Robert C. Jones

Subintimal Dissection of the Coronary Arteries

Selective coronary arteriography is now the procedure of choice in the determination of the existence and the delineation of the extent of chronic obstructive coronary artery disease. Since Sones and Shireys original description of this technique, variations in the procedure and the approach have evolved. More recently, the percutaneous transfemoral artery approach to selective coronary arteriography has gained increasing favor because of the ease of intubation of both coronary arteries, stability of the catheter once positioned in the coronary ostium, and the high quality of cinefluorography and direct serial radiography. Because of the tapered-tip design and positrol feature, the depth to which the coronary artery can be cannulated, and the angle formed by the tip of the catheter and the intima of the vessel, the possibility of subintimal dissection of the coronary arteries as an inherent complication of this approach arises. Two such cases of subintimal dissection of the left coronary artery are described with cinefluorographic documentation. It is recommended that after cannulation of the coronary vessels the catheter be withdrawn several millimeters from the lumen of the vessel in order to avoid this complication of an otherwise valuable diagnostic approach to selective coronary arteriography.Selective coronary arteriography is now the procedure of choice in the determination of the existence and the delineation of the extent of chronic obstructive coronary artery disease. Since Sones and Shireys original description of this technique, variations in the procedure and the approach have evolved. More recently, the percutaneous transfemoral artery approach to selective coronary arteriography has gained increasing favor because of the ease of intubation of both coronary arteries, stability of the catheter once positioned in the coronary ostium, and the high quality of cinefluorography and direct serial radiography.Because of the tapered-tip design and positrol feature, the depth to which the coronary artery can be cannulated, and the angle formed by the tip of the catheter and the intima of the vessel, the possibility of subintimal dissection of the coronary arteries as an inherent complication of this approach arises.Two such cases of subintimal dissection of the left coronary artery are described with cinefluorographic documentation.It is recommended that after cannulation of the coronary vessels the catheter be withdrawn several millimeters from the lumen of the vessel in order to avoid this complication of an otherwise valuable diagnostic approach to selective coronary arteriography.

Coronary Artery-Atrioventricular Fistula and Ventricular Septal Defect due to Penetrating Wound of the Heart

A patient with an unusual combination of lesions secondary to gunshot wound of the heart is presented. The predominant abnormality was a large fistula between the right coronary artery and the floor of the right atrium. The right coronary also communicated with the cavity of the right ventricle, and there was an associated posttraumatic ventricular septal defect. The presence of an arteriovenous fistula was suspected, based on the presence of a continuous precordial murmur. This diagnosis was confirmed by arteriography. Findings at surgery and the technic of repair are illustrated. Reference is made to three other patients with traumatic communication between the coronary artery and the atrium. Attention is directed to coronary artery atrio-ventricular fistula as another anatomic typeof deformity to consider in patients with penetrating wounds of the heart. The probable recurrence of the fistula 3 weeks after what appeared to be a successful repair illustrates one of the problems to consider in evaluating such patients for surgery.

Pulmonary stenosis: Cyanosis, interatrial communication and inadequate right ventricular distensibility following pulmonary valvotomy

Abstract Three patients with persistence of clinical venous-arterial admixture after successful valvotomy for severe pulmonary valvular stenosis with intact ventricular septum were studied by serial cardiac catheterization. Hemodynamic data after valvotomy documented the presence of atrial venous-arterial admixture in the absence of pulmonary hypertension, pulmonary stenosis or tricuspid stenosis in all 3 patients. Inadequate right ventricular distensibility was implicated as the cause of the atrial venous-arterial admixture. The secundum atrial septal defect was surgically closed to eliminate the potential hazards of such interatrial communications with significant venousarterial admixture. After closure, the inadequately compliant right ventricle accommodated itself to the reception of the total systemic venous return without residual evidence of right atrial hypertension.