Coronary arteriography 1984-1987: a report of the Registry of the Society for Cardiac Angiography and Interventions. II. An analysis of 218 deaths related to coronary arteriography.

In a 42-month period, 218 deaths occurred in 222,553 patients undergoing coronary arteriography (0.098%). Age greater than 60 years, NYHA Class IV function, presence of left main coronary disease, and ejection fraction less than 30% all significantly increased the risk of the procedure. Sex and approach (brachial or femoral) used for the catheterization did not affect mortality. Since the SCAI report in 1982, the death rate has dropped significantly in high-risk patients. Low-risk patients (NYHA Class I or normal coronary arteries) who died generally were elderly or had associated valvular heart disease.

Coronary arteriography 1984-1987: a report of the Registry of the Society for Cardiac Angiography and Interventions. I. Results and complications.

This prospective series of results and complications of coronary arteriography from the Registry of the Society for Cardiac Angiography and Interventions is the largest ever reported. Since the initial report published in 1982, the results of coronary artery surgery and angioplasty have improved and therefore older and more symptomatic patients are referred for coronary arteriography. More patients are now studied by the femoral approach, and the major complications of the techniques are similar. Despite studying older and higher-risk patients, the complications are remarkably similar to those reported in the older series. Because of the sicker patients being studied, it is probably unlikely that the complication rate will decrease further in the future. The Society for Cardiac Angiography and Interventions will continue its Registry to follow complication rates of both established and new procedure.

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.

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.

Sex hormones and coronary artery disease.

Previous investigators have found an increased risk of coronary heart disease in men with high levels of circulating estrogens. To elucidate further this relationship, a case-control study of atherosclerotic coronary artery disease (ASCAD) and sex hormones was undertaken in male patients. Hormone levels in men with severe ASCAD documented at angiography were compared with those in men found to be virtually free from disease and with those in a group of control subjects without signs or symptoms of ASCAD. Significantly lower total testosterone levels were observed among men with severe ASCAD compared with either control group; the free testosterone level was significantly lower than in angiographically disease-free control subjects. The same pattern of hormone levels persisted after control of covariates. Epidemiologic analysis demonstrated a fivefold decrease in risk for severe ASCAD between the lowest and the highest quartile of total testosterone. No overall pattern of association was seen between ASCAD and free or total estrogens.

Characterization of the human right ventricular pressure-volume relation: effect of dobutamine and right coronary artery stenosis.

Right ventricular function was assessed in 15 patients using right ventricular pressure-volume loops. Right ventricular pressure using a micromanometer-tipped catheter, thermodilution cardiac output and gated blood pool scintigrams were simultaneously obtained. To help isolate the right ventricle, a slant hole collimator was used. The measurements were repeated during dobutamine infusion, which was titrated so there was minimal change in systemic pressure and heart rate. The right ventricular pressure-volume loop resembles the usual left ventricular loop except that the isovolumic contraction phase is often not as distinct, and right-sided ejection may continue well beyond right ventricular peak systolic pressure. Systolic but not diastolic function improved with dobutamine administration. There was no significant difference in right ventricular systolic function (ejection fraction, stroke work index, stroke volume index and cardiac index) or in end-diastolic volume index between patients without (Group I) and with (Group II) significant right coronary artery stenosis. However, there was a small but significant difference in right ventricular end-diastolic pressure (5.3 +/- 2.5 and 8.1 +/- 1.8 mm Hg [p less than 0.05]) for Group I and II, respectively. Thus, the right ventricular pressure-volume loop can be used to graphically display right ventricular function and improvement in contractility with dobutamine. The right ventricular isovolumic contraction phase and ejection phase differ from those in the usual left ventricular loop. Although there was a small difference in right ventricular end-diastolic pressure in patients with and without right coronary artery stenosis, the right ventricular pressure-volume loop did not provide additional discriminatory information between these two groups of patients.

Intravenous nitroglycerin in the treatment of spontaneous angina pectoris: a prospective, randomized trial.

