B. George Wisoff

Coronary artery calcification: Clinical implications and angiographic correlates

Summary A prospective study of 250 consecutive patients with angiographically proved arteriosclerotic heart disease and 250 consecutive patients with normal coronary angiograms is reported to evaluate the significance of coronary artery calcification. Coronary artery calcification was present in 76 per cent of the patients with arteriosclerotic heart disease as compared to 22 per cent of the patients with normal coronary angiograms. The frequency of coronary artery calcification increased progressively with increasing age. In patients aged 49 or less the presence of coronary artery calcification strongly favors the diagnosis of arteriosclerotic heart disease. Patients with double- or triple-vessel disease are more likely to have coronary artery calcification than are patients with single-vessel disease. Calcification was more likely to involve a coronary artery involved with significant disease but was not related to the severity of that disease. Calcification of the main left coronary artery was not helpful in predicting significant disease of the main left coronary artery. Calcification of two or three coronary arteries indicated that singlevessel coronary artery disease was unlikely.

Homologous-Blood Syndrome during Extracorporeal Circulation in Man

IT has previously been demonstrated that circulating blood volume significantly diminishes after perfusion despite careful replacement of all measured blood loss.1 Clinical and experimental evidenc...

Outcome of Isolated Coronary Artery Bypass Surgery in Octogenarians

Abstract Background: Between 1989 and 1992 100 consecutive patients aged 80 or older underwent isolated coronary artery bypass grafting (CABG) in our institution. Eighty‐six percent had angina grade III or IV symptoms. Methods: Emergency surgery was required in 31, urgent surgery in 30, and elective surgery in 39 patients. The average left ventricular ejection fractions (LVEF) in these groups were 36%, 43%, and 45% respectively. The operative mortality was 8% for these octogenarians compared to 2% in the younger cohort (p = 0.002). It was zero in elective cases and 13% (8/61) in urgent and emergency cases. It was increased by preoperative admission to coronary care unit (CCU) (p = 0.02), urgency of operation (p = 0.02), the use of intra‐aortic balloon pump (IABP) (p = 0.0002), preoperative renal dysfunction (p < 0.03), and ± 3 grafts (p < 0.04). The late mortality was increased by LVEF ± 20% (p = 0.03) and operation from CCU (p < 0.05). On multivariate stepwise logistic regression analysis, the use of IABP (p < 0.0003) and preoperative renal dysfunction (p < 0.02) were independent predictors of operative mortality. LVEF ± 20% was the only independent predictor (p < 0.02) of late mortality. Results: Actuarial survival was noted to be 87%, 80%, 77%, and 73%, respectively, at 1, 2, 3, and 4 years, with two cardiac‐related late deaths. Long‐term follow‐up revealed that 97% of patients had no or minimal anginal symptoms. Conclusions: Due to increasing use of nonsurgical options, the profile of elderly referred for CABG currently involves gravely ill patients with comorbidities. CABG under elective conditions, before deterioration of left ventricular function, can achieve normal life expectancy and good symptomatic relief in octogenarians.

Significance of new Q waves after bypass grafting: Correlations between graft patency, ventriculogram, and surgical venting technique

New postoperative electrocardiographic Q waves have been described in eight of 40 per cent of patients undergoing bypass grafting for coronary artery disease. Various theories have been proposed to explain these new Q waves. Correlations of new Q waves to vein bypass occlusion, prolonged pump time or aortic cross-clamping time are controversial. Indeed, whether or not the appearance of new postoperative Q waves means real transmural myocardial infarction is not clear. We report herein our experience with postoperative Q waves in 56 patients with vein bypass grafts and the relationship of new Q waves to ventricular venting, graft patency, and the postoperative ventriculogram. Our observations indicate that: (1) Not all Q waves are due to occlusion of the saphenous bypass grafts (as noted by others). (2) A certain percentage of new Q waves may not reflect true transmural myocardial infarction, especially when all the vein grafts are patent and the postoperative ventriculograms show improvement. (3) Some new Q waves reflect true transmural infarction due to occlusion of grafts or of distal coronary arteries with deteriorated left ventriculograms. (4) The high incidence of new Q waves in patients with ventricular vents is probably due to direct myocardial trauma at the apex of the left ventricle.

The homologous blood syndrome

Abstract 1. 1. Rapid exchange of homologous blood in dog or man may precipitate a state of shock. The reaction is dose-related and becomes more pronounced with increasing duration. 2. 2. Severe hypovolemia (diminution of the effective circulating blood volume) results from sequestration of both plasma and cells. 3. 3. Eventual return of a portion of the trapped blood is evident from repetitive blood volume studies. 4. 4. Separate exchange of components of homologous blood did not eliminate the manifestations of the syndrome in the experimental animal. However, erythrocytes reconstituted in physiologic saline solution caused the least dynamic alterations. 5. 5. Data obtained during clinical exchange of homologous erythrocytes and saline are presented. 6. 6. Amelioration of the homologous blood syndrome during cardiopulmonary bypass has been obtained by (a) reduction of the extracorporeal priming volume, (b) substitution of electrolyte solutions for a portion of the homologous blood and (c) reutilization of blood collecting in pleural and precardial spaces during surgery. 7. 7. Possible etiologic mechanisms of the homologous blood syndrome are discussed.

New Q waves after bypass grafting: Correlations between graft patency, ventriculogram and surgical venting technique

New Q waves were observed in 35 (11%) of 321 patients undergoing saphenous vein bypass grafting with an overall mortality rate of 1.1%. Twenty-eight (80%) had postoperative arteriograms and ventriculograms and are reported. Ventricular venting was used intra-operatively in 17 patients and atrial venting in 11. The incidence of new Q wave was 22% in patients with ventricular venting and 5.5% in those with atrial venting (p less than 0.05). Complete or incomplete revascularization did not affect the incidence of new Q waves. New Q waves appeared in a zone of myocardium supplied by a grafted artery in all except two patients with ventricular venting in whom Q waves occurred within the zone of myocardium supplied by diseased ungrafted vessels. In the ventricular venting group, seven (41%) demonstrated an improved or unchanged postoperative ventriculogram and ten (59%) had deteriorated ventriculograms. In 11 patients with atrial venting, nine (82%) showed improved or unchanged postoperative ventriculograms and two (18%) had deteriorated ventriculograms. Ventricular venting patients with improved or unchanged postoperative ventriculograms had 7% graft closure as compared to 5% of those with atrial venting (pNS). Graft closure rate was 44% in ventricular venting and 20% (pNS) of patients with atrial venting who had deteriorated left ventriculograms. These findings indicate poor correlation between new Q waves and graft closure. Improved postoperative ventriculograms corrleated well with graft patency despite new Q waves. The etiology of new post bypass graft Q waves are varied. They include ventricular trauma and conduction delays resulting from surgery or venting, as well as infarction. This may be due to compromised arterial inflow either in nonoperated vessels or in the vessels distal to the anastomosis with patent grafts, or due to occluded grafts.

Recurrent angina after bypass surgery: evaluation by early and late arteriography

Abstract Arteriographic correlates of recurrent angina pectoris were obtained in 98 patients undergoing both early ( The present study indicates that late recurrent symptoms may be anticipated after bypass surgery, since for the most part, they are due to progressive atherosclerotic process in the native circulation. Primary graft failure plays only a minor role in producing recurrent symptoms. Thus, continued control of risk factors, especially lipid abnormalities, is warranted after bypass surgery.