Marvin L. Hartstein

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.

Comparative study of the postoperative flow in the saphenous vein and internal mammary artery bypass grafts

Postoperative coronary bypass flow was evaluated in two groups of randomly selected patients with grafts to the left anterior descending artery (LAD). Saphenous vein bypass grafts were placed in 27 patients and internal mammary artery grafts in 25 patients. Postoperative flow studies were performed in both groups with roentgendensitometric methods based on the transit time of radiopaque media along the graft plus the mean graft diameter. There was no significant difference between the two groups of patients for age, duration of symptoms, or the frequency of hypertension, diabetes mellitus, prior myocardial infarction, or cardiomegaly. Intraoperative bypass flows were 75+/-27 and 77+/-24 ml. per minute for the saphenous vein group (SVG) and internal mammary artery group (IMAG), respectively. There was no significant difference in the heart rate or mean aortic pressure at the time of the roentgendensitometric flow study. The mean graft diameters were 3.0+/-0.5 and 1.9+/-0.3 mm. for the SVG and IMAG, respectively (p less than 0.001). The ratios of graft diameter to LAD diameter were 1.9+/-0.3 and 1.2+/-0.2 for the SVG and IMAG, respectively (p less than 0.001). The roentgendensitometric postoperative flows were 68+/-27 ml. per minute in the SVG and 46+/-16 ml. per minute in the IMAG (p less than 0.01). The present study indicates that flow in significantly higher in saphenous vein than in internal mammary artery bypasses and that the difference in flow may in part be explained on the basis of the graft diameter.

Left ventricular hemodynamics and contractile pattern after aortocoronary bypass surgery: Factors affecting reversibility of abnormal left ventricular function

Abstract Left ventricular hemodynamics and contractile patterns were evaluated in 104 patients before and after aortocoronary bypass surgery. Patients were selected on the basis of referral for surgery because of angina pectoris and the demonstration, postoperatively, of all grafts being patent. Group I consisted of 47 patients with single grafts (LAD 33 and RCA 14). Mean left ventricular end-diastolic pressure, volume, and ejection fraction revealed no change after surgery. Twenty-four patients had asynergy prior to surgery; of these 24, 16 patients had a normal contractile pattern after surgery. Group II consisted of 47 patients with double vein grafts. Postoperatively, there was a significant decrease in left ventricular end-diastolic pressure (p

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.

Should the Pericardium Be Closed after an Open-Heart Operation?

A controlled clinical study was carried out to decide whether the pericardium should be left open or closed after open-heart operations. One hundred patients had the pericardium closed with interrupted silk, another 100 had the pericardium left open. Complications were alike except for the more frequent occurrence of a pericardial rub in the closed group (14 vs 3 patients), though the incidence of post-pericardiotomy syndrome was equal. There was no late tamponade. Two early reexplorations for bleeding were done in the open group, none in the closed. There were no postoperative deaths. In the patients who consented to postoperative angiography following revascularization procedures, the incidence of graft failure was equal in both groups. The pericardium should be closed after an open-heart operation. Morbidity and mortality are unchanged, and repeat cardiac exploration is safer.

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.

Cinefluorographic study of the aortic ball-cage prosthetic valve: Phonocardiographic, hemodynamic and angiographic correlates☆

Abstract Cinefluorographic evaluation of the Starr-Edwards aortic prosthetic valve (model 2320) was performed in 41 patients. The aortic pressure pulse, obtained with a catheter-tip manometer, the electrocardiogram and phonocardiogram were recorded simultaneously on cine film and photographic paper. The patients were classified into three groups on the basis of the behavior of the poppet during ejection. In Group I (20 patients) the poppet remained in a relatively fixed position at the apex of the cage throughout the ejection period. Ascent of the poppet at the beginning of ejection was associated with an opening sound and occurred simultaneously with the increase In aortic pressure. An ejection click occurred on Impact of the poppet against the apex of the cage. Descent of the poppet at the end of ejection started 50 msec before the incisura, at a time when supraaortic angiograms demonstrated reflux of contrast material into the left ventricle. Final closure occurred on inscription of the incisura and was associated with a closure sound. In Group II (11 patients) the poppet bounded away from the apex of the cage early during the ejection period and promptly returned to the apex for the remainder of the period. The double impact of the poppet early during ejection was associated with a double ejection click. In Group III (10 patients) premature partial closure of the valve occurred during ejection. After striking the apex of the cage during early ejection, the poppet descended almost one half the distance toward the base of the valve and remained in a relatively fixed, partially closed position during the rest of the ejection period. In this group, unlike Groups I and II, the high frequency component of the closure sound was almost half the amplitude of the ejection click. In three patients a slight tilt of the prosthetic valve in relation to the ascending aorta was noted. This tilt was not observed in Groups I and II. The behavior of the poppet in the three groups can be explained by the hydrodynamic principle of resistance of a solid body in a fluid stream. The angiographic findings indicate that in all patients final closure of the prosthetic valve was due to backward aortic flow.