A prospective, randomized study of i.v. nitroglycerin (TNG) in the management of repetitive spontaneous angina pectoris was undertaken in 40 consecutive patients. The clinical effectiveness of i.v. TNG (group A) was compared with that of oral isosorbide dinitrate (ISDN) and topical 2% nitroglycerin ointment (NO) in combination (group B) during a 72-hour treatment period. The doses of both nitrate regimens were adjusted so that the mean arterial pressure in the two groups was reduced by 15 +/- 3% of control values to the same level (77 mm Hg). The i.v. TNG dose of 10-200 micrograms/min yielded arterial plasma TNG levels of 1.2-65.3 ng/ml and estimated plasma (arterial) clearance of 106 +/- 55 ml/min/kg of body weight (mean +/- SD). In group B, the doses were 20-60 mg (oral ISDN) and 1/2-2 inches (NO) every 6 hours. Intravenous TNG reduced the number of spontaneous ischemic episodes from 3.3 +/- 0.8 per 24 hours during the control period to 1.0 +/- 0.3 per 24 hours during the treatment period (p less than 0.01), while the ISDN/NO combination reduced the number of episodes from 3.1 +/- 0.4 to 1.4 +/- 0.3 (p less than 0.01). Overall, the magnitude of the therapeutic effect of i.v. TNG was statistically indistinguishable from that of ISDN/NO, although i.v. TNG did have somewhat greater clinical benefit on day 2 of the 3-day treatment period. Furthermore, the data suggested more consistent control of ischemic episodes with i.v. TNG during the first 24 hours of the trial. Although both regimens markedly reduced the frequency of spontaneous ischemic episodes, only 36% of patients in group A and 17% in group B experienced no ischemic episodes during the study period (NS). Forty-three percent of patients in group A and 61% in group B (NS) required early coronary artery bypass surgery to control recurrent ischemic episodes refractory to medical therapy. We conclude that i.v. TNG and ISDN/NO, when administered in doses adjusted to produce similar effects on systemic arterial pressure, have nearly equivalent clinical effects in the management of patients with frequent episodes of spontaneous angina pectoris. Intravenous TNG offers the advantage of more consistent control of ischemic episodes during the first 24 hours of treatment. Nevertheless, the recurrence rate of spontaneous ischemic episodes during medical therapy is high with both regimens, and early coronary artery bypass surgery may be required for long-term management.

Fascicular conduction distrubances after coronary bypass surgery.

Two hundred patients underogoing coronary bypass graft surgery were studied to determine the frequency and significance fo new fascicular conduction distrubances. The follow-up period ranged from 13 to 39 months. New disturbances developed in 39 patients (20 percent). Isolated right bundle branch block (6 percent) and left anterior hemiblock (6 percent) were the most common disturbances. Righ bundle branch block was usually transient and was not associated with further complications in the follow-up period. However, patients with either transient or persistent left bundle branch block or left anterior hemiblock, or both, had (1) increased later mortality compared with patients without new fascicular conduction disturbances (5 of 26 versus 11 of 161; P less than 0.02), and (2) increased late myocardial infarction (2 of 26 versus 2 of 161; P less than 0.05). New left fascicular conduction disturbances after coronary surgery identified a subset of patients with more extensive ischemic heart disease, suggesting that these patients require close follow-up care.

New criteria to enhance the predictability of coronary artery disease by exercise testing in asymptomatic subjects.

Thirty-seven subjects (10 asymptomatic and 27 symptomatic) who had undergone maximal treadmill exercise tests and coronary arteriography were selected to determine whether the predictive value of ST-segment depression as a marker of coronary artery disease (CAD) in asymptomatic subjects could be enhanced. All subjects had greater than or equal to 2 mm ST-segment depression during testing. Three of the ten asymptomatic subjects had significant CAD (predictive accuracy 30%) and all had greater than or equal to 2 mm ST depression in the one-minute recovery tracing. ST-segment depression resolved by one minute in all seven subjects without CAD. All 27 symptomatic subjects had CAD (predictive accuracy 100%) and 26 of 27 had greater than or equal to 1 mm (21/24 greater than or equal to 2 mm) ST depression in the one-minute recovery tracing. The age, maximum heart rate and exercise tolerance did not differ significantly between the symptomatic and asymptomatic subjects. Thus the predictive accuracy for CAD in asymptomatic subjects is not enhanced by increasing the degree of ST depression required for a positive exercise test. The predictive value may be enhanced if ST depression persists for greater than or equal to 2 minutes into recovery. These data suggest that by using new criteria accurate identification of asymptomatic patients with CAD by exercise testing may be practical.

