Increased adventitial mast cells in a patient with coronary spasm.
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Adult↗
Biomedical subjects
M B Forman
Publications and source records attributed to M B Forman.
Correlation of saphenous vein bypass graft angiograms with histologic changes at necropsy.
Previous studies of saphenous vein (SV) bypass grafts have been either angiographic or morphologic, and few have correlated angiograms with histology. Nine necropsy patients who had received 21 SV implants 12 to 120 months (mean 67 +/- 42) before death were studied. All patients had severe coronary artery disease. Three types of histologic changes were found: atherosclerosis in 9 grafts, fibrointimal proliferation in 8 and total occlusion with fibrosis in 4. All patients had premortem angiograms 0 to 3 months (mean 0.7 +/- 1.1) before death. In 14 of 21 grafts, premortem angiograms accurately reflected the postmortem findings. In 7 grafts, the premortem angiograms either overestimated (4 grafts) or underestimated (3 grafts) the extent of luminal narrowing. Six of the 7 SV implants incorrectly assessed by angiography had fibrointimal proliferation and 1 had atherosclerosis. The presence of smooth muscle in SV implants with fibrointimal proliferation may be a mechanism of spasm or relaxation during angiography, which could cause errors in estimating the degree of stenosis. Nitrates or calcium antagonists may be useful in both assessing the degree of underlying vasomotion in SV grafts and as a therapeutic modality.
Aged↗
Effect of perfluorochemical (Fluosol-DA) on infarct morphology in dogs.
To assess the effect of Fluosol-DA treatment on infarct morphology, detailed histologic examination was performed in 17 dogs with permanent proximal left anterior descending coronary artery occlusion. Two of the three groups of dogs received an equal blood volume exchange (40 ml/kg i.v.) with either Fluosol-DA (F) or heparinized autologous blood (H) 30 min post occlusion while being ventilated with 100% oxygen. A third group received no therapy (C). Animals were sacrificed 3 days post occlusion and sections were obtained for light and electron microscopy. Histologic studies showed that infarct size was statistically smaller in dogs treated with F 54 +/- 7% versus heparin 64 +/- 10% treatment or no therapy 79 +/- 6%. Fluosol-DA animals demonstrated decreased inflammatory infiltrate, larger viable subepicardial zones and greater endocardial sparing in the area surrounding the central zone of necrosis. By electron microscopy, perfluorochemical particles were found within endothelial and inflammatory cells in subepicardial zones of infarction. In midmyocardial zones, Fluosol-DA particles were present in capillaries, extracellular spaces and necrotic myocytes. In the normal myocardium Fluosol-DA particles were rarely seen within endothelial cells and never within the interstitium or myocytes. Thus, Fluosol-DA reduces infarct size and alters infarct morphology in the 3 day post permanent coronary occlusion model.
Animals↗
Effects of indomethacin on systemic and coronary hemodynamics in patients with coronary artery disease.
The effects and possible mechanisms of actions of indomethacin on systemic and coronary hemodynamics were studied in 17 patients with coronary artery disease. Group I patients (12) were given either indomethacin or placebo in the absence of prior cyclooxygenase inhibition and group II (five) were given indomethacin after prior treatment with 2600 mg of aspirin. In group I, systolic blood pressure rose from a baseline of 136 +/- 5 mm Hg to a peak level of 158 +/- 8 mm Hg 5 minutes after drug (p less than 0.01). This was associated with a fall in coronary blood flow and a rise in coronary vascular resistance from a baseline of 1.36 +/- 0.4 mm Hg/ml/min to 1.99 +/- 0.7 mm Hg/ml/min 5 minutes after indomethacin (p less than 0.01). Immunoreactive thromboxane B2 levels fell from 191 to 1.4 ng/ml. No changes were noted in plasma renin activity, angiotensin II, or catecholamine levels. Immunoreactive thromboxane B2 levels were undetectable throughout the study period in group II patients and the blood pressure response to indomethacin was attenuated. Baseline coronary blood flow was significantly higher (p less than 0.01) and baseline coronary vascular resistance significantly lower (p less than 0.01) than in group I. At all time points after indomethacin, the fall in coronary blood flow was greater and the increase in coronary vascular resistance less in group II versus group I (p less than 0.001). These findings suggest a dissociation between the effect of indomethacin on systemic and coronary hemodynamics, the former apparently being more prostaglandin-dependent than the latter.
