Vladir Maranhao

Silent Coronary Artery-Left Ventricular Fistula: A Disorder of the Thebesian System?

Two cases with abnormal elec trocardiogram were found to have the unusual direct communication between the coronary artery and left ventricular chamber without any manifestations of the other reported coronary arterial fis tula.

Transcatheter Embolization of Hepatic Arteriovenous Fistula in Osler-Weber-Rendu Disease — A Case Report:

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) is asso ciated with arteriovenous fistulas throughout the body that can cause hemody namic abnormalities. Owing to their size and extent, surgical repair is often not feasible. A patient referred for presumed valvular heart disease is described. On the basis of oximetry data at cardiac catheterization, a large intrahepatic arterio venous fistula was discovered by aortography. This finding and a history of recurrent epistaxis were consistent with Osler-Weber-Rendu disease. Owing to the size of the fistula, embolization of the right hepatic artery with Gianturco coils was chosen as treatment, with resultant symptomatic improvement and decreased arteriovenous shunting.

Preliminary experience in the use of ultrafast computed tomography to diagnose aortic valve stenosis

Eight patients, mean age 72 years, with aortic valve stenosis were studied by ultrafast CT 1 day after cardiac catheterization. After injection of radiographic contrast material through a peripheral vein, two contiguous eight-level R wave-triggered cine mode scans in the short axis were acquired, starting above the aortic valve and continuing through the apex of the left ventricle. Seven of eight patients, all with calcified aortic valves, had a detectable central orifice. Catheterization-derived aortic valve areas were within 0.25 cm2 of the CT valve areas in six of seven. LV mass was measured by ultrafast CT in the eight patients with aortic valve stenosis (121.6 +/- 18.2 gm/m2) and was found to be significantly higher (p less than 0.0001) than that in a group of eight subjects with normal LV function, no history of hypertension, and normal ECGs (73.0 +/- 13.1 gm/m2). It is concluded that in selected cases ultrafast CT can contribute to the assessment of severity of calcific aortic stenosis by measurement of LV mass and valve area.

Intracardiac phonocardiography in tricuspid regurgitation: relation to clinical and angiographic findings.

Intracardiac phonocardiograms were obtained from the right atrium in order to study the relation between the clinical signs of tricuspid regurgitation, intracardiac murmurs and the degree of regurgitation demonstrated on right ventriculography with use of a preshaped catheter. In five patients with no heart disease, right ventriculograms showed no evidence of tricuspid regurgitation and intracardiac phonocardiograms in the right atrium demonstrated no murmur. Among 35 patients with valvular heart disease, a Carvallo sign (increased intensity of systolic murmur during inspiration) was present in 19 and absent in 16. All 19 patients with a Carvallo sign had variable degrees of tricuspid regurgitation on right ventriculography, and intracardiac phonocardiograms were positive for tricuspid regurgitation in 18. Among 16 patients with an absent Carvallo sign, neither right ventriculography nor intracardiac phonocardiography was indicative of tricuspid regurgitation in 5. Five patients had 1+ regurgitation and the intracardiac phonocardiogram was positive in three of these five patients. The other six patients showed 3+ to 4+ regurgitation and the intracardiac phonocardiogram was positive for tricuspid regurgitation in all. In conclusion, (1) the Carvallo sign is a reliable indicator of tricuspid regurgitation but its absence does not rule it out, and (2) right ventriculography using a preshaped catheter and intracardiac phonocardiography are useful in detecting clinically unrecognized tricuspid regurgitation.

Comparison of Left Ventricular Ejection Fraction by Cine Computed Tomography and Single Plane Right Anterior Oblique Ventriculography

Cine Computed Tomography (CCT) is a minimally invasive technique which offers high temporal (50 msec scan time) and spatial (2 line pairs) resolution. Left ventricular ejection fraction (LVEF) has been determined by this technique in dogs and normal subjects but no comparison has been made with contrast left ventriculography by cardiac catheterization. Ten patients, 9 male and 1 female, mean age 61 (range 46-70) had LVEF determined by both single plane RAO left ventriculography and CCT. Patients were studied in the fasting state, on differ ent days without change in medication. LVEF by CCT was determined in the long axis, a new view which has been developed for CCT to be comparable to the RAO view of contrast left ventriculography by catheterization. This view is obtained by positioning the patient head first into the scanner, supine, with a counterclockwise table slew (20°) without table tilt. Contrast is introduced via a median antecubital vein, and injected in a prolonged bolus of 7-13 seconds de pendent on arm to heart circulation time. Scans are performed in the cine mode (17 frames/sec) timed during maximal opacification of the right and left ventri cles. Four or six contiguous levels are imaged as required to slice the entire left ventricular cavity. End-systolic and end-diastolic frames are identified. Left ventricular cavity areas are determined by computerized planimetry after the Hounsfield level number is set at half the difference between the contrast in the cavity and the myocardium and setting the window width at one giving a black and white image. Left ventricular end-diastolic volume (LVEDV) and end-sys tolic volume (LVESV) per slice are summated to obtain LVEDV and LVESV from which LVEF is desired. LVEF was also determined in the same patients using single plane RAO contrast ventriculography at cardiac catheterization employing the area-length method. The LVEF was the average of two sinus beats not preceded by an extrasystole. Mean LVEF for CCT was 0.61 (range 0.38-0.80) versus catheterization LVEF of 0.56 (range 0.42-0.80). Comparing both methods we found a significant correlation (r = .92). We conclude that CCT determination of LVEF using the long axis view is a reliable method.

