Alfred A. Bove

Intracoronary thrombus: Role in coronary occlusion complicating percutaneous transluminal coronary angioplasty

Angiograms from 238 consecutive patients who underwent percutaneous transluminal coronary angioplasty at the Mayo Clinic were reviewed to determine the presence of intracoronary thrombus before dilation. Patients with previously occluded vessels and those receiving streptokinase therapy were excluded. Intracoronary thrombus before dilation was present in 15 patients (6%); complete occlusion occurred in 11 (73%) of these during or immediately after dilation. None of these patients had angiographic evidence of major intimal dissection. In contrast, among the 223 patients in whom no intracoronary thrombus was present before dilation, complete occlusion occurred in 18 (8%) and in 12 was associated with major intimal dissection. The difference between the complete occlusion rates for patients with and without prior intracoronary thrombus was highly significant (73 versus 8%, respectively, p less than 0.001). Therefore, the presence of intracoronary thrombus identifies a group of patients who are at increased risk of developing complete occlusion during or after attempted coronary artery dilation.

Follow-up clinical results in patients undergoing percutaneous transluminal coronary angioplasty.

Complete follow-up data were obtained from 229 consecutive patients who underwent percutaneous transluminal coronary angioplasty (PTCA) between 1979 and 1982 (mean follow-up 14 months, range 6 to 37). Single-vessel disease was present in 143 and multivessel disease in 86. PTCA was successful in 153 patients (67%). Failure was followed initially by bypass surgery in 59 and by continued medical therapy in 17. After successful PTCA, 90% of patients were improved subjectively and 74% were asymptomatic at follow-up. After unsuccessful PTCA but prompt bypass, 90% were improved subjectively and 85% were asymptomatic. Among the 229 patients, 39 (17%) required an additional intervention because of angina during follow-up; 15 of these had repeat PTCA and 18 had bypass surgery. Among patients with successful PTCA, revascularization was complete in 77% and partial in 23%. The completeness of revascularization with PTCA had a significant impact on follow-up. The follow-up data of patients with successful single-vessel PTCA and of those with multivessel disease with complete revascularization were similar. When the patients with complete revascularization were compared with those with multivessel disease but incomplete revascularization, the follow-up data were characterized by a higher incidence of angina or need for bypass surgery in the latter group (63%) than in the former group (29%); those with incomplete revascularization also had a significantly reduced event-free survival.

Instantaneous pressure gradient: a simultaneous Doppler and dual catheter correlative study.

To more precisely measure the beat to beat and instantaneous pressure gradients across outflow stenotic lesions, simultaneous Doppler and dual catheter pressure gradient measurements were performed in 95 patients (mean age 42 years, range 1.5 to 85). There were 38 right ventricular and 62 left ventricular outflow obstructive lesions. Forty-nine patients also had a nonsimultaneous Doppler study performed within 7 days before catheterization. The simultaneous pressure waveforms and Doppler spectral velocity profiles were digitized at 10 ms intervals deriving maximal, mean and instantaneous gradients (mm Hg). For simultaneous maximal Doppler and catheter gradient measurements, the correlation coefficient (r) was 0.95 (SEE = 10 mm Hg), for Doppler and catheter mean gradients it was 0.94 (SEE = 8 mm Hg) and for maximal Doppler and peak to peak catheter gradients it was 0.92 (SEE = 13 mm Hg). The correlation of maximal and mean Doppler gradients with the respective catheter gradients was similarly high when the right and left ventricular outflow lesions were analyzed separately. However, the maximal Doppler gradient was significantly higher than the peak to peak catheter gradient. This was more evident with left ventricular outflow stenotic lesions. The correlation of the outpatient maximal Doppler and catheter gradients (r = 0.80, SEE = 17 mm Hg) was significantly lower than the simultaneous correlation (r = 0.96, SEE = 10 mm Hg) in the 49 patients with two Doppler studies. Continuous wave Doppler echocardiography accurately measures the instantaneous pressure gradient across both left and right ventricular outflow obstructive lesions. The maximal Doppler gradient should not be equated with the peak to peak catheter gradient.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased vasoconstrictor activity of proximal coronary arteries with endothelial damage in intact dogs.

