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Left ventricular (LV) filling patterns in 26 elderly (mean age 81 years) patients with severe aortic stenosis (AS) were evaluated using pulsed-wave Doppler echocardiography. Parameters of LV filling, including the ratio of the peak atrial velocity to the peak early diastolic velocity (A/E ratio) and the percent contribution of active atrial filling to total LV filling (%A), of these patients with AS (group I) were compared with 2 groups presumed to have abnormal LV filling: elderly patients (group II) and hypertensives with increased LV mass (group III), as well as with normal volunteers (group IV). The patients with AS had a broad range of LV inflow velocity patterns (A/E = 0.91 +/- 0.56, range 0.20 to 1.91; %A = 34.3 +/- 16.4, range 3.0 to 65), as compared with the consistently low A/E ratio (0.48 +/- 0.13) and %A (25 +/- 7) in the normal volunteers and the high A/E ratio and %A in the elderly (A/E = 1.48 +/- 0.28, %A = 49 +/- 11) and hypertensive (A/E = 1.41 +/- 0.32, %A = 49 +/- 8) groups. When comparing the data obtained by Doppler with hemodynamics at catheterization, the patients with AS and a high A/E ratio (A/E ratio greater than 1, n = 11) had lower LV mid-diastolic pressures (7 vs 18 mm Hg, p less than 0.001), lower pulmonary artery systolic pressures (33 vs 49 mm Hg, p less than 0.05) and less symptomatic heart failure than those patients with AS and a low A/E ratio (A/E less than 1). The aortic valve area was similar in these 2 subgroups (0.40 vs 0.37 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)

This study attempts to determine whether exercise treadmill testing with clinical, electrocardiographic, and thallium-201 myocardial perfusion imaging data can identify which patients have left main or 3-vessel (anatomically high-risk) coronary artery disease (CAD) after their first transmural myocardial infarct (MI). Twelve exercise test criteria for high-risk disease were compared in 40 patients referred for cardiac catheterization; 34 had a history of chest pain and 17 had angiographically defined high-risk CAD. A thallium image defect outside the vascular distribution of the MI was the most reliable criterion to distinguish patients with high-risk CAD (p = 0.00052 for Fisher's exact test of discrimination). Thallium imaging was somewhat more sensitive (92 versus 65%, p = 0.108) when patients with negative thallium imaging criteria who failed to achieve 85% of the age-predicted maximal heart rate were excluded. Failure to achieve 85% of predicted heart rate was by itself a useful criterion for detecting high-risk CAD (p = 0.017), especially in patients not taking propranolol (p = 0.004). Development of positive S-T segment depression at less than 70% predicted heart rate also discriminated left main or 3-vessel disease from less extensive CAD (p = 0.016). Other criteria failed to discriminate significantly between high-risk and less extensive CAD in patients after their first MI (p greater than 0.05). S-T segment depression (p = 0.199) or chest pain (p = 0.577) during exercise testing were particularly unreliable. Further, none of the criteria for high-risk CAD were influenced by irreversible left ventricular dysfunction. It is concluded that patients with thallium imaging defects outside the region of the infarct, decreasing blood pressure during exercise, failure to achieve 85% of predicted heart rate, or S-T depression at less than 70% of predicted heart rate have a high probability of having left main or 3-vessel disease. Patients without these criteria have a very low probability of having high-risk CAD and probably do not need coronary angiography for the purpose of excluding these high-risk coronary lesions after a first MI.

This report reviews the experience with bypass graft surgery in the pure form, without associated cardiac procedures, in 6828 patients operated upon from 1967 through 1974. The hospital mortality rate in this group was 1.4%. The incidence of definite perioperative myocardial infarction was 6.9% prior to 1971, and 4.1% in the past 3 yr. Graft patency in postoperative studies performed an average of over 12 mo after surgery was 83.6%, and 89% of patients had one or more functioning grafts. In a subgroup of 741 consecutive patients operated upon with pure graft techniques from 1967 through 1970, survival seemed to be improved when compared to another group of similar, but nonoperated patients. The average annual mortality rate was 3.3% per yr in the surgical group (including surgical mortality) compared to 8.8% per year in the medical group. Differences in survival were most striking in patients with isolated anterior descending, double and triple vessel involvement. In the 741-patient subgroup the incidence of new occlusions of grafted arteries was related to the severity of the lesion(s) for which the operation was performed, and unrelated to graft patency. Arteriographically demonstrated new occlusions of ungrafted arteries were infrequent, and few patients developed significant new lesions during the period of observation. Symptomatic improvement is related to completeness of revascularization as determined by postoperative arteriography.

