Dominant hemodynamic parameters of chronic ischemic mitral regurgitation.

The study included 128 patients treated at the Institute of Cardiovascular Diseases in Sremska Kamenica within a year after the first posteroinferior myocardial infarction. On the basis of hemodynamic measurements, patients were divided into 2 groups. Group I (examinees) included 64 patients (58 males and 6 females, mean age 54.42 +/- 6.70 years) with proven mitral regurgitation and group 2 (control) included 64 patients (56 males and 8 females, mean age 51.71 +/- 8.84 years) without mitral regurgitation, but with stenotic changes in the right coronary artery and left circumflex coronary artery without significant stenotic lesions at the anterior descending left coronary artery. According to Sellers classification mitral regurgitation in group I was as follows: I grade 37.5%, II grade 31.3%, III grade 21.9% and IV grade 9.3%. Measured hemodynamic parameters in basal conditions (systolic, diastolic and mean pulmonary pressure, capillary pulmonary pressure and wave V, left ventricular end-diastolic pressure) point to significant impairment of diastolic function in group I apart from similar values of systolic function (cardiac output, cardiac index and ejection fraction). Dimension of the left atrium and left ventricle determined by transthoracic echocardiography confirm this. There was a positive correlation of examined parameters (pulmonary capillary and total pulmonary resistance) and the degree of mitral regurgitation, as well as the correlation between the degree of mitral regurgitation and hemodynamic parameters. It may be concluded that postinfarction mitral regurgitation in examined patients is of II degree on the average; total and capillary pulmonary resistance are most sensitive hemodynamic parameters for examining the severity of mitral regurgitation, whereas the size of the left atrium is the most sensitive echocardiographic parameter.

[Coronary collateral circulation and prevention of ischemic mitral regurgitation]. / Koronarna kolateralna cirkulacija i prevencija ishemicne mitralne regurgitacije.

INTRODUCTION: According to definition, collateral circulation is an alternative to major vascular flow which has become dysfunctional. Collateral channels, initially unused, are being formed due to impossibility of the main blood vessel to provide normal coronary flow. Recent controversies about collateral circulation are mainly based on their functional significance. The aim of this work was to evaluate the function of collateral circulation in patients after the first postero-inferior myocardial infarction i.e. whether adequate collateral circulation may reduce the size of myocardial infarction and prevent development of ischemic mitral regurgitation. MATERIAL AND METHODS: The investigation included 128 patients (pts) treated at the Institute of Cardiovascular Diseases in Sremska Kamenica during 1997 and 1998. The investigation group (I) included 64 pts, 58 males and 6 females, mean age 54.42 years. The control group (C) included 64 pts, 56 males and 8 females mean age 51.71 years. In all patients the first posterior, inferior and postero-inferior myocardial infarction were proven during 1-year period. Cineventriculography confirmed kinetic disturbance of the area with or without mitral insufficiency. Degree of mitral regurgitation was evaluated according to Seller's criterion. Alterations on the right coronary or circumflex branch of the left coronary artery were confirmed, but significant stenotic alterations were not verified on the anterior descendent branch of the left coronary artery. Alterations on epicardiac coronary vessels were presented as total coronary score--modification according to Benc (18 segments) while numerical values for stenosis according to Kaltenbach. This value represents the total coronary score (SCORE-A) including alterations before and after occlusion. Gensiny's principle modified for multiplication factor according to Benc and numerical value according to Kaltenbach were used for evaluation of collateral circulation. Levin's classification was used for evaluation of collateral circulation quality. We used quantitative classification according to Cohen. RESULTS: Distribution of mitral regurgitation was not statistically and significantly frequent in the subgroup of patients with lesions on the right coronary artery in relation to subgroup of patients with combined lesions on the right coronary artery and circumflex branch of the left coronary artery (p > 0.05). None of the investigated patients with extensive lesions (lesions on ACD and RCX) had mitral regurgitation of IV degree, so the number of investigated patients was not adequate for statistical evaluation. We did not find a statistically significant difference in the percentage of collateral circulation between the investigation (59.4%) and control group (62.5%) (p > 0.05). Poorly developed collaterals were statistically and significantly more frequent in the investigation group (60.5%) in relation to control group (10%) (p < 0.01). The percentage of moderately developed collateral circulation was similar in both groups. Well developed collateral circulation was statistically and significantly more frequent in control group (52.5%) in relation to investigation group (7.9%) (p < 0.01). The extension of stenotic alterations expressed as total coronary score A was statistically and significantly higher in subgroups of investigated patients with combined alterations on ACD and RCx, proving the sensitivity of our score system in smaller extensity of stenotic lesions on epicardial coronary blood vessels. Collateral circulation was significantly better in patients with ACD occlusion (100%) in relation to patients with significant stenosis or ACD subocclusion (33.3%) (p < 0.01). DISCUSSION: The functional role of collaterals has not been explained yet. The efficacy of coronary collateral vessels and mechanism of adequate compensation of regional perfusion in a position distal from the occluded vessel is highly controversial. (ABSTRACT TRUNCATED)

