Spontaneous left anterior descending artery to right ventricular fistula.

We report a very unusual case of a spontaneously acquired left anterior descending to right ventricular fistula. We believe that this spontaneous occurrence was the result of hemodynamic changes that occurred between the first and second catheterizations.

Single left coronary artery with origin of the right coronary artery from distal circumflex.

We report two very unusual cases of agenesis of the right coronary ostium with continuation of the left circumflex artery as the right coronary artery. The recognition of the anomaly in the first case lead to a better understanding of this finding in the second case, which translated into shorter procedure time, less contrast volume, and fewer catheter manipulations.

A simplified lesion classification for predicting success and complications of coronary angioplasty. Registry Committee of the Society for Cardiac Angiography and Intervention.

In 1988, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures presented a classification of coronary lesions utilizing 26 lesion features to predict the success and complications of balloon angioplasty. Using data from the Registry of the Society for Cardiac Angiography and Interventions (SCAI) we evaluated the ability of this classification to predict success and complications. Lesion success, death in hospital, emergency cardiac bypass surgery, and major adverse events were evaluated in 41,071 patients who underwent single-vessel angioplasty from January 1993 to June 1996. Logistic models using the ACC/AHA lesion classification, vessel patency, or both, were compared. A new classification based on the interaction of the ACC/AHA classification plus lesion patency was compared with the existing ACC/AHA classification. Vessel patency, added to the ACC/AHA classification, improved prediction of lesion success (p

0.125% ropivacaine is similar to 0.125% bupivacaine for labor analgesia using patient-controlled epidural infusion.

UNLABELLED: We compared the effects of 0.125% ropivacaine with 0.125% bupivacaine in laboring patients using patient-controlled epidural analgesia (PCEA). Fifty-one ASA physical status I or II term parturients with functioning epidural catheters were randomized to receive ropivacaine or bupivacaine using a prospective, double-blind design. Basal infusions (6 mL/h) were supplemented with patient-controlled boluses (5 mL) every 10 min as required. For inadequate analgesia, patients were administered 10-mL boluses of study solution until comfortable. There were no differences in verbal pain scores, amount of local anesthetics used, sensory levels, motor blockade, labor duration, mode of delivery, side effects, or patient satisfaction between the two local anesthetics. We conclude that 0.125% ropivacaine and bupivacaine are clinically indistinguishable and are both highly effective for labor analgesia using PCEA. IMPLICATIONS: This study compared labor analgesia from 0.125% ropivacaine and 0.125% bupivacaine using patient-controlled epidural analgesia. We found no significant differences in local anesthetic use, analgesic characteristics, or side effects between 0.125% ropivacaine and 0.125% bupivacaine. We conclude that these two drugs are clinically indistinguishable at this concentration.

Thrombolysis and intervention in acute myocardial infarction: an overview.

The use of thrombolytic agents in acute myocardial infarction (AMI) has been extensively studied for the past decade and a half and has become the standard of care for most patients presenting early in the course of AMI. Despite this general acceptance, there remains controversy over the choice of thrombolytic, the use of adjunctive anti-platelet and anti-thrombotic agents, the proper role for PTCA, especially direct PTCA, and the potential role for new interventional devices. The intent of this article is to examine in turn each of these areas, reviewing selected data from relevant trials. In so doing we shall develop an overall concept for reperfusion in AMI to quide our ongoing efforts at resolving our remaining therapeutic challenges.

Radiation-induced stenosis of the left main coronary artery.

Isolated left main coronary artery stenosis induced by mediastinal radiation is a well-documented but rare entity. Its clinical manifestations can be latent for many years, but its ominous sequela cannot be ignored. We report here such a patient presenting 16 yr postmediastinal radiation, the longest documented latency to date.

The reliability of adjustment in strabismus surgery.

It has been recommended that the position of the operated muscles be adjusted shortly after strabismus surgery to achieve better alignment on the first postoperative day and thereby ensure satisfactory later alignment. We compared prism cover test measurements on the first postoperative day with measurements within the first few months after surgery to determine whether day 1 measurements remained stable or whether they changed significantly, providing an inaccurate basis for adjustment. Our study found a fairly large variability in the deviation between the first and last day of the study. Eighteen percent of patients varied by 5 to 9D, and 49% differed by > 10D or more. Equally important was the finding that, had an adjustment been made, it would have made the final result worse than without adjustment. Both of these factors would seem to indicate a degree of variability that controverts the predictability of the adjustment procedure.

Selective versus routine predischarge coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction. TIMI II Investigators.

