The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation.

BACKGROUND: The aim of this study was to prospectively evaluate the angiographic results of a cohort of consecutive patients who underwent minimally invasive coronary artery revascularization. METHODS: From May 1997 to December 1998, 150 consecutive patients underwent left internal mammary artery to left anterior descending artery anastomosis through a left minithoracotomy on a beating heart in the Cardiovascular Department of Cliniche Gavazzeni, Bergamo, Italy. The mean age was 61.6 years (range, 36 to 84 years); 121 patients (81%) were men. Isolated left anterior descending artery disease was present in 74 patients. RESULTS: In-hospital patency was observed in 100% of the 149 angiographically controlled patients with no anomalies in 99.3% of the anastomoses. Anastomosis was performed on a diseased tract of the target vessel in 3 patients and a stenosis of the target vessel beyond the anastomosis was documented in 3 patients. In one case early angiographic control was not performed due to death of the patient on the 1st postoperative day. The morbidity included postoperative bleeding that required reopening (3.3%) and intraoperative myocardial infarction (2%). CONCLUSIONS: A left internal mammary artery to left anterior descending artery anastomosis on a beating heart through a left minithoracotomy is an alternative approach to myocardial revascularization. Surgical invasiveness is limited, cardiopulmonary bypass risks are avoided, and the procedure is safe and effective. In our consecutive series, postoperative angiographic controls demonstrated graft patency in all patients and very high quality anastomoses. Midterm clinical follow-up (14 months) appears favorable.

[The early angiographic follow-up of myocardial revascularization in a minithoracotomy: the results of the first 100 consecutive cases]. / Il controllo angiografico precoce della rivascolarizzazione miocardica in minitoracotomia: risultati dei primi cento casi consecutivi.

The use of the left internal thoracic artery anastomized to the left anterior descending coronary artery via a small left thoracotomy to revascularize the anterior wall of the left ventricle has gained wide acceptance since its introduction into clinical practice a few years ago. A mandatory, postoperative angiographic control was suggested in order to check the surgical results of this new method of revascularization. We herein analyze the results of the in-hospital angiographic control of a series of 100 consecutive patients who underwent minimally invasive coronary artery bypass. In all 100 patients the thoracic graft, the anastomosis and the target vessel were patent, with no anomalies in 90 subjects. In 4 patients, a sharp angulation of the thoracic artery in the last third before the anastomosis to the native vessel was observed; in 3 subjects, the arterial graft had been anastomized to a diseased tract of the target vessel and in 3 cases a significant stenosis of the target vessel beyond the anastomosis was documented; in 2 cases the persistence of a thoracic artery branch was discovered. Since 1) neither in-hospital total occlusion of the thoracic graft to the left anterior descending coronary artery via a small thoracotomy was documented nor a significant incidence of major anomalies was observed; 2) the anomalies documented seem to be clinically negligible and may regress in the midterm postoperative period; 3) Doppler flow analysis is able to detect not only the patency but also the presence of significant stenosis in the arterial graft; the in-hospital angiographic control of this surgical technique should be limited to patients with abnormal ultrasonic data or with reappearance of myocardial ischemia in the anterior wall of the left ventricle, thus not reducing the advantages in terms of speed and cost-control of this type of myocardial revascularization.

Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study.

Numerous studies have pointed out the frequent association of tetralogy of Fallot (TF) with other cardiovascular defects and coronary tree anomalies. We found cardiac defects in 181 (68%) out of 265 patients with TF investigated by catheterization and selective coronary angiography. These anomalies were isolated in 88 cases (49%) and associated with others in 93 patients. In the case of an isolated anomaly associated with TF, the coronary tree was involved in 37.5% and the cardiovascular system in the remaining 62.5%; in the case of two anomalies, the coronary system was involved in 66% of the patients and the cardiovascular apparatus in 34%; in the case of three or more anomalies, the coronary arteries were involved in 71% and the cardiovascular system in 29%. Anomalies in the course and/or distribution of coronary arteries were present in 96 patients (36%): 10 had a single coronary ostium, 13 a left anterior descending artery arising from the right coronary artery, one a circumflex artery arising from the right coronary artery. Small fistulas between coronary arteries and the pulmonary artery were found in 20 cases; anastomoses between coronary and bronchial arteries or right atrium in 42. In 39 patients we observed a large conus artery or large anterior ventricular branches crossing the right ventricle. A right aortic arch was found in 56 patients (21%), a stenosis of the trunk and/or the peripheral pulmonary artery in 35 (13%) and pulmonary artery atresia in five. Four patients showed a complete atrioventricular canal, three an atrial septal defect (primum type) with cleft of the mitral valve, 61 (23%) an atrial septal defect (ostium secundum). Eleven patients had anomalies of the systemic venous return, 26 (10%) a patent ductus arteriosus. Four patients had valvular abnormalities. In our series, a large proportion of cardiac defects associated with TF consists of anomalies of coronary arteries. Our data confirm the usefulness of performing preoperatively routine coronary angiography in patients with complex congenital heart disease.

