Biomedical subjects
Publications and source records attributed to P Angelini.
Two patients with coarctation of the abdominal aorta are reported. They both underwent successful transluminal balloon angioplasty. The immediate and short-term results have been excellent. This method and its role in the treatment of coarctation of the abdominal aorta are discussed.
The presence of cyanosis following repair of congenital cardiac defects may result from several different mechanisms. We report two patients in whom early postoperative arterial hypoxemia manifested by cyanosis was caused by right-to-left interatrial shunting. Two-dimensional contrast echocardiography correctly identified the site and direction of shunting, leading to surgical correction of the complication.
A rare paraganglioma of the chromaffin type, located intrapericardially, was removed from a 42-year-old man by autotransplantation of the heart. Although the results were unfavorable in this case, the technique of autotransplantation deserves consideration in resecting large tumors that encroach upon the heart. To our knowledge, this technique has not been previously used for surgical excision of cardiac tumors.
Some reports of coronary bypass spasm recently published in the literature aroused skepticism and discussions. Our own doubts were shared by many who have been doing coronary bypass angiography without ever finding such spasms. However, we report a case of a 45-year-old woman with spasm of a vein graft inadvertently induced by catheter manipulation.
Of 518 consecutive patients undergoing percutaneous transluminal coronary angioplasty for 571 coronary lesions, 184 eventually underwent coronary artery bypass because of angioplasty failure. Delayed coronary bypass (1 week to 19 months) was done in 27 patients with no deaths. Immediate bypass was done in 87 patients with two deaths, both of which were caused by further dissection of the artery after angioplasty. Urgent bypass was required in 63 patients who were in unstable condition because of ischemia on the electrocardiogram (52 patients), unrelieved angina (57 patients), or hypotension (13 patients). There was one death in this group. In the remaining seven patients, urgent coronary bypass was done because of cardiac arrest (three deaths). Myocardial complications occurred in 23 of the 70 unstable patients, including the seven patients with cardiac arrest. There were only eight completed myocardial infarctions in the 70 unstable patients and a completed myocardial infarction rate of 11 of 184 (6.0%) overall. In the 10 patients in whom extracorporeal circulation was established within 25 minutes of myocardial insult, mortality and myocardial complications were completely avoided. The remaining patients in the urgent group were placed on cardiopulmonary bypass within 26 to 300 minutes (mean 82 minutes). Operative mortality (3.3%), completed myocardial infarction (6.0%), myocardial infarction in unstable patients (32.9%), postoperative hemorrhage (5.0%), and sternal problems (2.8%) were all significantly different from those in 3,500 consecutive coronary bypasses not following angioplasty, that were done in 1982.
To evaluate the ability of transluminal coronary angioplasty (TCA) to relieve myocardial ischemia, 44 patients with single vessel disease underwent exercise gated radionuclide ventriculography (GRNV) before and 2.8 +/- 1.3 days following angiographically successful TCA. Pre-TCA GRNV was abnormal in 11 of 14 patients with right coronary artery (RCA) stenosis and 24 of 30 with left anterior descending (LAD) stenosis. Following TCA there was an increase in exercise duration from 500 +/- 288 sec to 625 +/- 273 sec (P less than 0.001), and in maximum double product from (209 +/- 69) x 10(2) to (263 +/- 70) x 10(2) (P less than 0.001). The number of patients with stress-induced ST-T abnormalities decreased from 13 to 4 (P less than 0.05), and the number with chest pain during exercise decreased from 18 to one (P less than 0.001). Whereas resting ejection fraction was unchanged (0.58 +/- 0.10 vs 0.59 +/- 0.11) following TCA, the ejection fraction at peak exercise increased from 0.61 +/- 0.13 to 0.66 +/- 0.12 (P less than 0.001). Of 24 patients with resting abnormalities, regional wall motion improved in 13. In 22 of 31 patients with stress-induced asynergy, the wall motion response to exercise improved (P less than 0.001). Of 19 patients restudied angiographically and with exercise GRNV at 6-12 months, restenosis of greater than or equal to 50% had occurred in six, four of whom had abnormal studies. In six of whom the degree of stenosis of the dilated artery had remained less than or equal to 20% the exercise GRNV study remained normal. It is concluded that GRNV is helpful in documenting the improvement in resting left ventricular function and functional reserve in patients with angiographically successful TCA. In the limited number of patients with late follow-up studies, data suggest that GRNV may be a valuable test to detect restenosis.