Adult↗
Correlation of two-dimensional echocardiography and pathologic findings in porcine valve dysfunction.
Two-dimensional echocardiographic findings in porcine valve dysfunction were compared with pathologic findings in 10 patients (12 valves). Three specific echocardiographic findings were identified in patients with regurgitant lesions: prolapse, fracture and flail leaflets. Prolapse was associated pathologically with thinning of the leaflets, longitudinal tears close to the ring margin and acid mucopolysaccharide accumulation. Valve fracture was seen with and without prolapse and was accompanied pathologically by small pinpoint perforations or tears of the leaflet. A flail leaflet was seen with a linear tear of the free margin and was associated with calcific deposits. Mild degrees of fracture seen pathologically were missed on the echocardiographic study in five patients. Thickening or calcification, when present in moderate or severe amounts, was correctly identified by echocardiography. When all abnormal features were considered collectively, two-dimensional echocardiography correctly identified at least one of them in all patients. Therefore, two-dimensional echocardiography may prove useful in assessing the source of valvular regurgitation in patients with bioprosthetic valves.
Adult↗
Right ventricular myocardial infarction in patients with chronic lung disease: possible role of right ventricular hypertrophy.
To determine the relation between right ventricular hypertrophy and right ventricular myocardial infarction in patients with chronic lung disease, the records of 28 patients with chronic lung disease, inferior myocardial infarction and significant coronary artery disease (group I) and 20 patients with right ventricular hypertrophy, chronic lung disease without inferior myocardial infarction or significant coronary artery disease (group II) were reviewed. Chronic lung disease was diagnosed by clinical criteria, chest radiographs and pulmonary function tests. All patients had postmortem examinations. Patients in group I were classified into two subgroups: group Ia (without right ventricular hypertrophy) and group Ib (with right ventricular hypertrophy). Right ventricular wall thickness was 3.3 mm +/- 0.5 in group Ia, 6.0 mm +/- 1.1 in group Ib and 8.8 mm +/- 2.4 in group II (group Ia versus Ib, p less than 0.001; group Ia versus II, p less than 0.001; group Ib versus II, p less than 0.001). Eleven patients (78.6%) in group Ib (chronic lung disease with both right ventricular hypertrophy and inferior myocardial infarction) had right ventricular myocardial infarction compared with only 3 patients (21.9%) in group Ia (chronic lung disease without right ventricular hypertrophy and with inferior myocardial infarction) (p less than 0.008). Isolated right ventricular myocardial infarction occurred in four patients (20%) in group II (chronic lung disease with right ventricular hypertrophy, but without evidence of infarction of the left ventricle or significant coronary artery disease). There was no significant difference in the extent of anatomic coronary disease in groups Ia and Ib.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Reflexes unique to myocardial ischemia and infarction.
Although arrhythmias caused by myocardial ischemia are a well recognized cause of sudden death, the potential influence of cardiogenic reflexes originating in areas of ischemia has received less attention. In this study, 12 patients with well documented single vessel coronary artery spasm, with a total of 2,240 episodes of transient transmural ischemia, are described. Continuous electrocardiographic and hemodynamic recordings were analyzed to determine possible relations between the anatomic area of ischemia and patterns of change in blood pressure and heart rate. Of seven patients with ischemia of the posterior or inferior left ventricular wall, six had associated bradycardia and hypotension, an apparent Bezold-Jarisch response. Only one of five patients with anterior ischemia had a similar response. A hypertensive, tachycardiac response resembling the James reflex was seen in two of the patients with anterior ischemia, with an increase in blood pressure of 36/22 +/- 12/6 mm Hg and an increase in heart rate of 8 +/- 3 beats/min. This increase began before the onset of chest pain and was seen even in asymptomatic episodes. These reflexly mediated hemodynamic responses may modulate the direct effects of myocardial ischemia and could play a role in sudden cardiac death.
