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Ran Kornowski

Publications and source records attributed to Ran Kornowski.

At least 37 records · Page 2Linked to original sources
PubMed2005

The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures.

The ACIST injection system is an automatic power injection device that allows for online control of injection rate and volume of contrast. Limited data is available whether this technology allows reducing use of contrast and fluoroscopy time. Accordingly, we compared the use of this system to manual injection among 450 consecutive patients who underwent diagnostic coronary angiography and/or angioplasty who were randomly assigned to either manual contrast injection (control; n=198) or to the ACIST system (study group; n=252). The amount of contrast, fluoroscopy and total procedural times were recorded for each patient. In the diagnostic group, the mean total amount of contrast (including wasted) was reduced by 63% when the ACIST was used compared to control (100+/-42 ml versus 163+/-56 ml; P<0.001, respectively). When only the net amount of contrast delivered to the patient was considered, the differences were smaller (20%, P=0.004). During angioplasty, the amount of contrast was also lower in the ACIST group (206+/-65 versus 230+/-69, P=0.008), whereas no difference were noted in net amount of contrast. Fluoroscopy time was significantly shorter in the ACIST group compared to control both during diagnostic catheterization (4.7+/-3.5 min versus 6.3+/-5.5 min, respectively; P=0.014), and angioplasty (16.7+/-9.1 min versus 19.6+/-12.4 min, respectively; P=0.05). Routine utilization of the ACIST system during diagnostic and interventional procedure significantly reduced the total amount of contrast media used and fluoroscopy time.

Aged↗
PubMed2005

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty.

BACKGROUND: Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines. AIM: To evaluate the in-hospital and 30-day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS. METHODS AND RESULTS: Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co-morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In-hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non-cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48 hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age 75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0-1.24, P=0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95-1.0, P=0.05), were independent predictors of all cause mortality at 30 days. CONCLUSION: Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.

Aged↗
PubMed2005

The impact of adjunctive eptifibatide therapy with percutaneous coronary intervention for acute myocardial infarction.

The role of small molecules anti-glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti-GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST-elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n=167) to those who were not on anti GP IIb/IIIa inhibitors (n=49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub-acute stent thrombosis. Nonetheless, there was a non-significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P=0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non-significant trend towards better short-term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.

Acute Disease↗
PubMed2005

Correlation between endocardial voltage mapping and myocardial perfusion: implications for the assessment of myocardial ischemia.

BACKGROUND: Recent clinical studies using a non-fluoroscopic three-dimensional (3D) left ventricular (LV) mapping system suggested reduced endocardial voltage amplitudes measured in zones sustaining myocardial ischemia or infarction. However, the direct relationship between myocardial perfusion and endomyocardial voltage amplitudes has not been fully elucidated. METHODS: In a pig model of chronic myocardial ischemia (n = 20), LV endocardial unipolar voltage (UpV) mapping was performed using the Biosense 3D navigation system (Johnson and Johnson, Warren, New Jersey, USA) 4 weeks after ameroid constrictor placement around the left circumflex coronary artery. Echocardiography was used to assess regional changes in myocardial wall thickening (MT) and fluorescent microspheres (4 x 10/injection) were used to quantify rest regional myocardial blood flow (MBF) in ischemic (left circumflex) and remote non-ischemic (left anterior descending) regions. RESULTS: UpV measurements were reduced in ischemic compared to non-ischemic zones (9.9+/-3.3 compared with 13.3+/-3.3 mV, P = 0.03). This corresponded to changes in endocardial MBF and MT, which were both noted to be significantly reduced in the ischemic compared to the non-ischemic area (MBF, 0.50+/-0.16 compared with 0.74+/-0.15 ml/g per min, P = 0.001; MT, 26.1+/-12.0 compared with 37.4+/-10.1%, P=0.003). A positive linear correlation was found between UpV at rest and endomyocardial (but not epicardial) perfusion: UpV (mV) = 7.8+5.9xMBFendocardial (r = 0.32, P = 0.05). CONCLUSIONS: Chronic myocardial ischemia, resulting in reduced perfusion and function at rest (that is, hibernating myocardium), is characterized by a significant reduction ( approximately 25%) in endocardial UpV potentials, which correlates with reduced endomyocardial blood flow and tissue perfusion at rest.

Animals↗
PubMed2004

Validation of viability assessment by electromechanical mapping by three-dimensional reconstruction with dobutamine stress echocardiography in patients with coronary artery disease.

