Esophageal function in patients with angina-type chest pain and normal coronary angiograms.

Ten per cent of patients with angina pectoris have normal coronary arteries and cardiac function and, despite this reassurance, continue to have chest pain. Since pain of cardiac or esophageal origin is clinically difficult to differentiate, 50 patients with severe chest pain, normal cardiac function, and normal coronary arteriography with ergotamine provocation were evaluated with a symptomatic questionnaire and esophageal function test. On 24-hour esophageal pH monitoring, 23 patients had abnormal reflux, and 27 were normal. There was no difference in the incidence and severity of chest pain, esophageal symptoms, or medication taken between refluxers and nonrefluxers. Ten refluxers and ten nonrefluxers had chest pain on exercise electrocardiography. Thirteen refluxers documented chest pain during the pH monitoring period, and in 12 it coincided with a reflux episode. Fifteen nonrefluxers documented chest pain during the monitoring period, and in only one did it coincide with a reflux episode. Of the 23 refluxers, 12 were treated with medical therapy and 11 by a surgical antireflux procedure, and all followed for two to three years. Ten (91%) of the 11 surgically treated patients are totally free of chest pain compared with five (42%) of the 12 medically treated patients. All 12 patients who had chest pain coincide with a documented reflux episode responded positively to antireflux therapy, eight surgical and four medical. It is concluded that 46% of patients complaining of angina pectoris with normal cardiac function and coronary arteriography have gastroesophageal reflux as a possible etiology. Seventy-three per cent of these patients have total abolition of chest pain by either surgical or medical antireflux therapy. Patients whose experience of chest pain coincided with a documented reflux episode on 24-hour esophageal pH monitoring had a 100% response to medical or surgical therapy. Overall, surgical therapy gave better results (91%) but was associated with an 18% temporary morbidity. Objective evaluation of reflux status and its correlation to the symptom of chest pain by 24-hour pH monitoring allows for selective therapy in these difficult to manage patients.

Anomalous origin of the right coronary artery from the pulmonary artery with large left-to-right shunt (anomalous right coronary artery).

A coronary arteriovenous fistula was diagnosed in a 20-year-old white male because of a continuous murmur atypically located along the left sternal border. Cardiac catheterization revealed a large left-to-right shunt, and selective coronary arteriography established the precise anatomic diagnosis. The patient was treated successfully by surgical reimplantation of the anomalous coronary artery into the aorta and ligation of its origin at the pulmonary artery. The embryological and clinical features of this anomaly are discussed, and mechanisms for its production are suggested. Attention is called to our observation of an apparent male sex predilection of this anomaly from review of the literature, in addition to the present patient. This is apparently the fourth patient with this anomaly whose condition was diagnosed antemortem by selective coronary arteriography and the fourth to have been treated by aortocoronary anastomosis providing an additive supply for both the present and the future. This is also the second case in the literature to have the transplanted right anomalous coronary artery demonstrated by selective coronary arteriography. It is likely that, with increasing use of selective coronary arteriography inthe diagnostic work-up of cardiac patients, more cases will be discovered and treated surgically.

Surgical closure of left coronary artery-left ventricular fistula: the second case reported in the literature and a review of the five previously reported cases of coronary artery fistula terminating in the left ventricle.

Surgical closure of a left coronary artery-left ventricular fistula in a 44-year-old black man is reported. The fistula was discovered by coronary arteriography after the patient was admitted to the hospital complaining of recurrent chest pain. The fistula was closed with cardiopulmonary bypass, ischemic arrest, and hypothermia, and there was an uneventful postoperative recovery. The previously reported five cases of fistulas terminating in the left ventricle that were closed surgically are reviewed. Four of these cases originated in the right coronary artery and one in the left coronary artery. Three of the six patients were symptomatic at the time of discovery of the lesion. Cardiopulmonary bypass was necessary in five of the six cases. One patient died in the postoperative period from intractable hemorrhage. It is recommended that coronary artery fistulas by closed upon establishment of the diagnosis because of the sequelae if they are allowed to remain open; these include premature atherosclerosis, aneurysmal dilatation of the coronary artery, and congestive heart failure.

Postperfusion coronary ostial stenosis: incidence and significance.

In a study of 117 consecutive aortic valve replacements in which selective coronary perfusion was routinely employed, four patients developed coronary ostial stenosis (3.5 per cent). Continuous selective coronary perfusion was performed by use of Mayo balloon catheters with individual measuring of pressure and flow. All 4 patients developed progressive symptoms of angina pectoris within 6 months of the original operation, after uneventful recoveries. All 4 were found to have lesions in the left main coronary ostium and required a coronary bypass. Two made uneventful recoveries and are presently asymptomatic, whereas 2 died in the immediate postoperative period. The literature indicates that the reported incidence of this complication varies from 1 to 5 per cent. Furthermore, the mortality rate for reoperation in these patients is higher than that for those undergoing uncomplicated coronary bypass without an antecedent procedure. Our experience confirms the lethal nature of this complication and the necessity for reoperation once the diagnosis is established. The development of these dangerous lesions must be taken into account in the prevailing controversy between the most effective methods of myocardial protection during aortic valve replacement.

Spontaneous closure of a traumatic ventricular septal defect following a penetrating injury.

A ventricular septal defect acquired from a penetrating injury to the membranous septum closed spontaneously, as documented by repeat cardiac catheterization. The patient was asymptomatic from the time the lesion was discovered until the present. We advise observation of these lesions for a period of time, provided that no evidence of cardiac decompensation or pulmonary hypertension is noted as determined by hemodynamic studies and clinical observation. Cardiac catheterization is mandatory to confirm the diagnosis, measure the magnitude of the shunt, and rule out associated intracardiac injuries. We believe the lesion should be closed on an elective basis, regardless of the absence of symptoms, if after a reasonable time there is no evidence that the ventricular septal defect is closing and a significant shunt is demonstrated.