Coronary artery anatomy in corrected transposition of the great arteries.

Congenitally corrected transposition of the great arteries is an unusual cardiac malformation with discordant atrioventricular and ventriculoarterial alignments. Because knowledge of the coronary artery anatomy is a prerequisite for successful repair of this cardiac anomaly, selective coronary arteriography was performed in 13 children (4 male and 9 female; age range 18 months to 16 years) and 1 adult (aged 59 years) with congenitally corrected transposition of the great arteries and associated intracardiac defects. The typical coronary distribution of corrected transposition (that is, coronary artery-ventricular concordance) was found in 11 patients. In one patient, a single coronary ostium was observed; the right sinus of Valsalva gave rise to a short common branch that divided into three arteries: a left circumflex artery going to the right, a well developed left anterior descending artery running into the anterior interventricular groove and a third vessel that continued on the normal course of the right coronary artery directed posteriorly. In one patient, the left circumflex artery was particularly small. In another patient, with severe hypoplasia of the left anterior descending coronary artery, the anterior ventricular wall of the heart was supplied by three small branches that ended a short distance from their origins. The adult patient had a large anterior ventricular branch arising from the morphologic left coronary ventricular as well as a large acute marginal branch, with a wide distribution, from the morphologic right coronary artery. Presurgical coronary angiographic documentation is helpful because, in congenitally corrected transposition as well as in complex congenital heart disease, coronary anomalies (in origin, course and distribution) are occasionally present and knowledge of their presence can help determine the most appropriate surgical approach.

A possible interface between autonomic function and pain control: opioid analgesia and the nucleus tractus solitarius.

Opioid peptides appear to be important neurochemical mediators in central nervous system mechanisms of analgesia, cardiovascular control, and many endocrinological responses to stress. The nucleus tractus solitarius (NTS), a brain region expressing all 3 opioid peptide families, is also associated with regulation of autonomic and endocrine functions. We now report that electrical stimulation of the NTS causes pronounced analgesia in rats. This analgesia appears to involve opioids and is pharmacologically dissociable from the hemodynamic changes elicited by NTS stimulation. These results suggest the NTS as a neural substrate for inter-relationships between stress, cardiovascular function, alterations in respiration, and pain sensitivity.

[D-Ala2, (F5) Phe4]-dynorphin 1-13-NH2 (DAFPHEDYN): a potent analog of dynorphin 1-13.

Intracerebroventricular administration of the dynorphin analog, [D-Ala2,(F5)Phe4]-dynorphin 1-13-NH2 (DAFPHEDYN) in rats produced diuresis and profound analgesia. Both effects were antagonized by central administration of naltrexone or naloxone. Intravenous administration of 10, 25, and 50 mg/kg of DAFPHEDYN failed to induce diuresis. The increased potency of DAFPHEDYN was apparent from the failure of an equal dose of the parent compound (dynorphin 1-13) to produce diuresis and the failure of [D-Ala2]-dynorphin 1-13-NH2 to produce analgesia. Radioligand binding studies indicated the DAFPHEDYN retains the same degree of kappa selectivity as the parent compound (dynorphin 1-13) though a drop in affinity occurred. DAFPHEDYN may be of significant interest because it retains the essential pharmacology of the parent compound and exhibits marked in vivo potency.

[Left atrial myxoma: radioisotopic diagnosis]. / Mixoma atriale sinistro: diagnosi radioisotopica.

A case of left atrial Myxoma shown on an equilibrium radionuclide ventriculography is presented. The finding were consistent with the ecocardiographic patterns and the gross anatomy of the tumour. The analysis of various parameters obtained with gated radionuclide cardiac blood pool scan shows that the Fourier phase image is another method to detect and study this disease.