We evaluated the ability of electromechanical mapping (EMM) to discriminate between normal, viable, and nonviable (scarred) myocardium in patients with coronary artery disease versus dobutamine stress echocardiography (DSE) when the correspondence between the test and reference data sets is established via a common 3-dimensional reconstruction of the left ventricle. We studied 21 patients with coronary artery disease who underwent angiography, biplane ventriculography, and EMM within 1 month of DSE. A 3-dimensional left ventricular (LV) reconstruction was prepared from the ventriculogram and spatially aligned with EMM. EMM measurements of unipolar voltage, bipolar voltage, and local linear shortening were projected onto the three-dimensional left ventricle, averaged in each of 16 segments, and compared with DSE viability (normal, viable, scar) assessed at a core laboratory. All of the EMM measurements varied significantly (p <0.001) between the normal, viable, and scarred myocardium as assessed by DSE. Local linear shortening for normal, viable, and scarred segments was 10.4 +/- 6.5%, 7.8 +/- 5.6%, and 4.8 +/- 4.4%, respectively. In discriminating between these 3 groups, local linear shortening was more powerful than unipolar voltage or bipolar voltage (F = 20.765, F = 10.655, F = 4.795, respectively). Local linear shortening correlated best with viability, perhaps because it shares the same cognitive function as DSE. Three-dimensional analysis provides an anatomic framework that enables direct comparison of data from multiple imaging modalities rather than assuming segmental correspondence. Our results show that EMM provides significant on-line, diagnostic information on myocardial viability assessed by DSE on a segment-by-segment basis.

Aged↗
PubMed2004

Administration of eptifibatide to acute coronary syndrome patients receiving enoxaparin or unfractionated heparin: effect on platelet function and thrombus formation.

OBJECTIVES: The goal of this study was to compare the antithrombotic effects of enoxaparin versus unfractionated heparin (UFH) when combined with eptifibatide in acute coronary syndrome (ACS) patients. BACKGROUND: An increasing number of high-risk ACS patients are treated with low-molecular-weight heparin and a glycoprotein (GP) IIb/IIIa inhibitor. There is a paucity of data regarding the antithrombotic properties of such a combination as compared with UFH and GP IIb/IIIa inhibitors. METHODS: Twenty-six ACS patients scheduled to undergo coronary angiography were treated with subcutaneous enoxaparin (n = 13) or intravenous UFH (n = 13). All patients received eptifibatide just before coronary angiography. Antithrombotic effects were assessed as changes in platelet-thrombus formation using the Badimon ex vivo perfusion chamber. Perfusions were carried out at a high shear rate (HSR) and a low shear rate (LSR). Patients underwent two perfusion studies: at baseline (under enoxaparin or UFH) and 10 min after the eptifibatide bolus. Platelet function was evaluated by ADP-induced platelet aggregation and the rapid platelet function analyzer. RESULTS: Both therapeutic combinations achieved a marked reduction in platelet aggregation after eptifibatide (83% to 89.7% reduction in the enoxaparin-eptifibatide group and 77.8% to 85.5% reduction in the UFH-eptifibatide group, inter-group differences not significant). Both groups also demonstrated marked reductions in thrombus formation, but the reductions achieved in the enoxaparin-eptifibatide group were significantly higher than those achieved in the UFH-eptifibatide group (HSR: 75.6% reduction vs. 63.9%, respectively, p = 0.01; LSR: 79.7% reduction vs. 66.1%, respectively, p = 0.0001). CONCLUSIONS: The combination of eptifibatide with enoxaparin appears to have a more potent antithrombotic effect than that of eptifibatide and UFH in the doses tested.

Anticoagulants↗
PubMed2004

Comparison of outcomes up to six months of Heparin-Coated with noncoated stents after percutaneous coronary intervention for acute myocardial infarction.

We prospectively followed 238 patients who underwent percutaneous coronary intervention for acute ST-elevation myocardial infarction and compared the outcomes of patients who received heparin-coated stents (n = 124) with those of patients who received noncoated stents (n = 114). The clinical characteristics and adjunctive medications of the 2 groups were similar. The use of heparin-coated stents was associated with improved 30-day outcome but had no significant effect on 180-day outcome.

Aged↗
PubMed2004

Anterior wall myocardial infarction in real world: does reperfusion strategy make any differences?

