James T. T. Chen

The Significance of Coronary Calcification Detected by Fluoroscopy A Report of 360 Patients

Cardiac fluoroscopy to detect coronary calcification was performed on 360 patients before undergoing coronary arteriography for proven or suspected coronary artery disease. Among the 154 patients in whom coronary calcification was identified, 97% had significant coronary disease angiographically (≧ 70% stenosis). In this group, the distribution of one, two, and three vessel coronary disease was 9%, 25%, and 66% respectively. The prevalence of coronary calcification increased with age and severity of coronary disease, but no difference in males versus females was demonstrable. The angiographic severity of coronary disease increased with multiple vessel calcification; three vessel disease occurred in 45%, 66%, and 82% of patients with one, two, and three vessel calcification, respectively. Patients with hyperlipidemia or hypertension had no significant difference in the prevalence of coronary calcification. Among the 267 patients with significant coronary lesions, 56% had calcification detected by fluoroscopy.Five of the 93 patients with no significant coronary disease angiographically had coronary calcification fluoroscopically. Four of the five had a prior history of myocardial infarction, and two showed asynergy on left ventriculography.This study demonstrates that cardiac fluoroscopy is a valuable procedure for detecting significant coronary artery disease since this highly specific test is easily performed, inexpensive, noninvasive, and widely applicable for screening large patient populations.

Natural history of experimental coronary occlusion in pigs: A serial cineangiographic study☆☆☆

Abstract In order to evaluate, in vivo, the serial changes of the coronary arteries and the development of collateral circulation during the course of a gradual coronary occlusion, 32 farm pigs were studied with serial selective coronary cineangiograms following placement of an Ameroid constrictor on the left anterior descending coronary artery. Delaved clearance of contrast medium and poststenotic dilatation of the constricted artery appeared by the second to third day; complete occlusion on the sixth to seventh day. Demonstrable collateral vessels developed in most of the surviving animals by the sixth to seventh day. These channels increased in size and number in the subsequent 4 to 5 weeks so that the left anterior descending artery distal to the constrictor again became completely opacified through the collateral channels. In 16 animals that survived longer than 6 days, major collateral channels perfusing the distal portion of the obstructed artery arose proximal to the constrictor in 8, from the left circumflex artery in 11, and from the right coronary artery in 13. Despite the development of such collateral circulation, massive myocardial infarction developed indicating that the rapidity and/or extent of the collateralization was inadequate to prevent myocardial death. These findings also provide the basic information needed for using this preparation as the model for studies of myocardial infarction.

Calcification in pulmonary metastases

A large variety of neoplasms can produce calcified lung metastases. Three unusual examples are presented and the relevant literature is reviewed. Each case involves a neoplasm not previously reported to produce calcified lung metastases: malignant mesenchymoma, fibrosarcoma of the breast, and medullary carcinoma of the thyroid. The sarcomas are reported in the literature to develop calcified lung metastases are osteogenic sarcoma, chondrosarcoma, synovial sarcoma, and giant cell tumour. Among carcinomas, the papillary and mucinous adenocarcinomas are the histological types most likely to develop calcified lung metastases. The metastases of a number of other tumours have calcified after antineoplastic therapy. Calcification in metastases arises through a variety of mechanisms: bone formation in tumour osteoid, calcification and ossification of tumour cartilage, dystrophic calcification and ossification of tumour cartilage, dystrophic calcification and mucoid calcification. Since calcified lung metastases can strongly resemble granulomas or hamartomas, a reasonable suspicion of malignancy is necessary when evaluating calcified pulmonary nodules.

Echocardiographic detection of perforation of the cardiac ventricular septum by a permanent pacemaker lead

Abstract Previously reported complications of temporary transvenous pacing include perforation of the ventricular septum or ventricular wall. 1–4 Perforation of the ventricular septum by a permanent pacing electrode with long-term left ventricular pacing has not been reported.