A 33 year old man with the findings of mild aortic stenosis had an echocardiographic diagnosis of left ventricular myxoma prolapsing through the aortic valve during each ventricular systole. The M-mode echocardiogram, B-scan ultrasonogram and angiograms of this patient are presented. The clinical characteristics in all the reported cases of left ventricular myxomas are reviewed.

A patient with angina pectoris, myocardial bridging of the left anterior descending coronary artery and otherwise normal coronary arteries is presented. Regional myocardial blood flow was studied with the thermodilution technique. Atrial pacing of the heart at a rate of over 140/min reproduced the anginal syndrome, with S-T segment depression in the electrocardiogram. There was a transient decrease in great cardiac vein flow during rapid pacing with a simultaneous increase in total coronary sinus flow. The study demonstrates that in this patient, a myocardial bridge was associated with decreased blood flow to the area perfused by the bridged artery with a concomitant increase in coronary sinus flow as the pacing rate was increased from 96 to 150 and 180/min. After administration of nitroglycerin, the bridging effect was more accentuated on angiography; pacing-induced tachycardia was associated with similar changes in great cardiac vein and coronary sinus flows with less S-T segment depression in the electrocardiogram and chest pain of milder intensity.

This study assesses the effect of dietary supplements with high dose omega-3 fatty acid (N3FA) on the frequency of clinical restenosis during the 6 months after successful percutaneous transluminal coronary angioplasty (PTCA). One hundred ninety-four patients (214 significant coronary narrowings) were randomized after successful PTCA to receive conventional medical therapy or to an identical regimen supplemented by high dose N3FA (4.5 g/day). Enrollment required angina pectoris and successful dilatation of all significant coronary narrowings. The subjects were randomly assigned to either no N3FA (control, n = 99) or N3FA supplementation (n = 95). After a 1-week trial period, 11 (group 2) declined further treatment because of side effects. The remaining 84 subjects (group 1) continued N3FA throughout the 6-month period. Monthly clinical follow-up was obtained in all patients. Ninety-two percent of patients had cardiac testing for evaluation of recurrent ischemia. Except for a greater percentage of women in the group refusing N3FA supplementation (group 2), the 3 groups were similar in demographic data, medical history, dietary habits, history of previous PTCA and angiographic characteristics. Of the 194 subjects, 56 had clinical restenosis (45 by cardiac catheterization, 8 by exercise testing and 3 by symptoms alone [refused further clinical testing]). Reocclusion rates were: group 1 19%, group 2 46%, and control 35%. Analysis both in accordance with the principle of intention to treat and for subjects who actually received N3FA revealed a significant effect of N3FA on preventing clinical restenosis (p less than 0.04 and p = 0.008, respectively). These data suggest that high dose N3FA supplements reduce the clinical restenosis rate after successful PTCA.

A totally occluded coronary vessel subtending a noninfarcted, entirely collateral-dependent myocardial region (NIECDMR) provides an opportunity to assess collateral perfusion during exercise stress. Collateral function was determined by analysis of exercise thallium-201 myocardial perfusion images from 31 patients who had at least one NIECDMR (total 41 NIECDMRs) documented during catheterization. Twenty-two of 41 NIECDMRs manifested exercise-induced perfusion defects and 19 were normally perfused. The exercise-negative NIECDMRs were further categorized: Group 1 NIECDMRs (n = 13) were associated with defects in other myocardial regions supplied by diseased vessels and were considered negative relative to other jeopardized regions; group 2 NIECDMRs (n = 6) were not associated with exercise-induced defects in other myocardial regions, which suggests that collateral perfusion was adequate during maximal exercise. Regions supplied by a diseased left anterior descending coronary artery manifested exercise defects regardless of collaterals, possibly because these regions were larger and required more perfusion. Angiographic indexes of collateral function did not clearly predict exercise results.