[Fixed subvalvular aortic stenosis. Monodimensional echocardiographic findings]. / Stenosi aortica sottovalvolare fissa. Reperti ecocardiografici monodimensionali.

19 patients affected by discrete subvalvular aortic stenosis were studied by M-mode echocardiography. The diagnosis was confirmed by cardiac catheterism and angiocardiography and by anatomic evidence in operative room. The most frequent echocardiographic pattern was the abnormal protosystolic movement of aortic valve leaflets, that was found in all the patients. A discrete linear echo in the outflow tract of the left ventricle was observed in almost half of the cases. In 40% of the cases the left ventricular outflow tract was narrowed. The relations between these echocardiographic patterns and the anatomical kinds of discrete subaortic stenosis are discussed. No correlations were found between echocardiographic patterns and severity of the subaortic stenosis.

Nonopiate effects of dynorphin and des-Tyr-dynorphin.

Intracerebroventricular administration of dynorphin produced potent and long-lasting effects on motor function and the electroencephalogram in rats. In addition, local iontophoretic or pressure ejection of dynorphin consistently inhibited hippocampal unit activity. None of these effects were significantly affected by naloxone even at high doses. Moreover, a fragment of dynorphin that failed to displace any of a number of tritiated narcotics from rat brain homogenates produced similar effects on these physiological measures in vivo. On the basis of a variety of criteria for "opiate action," the results suggest that a second biologically active site within the dynorphin sequence is capable of quite potent but nonopiate effects.

[Dyslipidemia and coronary disease. Clinico-coronarographic study]. / Dislipidemia e coronaropatia. Studio clinico-coronarografico.

An inverse relationship between alpha-cholesterol and coronary atherosclerosis was observed in 200 male patients given coronographies. Specifically the lowest alpha-cholesterol levels were observed in patients with the most serious and widespread atherosclerotic lesions. This inverse correlation was maintained at the same level in all age groups.

A further parametric study of imipramine in an animal model of depression.

We have proposed that chronic stress may produce motivational, behavioral, and neuroendocrine symptoms in rats resembling endogenous depression in humans. The chronic stress model has proved responsive to chronic treatment by antidepressant drugs. Two issues concerning this effect remain unresolved, these being; the requirement of drug chronicity, and treatment outcome to different drug doses. The present experiment examined both issues in a factorial design in which vehicle and two doses of the tricyclic antidepressant imipramine were varied across 2 treatment periods; acute (1 hr) and chronic (3 weeks). Both factors were found to significantly interact with treatment outcome, suggesting that chronic treatment is necessary for recovery and that this outcome is dependent upon drug level.

[The natural development of arteriosclerotic coronary disease. Coronarographic study in time intervals]. / L'evoluzione naturale della coronaropatia aterosclerotica. Studio coronarografico seriato nel tempo.

In 96 patients with coronary artery disease a coronary arteriography was performed twice at least with some months' interval, in order to establish the rate of progression of coronary atherosclerosis and the factors which could affect this progression. It was possible to select patients with progression of the coronary arteria lesions from patients with no increase of coronary stenosis. From the angiographic point of view, the progression of angina and the appearance of myocardial infarction are connected with a general progression of arterial lesions on all main coronary branches. As to the electrocardiographic aspects, the ECG at rest give no informations about the evolution of the coronary disease. Among the risk factors the smoking only has some importance in order to predict the progression of the coronary atherosclerosis.

[Aortic valve disease and coronary atherosclerosis. Clinical and coronarographic study (author's transl)]. / Valvulopatia aortica e aterosclerosi coronarica.

77 patients with aortic valve disease have undergone heart catheterization in prevision of valve replacement: in this group the incidence of angina pectoris and the incidence of coronary artery disease associated with the valvular disease have been evaluated. The most important data resulting from out study are: 1) High frequency of angina pectoris both aortic stenosis and in aortic regurgitation: respectively about 60% and 50%. 2) The frequency of coronary atherosclerosis associated with aortic valve disease is much higher in aortic stenosis than in aortic regurgitation: respectively 35% versus 15%. 3) Coronary atherosclerosis associated with aortic stenosis frequently occurs (about 30%) also in young-aged patients (under 40 years). On the contrary in case of aortic regurgitation it occurs much more frequently in elderly patients. 4) The absence of angina both in aortic stenosis and in aortic regurgitation virtually excludes the presence of associated coronary atherosclerosis. 5) The presence of angina in aortic stenosis indicated either severe valvular stenosis or associated coronary artery disease (in this case the valvular stenosis is mild or moderate). The presence of angina in aortic regurgitation indicates either severe impairment of left ventricular performance or associated coronary atherosclerosis.

