Biomedical subjects
Publications and source records attributed to L Wexler.
Computed tomographic (CT) cardiac imaging in vivo has been hampered by motion of the heart during its cardiac cycle. A technique of post data-acquisition correlation of the angular projection data using the electrocardiogram as a reference signal is described. This method produced seven "stop action" images of the heart and resulted in delineating morphological detail not recognizable on the conventional CT scan.
A pilot study involving 36 patients was undertaken to test the efficacy of combining 1% lidocaine with 60% methylglucamine iothalamate for relief of the severe burning pain often experienced during peripheral arteriography. Of 24 patients premedicated with meperidine hydrochloride and promethazine hydrochloride, 12 received lidocaine with the contrast medium and 12 did not. The remaining 12 patients were premedicated with diazepam and received lidocaine with the contrast material. By both subjective and objective criteria, those patients receiving lidocaine in the intraarterial injection of contrast medium suffered less pain. Optimum results were achieved for the lidocaine group receiving analgesic premedication. No adverse reactions attributable to the lidocaine were encountered. Subsequent to completion of the pilot study, more than 300 patients have been studied with similar impressive results of pain relief and safety.
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.
Complications statistics in 1625 patients undergoing selective coronary angiography by Judkin's technique have been analysed for four major areas-death, myocardial infarction, cerebral vascular accidents, and femoral thrombosis. Over a six-year period, considerable decrease in the number of complications has occurred. Myocardial infarctions have decreased from 2.4% (1967-71) to 0.44% (1973), an improvement related to careful catheter flushing, guidewire insertion technique and careful pressure monitoring within the coronary arteries. Cerebral accidents have decreased from a maximum of 1.3% (1972) to none (1973). This is also related to catheter guidewire techniques, and to avoidance of entering the cerebral vessels inadvertently when crossing the aortic arch with the coronary catheter. Femoral artery thromboses have decreased from 2.7% (1967-71) to none (1973). This is due to monitoring the dorsalis pedis pulse when compressing the femoral artery and avoiding complete femoral arterial obstruction with the associated lack of flow ultimately leading to thrombosis. Death rate has remained essentially unchanged (0.3-0.6%).
Multiple pulmonary arteriovenous fistulas were demonstrated angiographically in 8 patients who exhibited cyanosis and polycythemia during childhood. Cyanosis was first observed during infancy in 5 patients. The diffuse (telangiectatic) type was present in 2 cases, while the remainder were of the multiple discrete type with one or two dominant fistulas. The clinical and angiographic features and surgical implications of multiple pulmonary arteriovenous fistulas in these children and those reported previously are discussed.
Eleven of 21 consecutive patients with Prinzmetal angina (PMA) exhibited no significant fixed stenoses of the coronary arteries. Spontaneous coronary arterial spasm was demonstrated in 3 patients. Ergonovine maleate produced near-total occlusion of a major vessel in 3 of 4 other patients with PMA, but did not provoke spasm in 10 without PMA. The current study documents spasm as the mechanism of myocardial ischemia in some patients with normal coronary arteries and provides initial and favorable diagnostic results with provocative pharmacoangiography in this entity.
A distinctive angiographic appearance is described in two patients who had uncorrected levo-transposition of the great vessels. Although levo-transposition with inversion of the ventricles usually results in physiologically corrected transposition, in these patients the anatomy was arranged in such a way as to result in an uncorrected transposition. The following elements were responsible for this physiological condition: normal atrial situs, inverted ventricles with "criss-cross" atrioventricular flow, levo-transposed great arteries. In addition, the morphological right ventricle was hypoplastic, left sided and superior to the left ventricle and the ventricular septum was horizontal in position. The two ventricles were connected via a large ventricular septal defect. The importance of accurate, detailed, preoperative angiographic demonstration of the anatomic situation is stressed.
Diflorasone diacetate, a new topical corticosteroid, was generally more potent than three high potency reference standards (fluocinonide, beta-methasone 17-valerate and fluocinolone acetonide) when the compounds were dissolved in 95% alcohol and applied in vasoconstrictor assays in healthy volunteers. On the basis of additional vasoconstrictor assay results, a 0-05% concentration of the steroid in a cream vehicle containing 15% propylene glycol was developed for therapeutic evaluation. In a double-blind comparison in 384 patients with dermatoses, 0-05% diflorasone diacetate cream was as effective as 0-05% fluocinonide cream in the therapy of lesions of psoriasis or atopic/neurodermatitis.
A case of rupture of a thoracic aortic aneurysm into the left pulmonary artery is presented. This is an unusual complication of an aortic aneurysm. The importance of angiography in its accurate and early diagnosis is described.
The dominance of the coronary arterial system was determined angiographically in 75 adult patients with isolated aortic stenosis with or without insufficiency, 25 adult patients with pure aortic insufficiency, 51 adult patients with combined aortic stenosis and mitral valve disease, and 44 children with bicuspid aortic valves. There was an unusually high incidence of left dominance in adults with isolated aortic stenosis (36%) and in children with bicuspid aortic valves (56.8%). These findings suggest the existence of a variant developmental complex consisting of a bicuspid aortic valve and reversal of dominance of the coronary arterial system. Furthermore, it adds support to the concept that progressive stenosis of a bicuspid aortic valve is frequently the etiology of isolated aortic stenosis in adults.
The plain roentgenographic and angiocardiographic features of 15 patients with Ebstein's anomaly of the tricuspid valve were reviewed. Of note on the plain roentgenogram was the fact that the "posterior bulge" seen on the lateral view was demonstrated to be due to either a markedly enlarged right atrium or the posterior displacement of normal left heart structures. The angiocardiographic features described in the literature were reviewed. Two main features seen were the "sail-like" appearance of the anterior leaflet of the tricuspid valve, which sometimes produces a tumor like picture, and the 2 notches seen when the ventricle contracts. One notch corresponds to the true tricuspid annulus. The other represents the site of attachment of the displaced tricuspid valve. The previously undescribed features were noted: (a) all three leaflets could sometimes be identified; (b) fenestrations in the anterior leaflet were demonstrated in 5cases; and (c) the sinus portion of the ventricle was sometimes filled in a retrograde fashion from the infundibular chamber.
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