Angina Pectoris↗
Reduction of infarct size with intracoronary perfluorochemical in a canine preparation of reperfusion.
The effect of low-dose (15 ml/kg) intracoronary perfluorochemical (Fluosol-DA) on infarct size, regional myocardial blood flow, and ventricular function was studied in 20 anesthetized closed-chest dogs subjected to 11/2 hr of proximal left anterior descending occlusion. In this preparation reperfusion was simulated with fibrinolytic therapy. The animals were randomly assigned one of two treatment groups and given 15 ml/kg of either oxygenated intracoronary perfluorochemical (n = 9) or saline (n = 11). Contrast ventriculograms were obtained at baseline, 1 hr after occlusion, and at 24 hr after reperfusion and were analyzed with a radial fractional shortening method. Regional myocardial blood flow was measured with radioactive microspheres. At 24 hr the area at risk was defined in vivo with monastryl blue staining and the area of necrosis was estimated after incubation of left ventricular slices with triphenyltetrazolium chloride. No significant changes were noted in heart rate, blood pressure, pulmonary capillary wedge pressure, or dP/dt during the experimental protocol. Infarct size was significantly reduced (p less than .02) in the perfluorochemical-treated group, both when expressed as a percentage of the total left ventricular mass (7.9 +/- 1.7% vs 14.7 +/- 2.5%) and as a percentage of the area at risk (20.1 +/- 5.0% vs 46.8 +/- 8.5%). This was associated with significant improvement in fractional shortening in the jeopardized zone at 24 hr after reperfusion. Although endocardial blood flow was significantly greater in the central ischemic zone and lateral region at risk immediately after reperfusion in the perfluorochemical-treated group, no difference was found 1 hr after reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Morphologic changes in long-term saphenous vein bypass grafts.
A retrospective autopsy study was performed in 56 patients who had undergone saphenous vein bypass graft (SVBG) surgery 12 to 168 months prior to death. Twenty-five grafts had atherosclerosis, 66 grafts had fibrointimal proliferation, and 26 grafts were fibrotic with total occlusion. No significant differences were noted among the three morphologic groups with regard to age of the patient or number of native coronary arteries severely narrowed. Vein grafts with fibrointimal proliferation occurred with greater frequency in patients with systemic hypertension (p less than 0.001), and atherosclerotic grafts were more prevalent in patients with hypercholesterolemia (p less than 0.02). Therefore, the presence of risk factors may determine the type of change that occurs in saphenous vein bypass grafts: systemic hypertension leads to fibrointimal proliferation, whereas hypercholesterolemia leads to atherosclerotic change.
Adult↗
Effect of tyramine on myocardial catecholamine release in coronary heart disease.
The influence of tyramine on myocardial catecholamine release and on coronary blood flow has not previously been determined in man. Therefore, the effect of tyramine was measured on coronary and systemic hemodynamics and on norepinephrine (NE) and epinephrine levels in blood from the aorta and coronary sinus in 9 patients with coronary artery disease. Tyramine produced a striking increase in coronary sinus NE, from a baseline of 344 +/- 56 to a peak level of 1416 +/- 310 pg/ml (p less than 0.01) 2 minutes after tyramine. The increase in aortic NE was less striking, from 265 +/- 32 to 421 +/- 63 pg/ml (difference not significant). Therefore, the net release of NE from the heart was increased by tyramine from 12,007 +/- 393 to 139,357 +/- 46,156 pg/ml/min (p less than 0.03). There was no release of epinephrine across the coronary bed. There was a variable response of coronary blood flow and resistance after tyramine. Thus, the rich innervation of the heart by sympathetic nerve endings can result in marked NE release into the coronary sinus.
