Hratch Kasparian

Effects of Nitroglycerin on Hemodynamics During Rest and Exercise in Patients with Coronary Insufficiency

Twenty-three patients exhibiting coronary insufficiency on exercise have been studied at rest and at exercise prior to and following sublingual administration of nitroglycerin. The most consistent and marked effect of nitroglycerin was the reduction in pulmonary artery pressure, total pulmonary resistance, and right ventricular work at rest and during exercise. Our patients were grouped according to the degree of left ventricular failure as indicated by the abnormality of rise in pulmonary artery pressure during exercise. It became evident that nitroglycerin improved left ventricular function in terms of increased output and lessened pulmonary artery pressure in cases in which failure was most severe.

Cardiac Work Demands and Left Ventricular Function in End-Stage Renal Disease

Cardiac hemodynamics were assessed by right and left heart catheterizations in nine patients on hemodialysis. Results showed increased stroke work index and left ventricular work indices. Left ventricular end-diastolic pressure was elevated in all patients (markedly so in five) and did not fall with occlusion of arteriovenous communications. Cardiac output was significantly elevated, but fell to normal postocclusion. Myocardial oxygen consumption, indirectly assessed by tension time and pressure rate indices, appeared increased. Six patients died: four from complications attributed to myocardial failure without infarction, one from transplant-related complications, and one from bacterial meningitis. Five had increased cardiac weights at autopsy, but none showed infarction. This study suggests that increased cardiac work is present in chronic renal failure. Myocardial mass increases result in increased myocardial oxygen demand; however, the increased oxygen requirements may not be met because of reduced erythrocyte mass. Persistance of pressure-volume overload and severe anemia are conducive to myocardial failure.

PHARMACODYNAMIC EFFECTS OF ALPHA-METHYL DOPA IN HYPERTENSIVE SUBJECTS.

Abstract The decarboxylase inhibitor, alpha-methyl dopa, is a potent antihypertensive agent. The hypotensive action of the drug appears to be due primarily to peripheral arteriolar relaxation. Its ability to reduce renal vascular resistance suggests its potential usefulness in the hypertensive patient with renal functional impairment.

CLINICAL CORRELATION OF CORONARY ARTERIOGRAPHY.

Abstract Selective coronary arteriography is a satisfactory technic in the study of the distribution and severity of atherosclerosis in patients with coronary heart disease. This investigation analyzes the placement and gradation of pathology in patients with angina pectoris whose resting electrocardiograms varied from normal patterns to tracings indicative of past transmural myocardial infarctions. Atherosclerosis was visualized as a diffuse process involving two or three main arteries even in those individuals who had the earliest clinical form of coronary heart disease, namely, angina pectoris and a normal resting electrocardiogram. The severity of the atherosclerotic process in terms of its stenosing effect on the vascular vessels increased materially as the electrocardiographic tracing deteriorated from normal to a pattern indicative of a past transmural myocardial infarction. Channels of anastomosis did not develop when atherosclerosis was diffuse but not occlusive. Particular attention is drawn to patients with angina pectoris and normal resting electrocardiograms who had in the past RS-T or T wave abnormalities or both. The occlusive disease in these patients was considerable and hardly compatible with the term “mild coronary.”

Evaluation of “coronary vasodilators” by coronary arteriography

Abstract The primary purpose of a coronary vasodilator is to increase the caliber of the coronary vascular bed. Selective coronary arteriography currently is the most direct and effective means of evaluating changes in the size of the coronary arteries in the intact organism. Utilizing this method of examination, it is apparent that glyceryl trinitrate and erythrityl tetranitrate have coronary vasodilating actions even in those patients with overt and serious coronary atherosclerosis. The demonstration of this action, however, does not imply that coronary blood flow is consequently improved.

Traumatic aneurysm of the left coronary artery

Abstract To our knowledge, this is the first reported case of the development of an aneurysm of a major coronary artery secondary to a traumatic wound to the heart. The patient sustained a single shotgun pellet wound to the heart, the pellet hitting the left anterior descending coronary artery and lodging in the wall of the left atrium. The patient incurred an anteroseptal wall infarction and had an uneventful recovery. Selective coronary artery visualization performed 4 weeks and 6 months after the injury occurred revealed a localized aneurysm of the anterior descending artery. The problems presented by this lesion are discussed.

Right atrial myxoma: Echocardiographic, phonocardiographic, and hemodynamic signs

Abstract A case of a right atrial myxoma successfully removed surgically and presenting clinically as right heart failure is described. The phonocardiogram revealed a systolic ejection and early diastolic sound, both of which may be the result of tumor movement. Cardiac catheterization showed right atrial hypertension, a diastolic gradient across the tricuspid valve, and a notch on the upstroke of the right ventricular pressure curve. Echocardiography demonstrated an abnormal cluster of echoes behind the tricuspid valve.

Myocardial infarction without obstructive coronary artery disease

Abstract The present report describes five cases of transmural myocardial infarction occurring in patients without occlusive coronary artery disease or other discernible abnormalities. It is apparent from these cases and others described in the literature that such patients may present with or without angina and, in some, the clinical course will be complicated by recurrent infarction and/or significant residual myocardial dysfunction. At present the exact incidence and natural history of this syndrome is unclear. Undoubtedly the increasing application of coronary arteriography will identify many more such patients. Delineation of the genesis and the full clinical spectrum of myocardial infarction without coronary artery disease warrants further investigative attention.

Coronary artery-coronary sinus fistula

Abstract Two cases of coronary artery-coronary sinus fistula are reported. A review of the literature is presented, and the data of the reported cases are analyzed. A continuous murmur has been described in most of the cases, and factors that may modify the character of the murmur are discussed. Cardiac X-ray films usually show a prominent main pulmonary artery, left or right ventricular enlargement and increased or normal pulmonary vascularity depending on the degree of the shunt. The electrocardiogram usually shows left ventricular hypertrophy and ischemia or incomplete right bundle branch block. Cardiac catheterization shows a step-up of oxygen content at the atrial level, and dye-dilution curves are diagnostic of left to right shunt. The only accurate methods for diagnosis are aortography and selective coronary arteriography. The treatment of choice is surgical correction of the anomaly at the time of the diagnosis.

Coronary arteriography: Correlation with electrocardiographic response to measured exercise

Abstract Measured exercise rarely produced specific S-T segment deviations when the coronaryarteries were free of discernible atherosclerosis, provided other conditions capable of interfering with the balance between coronary flow and the metabolic needs of the myocardium were not present. However, negative exercise electrocardiograms were also recorded in patients with angina pectoris and both nonobstructive and obstructive coronary atherosclerosis as visualized by arteriography. The incidence of negative responses was influenced by the inclusion of patients with past transmural infarctions. Abnormal exercise electrocardiograms were obtained mainly when patients with angina pectoris had demonstrable nonobstructive and obstructive coronary artery disease. However, specific S-T segment alterations were also encountered when the coronary arteriography was normal if a structural or functional defect was present capable of altering the balance between coronary flow and myocardial need.