Some prospective randomized trials have established the superiority of primary percutaneous coronary intervention (PCI) over fibrinolytic treatment in patients with acute myocardial infarction (MI). These excellent PCI results are not duplicated in smaller hospitals where there may be delays in getting the cardiac catheterization team to the laboratory. This study aimed to compare the outcome of patients with anterior wall MI, without cardiogenic shock on admission, treated with primary PCI or thrombolytic therapy, in everyday practice. The data of all patients with MI hospitalized in all coronary care units operating in Israel during three consecutive national surveys was analyzed. A total of 1,038 patients with anterior wall MI were treated by reperfusion (886 received thrombolytic therapy, 152 primary PCI). Overall, the outcome of patients treated using primary PCI was better compared to patients treated with thrombolysis, with 68% relative risk reduction of 30-day mortality (mortality at 30 days: 2% vs. 6.3%; P = 0.04). A subanalysis of patients according to age showed that the beneficial effect of primary PCI on mortality was mainly clustered among the younger. In our study, patients (especially younger than 75 years) with anterior wall MI allocated to primary PCI have a better clinical outcome.

Age Factors↗
PubMed2004

Clinical experiences using the FilterWire EX for distal embolic protection during complex percutaneous coronary interventions.

BACKGROUND: Distal embolization during coronary angioplasty may result in vessel occlusion, no reflow and myonecrosis. This study tested the authors' clinical experiences using a guidewire system designed to preserve distal flow during angioplasty. METHODS AND RESULTS: The FilterWire EX trade mark (Boston Scientific, Natick, MA, USA) consists of a 0.014-inch guidewire on which an expandable loop structure is attached to a porous polyurethane membrane. The assembly is delivered across the target lesion, followed by deployment of the filter distal to the lesion. Procedural and angiographic outcome data were obtained from patients undergoing saphenous vein grafts (SVGs) (n = 16) or native coronary (n = 4) interventions. The mean age was 62 +/- 10 years. All four patients with native coronary lesions sustained acute myocardial infarction while 15/16 patients with degenerated SVGs presented with accelerated angina pectoris. The mean proximal reference diameter was 3.62 +/- 0.32 mm, percentage diameter stenosis was 72 +/- 13%, and lesion length was 16.3 +/- 5.7 mm. Angiographic visible thrombus was detected in 12/20 (60%) cases. Stents were used in 19/20 patients (95%) with average stent diameter/length equal to 3.81 +/- 0.42/23 +/- 7 mm. Overall procedural success was obtained in 93.3% as no-reflow and total CK elevation occurred in 1/16 treated patients (6.7%) despite distal embolic filtration. In-hospital and 30-day survival was 100% with no episodes of target vessel thrombosis and/or myocardial infarction. CONCLUSIONS: The use of the FilterWire EX seems to be feasible and safe in suitable lesion subsets and in relatively large-sized vessels among patients who are at high risk for distal embolization.

Angioplasty, Balloon, Coronary↗
PubMed2004

Acute and intermediate-term clinical outcomes following Heparin coated BX coronary stent implantation in patients with thrombus containing lesions.

BACKGROUND: Coronary stenting in acute coronary syndromes might be associated with increased procedural complications and stent thrombosis risk. Heparin-coated stent (HCS) may improve procedural outcomes when treating these high-risk lesions. The purpose of this study was to determine the safety and efficacy of HCS in patients with acute coronary syndromes and thrombus containing lesions. METHODS: Between January 2001 and January 2002, 49 patients (42 male) with thrombus containing lesions (32 sustained acute myocardial infarction) received HC BX stents (HepaCoat) at our hospital. Procedural, hospital and six-month outcomes and quantitative angiographic analysis data were obtained from all patients. RESULTS: The mean age of patients was 58 +/- 14 years, 45% had multi-vessel disease and 24% were diabetics. Fifteen patients (31%) received a second HCS for sub-optimal results or threatened closure. Procedural success was achieved in 94% of patients. The mean stent diameter and length was 3.2 +/- 0.2 mm and 18.2 +/- 7.4 mm. The mean TIMI flow increased from 1.3 +/- 1.3 to 2.9 +/- 0.3 and the mean diameter stenosis before and after intervention was 84 +/- 21% and 12 +/- 14%. In-hospital and 30-day follow-up were eventually without occurrence of death, myocardial infarction, stent thrombosis, coronary bypass. At six-months follow-up, cardiac event-free survival was 89.8%, target vessel revascularization was 6.1 and 90% of patients were free of angina. CONCLUSION: In this series of patients with acute ischemic syndromes associated with visible thrombus, the use of HCS resulted in (1) favorable procedural and six-month outcomes, (2) no incidence of stent thrombosis, and (3) overall good cardiac prognosis at six-month follow-up.

Adult↗
PubMed2004

Trends in cardiac surgery in Israel, 1985-2002.