Coronary vascular reserve was studied in 11 patients with severe chronic aortic regurgitation (AR). Nineteen patients with the chest pain syndrome and normal findings on cardiac catheterization served as control subjects. Resting coronary sinus flow and contrast-agent-induced hyperemia were measured by continuous thermodilution. Left ventricular (LV) dimensions and mass were obtained echocardiographically. All patients had normal coronary arteries. Resting coronary flow was increased and coronary reserve was decreased in patients with AR compared with the control subjects: 310 +/- 38 versus 121 +/- 13 ml/min and 56 +/- 9 versus 86 +/- 7.5%, respectively. The decrease in coronary vascular reserve correlated with the increase in LV mass (r = -0.86, p = 0.001) and LV wall thickness (r = -0.83, p = 0.002) and with the decrease in LV volume/mass ratio (r = 0.761, p = 0.007). There was no significant correlation between the decrease in coronary vascular reserve and LV volume (r = 0.255), LV peak wall stress (r = 0.292), LV systolic pressure (r = -0.495), aortic or LV diastolic pressure (r = 0.322 and -0.318, respectively), or aortic-LV diastolic gradient, nor with the voltage on the electrocardiogram (limb leads r = -0.60, precordial leads r = -0.118). Thus, coronary vascular reserve is decreased in proportion to the degree of left ventricular hypertrophy in patients with chronic AR. Patients with angina pectoris tended to have a lower coronary vascular reserve than those without angina (median 26 versus 76%, difference not significant). LV wall thickness and not LV volume is the critical component of left ventricular mass related to coronary reserve. No significant correlation between the decrease in coronary vascular reserve and the presence of angina pectoris was demonstrated.

Two cases with acute myocardial infarction are presented. Both had thrombotic occlusion of the infarct-related artery. Following successful thrombolysis with streptokinase, coronary angiography was normal. These cases prove that "myocardial infarction with normal coronaries" can be associated with coronary thrombosis in the acute stage.

Increased myocardial blood flow occurs in ventricular hypertrophy, but flow per 100 grams of myocardium remains normal. The increase in flow may be obtained at the expense of the existing coronary vascular reserve or by an increase in the vascular bed. The coronary vascular reserve was studied by analyzing the hyperemic reaction to selective injection of contrast agent into the coronary arteries in 25 patients: a control group (9 patients) with chest pain syndrome, normal coronary arteries and a normal left ventricle (Group I) and 16 patients with aortic stenosis, left ventricular hypertrophy and normal coronary arteries (Group II). The hyperemic response in Groups I and II was 73.3 +/- 2.2 and 65.8 +/- 9.1 percent, respectively (difference not significant). Group II was subdivided into two groups: Group IIA had five patients with a left ventricular mass of less than 200 g (mean 158.8 +/- 25.9); this group had a hyperemic response of 102.3 +/- 9.9 percent. Group IIB had 11 patients with a left ventricular mass of more than 200 g (mean 308.9 +/- 22.5) and a hyperemic response of 49.27 +/- 10.42 percent. The hyperemic response was correlated with the diastolic left ventricular-aortic gradient (r = +0.64, p less than 0.001), left ventricular mass (r = -0.51, p less than 0.01) and aortic diastolic pressure (r = +0.636, p less than 0.001). Group I had a left ventricular mass similar to that of Group IIA (124.9 +/- 9 and 158.8 +/- 26 g, respectively) but a lower hyperemic response (73.3 +/- 2 and 102.3 +/- 10 percent, respectively). These data suggest that severe left ventricular hypertrophy is associated with a reduction in coronary vascular reserve; it is speculated that this decrease in the vascular reserve capacity may be related to the ischemic component of hypertrophic heart disease.

