in the same patient. The apicocardiogram presented a characteristic systolic re-entry which coincided with the non-ejective click. In all cases, the echocardiogram demonstrated a systolic movement backwards from the mitralic strips with different aspects. The endocavitary pressures in the studied cases were normal or only slightly altered. The left ventriculography frequently demonstrated assynergic areas, and constantly, eversion of the posterior mitralic strips in the left atrium. In most of the cases, the selective coronarography showed the absence of the ventricular atrial tract of the circumflex. The sustained role of the mixomatous degeneration in the pathogenetic mechanism of the MPS must be emphasized. The beta-blockers were the most effective drugs against arrhythmias, which in some cases showed themselves impervious to any medicinal treatment. MPS is considered a very diffuse disease which can run its course without detection or which can be accompanied by serious rhythm disturbances that can threaten the patient's life. The importance of echocardiography in the diagnosis of MPS is emphasized. The SPM patient showed undergo a series of wave tests which reveal malignant potentialities, so that the best therapeutic principles, both for the treatment and prevention of the arrhythmias, can be applied.

100 patients with endocardial cushion defect of the partial type underwent surgical correction between the years 1957-1975. The age of patients ranged from 3 to 57 years with a mean of 18 years. In 89 patients there was a mitral insufficiency. The repair of the mitral valve was performed in 78 patients; in 21 was repaired also the tricuspidal valve. The hospital mortality was of 8 patients. The mortality was correlated with the age of the patients, the pulmonary pressure and with the presence of malformations of the tricuspid valve. A major complication was represented by a complete atrioventricular block that occurred in 8 patients, in 5 of these the block disappeared before the dimission from the hospital. 86 patients have been followed for a period variable from 2 to 228 months and an average of 61 months. The late mortality was of 4 patients. Two patients have been reoperated of mitral valve replacement because of residual important mitral insufficiency. The phonocardiographic study, done in 50 patients, showed a presence of a holosystolic murmur in 20. The standard X-ray chest and electrocardiogram iid not show important changes between the pre and post operative examination.

A standardized method for the representation and filing of coronary angiographies is proposed. Semi-automatic reference is guided by a computer algorithm. The final report displays a diagram which shows all the information in graphic and alpha-numeric form. Personalized coronary anatomy is drawn using the Coronary Artery Surgery Study (CASS) guidelines. The algorithm semi-automatically designs coronary segments according to CASS criteria. Five levels of percentage reduction in luminal transverse diameter (25, 50, 75, 90, 100%) can be represented. In addition, plaque morphology (concentric or eccentric, greater or less than 0.5 cm in size) and plaque complications, (calcification, ulceration, thrombosis, aneurysmal dilatation, wall irregularity, and diffuse disease) can be added as additional information. Twenty pathological entities (stenosis or plaque complications) can be filed for each patient. Collateral circulation can be represented by identifying the site of origin, one or more mid-points on the pathway, and the point of contact with the recipient vessel. As many as 10 single pathways can be identified. The same method can represent and file by-pass grafting using different symbols. Data can be easily put into the computer in three to four minutes. Coding and filing are automatically stored. Ten Mb can contain 4355 reports, including patient data and five lines of optional comment. Data can be retrieved in the original graphic form or the system can analyze filed data and retrieve series of patients with a given angiographic pattern. This option enables comprehensive research to be performed on any patient population, selecting subgroups of patients with specific anatomic and/or pathologic characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)

For quantitative evaluation of cardiac dimensions by Nuclear Magnetic Resonance (NMR), we compared the values obtained by ECG gated NMR with those obtained by two-dimensional echocardiography (2D-echo) in 18 adult healthy volunteers aged 20-40 years (mean 31.6 +/- 5.8). NMR was performed using a 2 T super-conducting magnet operating at 0.5 T with a radiofrequency impulse of 21 MHz. Spin-echo pulse sequences with echo-delay times (TEs) of 30-45 msec were used for data acquisition. The interpulse interval was obtained from the R-R interval on the ECG. Slice thickness was set at 1 cm. To obtain planes oriented along the long axis of the left ventricle similar to 2D-echo, paraxial planes were obtained by double angulation. No significant differences of mean values obtained by NMR and 2D-echo were observed. Regression coefficients were not statistically different from 1 for any of the structures measured: left atrium (y = 1.106x), aorta (y = 1.077x), left ventricle (y = 0.66x), interventricular septum (y = x 1.009x), postero-lateral wall of the left ventricle (y = 1.133x), right ventricle (y = 1.093x). However high coefficients of variation were found for measurement of postero lateral wall (79.5) and interventricular septum (41.4) thicknesses; potential causative factors are discussed.