Successful transcatheter closure with the buttoned device of aortopulmonary window in an adult.

This case report describes a technique to close an intermediate aortopulmonary window with the use of the buttoned device in an adult.

Paucity of subtle myocardial injury after angioplasty delineated with MB CK.

To determine the extent to which PTCA elicits subtle myocardial ischemic injury, 28 patients were studied prospectively. The presence of myocardial injury was assessed by analysis of frequent (q4 hours) serial samples of MB CK, a sensitive and specific marker of myocardial injury. Immediately prior to angioplasty, baseline 12-lead ECGs and blood samples for evaluation of total CK and MB CK were obtained. Additional ECGs were obtained immediately after the procedure and on the following morning, and serial samples for total and MB CK were obtained at 4-hour intervals for 24 hours. Patients requiring cardiac surgery within 24 hours after PTCA were excluded. Samples (n = 203) were assayed by the glass bead method. Total CK rose by more than 20 IU/L in only five patients, four of whom had received intramuscular premedication. Mean MB CK was 3.4 +/- 6.1 IU/L at 12 hours and 4.1 +/- 4.7 IU/L at 24 hours compared to 3.1 +/- 1.7 IU/L prior to angioplasty. Only one patient with obvious infarction had a value for MB CK above the normal range. Thus, uncomplicated PTCA is not accompanied by objectively detectable subtle myocardial injury.

Digital subtraction angiography of the coronary arteries.

The application of digital coronary arteriography in the evaluation of patients with known or suspected coronary artery disease is considered. Digital imaging of coronary arteries and bypass grafts can augment 35-mm cineangiography and may eventually replace film for coronary arteriography. The clinical efficacy of both selective and nonselective digital coronary arteriography is not yet established, however, a number of advantages over 35 mm cine have now been delineated including high contrast sensitivity image subtraction and digital image processing. One particular advantage of digital coronary arteriography is the ability to perform an immediate quantitative analysis of coronary images providing a reliable and consistent measure of the significance of a stenotic lesion. Technical requirements for digital coronary arteriography include a high output X-ray generator, low noise television chain, a 512 X 512 digital image matrix, frame rates of at least 15 fps, and high data storage capacity of c500 megabytes. The utilization of digital coronary imaging as a supplement or in place of 35-mm cine angiography will provide improved coronary imaging and enable quantification for more accurate and clinically significant coronary artery imaging.

Increased congestive heart failure after myocardial infarction of modest extent in patients with diabetes mellitus.

To elucidate the factors involved in the reduced survival rate of diabetic patients after acute myocardial infarction (AMI), we prospectively evaluated 100 patients with well-documented diabetes and 426 control patients. We characterized infarct size and analyzed the incidence and severity of congestive heart failure (CHF) and subsequent death with respect to infarct size. The extent of the index infarct was less in diabetic compared to nondiabetic patients, 16.2 +/- 2.2 CK-gm-eq/m2 compared with 19.2 +/- 0.9 (p less than 0.02). However, CHF was more prevalent in diabetic patients (31.2% of the diabetic patients compared to 15.7%). The difference was most prominent in diabetic patients who had sustained prior infarction (50% compared to 16%), but was evident also in diabetic patients with initial infarction (26% compared to 16%). The mortality rate was greater in diabetic patients (p less than 0.04). When diabetic and nondiabetic patients were stratified with respect to the presence or absence of CHF, survival curves were comparable. The increased incidence of CHF despite a smaller infarct size suggests that additional factors must contribute to myocardial dysfunction and the resultant excess in mortality.

Improvement of regional myocardial metabolism after coronary thrombolysis induced with tissue-type plasminogen activator or streptokinase.

To assess the effects on the heart itself of coronary thrombolysis induced with either tissue-type plasminogen activator (t-PA) or streptokinase (SK), we performed positron emission tomography with 11C-palmitate in 19 patients with initial transmural myocardial infarction immediately after admission and again within 48 to 72 hr after intracoronary administration of t-PA (n = 2) or SK (n = 17). Clots were persistent in eight patients treated with SK despite an average dose of 336,000 IU, sufficient to markedly deplete fibrinogen. In the absence of lysis, favorable tomographic changes did not occur. In contrast, in each of the 11 patients in whom lysis was induced (two with t-PA and nine with SK) myocardial accumulation of 11C-palmitate improved by an average of 29% in late compared with early studies (p less than .001). Results were comparable in patients with anterior and those with inferior infarction. Thus clot lysis induced with either t-PA or SK led to improved regional myocardial metabolism.

Prolonged coronary vasoconstrictor effect of ergonovine maleate.

The duration of the coronary artery vasoconstrictor effect of ergonovine maleate is an important clinical parameter that has not been clearly defined. Since ergonovine is generally administered in incremental, cumulative doses and since this agent may have potentially serious toxic effects related to its vasoconstrictor properties, knowledge of duration of this effect is crucial to its safe and efficacious use. We present clinical evidence of ergonovine-induced coronary artery spasm recurring after pharmacologic relief of a first episode of ergonovine-induced spasm. Recurrent spasm occurred 18 minutes after a cumulative dose of 0.15 mg ergonovine and 14 minutes after intravenous nitroglycerin was given to ameliorate the initial spasm. Therefore, clinical monitoring of patients after ergonovine administration should be designed to identify a possibly prolonged duration of vasoconstrictor effect of the drug. Sequential doses of ergonovine at intervals of ten minutes or less should be recognized as having cumulative effect. The duration of action of pharmacologic agents utilized to alleviate ergonovine-induced coronary artery spasm should exceed the potential duration of action of ergonovine in order to minimize the possibility of late spasm.

Technetium-99m-labelled macroaggregated albumin in demonstration of trans-diaphragmatic leakage of dialysate in peritoneal dialysis.

A patient developed a right pleural effusion soon after starting a program of continuous ambulatory peritoneal dialysis. The etiology of the effusion was unclear. 99mTc-labelled macroaggregated albumin was administered intraperitoneally, followed by 2 liters of dialysate. Trans-diaphragmatic leakage was clearly demonstrated, and confirmed by high count rates of pleural fluid with negligible blood count. This method can safely be used to demonstrate trans-diaphragmatic fluid leakage in peritoneal dialysis patients.

Surgical treatment of urethral stricture.

We reviewed 59 cases of urethral stricture diseases treated at Charity Hospital of Louisiana in New Orleans from 1965 to 1975 to determine whether surgery was a feasible alternative to repeated urethral dilatations. Five different surgical procedures were done: internal urethrotomy, Johanson-Leadbetter, patch-graft, Turner-Warwich, and dismembered technics. Results of internal urethrotomy were poor, but the other procedures had an overall success of 72 percent.