Hugo Spindola-Franco

Pseudoaneurysm of the Left Ventricle: Radiographic and Angiocardiographic Diagnosis

Left ventricular pseudoaneurysms represent intrapericardial ruptures contained by adherent pericardium and fibrous tissue, forming an avascular wall; in contrast, the wall of a true aneurysm is formed of fibrous elements of the infarcted myocardium and contains coronary vessels. Prior myocardial infarction and/or aneurysmectomy may predispose to pseudoaneurysm formation. Plain radiographs, echocardiography, gated cardiac blood pool imaging, and left ventriculography are helpful, and the combination of left ventriculography and selective coronary arteriography is diagnostic. A uni- or multiloculated chamber communicating with the left ventricle by a relatively small orifice without draping of coronary vessels is diagnostic of pseudoaneurysm.

Comparison of observer performance with 16 mm cinefluorography and 70 mm camera fluorography in coronary arteriography

Clinical 16 mm cinefluorography and 70 mm camera fluorography were compared in 30 unselected patients undergoing coronary arteriography. Accuracy in detecting coronary arterial stenosis and collateral vessels and in assessing the degree of stenosis was similar with the two techniques. With both methods, there were significant inter- and intraobserver differences in estimating the degree of stenosis. These differences indicate that coronary arteriography is only a semiquantitative method for making decisions about treatment, prognosis and follow-up of patients. The use of more than one observer increases the likelihood that stenotic lesions will be detected. Interobserver variation in detecting collateral circulation is small.

Pulmonary Steal Syndrome: An Unusual Case of Coronary-Bronchial Pulmonary Artery Communication

The authors report a patient with angina pectoris in whom selective left coronary angiography demonstrated that the pulmonary artery branch to an apical lung segment was supplied by a bronchial collateral vessel which arose from the left circumflex artery. The anatomic and physiological developmental mechanisms, and the clinical implications, are discussed. Relief of the patients angina following ligation of the pulmonary artery branch indicated the development of a form of pulmonary steal syndrome.

Classification of the radiological morphology of the mitral valve. Differentiation between true and pseudoprolapse.

The morphology of the mitral valve apparatus was assessed on 100 normal left ventriculograms. Four distinct types of mitral valve were identified according to the position of the mitral fulcrum (the point of attachment of the leaflets to the annulus) and the configuration of the adjacent left ventricular wall (left ventricular fornix) during diastole. Types I and II closely simulated prolapse of the mitral valve (pseudoprolapse) in the right anterior oblique projection during the ejection period. Measurements showed that contraction of the ventricle failed to reduce the diameter of the mitral valve annulus in 26 per cent of normal left ventricles.

Coronary vascular patterns during occlusion arteriography.

The arteriograms from 18 studies in which the catheter accidentally occluded the right coronary artery were analyzed and compared with successful studies in 25 patients with normal coronary arteries and 20 patients with coronary artery stenosis. The occlusion arteriograms showed distinct early filling of the anterior cardiac veins and occasionally retrograde filling of the left circumflex artery. Although there were no serious complications due to occlusion arteriography in our patients, the potential for producing ventricular tachycardia, ventricular fibrillation or cardiac arrest must be borne in mind. Angiographers should be aware of these filling patterns in order to recognize them as artifacts of the technique and not as manifestations of disease.

Migration of epicardial pacemaker leads

The implantation of permanent pacemakers often gives rise to complications. Migration of leads, an unusual complication, occurred in two of our patients with epicardial pacemakers. In one case lead fracture and sussequent displacement due to heart action occurred after an automobile accident. In the second case looping and migration of the wire occurred within a day after implantation although the lead continued to function properly for six months. The probable cause of migration in this patient was excess slack.

Reciprocating Flow in the Coronary Circulation

Selective cine coronary arteriograms in 125 patients with coronary artery disease were analyzed. In the 75 patients with demonstrable collateral channels and obstruction or stenosis of more than 505%, reciprocating flow (phasic alternation of the direction of blood flow) was demonstrated in one or more branches in 25 patients. The timing of this phenomenon was related to the events of the cardiac cycle, and three distinct patterns emerged: primary epicardial, secondary epicardial, and intramyocardial. Visualization of reciprocating flow in epicardial vessels was associated with significant localized coronary stenosis with collateral pathways and a perfusable capillary bed. Reciprocating flow was not detected in diffusely diseased coronary arteries. Thus the presence of reciprocating flow should be construed as a favorable sign if coronary bypass surgery is contemplated.

Venous visualization during left ventriculography.

In 3 patients, coronary venous channels filled during ventriculography in the absence of an interstitial stain. Coronary arteriography demonstrated coronary atherosclerotic disease in 2 patients and normal coronary arteries and cardiomyopathy in the third. No abnormal communication between coronary arteries and cardiac chambers was seen. Repeat ventriculography failed to demonstrate this phenomenon. This appearance is most consistent with reversal of flow in the thebesian venous system caused by trapping of the catheter in a segment of the ventricular cavity during injection.