This prospective series of results and complications of coronary arteriography from the Registry of the Society for Cardiac Angiography and Interventions is the largest ever reported. Since the initial report published in 1982, the results of coronary artery surgery and angioplasty have improved and therefore older and more symptomatic patients are referred for coronary arteriography. More patients are now studied by the femoral approach, and the major complications of the techniques are similar. Despite studying older and higher-risk patients, the complications are remarkably similar to those reported in the older series. Because of the sicker patients being studied, it is probably unlikely that the complication rate will decrease further in the future. The Society for Cardiac Angiography and Interventions will continue its Registry to follow complication rates of both established and new procedure.

The use of myocardial perfusion imaging (MPI) to identify obstructive coronary disease of the left anterior descending coronary artery proximal to the first septal perforator (prox LAD) was studied in 60 patients. Perfusion of the septum and anteroapical areas with thallium-201 injected during exercise was compared to results of coronary arteriography. Septal MPI defect was found in 92.3% of patients with obstruction of the proximal LAD, 27.7% of patients with obstruction of LAD distal to first septal perforator, 0% in patients with obstructions involving right or circumflex arteries, and in 10.5% of patients without coronary disease. Anteroapical MPI defects were found with similar frequency in the three groups with obstructive coronary disease. Septal MPI defect had a sensitivity of 92.3% and specificity of 85.4% in the diagnosis of proximal LAD disease. Normal septal perfusion with thallium-201 virtually excluded proximal LAD disease.

To study the influence of left ventricular (LV) late diastolic filling on the A wave of the LV pressure, simultaneously recorded echocardiographic LV dimensions and high-fidelity LV pressure measurements were taken in 24 patients. Group 1 comprised eight patients without LV hypertrophy (LVH) and LV end-diastolic pressure (LVEDP) less than or equal to 13 mm Hg. Group 2 comprised 16 patients with LVH secondary to aortic stenosis, idiopathic hypertrophic subaortic stenosis, or hypertension and increased LVEDP. Patients in group 2 had significantly thicker left ventricles, decreased mitral E-to-F slopes, and larger A waves in the LV pressure curve. On the basis of end-diastolic chamber stiffness, we divided group 2 into two populations: 12 patients (group 2A) with end-diastolic chamber stiffness similar to that in group 1, and four patients (group 2B) with markedly elevated end-diastolic chamber stiffness. Patients in group 2A had a larger atrial contribution to LV filling than those with markedly abnormal stiffness (group 2B). Therefore, in LVH an increased A wave in the LV pressure may be related to either elevated end-diastolic chamber stiffness or augmented left atrial volume transport.

A patient with a large fistula from the left circumflex coronary artery to the coronary sinus that recurred in spite of proximal and distal ligation is presented. It suggests that ligation is not an adequate procedure for large coronary fistulae. Division and oversewing should be done whenever feasible.

Thirty-four patients undergoing elective cardiac catheterization were followed linearly with three questionnaires during their hospitalization to study some of the effects of informed consent. Patients learn about catheterization from the informed consent session conducted by a cardiology fellow. Several areas of knowledge deficiency were found. The emotional experience of hospitalization and the amount of knowledge about catheterization determined at the end of hospital stay is shown to be dependent on the educational level of the patient. Several recommendations are made for the conduct of the informed consent sessions to improve the knowledge of the less educated.

Fifty-five consecutive patients with a normal resting electrocardiogram and coronary artery disease were examined to determine left ventricular function. Fifty-two (95%) had no evidence of left ventricular asynergy; 3 patients had only mild hypokinesis. Of this group of patients, 25 (47%) had one vessel disease, 17 (30%) had two vessel disease, and 13 (23%) had three vessel disease. Significant left ventricular asynergy was not found in patients with coronary artery disease and normal electrocardiograms. In addition, a normal electrocardiogram was not related to the number of coronary arteries involved.