Exercise First-Pass Radionuclide Assessment of Left and Right Ventricular Function and Valvular Regurgitation in Symptomatic Mitral Valve Prolapse:

The changes in right ventricular (RV) and left ventricular (LV) function and in regurgitant fractions on first-pass exercise radionuclide angiography (RNA) were assessed in 29 consecutive patients with symptomatic mitral valve prolapse (MVP). The mean right ventricular ejection fraction (RVEF) was 35±8% at rest and 46±15% after exercise (p < 0.001). The mean left ventricular ejection fraction (LVEF) was 62 ± 11 % at rest and 74±13% after exercise (p < 0.001) . Seven of 29 patients had an abnormal RV response and 6 had an abnormal LV response. Eight had abnormal wall motion after exercise. A total of 12/29 patients (41 %) had one or more abnormalities. The mean left-sided regurgitant fraction before exercise was 27±17% in 21/29 patients (72%) and 31±21% after exercise (p=ns) . An additional 5 pa tients (17%) developed left-sided regurgitation after exercise. These fmdings indicate that wall motion abnormalities and abnormal RVEF and LVEF responses to exercise occur in symptomatic MVP patients. In addi tion, 26/29 (89.6%) had left-sided regurgitation after exercise. Since the presence of a murmur did not correlate with the presence of mitral regurgitation by RNA, then symptomatic patients with MVP should have first- pass exercise RNA to assess the presence of regurgitation at rest and after exer cise. Antibiotic prophylaxis is recommended in MVP patients with systolic mur murs or with regurgitation. Since patients without murmurs can have regurgi tation, further study is necessary to determine the need for endocarditis pro phylaxis in these patients.

Rapid Acquisition Computed Tomographic Assessment of Left Ventricular Regional Wall Motion Using a New Long Axis View

A long axis view to demonstrate left ventricular regional wall motion was devised for the ultrafast CT scanner. The patients are positioned supine, head first, into the scanner. The scan table is slewed 20° counter-clockwise in the horizontal plane without tilt. A bolus of contrast is injected via a median antecu bital vein. Contiguous level R wave triggered cine studies are obtained during peak passage of contrast through the heart to image the entire left ventricular cavity. Fourteen patients had left ventricular wall motion compared by long axis CT and RAO 30° single plane ventriculography at catheterization. In all cases, regional wall motion in comparable segments by both methods was in agree ment. It is concluded that the ultrafast CT long axis view permits diagnosis of left ventricular regional wall motion abnormalities. This view images the apex and sections the interventricular septum and lateral free wall horizontally. Un like conventional CT views, it is comparable to the RAO left ventriculogram.

Exercise Radionuclide Assessment of Left Ventricular Function Before and After Coronary Bypass Surgery

The effects of elective saphenous vein coronary artery bypass surgery on left ventricular ejection fraction were assessed by using exercise first-pass radionu clide angiography in 66 consecutive patients. All patients with left main coro nary artery or concomitant valvular disease were eliminated from the study. Before surgery, 7 patients had normal postexercise left ventricular function (Group 1), 33 had normal resting left ventricular function with an abnormal response to exercise (Group 2), and 26 had an abnormal resting left ventricular ejection fraction with an abnormal response to exercise (Group 3). Following surgery, patients in all three groups had no change in mean resting left ventricu lar ejection fraction; however, patients in Groups 2 and 3 had significant im provement in mean postexercise left ventricular ejection fraction (p < 0.0001 and p < 0.0054 respectively), whereas patients in Group 1 did not. Previous studies reported improvement in postexercise ejection fraction in patients with reduced resting left ventricular function and with an ischemic response to exer cise (Group 3). But this is the first study to confirm improvement in postexercise function in patients with normal resting function and an ischemic response to exercise (Group 2).

Persistent ST segment elevation in left ventricular aneurysm before and after surgery

Post-myocardial infarction aneurysms are often accompanied by persistent ST segment elevations. To determine whether or not these ST segments regress following successful surgery for left ventricular aneurysms, serial electrocardiograms were studied in 74 patients and compared to changes of heart size and NYHA Functional Class. The mean postoperative follow-up period was 18.2 months (range 3 to 52 months). The mean precordial sigma ST elevation preoperatively was 5.27 mm. and 4.71 mm. after surgery (P less than 0.025). For the highest ST segment of an individual lead, the mean values were 1.9 mm. before surgery and 1.88 mm. postoperatively (P less than 0.1). Although clinical improvement occurred in 66 (89.2 per cent) by NYHA class and x-ray evidence of improvement was seen in 46 (62.2 per cent), a degree of ST elevation remained in all cases and was less elevated in only 19 (25.7 per cent). After surgery for left ventricular aneurysm, ST segments tend to remain elevated with little apparent relation to reduction of heart size or clinical improvement.

Demonstration of Mitral Valve Function by Cine Computed Tomography Using a New Long Axis View

Comparison was made between contrast enhanced cine computed tomo graphy (Cine/CT) and echocardiography in the imaging of the mitral valve in 14 patients. The mitral valve was seen in all 14 patients by Cine/CT using a new long axis view. There was agreement with echocardiography in 12 patients. Abnormalities in mitral valve movement were detected by Cine/CT. Left atrial size and contraction was measured by Cine/CT with a difference in left atrial ejection fraction observed between 13 patients with no evidence of mitral dis ease and 3 patients with mitral disease.