Adult↗
Two-dimensional echocardiography in the diagnosis of carcinoid heart disease.
Tricuspid valve disease accounts for significant morbidity and mortality in the carcinoid syndrome, but M-mode echocardiography is often insensitive in completely defining the tricuspid valve. We performed two-dimensional echocardiography (2DE) in seven patients with proven carcinoid syndrome. There were five males and two females whose ages ranged from 53 to 79 years. The carcinoid syndrome had been present by symptoms for 12 to 84 months and by 5-HIAA levels for 6 to 84 months prior to 2DE. Short, thickened, immobile tricuspid valve leaflets, fixed in a partially open position, were visualized in two patients and confirmed in one patient at surgery. Tricuspid regurgitation was demonstrated angiographically in one and by contrast 2DE in the other. A third patient had clinical evidence of tricuspid stenosis with a doming tricuspid valve on 2DE. The motion of the tricuspid value viewed in real time was clearly distinct in these two situations. Four patients had both normal M-mode and 2DE studies despite the fact that clinical and biochemical evidence of carcinoid disease had been present for equally long periods of time. The tricuspid valve was best visualized in the parasternal right ventricular long-axis and short-axis views. The apical four-chamber view was less helpful. Thus, 2DE demonstrated specific tricuspid valve abnormalities in the carcinoid syndrome with thickening, shortening, and immobility of the leaflets when valvular regurgitation was present and thickening and doming when the valve was stenotic. 2DE should be a useful method in the diagnosis and sequential evaluation of patients with carcinoid heart disease.
Aged↗
Electrocardiographic changes associated with isolated right ventricular infarction.
Isolated infarction of the right ventricle is an extremely rare entity. A patient is described with diffuse interstitial lung disease who developed ST segment elevation in inferior and anterior leads on a routine electrocardiogram and at autopsy was found to have an isolated right ventricular infarct involving approximately 70% of the right ventricular circumference without involvement of the left ventricle and septum. This case illustrates that isolated right ventricular infarction in the presence of cor pulmonale and right ventricular hypertrophy can produce an injury current in the limb and precordial leads of the electrocardiogram which mimics that seen in typical transmural infarction of the left ventricle.
Electrocardiography↗
Dynamic fluctuations in blood and spleen radioactivity: splenic contraction and relation to clinical radionuclide volume calculations.
Alterations in the blood radioactivity affect ventricular volume calculations using count-based radionuclide ventriculography. To study this phenomenon, the effect of time, posture and supine exercise on blood radioactivity, red blood cell count and splenic radioactivity was evaluated. The red blood cell count, and blood, splanchnic and splenic radioactivity remained stable in five patients studied at rest in the supine position. On standing, blood radioactivity increased 10 +/- 3% (standard error of the mean), and abdominal radioactivity decreased 14.5 +/- 6.5% (both p less than 0.05). In 10 patients, splenic radioactivity decreased after supine exercise by 49 +/- 7%, while blood radioactivity increased 10.5 +/- 1.5% and red blood cell count increased 7.5 +/- 1.5% (all p less than 0.001). Splenic radioactivity increased gradually after exercise and decreased after a second exercise period. In the exercising patients, blood radioactivity increased by 14.5% and correlated with an increase in the red blood cell count (r = 0.57, p = 0.01, 19 samples from 10 patients). Reduction in splenic radioactivity also correlated with the increase in red blood cell count (r = -0.51, p = 0.025). The data demonstrate splenic shrinkage in human beings and an inverse relation between changes in splenic and blood radioactivity. These dynamic fluctuations emphasize the need for simultaneous blood sampling for accurate calculation of left ventricular volume and high-light the importance of regional volume shifts during exercise.
Animals↗
Mitral anular calcification in chronic renal failure.