To ascertain whether predischarge arteriography is beneficial in patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator (rt-PA), heparin and aspirin, the outcome of 197 patients in the Thrombolysis in Myocardial Infarction (TIMI) IIA study assigned to conservative management and routine predischarge coronary arteriography (routine catheterization group) was compared with the outcome of 1,461 patients from the TIMI IIB study assigned to conservative management without routine coronary arteriography unless ischemia recurred spontaneously or on predischarge exercise testing (selective catheterization group). The two groups were similar with regard to important baseline variables. During the initial hospital stay, coronary arteriography was performed in 93.9% of the routine catheterization group and 34.7% of the selective catheterization group (p less than 0.001), but the frequency of coronary revascularization (angioplasty or coronary artery bypass surgery) was similar in the two groups (24.4% versus 20.7%, p = NS). Coronary arteriograms showed a predominance of zero or one vessel disease (stenosis greater than or equal to 60%) in both groups (routine catheterization group 73.1%, selective catheterization group 61.3%). During the 1st year after infarction, rehospitalization for cardiac reasons and the interim performance of coronary arteriography were more common in the selective catheterization group (37.9% versus 27.6%, p = 0.007 and 28.6% versus 11.6%, p less than 0.001, respectively); however, the interim rates of death, nonfatal reinfarction and performance of coronary revascularization procedures were similar. At the end of 1 year, coronary arteriography had been performed one or more times in 98.9% of the routine catheterization group and 59.4% of the selective catheterization group (p less than 0.001), whereas death and nonfatal reinfarction had occurred in 10.2% versus 7.0% (p = 0.10) and 8.6% versus 9.0% (p = 0.87), respectively. Because the selective coronary arteriography policy exposes about 40% fewer patients to the small but finite risks and inconvenience of the procedure without compromising the 1 year survival or reinfarction rates, it seems to be an appropriate management strategy.

Comparison of immediate invasive, delayed invasive, and conservative strategies after tissue-type plasminogen activator. Results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II-A trial.

To assess the value and timing of percutaneous transluminal coronary angioplasty (PTCA) after thrombolytic therapy for acute myocardial infarction (AMI), 586 patients in the Thrombolysis in Myocardial Infarction Study Phase II-A were randomized among three treatment strategies, one using immediate coronary arteriography followed by PTCA if appropriate (immediate invasive strategy group, n = 195), a second that deferred angiography and PTCA for 18-48 hours (delayed invasive strategy group, n = 194), and a third, more conservative, approach in which PTCA was used only if ischemia occurred spontaneously or at the time of predischarge exercise testing (conservative strategy group, n = 197). Predischarge contrast left ventricular ejection fraction, the primary study end point, was similar among the patients in all three treatment groups and averaged 49.3%. The finding of a patent infarct-related artery at the time of predischarge arteriography was equally common among the patients in the three groups (mean, 83.7%); however, the mean residual infarct artery stenosis was greater in the patients in the conservative strategy group (67.2%) as compared with the patients in the immediate invasive (50.6%) and the delayed invasive strategy groups (47.8%) (p less than 0.001). Immediate invasive strategy led to a higher rate of coronary artery bypass graft surgery (CABG) after PTCA (7.7%) than did delayed invasive and conservative strategies (2.1% and 2.5%, respectively; p less than 0.01). Furthermore, among patients not undergoing CABG during the first 21 days, blood transfusion of more than 1 unit was used in 13.8% of the patients in the immediate invasive strategy group, 3.1% of the patients in the delayed invasive strategy group, and 2.0% of the patients in the conservative strategy group (p less than 0.001). At 1-year follow-up, the three treatment groups had similar cumulative rates of mortality (8.7%, pooled over all groups), fatal and nonfatal reinfarction (8.5%), combined death and reinfarction (14.5%), and CABG (17.2%), although the cumulative performance rate of PTCA remained higher in the invasive groups (immediate invasive strategy group, 75.8%; delayed invasive strategy group, 64.3%; and conservative strategy group, 23.9%; p less than 0.001). Thus, because conservative strategy achieves equally good short- and long-term outcome with less morbidity and a lower use of PTCA, it seems to be the preferred initial management strategy.

Management of cerebrospinal fluid.

In traditional practice, doctors order tests and the laboratory performs them. A series of tests are requested before the results of any of the tests are known. The authors of this paper examine the interface between the clinicians and the laboratory. They produce a cost effective and clinically useful routine for handling spinal fluid. They bring to their practice an excellent example of quality assurance which is genuine, improves practice and is not "busy work." The editor heard Dr. Albright present this material and urged him to make it available to North Carolina doctors.

Detection of tricuspid regurgitation and estimation of central venous pressure by two-dimensional contrast echocardiography of the right superior hepatic vein.