Surgical Treatment of Mycotic Aneurysm Associated with Coarctation of the Aorta

Abstract Mycotic aneurysm is a rare complication associated with coarctation of the aorta. A review of 13 patients treated surgically for this combination of lesions illustrates the typical pathological characteristics, the importance of proper timing of surgical intervention, and the significant improvement in survival following excision of the aneurysm and coarctation after a course of appropriate antibiotic therapy.

Pulmonary arterial diastolic pressure in acute myocardial infarction.

Abstract Pulmonary arterial diastolic pressure has been shown to be a reliable estimate of left ventricular filling pressure. In 91 patients with acute myocardial infarction, the Swan-Ganz flow-directed catheter was used to measure pulmonary arterial diastolic pressure, which was correlated with clinical and radiographic estimates of left ventricular failure. The physical findings of a third sound gallop and rales were significantly correlated with the level of pulmonary arterial diastolic pressure. In the absence of either a third sound gallop or rales, the pulmonary arterial diastolic pressure was found to be increased in 47 percent of the patients. The presence of rales was a less sensitive determinant of left ventricular dysfunction than a third sound gallop alone or in association with rales. Radiographic findings of increasing pulmonary congestion were significantly correlated with the level of pulmonary arterial diastolic pressure. In the absence of radiographic pulmonary congestion, 24 percent of patients had abnormal pulmonary arterial diastolic pressure. We conclude that measurement of pulmonary arterial diastolic pressure increases the objectivity of the clinical evaluation in patients with acute myocardial infarction.

Kerley B lines in total anomalous pulmonary venous connection below the diaphragm (type III)

Abstract A case is presented of total anomalous pulmonary venous connection below the diaphragm, with roentgenographic evidence of pulmonary edema, interstitial edema and a normal cardiac silhouette. These findings led to a diagnosis of pulmonary venous obstruction proximal to the mitral valve. Our findings confirm that the morphologic substratum of Kerley B lines is predominantly edema of the interlobular septum.

Chest roentgenographic evaluation of the severity of aortic stenosis.

The chest radiographs of 44 adult patients with proven valvular aortic stenosis (AS) were analyzed for the evaluation of severity of the disease. Five parameters were correlated with the aortic valve area (AVA) as the determinant of AS severity: the area of aortic valve calcification (AVCa), the cardio--thoracic (C--T) ratio, the Hoffman-Rigler (H-R) sign, left atrial enlargement (LAE), and the transverse diameter of the thoracic aorta (TDAo). There was a significant correlation between AVCa and severe AS only in women over 40 years of age. The increased C--T ratio and evidence of LAE was predictive of severe AS in men over 40 years of age. The positive H-R sign and an increased TDAo were not useful in assessing the severity of AS. Accordingly, the radiographic analysis of signs is a simple, useful, and noninvasive technique for diagnosing AS and for assessing its severity in patients over 40 years of age.

CT in congenitally-corrected transposition of the great vessels

Congenitally-corrected transposition of the great vessels (CTGV) may be detected de novo in adulthood and the plain radiographic findings may be ambiguous or they may be mimicked by a mediastinal mass. CT readily shows the malposition of the aorta and pulmonary artery, and may also show associated congenital heart lesions. The following cases demonstrate the CT findings in CTGV and the distinction of CTGV from conditions resembling it on radiographs.

X-ray appearance and clinical significance of left atrial wall calcification.

Ten patients with calcifications of the left atrium are reported with review of the literature. Calcification of the left atrium is frequently associated with history of rheumatic fever, longstanding congestive heart failure, atrial fibrillation, mural thrombus and embolization. Early recognition of such lesions is essential for the management of the patients, particularly when surgical intervention is contemplated. A practical classification of left atrial calcification is proposed according to the dominant lesion in each group: (a) Calcification of the left atrial appendage alone (Mitral stenosis). (b) cacification of all 3 component lesions of the left atrium, i.e., the left atrial appendage, the free wall, and the mitral valve (Severe mitral stenosis). (c) Calcification of the left atrium in MacCallums patch alone (Mitral insufficiency).