Intracoronary Ergonovine Provocation Test in Patients with Coronary Artery Spasm

BACKGROUND: Intravenous ergonovine and intracoronary acetylcholine tests have been used to induce coronary artery spasm, however, potential preblems with each test require a safer and more specific test. METHODS: To evaluate the usefulness of the intracoronary ergonovine provocation test in patients with coronary artery spasm, this test was performed in 83 patients(male 47, female 36) with normal or near-normal looking coronary angiography or insignificant lesion less than 50% in diameter after routine diagnostic coronary angiography. Ten micrograms of ergonovine maleate diluted in 1 ml of saline was injected into right coronary artery up to 2 times and into left coronary artery up to 3 times. Induction of coronary arterial narrowing more than 75% of luminal diameter with typical chest pain and/or ECG changes in two or more adjacent leads was considered as a positive test. RESULTS: Intracoronary ergonovine provocation tests were positive in 33 patients among 83 patients. In 24 patients, coronary artery spasm was induced in RCA, 12 patients in LAD and 8 patients in LCX. Coronary artery spasm of 2 sites was observed in 11 patients. In 27 patients, typical chest pain was developed with spasm. The ECG changes during spasm were ST elevation in 19 patients, ST depression in 3 patients, T wave change only in 2 patients and no change in 9 patients. The provocation tests showed focal spasm in 23 patients(70%) and diffuse spasm in 10 patients(30%). CONCLUSION: Intracoronary ergonovine provocation test appears to be a safe and effective method to provoke the coronary artery spasm.

Clinical Utility of Transesophageal Echocardiography(TEE) in Prosthetic Valve Dysfunction

BACKGROUND: Better imaging resolution and less flow masking with TEE than with TTE makes it easier to evaluate the prosthetic valve dysfunction. However, direct comparison between two methods to evaluate prosthetic valve dysfunction remains elucidated. METHODS: Both TTE and TEE were performed in 19 patients with suspected prosthetic valve dysfunction who were admitted to Seoul National University Hospital for evaluating porsthetic valve dysfunction from July, 1992 to May, 1993 and those findings were compared with those of cardiac catheterization and angiography, and surgery 19 cases were included in this study. RESULTS: 11 patients with congestive heart failure underwent TTE, TEE and angiography and each finding was compared to one another. We could see that there is good correlation between transesophageal echocardiographic and angiographic grading in the severity of regurgitation but poor correlation between transthoracic echocardiographic and angiographic finding in that of regurgitation. We also could differentiate between central and eccentric leakage with TEE and in 2 cases TEE enabled us to detect a vegetation on prosthetic valve not detected with TTE and in 1 case the cause of cardiac hemolysis could be known with TEE : eccentric leakage in prosthetic mitral valve. Left atrial thrombi were detected with TEE in two patients with recent cerebral infaction history. CONCLUSION: We conclude that TEE is a good method that enables us to diagnosize the prosthetic valve dysfunction and detect the structural abnormalities surrounding prosthetic valve such as paravalvular leakage, vegetation, cardiac hemolysis and Left atrial thrombi not detected easily by TTE.

Evaluation of the Left-to-Right Shunt after Percutaneous Mitral Valvuloplasty

BACKGROUND: A left to right shunt through an iatrogenic atrial septal defect(ASD) is known to occur after percutaneous mitral valvuloplasty(PMV), however, its hemodynamic significance as well as methods for the quantitation and follow-up evaluation have not been well established. SUBJECTS AND METHOD: In order to compare the feasibilities of noninvasive diagnostic methods for the detection and quantitation of the left-to-right shunt after PMV. 35 patients(age 37+/-10 years) undertook either radionuclide angiography or transesophageal echocardiography or both within a week after PMV. Qp/Qs was calculated by Fick's oxygen method during cardiac catheterization and by indicator dilution method during radionuclide angiography. The left-to-right shunt was also quantified with transesophageal echocardiography(TEE) by calculating shunt flow rate(Q=2 pir2Vr) using isovelocity surface area. RESULT: TEE was the most sensitive to detect ASD(16 among 27 patients, 59%) compared to either RI angiography(5 among 27 patients, 18%, Qp/Qs>1.5) or cardiac catheterization(4 among 35 patients, 11%, oxygen step-up>7%). Calculated shunt flow rate by TEE showed significant linear correlation to the Qp/Qs by cardiac catheterization(r=0.73, p<0.001). Also there was a significant correlation between Qp/Qs by radionuclide angiography and by cardiac catheterization(r=0.49, p<0.01). CONCLUSION: Both radionuclide angiography and TEE appear useful for the detection and quantitation of the left to right shunt after PMV. Since TEE seems to be not only more sensitive to detect the presence of the ASD than either radionuclide angiography or cardiac catheterization but useful to quantify the left-to-right shunt, it appears to be useful method for the follow-up evaluation after PMV.