Two-dimensional echocardiography (2DE) was utilized to visualize the right superior hepatic vein (RSHV) for detection of tricuspid regurgitation (TR) and estimation of central venous pressure (CVP). Patients were divided into two groups. Eighteen patients were placed in group I on the basis of typical clinical features of TR (five patients) or 2DE contrast evidence of TR (13 patients). Group II included 55 patients without TR. Maximal transverse dimension of RSHV of at least 1.8 cm (range 1.8 to 3.8 cm, mean 2.4 cm) identified all patients in group I (100% sensitivity). One patient in Group II had RSHV width of 2.1 cm (96% specificity). Predictive value was 95%. RSHV width ranged from 0.4 to 2.1 cm (mean 1.3 cm) in group II. Mean values for group I and II were significantly different (p less than 0.001). Linear regression analysis was utilized to compare CVP and maximal RSHV width in 42 patients (15 group I and 27 group II). The slope of the line was significantly different from zero (p less than 0.005); the correlation coefficient was 0.70. In patients with maximal RSHV width greater than 1.5 cm, the predictive value for elevated CVP (greater than 6 mm Hg) was 87% with 69% sensitivity and 78% specificity. In 13 group II patients with technically satisfactory 2DE but no distinctly visible RSHV, CVP ranged from 4 to 12 mm Hg with four elevated values (greater than 6 mm Hg). Predictive value of normal CVP in absence of visible RSHV was 69%. This study suggests that determination of maximal RSHV width is useful in detection of TR and may be helpful in estimation of CVP.

Isolated partial anomalous venous connection: a congenital defect with late and serious complications.

The cases of 3 patients with partial anomalous pulmonary venous return with intact atrial septum are reported. The 2 adult patients had evidence of severe pulmonary artery hypertension with markedly increased pulmonary vascular resistance indicating advanced pulmonary vascular obstructive disease. This confirms earlier limited observations and emphasizes the potential for this congenital lesion to develop late, serious complications. In view of this potential, surgical repair of the anomaly should be considered whenever it is found. Descriptions of a successful operative approach are included.

Prolapsed left atrium behind the left ventricular posterior wall: two dimensional echocardiographic and angiographic features.

Left atrial enlargement can usually be detected accurately using M mode echocardiography. However, in the presence of heart disease, asymmetric enlargement may lead to inaccurate assessment of left atrial size and shape. Pericardial effusion can usually be diagnosed on the basis of characteristic M mode echocardiographic findings. However, false positive patterns sometimes occur with the use of this single dimensional technique. Three patients with a greatly enlarged left atrium are described whose M mode echocardiogram suggested significant posterior pericardial fluid accumulation. In each patient, two dimensional echocardiography detected portions of a huge left atrium that prolapsed behind the left ventricular posterior wall and mimicked an isolated posterior pericardial effusion. In one case a right anterior oblique left ventricular cineangiogram suggested the presence of a ventricular septal defect or a false aneurysm of the left ventricle due to the prolapsed left atrium. Because two dimensional echocardiography can provide accurate spatial orientation with visualization of intracardiac structures in relation to one another in real time, it can identify the presence of left atrial prolapse and play an important role in the differential diagnosis of isolated echo-free spaces behind the left ventricle detected with M mode echocardiography.

Predicting aortic valve prosthesis size. A step toward better matching of patient and prosthesis.

We have developed a simple method of predicting aortic valve prosthesis size from supravalvular aortic cineangiograms, taken in the 30 degree right anterior oblique projection, during routine diagnostic cardiac catheterization. Measurements made on the aortogram were corrected to true size by means of a 1 cm2 grid reference plate filmed at the conclusion of the catheterization. This method was utilized prospectively to predict the anulus size in 26 patients undergoing aortic valve replacement alone or as part of a more extensive procedure. The catheterization prediction of anulus size was perfectly predictive of the prosthesis size used in eight of 26 (31%) cases, within 1 mm of the prosthesis size used in 20 of 26 (77%), and within one prosthesis size in all 26 (100%) cases. Comparing the measured anulus diameter to the actual prosthesis diameter yielded r = 0.93. When both systolic and diastolic frames were available for analysis, the diastolic frame was more accurately predictive than the systolic frame (diastolic r = 0.93; systolic r = 0.88), although both yielded acceptable results. Utilization of this method has significantly altered operative plans in four patients with a small anulus. Such preoperative assessment should allow improved matching of patient and valve prosthesis and thereby yield improved long-term results in aortic valve replacement.

Ruptured chordae tendineae. Its association with systemic lupus erythematosus.

A case of systemic lupus erythematosus (SLE) was complicated by ruptured chordae tendineae. The mechanisms responsible for severe cardiac dysfunction in SLE are discussed.