In order to determine the incidence and pathogenesis of mitral anular calcification (MAC) in chronic renal failure, we analyzed biochemical, hemodynamic and echocardiographic data in 168 patients on long-term hemodialysis. Mitral anular calcification is more common in patients with chronic renal failure than in other patients of similar age. Its pathogenesis appears to be due to abnormal calcium-phosphorus homeostasis in the setting of secondary hyperparathyroidism. Hypertension did not appear to be an important etiologic factor in our patients. Meticulous control of hyperphosphatemia would appear to be the most important therapeutic measure in preventing this complication.
Adult↗
Coronary artery dissections.
Isolated spontaneous coronary artery dissections are rare and usually occur in women, the majority of whom are less than 40 years of age. Coronary artery dissection may also be caused by an extension of aortic dissection, especially in Marfan's syndrome. Iatrogenic coronary artery dissections are extremely rare, especially those secondary to coronary catheterization. The consequences of dissection may be fatal; therefore, early recognition and prompt therapy may be lifesaving.
Adolescent↗
Cardiac infections in the immunocompromised host.
Bacterial infections of the heart in compromised patients are uncommon but may be increasing in relative frequency. They are associated with near-equal frequencies in patients who have pre-existing or simultaneous infections at other sites, patients with neoplasms (usually solid tumors), those who have undergone cardiac surgery, and intravenous drug or ethanol abusers. Staphylococcus aureus is the bacteria most often identified, in contrast to a preponderance of Streptococcus isolated in the pre- and early antibiotic era. Gram-negative bacilli are the causative organisms in a significant number of cases. The endocardium remains the most common site of infection, and left-sided valves are most commonly involved, especially the mitral valve, often in the absence of pre-existing valvular damage. The majority of cases are associated with involvement at other sites, and premortem blood cultures are positive in approximately two thirds of patients who undergo autopsy. Fungal infections involving the heart do not occur as often as bacterial infections. The frequency, however, is increasing. Fungal infections usually occur in patients who have received treatment with antineoplastic agents, antibiotics, or corticosteroids, alone or in combination, or who have had abdominal or cardiac surgery. Candida is the organism found most frequently and usually causes myocarditis or endocarditis, whereas Aspergillus involves the myocardium but may be invasive to the endocardium or pericardium. Other fungi that occasionally infect the heart include Phycomycetes and Cryptococcus. Dissemination is usually present and involves the lungs, kidneys, brain, or gastrointestinal tract. The diagnosis may be difficult prior to death, because blood cultures are positive in only one third of patients who come to autopsy. Precipitin tests and antibody titers for specific organisms may be helpful in providing early diagnosis. Survival rates can be improved by early diagnosis and the institution of aggressive antifungal treatment.
Adolescent↗
Radionuclide imaging in myocardial sarcoidosis. Demonstration of myocardial uptake of technetium pyrophosphate99m and gallium.
A patient had severe congestive cardiomyopathy secondary to myocardial sarcoidosis. The clinical diagnosis was confirmed by radionuclide ventriculography, thallium 201 (201Tl), gallium-67 (67Ga), and technetium-99m (99mTc) pyrophosphate (TcPYP) scintigraphy. Myocardial TcPYP uptake has not been reported previously in sarcoidosis. In this patient, TcPYP was as useful as gallium scanning and thallium imaging in documenting the myocardial process.
Adult↗
Severe airway obstruction associated with rheumatoid arthritis and Sjögren's syndrome. A case report.
Numerous pulmonary complications associated with rheumatoid arthritis (RA) and Sjögren's syndrome (SS) have been described. Mild airway obstruction has recently been recognized in these disorders, severe obstruction occurring in only a few patients with RA. We report a patient with RA and SS who developed severe irreversible airway obstruction, an association not hitherto described. The airway disease failed to respond to bronchodilators, steroids or immunosuppressive agents.
Arthritis, Rheumatoid↗