Wayne E. Dear

Restenosis after transluminal coronary angioplasty detected with exercise-gated radionuclide ventriculography

Forty-one patients were evaluated with exercise-gated radionuclide ventriculography before and within 4 days after successful transluminal coronary angioplasty and 4 to 12 months later. Patients were subgrouped according to the degree of restenosis demonstrated angiographically at 4 to 12 months (Group I [n = 23]: less than or equal to 20%; Group II [n = 10]: greater than 20% but less than 50%; Group III [n = 8]: greater than or equal to 50%). Patients with abnormal findings on gated radionuclide ventriculography (less than 5 point increase in ejection fraction or wall motion deterioration) early after angioplasty were eventually found to have a greater degree of restenosis than were patients with normal findings (41.2 +/- 30.3 versus 19.0 +/- 25.4% restenosis, p less than 0.0001). The accuracy of abnormal radionuclide ventriculography in predicting 50% or greater restenosis was 73% immediately after angioplasty and 77% at the time of follow-up angiography. Gated radionuclide ventriculographic results were abnormal in 5% of Group I patients compared with 75% of Group III patients (p less than 0.01) early after angioplasty; at late follow-up, they were abnormal in 27% of Group I patients compared with 88% of Group III patients (p less than 0.01). Group I patients had a greater increase in ejection fraction than did Group III patients at early (+11.3 +/- 7.5 versus + 3.5 +/- 6.5 points, p less than 0.01) and late (+11.8 +/- 7.8 versus -1.9 +/- 8.7 points, p less than 0.0005) follow-up. It is concluded that gated radionuclide ventriculography is useful in predicting coronary restenosis after transluminal coronary angioplasty.

Guidelines for internal peer review in the cardiac catheterization laboratory

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has proposed guidelines for establishing an internal peer review program in the cardiac catheterization laboratory. The first step is to establish a committee and a data base. This data base should include quality indicators that reflect: physician qualifications, outcomes of procedures, and processes of care. The outcomes must be risk-adjusted to account for the variable severity of illness. Data should be collected by catheterization laboratory personnel and entered into a laboratory-specific computerized data base. These data must be analyzed and organized into profiles that reflect the quality of care. Based on this information, the Committee would institute the following interventions to improve physician performance: education, clinical practice standardization, feedback and benchmarking, professional interaction, incentives, decision-support systems, and administrative interventions. The legal aspects of peer review are reviewed briefly.

Total Anomalous Pulmonary Venous Return: Correlation of Hemodynamic Observations and Surgical Mortality in 58 Cases

One hundred twenty-five patients undergoing surgical correction of total anomalous pulmonary venous return were studied. The overall mortality was 37% and was related to age at the time operation was required. Mortality was 57% during the first year of life, 29% in patients between 13 and 24 months, and 15% in those between 2 and 10 years; no deaths occurred in those over 10 years. Mortality was highest in patients with infracardiac lesions (62%), and lowest in those with cardiac defects (30%). The major cause of death was pulmonary edema, and survival was closely related to the degree of increased pulmonary vascular resistance. Surgical treatment should be delayed until at least 6 months of age, but the development of congestive heart failure may necessitate earlier operation. mong cyanotic congenital cardiac defects that require operation during the first year of life, total anomalous pulmonary venous return A (TAPVR) ranks fourth in frequency at the Texas Heart Institute, following transposition of the great vessels, tetralogy of Fallot, and tricuspid atresia. The anomaly continues to represent a challenging problem to both the cardiologist and the cardiovascular surgeon. Despite recent advances in treatment, this severe malformation in its various anatomical forms has a high surgical mortality during early infancy. Because of the high natural mortality in the untreated infant, and the surgical risk in the first year of life, timing of the operation remains important for optimal results. The clinical findings in patients with TAPVR have been well described [7,9, 10, 12, 17, 19,20,23,24], with the major hemodynamic abnormalities consisting of volume overload of the right ventricle, leading to cardiac failure, and severe arterial desaturation. Muller [21] in 1950 first undertook a palliative procedure by performing a closed side-to-side anastomosis between the common pulmonary venous trunk and the left atrium. The first successful correction of TAPVR, however, was reported from this surgical unit in 1957 [6]. Prior and subsequent to that time, various techniques for repair have been described [ l , 3, 1416,25,26]. In 1.962 From the Division of Surgery of the Texas Heart Institute, St. Luke’s Episcopal and Texas Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Address reprint requests to Dr. Wukasch, Texas Heart Institute, P.O. Box 20345, Houston, Children’s Hospitals, Houston, Tex. Williamsburg, Va., Nov. 7-9, 1974.

Atrial Septal Defect with Communication Through the Coronary Sinus

Abstract An unusual case is reported which illustrates a unique variation of the usually routine repair of atrial septal defects. Initial exploration of the right atrium failed to reveal a septal defect. Oxygenated blood appearing in the enlarged ostium of the coronary sinus suggested an anomaly with pulmonary venous blood entering that chamber. Identification of the communication was made by exploring the left atrium, and surgical repair could only be accomplished by the left atrial approach.