Simplified two-wire technique for bifurcation lesions during coronary angioplasty.

Bifurcation lesions are commonly encountered in coronary angioplasty. This paper describes a simplified approach to the problem with emphasis on the equipment used.

Pulmonary hypertension in isolated aortic stenosis. Hemodynamic correlations and follow-up.

The clinical, hemodynamic, and angiographic data on 92 patients with severe isolated aortic stenosis were reviewed to determine the incidence and mechanism of pulmonary hypertension. The status of each of these patients was determined 1 to 8 years after diagnosis by cardiac catheterization. Patients were divided into three groups on the basis of the pulmonary artery systolic pressure: group 1 (less than or equal to 30 mm Hg), 46 patients; Group 2 (31 to 50 mm Hg), 31 patients; and Group 3 (greater than 50 mm Hg), 15 patients. The prevalence of pulmonary hypertension was 50% (46/92) and that of severe pulmonary hypertension, 16% (15/92). There was no significant difference in age, aortic valve gradient, or valve area among the three groups. There was a significant positive correlation in left ventricular end-diastolic pressure (group 1, 15.5 +/- 7.2 mm Hg; group 2, 23.3 +/- 8.1 mm Hg; and group 3, 29.5 +/- 5.8 mm Hg; R = 0.56, p less than 0.01). There was also a significant negative correlation in left ventricular ejection fraction (group 1, 67.5% +/- 14%; group 2, 62.3% +/- 13.8%; and group 3 49.9% +/- 18.3%; R = 0.43, p less than 0.01). Of the 92 patients, 85 had aortic valve replacement with four (4.7%) hospital deaths. Follow-up showed excellent symptomatic relief in all three groups. Thirteen of the 15 patients in group 3, with severe pulmonary hypertension, had aortic valve replacement. There were no hospital deaths and only one noncardiac death at follow-up in Group 3 patients, and 11 of the 12 surviving patients were in New York Heart Association functional class I. We conclude that pulmonary hypertension is common in isolated aortic stenosis and is related to an elevated left ventricular end-diastolic pressure, frequently with preserved systolic function. Surgical results are excellent.

Use of temporary pacemakers during coronary angioplasty: an evolving experience with ventricular fibrillation in 400 cases.

Because of a perceived high frequency of ventricular fibrillation when a pacemaker catheter was placed in the right ventricular apex during PTCA, we reviewed our first 400 cases for this complication. The incidence of ventricular fibrillation in the entire group was 10 of 400 cases (2.5%) compared with 17 of 3,806 (0.4%) diagnostic coronary arteriograms performed in our laboratory during the same time period (P less than .001). Ventricular fibrillation occurred more frequently during PTCA when the pacemaker catheter tip was placed in the right ventricular apex (8 of 63 cases, 12.6%) than when it was positioned in either the pulmonary artery, vena cava, or when a pacemaker catheter was not used (2 of 337 cases, 0.6%, P less than .001). Based on these data we have developed a policy of inserting temporary pacemakers prophylactically during PTCA only for patients undergoing dilation of dominant right or dominant left circumflex coronary arteries and in patients with acute myocardial infarction.

Pulmonary hypertension in severe aortic stenosis. Incidence, mechanisms, clinical and surgical implications.

Pulmonary arterial hypertension in aortic stenosis (AS) is considered uncommon, and the possible mechanisms involved in its insorgence are only speculative. We analyzed a group of 95 patients with severe AS (mean systolic gradient greater than or equal to 50 mmHg and/or aortic valve area less than or equal to 0.7 cm2) studied by standard hemodynamic techniques. In the study group the incidence of pulmonary hypertension was 50.5%. We divided the overall population in: Group I (47 patients), with systolic pulmonary artery pressure (PAP) less than or equal to 30 mmHg; Group II (33 patients), with moderate hypertension (PAP 31-50 mmHg); Group III (15 patients), with severe hypertension (PAP greater than 50 mmHg). Subjects with pulmonary hypertension were slightly older, and had more severe obstruction to left ventricular (LV) outflow. Impairment of LV diastolic function in the presence of pulmonary hypertension was expressed by a highly significant increase of LV end-diastolic pressure (p less than .001); reduced ejection performance was represented by a significant decrease of ejection fraction (p less than .01). Pulmonary vascular resistances also appeared to be increased. The correlation between variables showed PAP to be strongly correlated in a positive way to the LV end-diastolic pressure, and in an inverse way to the LV systolic performance (p less than .001 for both). Less striking was the correlation of pulmonary vascular resistances to LV diastolic and systolic function: a reactive and reversible vasoconstriction seemed likely. Surgery was not performed in 8 of the 95 patients: 5 of them died shortly after diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary osteosarcoma of left atrium: complete surgical excision.

A patient with primary osteogenic sarcoma of the left atrium with clinical features of severe congestive heart failure is described. The operative procedure required excision of the posterior atrial wall in continuity with the left pulmonary veins. The resultant defect in the atrium was reconstructed with the left atrial appendage. The left pulmonary artery was ligated, and the lung was removed at a subsequent procedure. The patient survived operation but subsequently was found to have distant metastasis. He died seven months after the operation.

Hemodynamic, ventilatory and blood gas changes during infusion of sodium nitroferricyanide (nitroprusside). Studies in patients with congestive heart failure.

Simultaneous hemodynamic, ventilatory, and blood gas studies were performed in 16 men with congestive heart failure before and during infusion of sodium nitroferricyanide (nitroprusside). The cardiac index increased from 2.00+/-0.16 L/min/sq m (SE) to 2.38+/-0.14 L/min/sq m, and the total pulmonary and systemic peripheral resistances fell from 928+/-123 to 494+/-57 dynes sec cm-5 and from 2,208+/-210 to 1,558+/-121 dynes sec cm-5, respectively. Both systemic and pulmonary arterial decreased during infusion of sodium nitroferricyanide, and the mixed venous oxygen pressure increased. There was no change in total or alveolar ventilation, arterial carbon dioxide tension, pH, or base excess; however, the mean arterial oxygen pressure (PaO2) decreased from 74+/-3 mm Hg to 68+/-3 mm Hg and the venous admixture effect increased from 8+/-1% to 13+/-2%. We conclude that the decrease in PaO2 during infusion of sodium nitroferricyanide resulted from a worsening of the ventilation-perfusion relationships due to increased perfusion of underventilated pulmonary units.