Mixed lymphocyte reactivity and cell-mediated lympholysis to trinitrophenyl-modified autologous lymphocytes in C57BL/10 congenic and B10-A recombinant mouse strains.

Cell-mediated lympholysis (CML) to trinitrophenyl (TNP)-modified autologous splenic lymphocytes has been recently reported in the mouse (1). Both the sensitization and effector phases of this phenomenon were shown to be T-cell mediated. Effector cell specificity studies indicated that modification of the target cells is a necessary but insufficient requirement for cytolysis, and suggested that altered cell surface components controlled by genes mapping in the mouse major histocompatibility H-2 complex (MHC) are important in the specificity of the cytotoxic reaction (1). In allogeneic models the generation of cytotoxic effector cells has been shown to be preceded or accompanied by immunogen- induced proliferation of responding lymphocytes, i.e. a mixed lymphocyte reaction (MLR) (2-5), although the generation of effectors may not necessarily always be the consequence of extensive cell proliferation (5). If the induction of cytotoxic effector lymphocytes by modified syngeneic spleen cells is characteristic of sensitization with cellular alloantigens, one would expect to find that sensitization with TNP-modified autologous cells would also induce thymidine incorporation by the responding cells in the culture. The present report demonstrates that both stimulation of thymidine incorporation and generation of cytotoxic effector cells are part of the in vitro response to TNP-modified autologous lymphocytes. However, the MLR to TNP- modified autologous cells consistently appeared to be less pronounced when compared with an allogeneic MLR, whereas the cytotoxic activity of the effector cells generated by sensitization against TNP-modified autologous cells was frequently as high as that detected against H-2 alloantigens. These two components of reactivity to "modified self" are verified in several C57BL/10 congenic and B10.A recombinant mouse strains.

Genetic control of the immune response to staphylococcal nuclease. I. Ir-Nase: control of the antibody response to nuclease by the Ir region of the mouse H-2 complex.

A number of inbred and congenic resistant strains of mice were immunized with staphylococcal nuclease (Nase). Antibody responses were measured in the sera of the animals by a sensitive method involving inhibition of enzymatic hydrolysis of DNA, High responder strains included A/J, DBA/2, BALB/c, AKR/J, C57BR, and SJL/J. DBA/1 and C57BL/6 mice were low responders. The strain distribution of anti-Nase response potential was compatible with the relevant immune response gene(s) being linked to the murine major histocompatibility complex. Linkage of this response to H-2 was demonstrated by the findings that: (a) the congenic C3H/HeJ and C3H.SW mice were respectively high and low responders; (b) the congenic lines B10.A and B10.D2 were high responders, whereas the C57BL/10 strain was a poor responder; and (c) anti-Nase response potential of F(2) progeny from DBA/1 x SJL/J matings correlated with their H-2 type. Three B10.A recombinant lines were used to map this Ir gene within H-2. B10.A(4R) was a high responder to Nase, whereas B10.A(2R) and B10.A(5R) were both low responders. We wish to propose the name Ir-Nase for the gene(s) controlling antibody responsiveness to this immunogen. Our data indicate that Ir-Nase is located within the same chromosomal segment of the H-2 complex as is Ir-IgG.

B-cell alloantigens determined by the H-2 linked Ir region are associated with mixed lymphocyte culture stimulation.

Cell surface antigens, controlled by genes located in the Ir region of the murine major histocompatibility complex, are shown serologically to be expressed preferentially on bone marrow-derived lymphocytes. These antigens may play a major role as stimulators in mixed lymphocyte cultures.