BACKGROUND: Reports from Europe and North America indicate that significant changes have occurred in the practice of cardiac surgery in the last two decades. OBJECTIVES: To examine the trends and case-mix in cardiac surgery in Israel and their relationship with changes in invasive cardiology. METHODS: We analysed data collected by the Ministry of Health from all cardiac centers in Israel from 1985 to 2002. RESULTS: Three periods were identified: the 1980s, when a relatively small number of operations were performed; 1990-1994, characterized by a dramatic rise in the number of operations; and 1994-present, characterized by a small decline and stabilization in the rate of operations. The percentage of valve procedures increased significantly from 15% of all cardiac surgeries in 1991 to 21% in 2002 (P = 0.002). In addition, the chance of a diagnostic coronary angiography being followed, in the same patient, by an interventional procedure such as percutaneous transluminal coronary angioplasty or by a coronary artery bypass graft increased dramatically from 42% in 1991 to 69% in 2002. At Rabin Medical Center, there was a constant decline in the percent of repeated CABGs out of the total CABGs performed, from 6.7% in 1996 to 1.3% in 2002. CONCLUSIONS: Despite the rise in the rate of percutaneous coronary interventions since 1991, there has been no significant decline in the rate of CABGs performed. However, there is a significant shift to more complex operations. The number of repeated CABG operations has significantly decreased and, in view of the growing use of arterial grafts and further improvements in invasive cardiology techniques, we expect this decline to continue.

Angioplasty, Balloon, Coronary↗
PubMed2004

Coronary bifurcation lesions: to stent one branch or both?

OBJECTIVE: The purpose of this study was to evaluate two different stent placement techniques for bifurcation lesions: 1) stenting of the main branch and balloon dilatation of the sidebranch versus 2) stenting of both branches. BACKGROUND: Percutaneous coronary intervention (PCI) of coronary bifurcation lesions remains challenging, and limited information is available regarding whether stent placement is necessary in both branches of the bifurcation using bare-metal stents. Methods. We prospectively followed all patients who underwent PCI for symptomatic bifurcation lesions at our center. All patients were carefully followed for subsequent clinical events. RESULTS: Between March 2001 and November 2002, a total of 50 patients were treated with either stenting of both vessels (double stent group; n = 32) or stenting of the parent vessel and balloon angioplasty of the sidebranch (single stent group; n = 18). Optimal angiographic success was 87.5% in the single stent group and 100% in the double stent group (p = 0.1). The post-procedure percent diameter stenosis of the sidebranch vessel was significantly higher in the single stent group (18 +/- 25% versus 4 +/- 8%; p = 0.005). At 6 months, the incidence of clinically driven repeat target lesion revascularization was 37.6% with 2 stents as compared to 5.6% using 1 stent (p = 0.01). Angiographic restenosis was documented in 40.6% using 2 bifurcation stents, as compared to 11% when using 1 stent (p = 0.05). By multivariable analysis adjusted for baseline differences, stenting the sidebranch was a borderline predictor for major adverse cardiac events at 6 months (odds ratio = 10.3; 95% confidence interval, 0.9-116; p = 0.053). CONCLUSION: For the treatment of true bifurcation lesions, a strategy of stenting both vessels using bare metal stents seems to be associated with worse long-term results, as compared to stenting only the parent vessel.

Angioplasty, Balloon↗
PubMed2004

Acute and intermediate-term results of percutaneus left main coronary artery interventions.

BACKGROUND: Left main coronary artery disease is considered a surgical indication in most centers. However, in some cases prohibited from surgery or in patients with prior bypass grafting, there is a need for percutaneous coronary intervention in LMCA disease scenarios. OBJECTIVES: To assess the clinical outcomes among patients undergoing stent-based LMCA angioplasty. METHODS: We identified 34 consecutive patients who underwent PCI in LMCA at our institution. Procedural data and clinical outcomes were obtained for all patients. RESULTS: The mean age was 71 +/- 12 years. There were 27 elective and 7 emergent procedures performed on 23 "protected" LMCA and 11 "unprotected" LMCA. In emergent procedures, the prevalence of cardiogenic shock (29% vs. 0%, P = 0.04) in patients with prior coronary bypass (29% vs. 8.5%, P = 0.007) was significantly higher compared to elective cases. Procedural success in emergent procedures was significantly lower than in elective procedures (71 vs. 100%, P = 0.04). In emergent versus elective procedures, the in-hospital mortality rate was higher (43 vs. 0%, P = 0.006). The rate of cumulative major adverse cardiac events at 1 and 6 months was 43% and 71% in emergent cases versus 0% and 33% in elective cases (P < 0.05 for both comparisons). In patients with "unprotected" LMCA the overall rate of major cardiac events at 1 month was higher compared to "protected" LMCA patients (27 vs. 0%, P = 0.02). Multivariate analysis revealed emergent procedure as an independent predictor for mortality and adverse cardiac events (odds ratio 6.7, 95% confidence interval 1.2-36; P = 0.02). CONCLUSIONS: Percutaneous interventions in LMCA are feasible and relatively safe in carefully selected cases. Procedural outcomes and clinical prognosis is highly dependent on the nature of disease prior to angioplasty (e.g., elective vs. emergent procedure) as well as on protection of the LMCA by patent grafts.

