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Transluminal coronary angioplasty (TCA) of the right coronary artery (RCA) was performed by brachial cut-down approach in 33 patients during a period of 16 months. Flexible-tip guiding catheters were used in all cases. TCA was successful in 27 of 33 patients (81%). The stenosis was reduced in successful cases from a mean of 89% predilatation to 26% postdilatation (P less than 0.001). The systolic pressure gradient across the lesion was reduced from a mean of 49 mm Hg to 4 mm Hg (P less than 0.001). Following successful TCA, patients experienced marked improvement in clinical status, functional capacity, and relief of angina. The complication rate in this study was low. There was no early or late mortality. The most common complication was dissection of the coronary artery occurring in four cases (12%). One patient sustained an acute inferior myocardial infarction. Only one patient required emergency coronary artery bypass surgery. The late follow-up (mean 6 months) angiography was obtained in 17 patients. The stenosis recurred in late follow-up in three cases (18%). Our initial experience revealed that the use of softer guiding catheters by brachial technique offers more selective approach for TCA of RCA lesions and provides better results than percutaneous femoral approach with fixed-tip catheters. Our success rate of 81% for dilatation of RCA is significantly higher than previously reported.

A national study was carried out to determine the relative costs of PTCA and CABG. Baseline clinical criteria for the 2 groups were similar. Data were collected in 186 sets for the PTCA group and 175 sets for the CABG group. Male patients make up 81% of the PTCA group and 80% of the CABG group. Mean hospital stay was 12 +/- 5 days in the CABG group, compared with 4 +/- 2 days in the PTCA group (p less than 0.001). The base charges for hospital and professional components of the CABG procedure were $15,580 +/- $2,159, whereas the same charges for the PTCA procedure were $5,315 +/- $2,159 (p less than 0.001). With an 80% primary success rate, which was the group mean success rate, the average dollar savings per PTCA procedure would be $7,149, or $7,149,000 per 1,000 cases. Thus, PTCA for revascularization in 1-vessel CAD is significantly more cost-effective than CABG in the short term.

Forty-one patients were evaluated with exercise-gated radionuclide ventriculography before and within 4 days after successful transluminal coronary angioplasty and 4 to 12 months later. Patients were subgrouped according to the degree of restenosis demonstrated angiographically at 4 to 12 months (Group I [n = 23]: less than or equal to 20%; Group II [n = 10]: greater than 20% but less than 50%; Group III [n = 8]: greater than or equal to 50%). Patients with abnormal findings on gated radionuclide ventriculography (less than 5 point increase in ejection fraction or wall motion deterioration) early after angioplasty were eventually found to have a greater degree of restenosis than were patients with normal findings (41.2 +/- 30.3 versus 19.0 +/- 25.4% restenosis, p less than 0.0001). The accuracy of abnormal radionuclide ventriculography in predicting 50% or greater restenosis was 73% immediately after angioplasty and 77% at the time of follow-up angiography. Gated radionuclide ventriculographic results were abnormal in 5% of Group I patients compared with 75% of Group III patients (p less than 0.01) early after angioplasty; at late follow-up, they were abnormal in 27% of Group I patients compared with 88% of Group III patients (p less than 0.01). Group I patients had a greater increase in ejection fraction than did Group III patients at early (+11.3 +/- 7.5 versus + 3.5 +/- 6.5 points, p less than 0.01) and late (+11.8 +/- 7.8 versus -1.9 +/- 8.7 points, p less than 0.0005) follow-up. It is concluded that gated radionuclide ventriculography is useful in predicting coronary restenosis after transluminal coronary angioplasty.

Two patients with a large posterior pericardial effusion after cardiac surgery presented with electrocardiographic precordial Q waves without evidence of myocardial infarction. Resolution of the pericardial fluid resulted in the disappearance of the Q waves. Changes in conductivity and orientation of the heart within the pericardial space, along with a decrease in QRS voltage, could lead to the loss of initial R waves in the precordial leads, eventually resulting in a QS complex. Care should be taken in interpreting the electrocardiogram after cardiac surgery in patients with a large posterior pericardial effusion. The clinical course along with serial electrocardiographic and echocardiographic tracings should be helpful in identifying this false infarction pattern.

Takayasu's arteritis, the nonspecific occlusive disease originally believed to affect young Oriental women exclusively, was identified in a 19-year-old man who had severe involvement of the aortic arch and its branches. Successful surgical treatment was accomplished with a bypass from the ascending aorta to the supraceliac abdominal aorta using a tube graft. The right vertebral artery, as the single patent vessel reaching the head, was revascularized distal to the stenosis with a tube graft that extended from the aortic graft. Revascularization of ischemic organ systems and body areas may be accomplished in most patients with Takayasu's arteritis using the bypass concept and fabric conduit grafts.

The observation by Heyde that unexplained gastrointestinal bleeding may be associated with aortic stenosis has been confirmed by many others. It has been suggested that the combination of gastrointestinal bleeding and aortic stenosis be termed Heyde's syndrome. Gastrointestinal bleeding in this syndrome has been attributed to angiodysplasia. Segmental resection of those portions of the gastrointestinal tract containing the angiodysplastic lesions has been considered the definitive treatment for patients with Heyde's syndrome who are symptomatic because of chronic blood loss. However, recent observations suggest that aortic valve replacement with a bioprosthesis is a better therapeutic approach for those patients with severe aortic stenosis. This treatment has been shown to alleviate the symptomatology of both the stenosed aortic valve and the chronically bleeding bowel.

Embolization of the occluder from a prosthetic mitral valve is an extremely rare event. Previous reports in the literature have described the uniformly fatal outcome of this complication. A case in which the occluder from a Wada-Cutter mitral prosthesis embolized five years following implantation is presented. The patient survived following emergency reoperation. Several unique features of escaped mitral poppet are discussed. Depending upon cardiac reserves, patients who have this complication may live long enough to allow emergency operative intervention and eventual recovery.