During a 14-month period, 75 deaths occurring in relation to 53,581 cardiac catheterizations were consecutively and prospectively reported to the Registry Committee of the Society for Cardiac Angiography. Three of the patients died several days after their catheterization from an unrelated cause and are excluded from this analysis. There were 21 patients (group I) who arrived at the laboratory in extremis and whose deaths were expected irrespective of the catheterization. Most of these patients suffered from recent myocardial infarctions and cardiogenic shock, or had complex congenital malformations. In 35 patients (group II), a cardiovascular complication occurring during the catheterization resulted in death. In 16 patients (group III) catheterization seemed uneventful, but death occurred suddenly 10 min to 10 h after the procedure. Of these 16 patients, eight had left main coronary artery obstruction greater than or equal to 90%, five had three-vessel disease all with 90% obstructions, one had 2-vessel disease both with 90% obstructions, and who had critical aortic stenosis. The 51 unexpected deaths (groups II and III) were considered to be causally related to the procedure, a mortality rate of 0.10%. Subsets with an increased mortality rate (M), were patients with: a) left main disease greater than 50% (M = 0.94%); b) ejection fraction less than 30% (M = 0.54%); c) NYHA class III or IV (m = 0.24%); d) age over 60 years (M = 0.23%); or e) three-vessel disease (M = 0.13%). In conclusion, catheterization related mortality occurs mostly in patients with far advanced cardiac disease. Nearly 1/3 of the unexpected deaths occurred suddenly after a seemingly uneventful procedure. Close monitoring after catheterization of patients with similar characteristics (left main disease greater than or equal to 90%, or three-vessel disease all greater than or equal to 90%) might disclose avenues for reducing mortality occurring after catheterization.

In a 42-month period, 218 deaths occurred in 222,553 patients undergoing coronary arteriography (0.098%). Age greater than 60 years, NYHA Class IV function, presence of left main coronary disease, and ejection fraction less than 30% all significantly increased the risk of the procedure. Sex and approach (brachial or femoral) used for the catheterization did not affect mortality. Since the SCAI report in 1982, the death rate has dropped significantly in high-risk patients. Low-risk patients (NYHA Class I or normal coronary arteries) who died generally were elderly or had associated valvular heart disease.

Motion of the posterior aortic root on echocardiography is related to left atrial volume changes. Early diastolic posterior motion of the aortic root reflects both LA emptying and filling and has been measured as the atrial emptying index. To study late diastolic motion of the aortic root, we measured the slope of posterior motion of the aortic root after left atrial systole (following the P wave of the ECG) in 25 subjects without heart disease (Group 1), in 15 patients with left ventricular hypertrophy due to pressure overload (Group 3) with mitral stenosis. The aortic root slope measured (mean +/- SEM) 58.0 +/- 1.9 mm./sec. in Group 1, 50.6 +/- 4.5 mm./sec. in Group 2 (NS vs 1) and 28.8 +/- 4.5 mm./sec. in Group 3, (p < 0.01 vs 1 or 2). In 16 patients (four in Group 1 and 12 in Group 2) studied at catheterization, an inverse correlation ( r = -0.74, p < 0.01) was found between the aortic root slope (over a range of 30 to 73 mm./sec.) and left ventricular late diastolic chamber stiffness measured with simultaneous left ventricular echo and high-fidelity pressure recordings. No correlation was found between this slope and either left atrial size, total aortic root excursion, left ventricular pressure pre "A" wave, height of the A wave, end-diastolic pressure, or the atrial contribution to left ventricular filling. Therefore, the aortic root slope in late diastole is decreased in mitral stenosis and in the absence of mitral stenosis, it appears to be related to late diastolic properties of the left ventricle.

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. We have therefore developed a technique for PTCA of chronic total coronary occlusions using the ultralow profile "balloon-on-a-wire" Probe. An intracoronary Probing Catheter is used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe into the obstruction for balloon dilatation. This technique was used in 13 patients including six in whom other dilating systems had failed to cross the occlusion. Successful dilatation was performed in nine patients (67%). Among the six patients in whom other dilating systems had failed, dilatation was performed in five using the Probing Catheter technique with a successful outcome achieved in four (67%). The Probing Catheter technique offers a promising new method to apply "balloon-on-a-wire" technology to the dilatation of chronic total coronary occlusions. This method may allow successful dilatation when other dilating systems fail.