Aged↗
PubMed2003

Degrees of severe stenoses in sigma-shaped versus C-shaped right coronary arteries.

The right coronary artery (RCA) appears either C-shaped or sigma-shaped during standard angiography. The purpose of the present investigation was to assess whether C-shaped RCAs are associated with more atherosclerotic disease than sigma-shaped RCAs. The study sample comprised 120 consecutive patients who underwent coronary catheterization and multivariate analysis was conducted using several systemic risk factors for atherosclerosis. The proportion of sigma-shaped RCAs found in a group whose angiograms showed little or no obstruction (70%) was significantly higher than that found in the group with significant obstruction (33%, p <0.001). In conclusion, a C-shaped RCA is associated with atherosclerosis.

Adult↗
PubMed2003

Catheter-based autologous bone marrow myocardial injection in no-option patients with advanced coronary artery disease: a feasibility study.

OBJECTIVES: We conducted a pilot study to evaluate the feasibility of transendocardial delivery of autologous bone marrow (ABM) strategy in patients with severe symptomatic chronic myocardial ischemia not amenable to conventional revascularization. BACKGROUND: Transendocardial injection of ABM cells appears to enhance perfusion of ischemic porcine myocardium. METHODS: Ten patients underwent transendocardial injection of freshly aspirated and filtered unfractionated ABM using left ventricular electromechanical guidance. Twelve injections of 0.2 ml each were successfully delivered into ischemic noninfarcted myocardium pre-identified by single-photon emission computed tomography perfusion imaging. RESULTS: Autologous bone marrow injection was successful in all patients and was associated with no serious adverse effects; in particular, there was no arrhythmia, evidence of infection, myocardial inflammation, or increased scar formation. Two patients were readmitted for recurrent chest pain. At three months, Canadian Cardiovascular Society angina score significantly improved (3.1 +/- 0.3 vs. 2.0 +/- 0.94, p = 0.001), as well as stress-induced ischemia occurring within the injected territories (2.1 +/- 0.8 vs. 1.6 +/- 0.8, p < 0.001). Treadmill exercise duration, available in nine patients, increased, but the change was not significant (391 +/- 155 vs. 485 +/- 198, p = 0.11). CONCLUSIONS: This study provides preliminary clinical data indicating feasibility of catheter-based transendocardial delivery of ABM to ischemic myocardium.

Bone Marrow Transplantation↗
PubMed2003

Preliminary experiences using X-sizer catheter for mechanical thrombectomy of thrombus-containing lesions during acute coronary syndromes.

Thrombus-containing lesions are frequently observed in patients with acute coronary syndromes. These lesions are prone to increased procedural risks, including distal embolization and abrupt closure of the vessel. This preliminary report evaluates if thrombus removal using a new X-Sizer catheter could reduce thrombotic burden and optimize angioplasty results. Thrombectomy was attempted with the X-Sizer catheter in 11 patients (age, 59 +/- 10 years) undergoing coronary angioplasty with angiographic evidence of intracoronary thrombus. The device uses a helix cutter contained in a 4.5 or 5.5 Fr catheter tip connected to a closed vacuum aspiration system. Procedural outcomes using detailed angiographic analysis and clinical data were obtained from all treated patients. Seven patients (64%) had acute or recent myocardial infarction and four patients (36%) presented with unstable angina. The culprit lesion was located in right coronary, left anterior, vein graft, and circumflex-marginal in five, three, two, and one patient, respectively. The mean proximal reference diameter was 3.37 +/- 0.39 mm and % diameter stenosis was 90% +/- 15% prior to thrombectomy and decreased to 72% +/- 16% afterward and was 9% +/- 10% at the end of the procedure. The TIMI flow increased from 0.8 +/- 1.0 to 2.1 +/- 0.9 following thrombectomy and the final TIMI grade was 2.9 +/- 0.3. Stents were used in 9 of 11 patients. Procedural success was achieved in 10 of 11 patients (91%). No evidence of stent thrombosis was noted among treated patients in hospital and at 30-day follow-up. In this preliminary series of patients with angiographic evidence of thrombus, the use of X-Sizer thrombectomy seems to be feasible and relatively safe, permitting thrombus removal and improved intracoronary flow.

Aged↗