[Coronary score in patients with low ejection fraction after myocardial infarct]. / Koronarni skor u bolesnika sa niskom ejekcionom frakcijom nakon prelezanog infarkta miokarda.

INTRODUCTION: The most frequent cause of heart failure is ischemic heart disease (1). This paper was aimed at comparing the coronary score of patients with low ejection fraction whose ejection fraction was not significantly changed after sustained myocardial infarction. MATERIAL AND METHODS: The study involved patients after sustained myocardial infarction treated at the Institute of Cardiovascular Diseases in Sremska Kamenica. Total coronary score and score of each individual coronary artery were emphasized. RESULTS: The investigation study comprised 56 patients aged 33-83 years of various occupations. Patients were divided into two groups: the first--A group consisted of 28 (50%) patients with ejection fraction 35% or lower; the second--B group also consisted of 28 (50%) patients with ejection fraction higher that 35%. Table 1. shows the dominant coronary artery in investigated groups of patients. Table 2. shows values of total and scores of each coronary artery. The right coronary artery was dominant in 75% of patients from the A group and in 82.1% of patients from the B group. A significantly higher individual score of coronary arteries, as well as the total score, was established in the group of patients with low ejection fraction, and especially the score of the anterior descendent artery which is almost twice higher in regard to the second group of examined patients. Table 3. describes the analyzed score in male and female patients. DISCUSSION: Patients with low ejection fraction after sustained myocardial infarction have more changes of coronary arteries than patients with better ejection fraction. The total score, score of the right coronary artery (ACD), circumflex artery (RCX) and especially anterior descendent artery (LAD) are significantly higher in patients with ejection fraction lower than 35%. There are no differences in the dominant coronary artery in investigated patients. In both investigated groups women had a smaller score of ACD and RCX and a higher score of LAD, but the difference is not significant. In regard to total score there were no differences in men and women. Numerous investigations also point to the fact that patients with lower ejection fraction and ischemic heart disease have more changes on coronary artery than patients with better ejection fraction. CONCLUSION: 1. Patients with low ejection fraction after sustained myocardial infarction have a higher total score and scores of ACD. LAD and RCX. 2. There are no differences in coronary score of men and women within the same investigated groups. 3. There are no differences in dominant coronary artery in investigated groups of patients.

Ultrastructural aspect of myocarditis: its relevance for the diagnosis.

The Dallas consensus was used to reveal active or borderline inflammatory loci by light microscopy (LM). When lymphocyte-cardiocyte interaction was observed by electron microscopy (EM), the deleterious or dormant pattern of inflammatory process was recognized. The first was determined by lymphocytes that adhered to cardiocytes, next to necrotic cardiocytes or admixed with debris. The second was marked by scattered lymphocytes between preserved cardiocytes and the absence of lymphocytes adhered to cardiocytes and necrotic cardiocytes. The deleterious pattern of the inflammatory process (EM) commonly supplemented the active appearance of inflammatory loci (LM). In contrast, the borderline outlook of the LM completed either the deleterious or dormant pattern of the EM. This discrepancy was related to the restricted resolution of LM, which might hide the actual stage of the disease. The diagnosis of myocarditis was founded on mutual LM and EM observations. The active or borderline appearance of LM of the deleterious pattern (EM) was considered indicative for the active stage of myocarditis. The borderline outlook of the LM of the dormant pattern of the EM was admitted to indicate either the healing phase of the disease with lymphocytes still lagging behind, or a latent phase of the ongoing myocarditis, according to the patient's hemodynamic status.