In this study we examined the hypothesis that endothelial damage increases proximal coronary arterial vasomotor tone and sensitivity to vasoconstrictor stimulation. The response of the left anterior descending coronary artery (LAD) (% area change) to serotonin and nitroglycerin were examined in eight anesthetized (Innovar + nitrous oxide), closed-chest dogs by means of quantitative coronary angiography. Dose-response curves of percent change in arterial cross-sectional area for three doses of intracoronary serotonin were examined before and after endothelial damage produced by a balloon catheter in the LAD. Endothelial damage was verified by postmortem scanning electron microscopic examination. Intracoronary injection of 133Xe provided coronary flow data. The damaged segment of LAD showed spontaneous vasoconstriction and further constriction in response to serotonin (33 +/- 5% before and 52 +/- 6% area reduction after damage; p less than .05). Nitroglycerin reversed serotonin-induced vasoconstriction in LAD segments without damage but not in the LAD segment with endothelial damage. No significant changes were observed in aortic pressure, and heart rate was kept constant by pacing. Blood flow in the LAD was not affected by endothelial damage itself (control, 2.44 +/- 0.09 ml/min/g; damage, 2.53 +/- 0.22 ml/min/g). Endothelial damage induced spontaneous proximal coronary constriction and diminished the relaxant response to nitroglycerin in the presence of serotonin. These results suggest that focal coronary narrowing that occurs in some patients after provocation with vasoconstrictor agents may be caused by local areas of damaged endothelium.

Angiographic changes produced by percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is being used with increasing frequency in the treatment of patients with symptomatic coronary artery disease. Balloon inflation results in diverse angiographic findings, reflecting the great variety of anatomic and pathologic changes produced. The long-term effects of inflation on the underlying atherosclerotic lesion and the clinical outcome are unknown but may depend in part on the anatomic changes caused by the dilatation itself. To facilitate communication and evaluation of the results of PTCA, a classification of the angiographic findings and their potential mechanisms is presented. Recognition and analysis of these angiographic findings may be helpful in evaluating the long-term outcome of patients undergoing PTCA.

Gender-related differences in cardiac response to supine exercise assessed by radionuclide angiography.

This study examines the recently reported gender differences in cardiac responses to exercise. The study group consisted of 192 men and 67 women with a low probability of coronary artery disease who underwent supine exercise radionuclide angiography. Men had a lower rest ejection fraction than that of women (0.63 versus 0.66, p = 0.02) and greater increases in ejection fraction with exercise (0.08 versus 0.02, p = 0.0001). The slope relating ejection fraction to metabolic equivalents of exercise (METs) was greater (p = 0.004) for men, even after adjustment for differences in rest ejection fraction and end-diastolic volume index. Compared with men, women had a smaller rest end-diastolic volume index (87 versus 97 ml/m2, p = 0.003) and a greater increase in end-diastolic volume index with exercise (6 versus -2 ml/m2, p = 0.002). The slope relating end-diastolic volume to METs was greater for women, even after adjustment for differences in rest end-diastolic volume index and peak work load. There are clear gender differences in the supine exercise response of ejection fraction and end-diastolic volume that are not explained by differences in exercise capacity.

Influence of left ventricular mass on coronary artery cross-sectional area

Observations from cardiac catheterization suggest that coronary artery cross-sectional area (CSA) is increased in patients with left ventricular (LV) hypertrophy and is proportional to LV mass. This hypothesis was tested using computer-based quantitative analysis of LV mass and CSA from angiographic images of the left ventricle and proximal coronary arteries from 19 men and 21 women, aged 23 to 78 years (mean 56). Twenty-seven patients had valvular heart disease, 16 of whom had multivalvular involvement; diagnoses included aortic stenosis in 19, aortic regurgitation in 13 and mitral regurgitation in 12. Thirteen patients had normal valvular and ventricular function. All patients had normal coronary arteries. Significant differences between normal patients and those with valvular disease were noted in LV mass (88 +/- 7 vs 165 +/- 12 g/m2, p less than 0.001) and coronary CSA (26 +/- 2 vs 46 +/- 3 mm2, p less than 0.001). Furthermore, a linear relation between LV mass and coronary CSA was noted (r = 0.788, p less than 0.001). Thus, proximal coronary artery CSA is significantly larger in valvular heart disease patients with LV hypertrophy than in those with normal ventricles, and proximal coronary artery area increases in proportion to LV mass in hypertrophied ventricles.

