Characterization of a saphenous vein graft aneurysm by intravascular ultrasound and computerized three-dimensional reconstruction.

Aneurysmal dilatations in saphenous vein grafts are rare complications of coronary artery bypass surgery that mostly represent thin-wall pseudoaneurysms at anastomotic sites. We describe a case of an enlarging distal saphenous vein graft aneurysm in which intravascular ultrasound (IVUS) and computerized three-dimensional reconstruction (3DR) of the IVUS images was performed to conclusively demonstrate true aneurysm morphology. Although both atherosclerotic and nonatherosclerotic mechanisms for vein graft aneurysm formation have been previously suggested, IVUS images and 3DR of the aneurysm in this case did not reveal any of the features typical for atherosclerotic lesions. Further, the IVUS images and 3DR suggest that progressive atherosclerosis is not the likely cause of aneurysm formation in this case. This application of IVUS and 3DR provides detailed information about saphenous vein graft aneurysm structure, clues to aneurysm formation, and suggests a natural history that may differ from that of pseudoaneurysms.

Noninvasive identification of initial site of abnormal ventricular activation by least-square phase analysis of radionuclide cineangiograms.

Least-square phase analysis (LSPA) of radionuclide cineangiograms demonstrates the sequence of onset of inward ventricular movement noninvasively. To validate the method and explore its ability to identify abnormal initial sites of ventricular activation, LSPA was applied to 14 patients with pacemakers (one with electrodes in two locations) (group 1) and three patients with recurrent ventricular tachycardia (VT) (group 2) who had undergone electrophysiologic endocardial mapping. The segment in which the site of initial ventricular activation was located was correctly identified in 13 of 15 paced studies and in two of three group 2 patients during VT. Pacing increased the duration of spread of onset of inward ventricular movement, and the duration of spread of onset correlated well with the duration of the QRS (r = 0.80). The sequence of onset of inward ventricular movement during VT was similar to the sequence of depolarization in all three group 2 patients. These preliminary results suggest that the sequence of onset of ventricular contraction as depicted by LSPA is a valid representation of the actual contraction sequence and that LSPA or radionuclide cineangiography correctly identifies abnormal sites of initial ventricular activation.

Diaphragmatic left ventricular aneurysm. Clinical features, surgical treatment, and long-term follow-up in 22 patients.

Although the formation of a left ventricular aneurysm (LVA) is a common and well-recognized complication of myocardial infarction (MI), diaphragmatic LVA is a rare clinical entity. Of 354 consecutive patients who underwent LVA resection, we describe the clinical features and surgical results of 22 patients (6%) with diaphragmatic LVA. All patients had a history of MI. The principal clinical indication for surgery was heart failure in nine patients, angina pectoris in ten patients, and recurrent ventricular tachycardia unresponsive to medical therapy in three patients. A ventricular septal defect was present in two patients, and moderate to severe mitral regurgitation was present in four patients. Three of the four surgical deaths (operative mortality, 18%) occurred in patients with mitral regurgitation or with ventricular septal defect. Eleven patients are alive at a mean follow-up of 40 months. Six of them are asymptomatic and two have angina at a higher level of physical activity than before surgery. Notable differences exist in the clinical presentation and surgical findings between patients with diaphragmatic and anterior LVA.

Atrial septal defect: repair in patients over thirty-five years of age.

Fifty-eight patients over age 35 underwent repair of atrial septal defect. The operative mortality was zero for the seven N.Y.H.A. class I and 26 N.Y.H.A. class II patients. One of 16 class III patients and two of nine class IV patients died; consequently, overall hospital mortality was five percent. The operative mortality was not related to age or level of pulmonary hypertension. Long-term clinical improvement was documented in 75 percent of patients who had been symptomatic preoperatively. The suggestion in early reports that pulmonary hypertension, or age per se, many contraindicate repair of an ASD cannot be supported by our results.