The initial anatomic findings of angiography during acute myocardial infarction, as well as the techniques used for selective coronary streptokinase infusion, are presented in this report. Preliminary evaluation of streptokinase infusion studies seems to indicate that revascularization of coronary arteries occluded during myocardial infarction is quickly and easily achievable and could constitute the treatment of choice; however, critical questions still remain to be answered. Recanalization rates vary from 75 to 90% in the different, usually small, series. The time of recanalization seems critical to the salvage of ventricular myocardium; e.g., recanalizations accomplished before a time lapse of 3 to 4 hours appear to limit infarct size, whereas, results appear doubtful after that time. The early mortality rate is similar to that of patients not treated with streptokinase, but the mortality at 1 month and 6 months is apparently in favor of the treated group. While thrombolytic agents may not turn out to be the panacea that some researchers have expected, recent experience has greatly contributed to the understanding of the pathophysiology of myocardial infarction and the critical importance of the time factor in planning therapy.
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.
Sixteen transluminal coronary angioplasty procedures (TCA), eight right coronary artery (RCA) and eight left anterior descending coronary artery (LAD), by the brachial artery cut-down approach, were attempted with 9/16 (56%) immediate successes and 2/16(12%) early recurrences. The procedure success rate for RCA obstructive lesions, 6/8 (75%) was greater than for LCA obstructions, 3/8 (38%). In six unsuccessful procedures the balloon catheter could not be advanced into the lesion, and in one unsuccessful procedure dissection of the coronary artery proximal to the lesion occurred. The brachial (Sones) technique for transluminal coronary angioplasty permits the use of softer guiding catheters for selective probing and approach to the coronary lesion but may be more likely to induce coronary spasm. Complete and high-resolution pre TCA angiograms with multiple views to disclose the exact anatomy of the coronary artery and its lesion is essential to ensure successful dilatation.
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A rare case of coronary anomaly is presented: all of the coronary arteries orignated from a single ostium located in the right coronary cusp. No clinical evidence of coronary pathology was recognized until the age of 57 years when the patient was found to have coronary obstructive disease. The single coronary artery had a main branch corresponding to the usual dominant right coronary artery. Three other branches separated from this and vascularized the areas normally receiving the circumflex and ramus medianus, the left anterior descending, and a large septal branch.
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An unusual case of cor triatriatum dexter is presented. Abnormal embryologic development of the eustachian valve caused nearly complete septation of the right atrium in a 67-year-old woman. Multiple supraventricular arrhythmias prompted clinical evaluation and diagnosis. Surgical excision of the anomalous membrane resulted in complete relief from arrhythmias and a clinical cure. Cor triatriatum dexter is rare and is infrequently diagnosed before postmortem study; however, once the diagnosis is extablished, the condition is amenable to a relatively simple surgical correction. Supraventricular tachycardia has not previously been reported to be associated with cor triatriatum dexter. We believe this is the first case in which such arrhythmias led to early diagnosis and successful surgical correction.
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A 42-year-old woman with an anomalous left coronary artery originating from the pulmonary artery and a fistula from the left coronary artery to the left ventricle was treated by aortocoronary bypass grafting of an autologous saphenous vein. The presence of an abundant collateral circulation and of fistulous communications between the left coronary artery and the left ventricle, in our opinion, was the reason that this patient remained asymptomatic until the age of 40 years. We believe that this is the first report of the findings in an adult patient who had these two rare congenital anomalies complicated occlusive coronary arterial disease.