Effects of serotonin and histamine on proximal and distal coronary vasculature in dogs: Comparison with alpha-adrenergic stimulation☆

The effect of several vasoactive agents on epicardial conductance arteries and distal resistance arteries was studied in intact dogs using a special catheter system to infuse vasoactive mediators directly into the left anterior descending coronary artery of intact dogs. Serotonin produced significant epicardial vasoconstriction (42% cross-sectional area reduction, p less than 0.01), whereas histamine had no effect on proximal coronary arteries. Phenylephrine, an alpha-adrenergic agonist, produced an 11% reduction in cross-sectional area. Distal coronary vascular resistance (pressure/flow) changes were small for serotonin and phenylephrine, whereas histamine significantly dilated the peripheral vascular bed and caused flow measured by xenon-133 washout to increase from 30.4 +/- 4.0 to 72.4 +/- 12.6 ml/min . 100 g (p less than 0.05). These results show that vasoactive mediators can have different actions on coronary resistance and conductance vessels. Serotonin is a potent vasoconstrictor of epicardial coronary arteries but does not produce significant constriction of coronary resistance vessels.

Action and localization of vasoactive intestinal peptide in the coronary circulation: Evidence for nonadrenergic, noncholinergic coronary regulation

Vasoactive intestinal polypeptide, a neurotransmitter peptide detected in animal and human hearts, has been found in nerves of coronary arteries. To determine the amount and distribution of vasoactive intestinal polypeptide in the large coronary vessels and its possible participation in coronary vasoregulation, two groups of animals were studied. In the first group, 11 anesthetized dogs were sacrificed to collect three (1 cm) segments along the circumflex and left anterior descending coronary arteries. These segments represented proximal (I), middle (II) and distal (III) portions of the two arteries. Concentrations (ng/g) of vasoactive intestinal polypeptide-like immunoreactive substance were determined by radioimmunoassay. Vasoactive intestinal polypeptide-like immunoreactivity was present in the left anterior descending (I = 7.28 +/- 1.65, II = 3.74 +/- 0.57, III = 2.29 +/- 0.53) and circumflex (I = 4.16 +/- 1.52, II = 4.58 +/- 1.13, III = 4.00 +/- 0.81) coronary arteries. The difference in vasoactive intestinal polypeptide-like immunoreactivity among epicardial segments of the anterior descending artery was significant, but there was no significant difference among segments of the circumflex coronary artery. In the second group (eight closed chest anesthetized dogs), the effects of vasoactive intestinal polypeptide intracoronary infusion on epicardial coronary constriction were examined at rest and with the artery constricted by serotonin. Left anterior descending (segments I, II and III) artery responses (% area change) to vasoactive intestinal polypeptide and vasoactive intestinal polypeptide plus serotonin were examined using quantitative coronary angiography. Vasoactive intestinal polypeptide infusion resulted in significant vasodilation in all the segments (I, II and III) of the left anterior descending artery.(ABSTRACT TRUNCATED AT 250 WORDS)

Validation of instantaneous pressure gradients measured by continuous-wave Doppler in experimentally induced aortic stenosis

The relation between catheter-measured and Doppler-derived aortic pressure gradients was examined in 8 open-chest dogs. A snare was placed around the proximal ascending aorta and adjusted to provide a wide range of gradient to left ventricular (LV) outflow. A continuous-wave Doppler transducer was placed above the level of the obstruction and angled to optimize the audio and spectral signals. Pressure tip transducer catheters recorded LV and ascending aortic pressures simultaneously with the Doppler signal. In 120 randomly selected sinus beats, Doppler-derived maximal gradient correlated well with maximal instantaneous catheter gradient from 4 to 179 mm Hg (r = 0.99). Mean gradients also were closely related (r = 0.98). For gradients above 100 mm Hg, the correlation remained good (r = 0.98), but for gradients below 50 mm Hg, the correlation was not as precise (r = 0.81). All 120 cycles were digitized at 10-ms intervals to examine the correspondence between the Doppler and catheter data throughout systole. For the 2,742 pairs of points so obtained, the correlation was excellent (r = 0.95). The close relation between Doppler-derived pressure gradient and that measured simultaneously by catheterization provides further validation of the use of continuous-wave Doppler in the assessment of aortic stenosis, not only at maximal gradient, but throughout the period of LV ejection.