Ali Ghahramani

Myocardial infarction due to congenital coronary arterial aneurysm (with successful saphenous vein bypass graft)

Abstract A 32 year old white woman with congenital saccular aneurysm of the left coronary artery is described. The patient presented with acute myocardial infarction. Calcification in the wall of the aneurysm could be seen on the chest roentgenogram. Selective coronary cineangiograms demonstrated a calcified aneurysm at the origin of the left anterior descending coronary artery which caused complete occlusion of this vessel and partial compression of the circumflex coronary artery. Left ventricular cineangiograms disclosed an akinetic area in the anterior wall and mild mitral regurgitation. The patient successfully underwent saphenous vein bypass graft from aorta to left anterior descending coronary artery. Postoperative studies demonstrated patency of the vein graft with excellent antegrade filling of a normal vessel and nonfunctioning of the previously demonstrated collateral channels.

Hemodynamic features of prolapsing and nonprolapsing left atrial myxoma.

In the course of the evaluation of five patients with left atrial myxoma, it was noted that the movement of the myxoma was related to specific changes in left atrial hemodynamics. Prolapsing tumors, Type I, move from the left ventricle to the left atrium in early systole and from the left atrium to the left ventricle in early diastole, thereby causing prominent c and v waves accompanied by a rapid y descent. Nonprolapsing tumors, Type II, remain in the left atrium during the entire cardiac cycle, impeding flow across the mitral valve. In these latter cases, the y descent is slow and indistinguishable from that caused by mitral valvular stenosis. The cineangiocardiograms and echocardiograms corroborate these two types of hemodynamic observations. The particular value of direct echocardiographic examination of the left atrium prior to cardiac catheterization was evident in two of the three patients with nonprolapsing tumors. Since the hemodynamic pattern of nonprolapsing left atrial myxoma resembles that of mitral valvular stenosis, it is stressed that echocardiography should have an important place in precatheterization assessment of patients with mitral valve disease. If left atrial myxoma is suspected clinically or on the basis of echocardiographic findings, regardless of the pressure curve contours, transseptal cardiac catheterization should be avoided and the left atrium visualized by pulmonary angiography levophase.

Left atrial myxoma: Hemodynamic and phonocardiographic features

Abstract Two cases of left atrial myxoma are presented, with a review of clinical clues which may help in distinguishing this disease from mitral valve disease. Suggestive features in the apexcardiogram and internal and external phonocardiograms are discussed, together with related hemodynamic events indicated on the pulmonary capillary wedge, left atrial and left ventricular pressure tracings. The origins of various auscultatory features are analyzed in the light of specific hemodynamic events. Hemolytic anemia was present in one case, and ruptured chordae tendineae with scarring and myxomatous degeneration of the mitral leaflets in the other. Possible mechanisms for these lesions related to myxoma are discussed. The role of cardiac fluoroscopy, left ventricular cineangiography and the levophase of pulmonary angiography in helping to delineate left atrial myxoma is also mentioned.

Clinical, Surgical, and Pathologic Correlation in Patients with Acute Myocardial Infarction and Pump Failure

A review was made of the entire hospital course of 20 patients aged 44 to 79 years who suddenly developed clinically intractable left-heart pump failure as a result of acute myocardial infarction. They were divided into three groups according to their presenting circulatory state. Thirteen patients were in cardiac arrest (group I), four had cardiogenic shock due to myocardial rupture (group II), and three had severe intractable left-heart failure (group III). Preoperative partial or complete cardiac catheterization was possible in six patients.Surgical treatment using cardiopulmonary bypass was selectively undertaken as a mode of therapy in 11 of the 20 cases. In 10, the area of infarction was delineated and was resected. Pathologically, the infarcts were from 1 to 14 days old, and in 19 of 20 cases involved the anterior wall. The specimens weighed 25 to 83 g. One patient, who was discharged, had infarctectomy and double coronary vein bypass graft. One patient lived for 3 weeks after infarctectomy and pulmonary embolectomy. Two others survived after surgery for 2 and 36 hours, respectively.The results of this prospective study suggest that identification of patients possibly amenable to successful treatment of medically irreversible pump failure by surgical means will require earlier recognition of the high-risk group and intensive hemodynamic and radiographic evaluation of the extent of the disease process.

Case reportLeft atrial myxoma: Hemodynamic and phonocardiographic features

Abstract Two cases of left atrial myxoma are presented, with a review of clinical clues which may help in distinguishing this disease from mitral valve disease. Suggestive features in the apexcardiogram and internal and external phonocardiograms are discussed, together with related hemodynamic events indicated on the pulmonary capillary wedge, left atrial and left ventricular pressure tracings. The origins of various auscultatory features are analyzed in the light of specific hemodynamic events. Hemolytic anemia was present in one case, and ruptured chordae tendineae with scarring and myxomatous degeneration of the mitral leaflets in the other. Possible mechanisms for these lesions related to myxoma are discussed. The role of cardiac fluoroscopy, left ventricular cineangiography and the levophase of pulmonary angiography in helping to delineate left atrial myxoma is also mentioned.

Complications of Coronary Bypass Surgery

In the past three years, among 170 patients undergoing aortocoronary bypass surgery, 11 (6%) developed acute myocardial infarction within 24 hours after surgery. An additional four patients (2%) developed myocardial infarction within three months after discharge. Clinically, acute myocardial infarction was suspected because of sudden, transient hypotension associated with dysrhythmia, angina, or cardiac arrest which responded to conventional therapy. Elevation of serum enzymes with acute ECG changes was also observed. Three of the 15 patients developing myocardial infarction died. In 12 patients cardiac catheterization studies were performed within two to ten weeks after the incident. Eleven of the 20 grafts were found occluded, and progression of coronary occlusive disease was seen in five. There was a marked decrease in left ventricular function, contractility, and compliance in all patients with left ventricular aneurysm formation or dyskinesia. Eight of these patients were asymptomatic. The results indicate that after coronary surgery a combination of sudden arrhythmia and transient hypotension is diagnostic of graft closure or development of acute myocardial infarction. Also, in spite of depressed cardiac function, most surviving patients remain angina free.