Physiological response to hyper- and hypogravity during rollercoaster flight.

Healthy male subjects--26--were flown in a Lear jet aircraft through rollercoaster and parabolic weightlessness flight. Eye movements, respiration, and blood volume pulse were recorded on magnetic tape. The same subjects underwent a battery of five vestibular tests in the laboratory on the ground. One subject in each flight was flown in an upright position, the other in a 90 degree foreward tilted head position. The foreward tilted subjects always reported motion sickness earlier and after fewer rollercoaster manoeuvres than the upright sitting subjects. It is concluded that the susceptibility to changes of X-axis acceleration is higher than to changes of Z-axis acceleration. Correlation was found between the ability to estimate the subjective vertical (modified Müller-Aubert-test), optokinetic nystagmus asymmetries, and susceptibility to rollercoaster flight sickness.

Distribution and anomalies of coronary arteries in tetralogy of fallot.

The surgical management of tetralogy of Fallot (TF) may be complicated by anomalies in the course and distribution of coronary arteries. Selective coronary angiography was performed in 119 cases of TF in order to prevent injury of aberrant vessels. In 11 patients, anomalies in the origin of coronary branches were revealed (five patients with a single coronary ostium, five with the anterior descending coronary artery arising from the right coronary artery or right sinus of Valsalva, and one with the circumflex artery arising from the right coronary artery). Other findings include anastomoses between coronary and bronchial arteries, small fistulas between coronary arteries and the pulmonary artery or right atrium, and hypoplasia of the coronary tree. The onset of left anterior hemiblock after total correction of TF could possibly be explained, in cases with a dominant left pattern, by injury to the coronary system after closure of the interventricular septal defect, rather than by injury to the conduction system.

Serotonergic mediation of reward within the medial raphe nucleus: some persistent problems in interpretation.

Adult male Sprague Dawley rats were implanted with unipolar stimulating electrodes aimed at the medial forebrain bundle (MFB) or the medial raphe nucleus (MR). All MFB implanted subjects self-stimulated at high stable rates for at least three weeks. Only a minority (1/3) of MR rats self-stimulated at all. Rates for the MR group were considerably more variable, and could not be maintained for more than two weeks. Treatment with methysergide increased MFB self-stimulation but decreased MR self-stimulation. While this result suggests serotonergic mediation of self-stimulation this conclusion must be interpreted cautiously since parachlorophenylalanine (PCPA) reinstated self-stimulation in raphe animals which had spontaneously ceased responding.

[Distribution and anomalies of coronary arteries in tetralogy of Fallot (author's transl)]. / Distribuzione e anomalie delle arterie coronarie nella tetrade di Fallot.

Anomalies in the course and distribution of coronary arteries may complicate the surgical correction of tetralogy of Fallot (TF). With the aim of preventing possible serious, and even lethal, cardiac events caused by the injury of aberrant vessels, 119 patients with TF were subjected to selective coronary angiography. Apart from demonstrating anastomoses between the coronary and bronchial arteries in 31 cases, small fistulas between the coronary arteries and pulmonary artery (in 14 cases) and hypoplasia of the entire coronary tree in 1 case, this investigation revealed anomalies in the origin of coronary branches in 11 cases. In some cases the first septal branch was absent and the diagonal branches were poorly developed. An injury to the coronary system, following the closure of the interventricular septal defect, may possibly explain the onset of a "left anterior hemiblock" after total correction of TF. Selective coronary angiography in small children presents no riskes provided it is correctly performed. In our cases no complications arose.

Behavioral activation by enkephalins in mice.

Intraventricular injection of long lasting enkephalin analogues (D--Ala2Leu and Met enkephalin-amides) produced a sustained elevation of psychomotor activity in mice. The motor syndromes were characterized by continual stereotyped activity and were reversed by naloxone pretreatment. Naloxone administered to a separate group of mice reduced the initial activation seen after exposure to a novel environment. The present findings suggest one or more endogenous opiates normally facilitates behavioral excitation in mice.