Clinical significance of plasma tissue plasminogen activator and plasminogen activator inhibitor-1 in chronic stable angina

BACKGROUND: Impaired fibrinolytic system has been considered to play an important role in the pathogenesis of coronary artery disease, especially associated with thrombus formation. To evaluate the pathogenetic role of fibrinolytic system in coronary artery disease, major determinants of fibrinolytic system, tissue plasminogen activator(t-PA) and palsminogen activator inhibitor-1(PAI-1) levels were measured in control(n=7) and chronic stable angina patients(n=7). METHODS: Blood samplings were done in resting state, venous occlusion and peak exercise. Levels of plasma t-PA antigen and PAI-1 antigen were measured by ELISA method. RESULTS: 1) In resting state, there was no significant difference in plasma level of t-PA(control group : 9.15+/-2.82ng/ml vs, study group ; 9.65+/-3.53ng/ml) and PAI-1(control group ; 20.27+/-9.98ng/ml vs, study group ; 17.43+/-3.53ng/ml) between each group. 2) With venous occlusion test, increment of plasma t-PA level was noted in both groups which was lower in patient group, however, this difference in increment was not statistically significant. 3) Increased plasma t-PA level was noted after exercise in both groups. 4) Plasma level of PAI-1 was not significantly changed after venous occlusion or exercise in both groups. CONCLUSIONS: In patients with chronic stable angina, there was no definite evidence of impaired fibriolytic system although plasma t-PA increased somewhat less after venous occlusion in patients with chronic stable angina than control.

A Case of Reflux Esophagitis, Classic Migraine and Raynaud's Disease in Proven Variant Angina

The high prevalence of migraine. Raynaud's phenomenon, visual field defect and Crohn's disease in variant angina raises the possibility that a common underlying defect of mechanism may partially account for all conditions. These are generalized vascular smooth muscle hypercontractility syndromes. Recently high prevalence of esophageal motility disorders has been noted in patients with coronary artery spasm or microvascular angina, leading to the hypothesis of a generalized abnormality in smooth muscle function1,4,5). We expirienced a case of 55-year-old man with angiographically proven variant angina. Who showed reflux esophagitis, classic migraine and Raynaud's disease.

Clinical and Electrophysiologic Characteristics of Idiopathic Sustained Left Ventricular Tachycardia

Ventricular tachycardias(VTs) usually complicate iscemic heart disease. Cardiomyopathy or other organic heart disease and are aften associated with sudden cardiac death. Ventricular tachycardias with no apparent cardiac abnormalities, however, have been known to have different clinical features comprising a unique clinical entity among other tachycardias. Eleven patients(7men, 4 women) were investigated on their clinical features, electrophysiologic studies and late potentials. 1) The mean age at diagnosis was 23.4+/-6.5 years and the predominating clincal features were palpitation, syncope or congestive heart failure. No death occured over a mean follow up period of 29.2+/-26.5 months. 2) The resting ECGs were within normal limits in 8 patients and showed nonspecific ST-T changes in 3 patients. 3) Ventricular pacing induced sustained ventricular tachycardias in 7 patients and nonsustained VT in 1 aptient. Atrial pacing could provoke sustained VTs in 3 patients. 4) His bundle electrograms(HBE) were obtained in 7 patients during tachycardial. The HV intervals of the induced VTs distributed between 0 to -25msec in 5 patients and there was no definite His potentials in two patients. 5) The coupling interval of premature stimuli and the echo interval(the interval from the stimulus to the initiation of resulting VT) showed inverse relationship in 5 cases. No direct relationship was observed. 6) The termination mode, observed in 7 patients, showed delayed ternmination in 2 patients. 7) Late potentials(LPs) were pisitive in three patients but there was no significant statistical difference between LPs in normal control and those with idiopathic sustained left VTs. 8) Verapamil terminated VTs in 8 patients and slowed the rate of tachycardial in 1 patient. In conclusion, idiopathic sustained left ventricular tachycardias occur in younger age group and have more favorable prognosis. The findings of EPS and LPs suggest microreentry or triggered activity as their basic mechanism and verapamil can be used effectively for their termination.

Intravenous Verapamil for Reversal of Refractory Coronary Vasospasm and Cardiac Arrest

No abstract available.