William R. Meadows

Progression of native coronary artery disease at 10 years: insights from a randomized study of medical versus surgical therapy for angina.

Repeat coronary angiography was performed in 42 patients 10 years after randomization to medical (n = 21) or surgical (n = 21) therapy for chronic angina. The native coronary arteries were classified into 15 angiographic segments and 3 arterial trunks for analysis of progression of coronary artery disease. The incidence rate of disease progression in coronary segments was 24% and 28% in medically and surgically treated patients, respectively (p = NS). Grafted segments showed a 38% rate of disease progression, which was higher than the 18% rate of for nongrafted segments (p less than 0.001) and the overall rate of 24% for medically treated patients (p less than 0.01). Similarly, 29 (94%) of 31 grafted arteries exhibited disease progression compared with 19 (59%) of 32 nongrafted arteries (p less than 0.01) and 42 (67%) of 63 arteries in medically treated patients (p less than 0.01). In grafted vessels, disease progression occurred more often in arteries proximal (84%) to the anastomosis than in arteries distal (16%) to graft insertion (p less than 0.001). Progression occurred in 46% of proximal segments compared with 23% of distal segments (p less than 0.02). Progression was seen in 23 (55%) of 43 segments with an occluded graft compared with 30 (31%) of 96 segments with a patent graft (p less than 0.02). Ten years after randomization, medically and surgically treated patients showed a comparable rate of disease progression in coronary segments. However, surgical therapy appeared to significantly accelerate atherosclerotic progression in the grafted vessels, especially in the proximal portions. Occluded grafts also correlated with an adverse effect on disease progression.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular—Right atrial canal with aortic incompetence of probable traumatic origin

Abstract A fatal case is reported of left ventricular—right atrial canal in association with aortic insufficiency secondary to nonpenetrating trauma. The presence of a continuous murmur led to the mistaken diagnosis of ruptured sinus of Valsalva aneurysm.

Peripheral pulmonary artery stenosis secondary to chronic pulmonary thromboembolic disease

Abstract A patient is described with chronic thromboembolic pulmonary disease and clinical and cardiac catheterization findings indicating stenosis of a branch of the right pulmonary artery. A continuous murmur over the lung, present in this case, may serve as a clue to the diagnosis and should be looked for in patients with recurrent pulmonary thromboembolism. Although symptoms and exercise tolerance improved after pulmonary thromboembolectomy, severe pulmonary hypertension persisted and hemodynamics were unchanged.

Dicrotism in heart disease: Correlations with cardiomyopathy, pericardial tamponade, youth, tachycardia, and normotension

Abstract Dicrotism of the brachial pulse as seen in this laboratory is highly correlated with congestive cardiomyopathy and pericardial tamponade when these diagnoses are made on patients below the age of 40 who have a heart rate over 90 beats per minute (in regular rhythm). When not present otherwise, the phenomenon may be elicited by occlusive pressure at or just distal to the point from which it is being sensed, and under these circumstances age drops out as a major determinant of its occurrence. Observations from the previous literature as well as from this laboratory also indicate that dicrotism probably occurs with much less frequency in the presence of elevated blood pressures. Barner, Willman, and Kaisers 20 experience during the early period following prosthetic replacement of the regurgitant aortic valve and our own with cardiomyopathy suggest that certain cardiac disease states may be more likely than others to give rise to dicrotism. There is a need for further clarification of this possibility. Such a study should include significant numbers of all types of heart disease, but it should also be done, insofar as is possible, in the presence of all those other factors known to favor dicrotism. Historically the dicrotic pulse appears to have excited the attention of clinicians of the last third of the nineteenth century as a part of the new knowledge obtained from the sphygmograph introduced by Marey in 1863. As the sphygmograph fell into disuse with the appearance of the sphygmomanometer and the string galvanometer, interest in the dicrotic pulse also waned, and it is only now, late in the resurgence of interest in pulses afforded by the introduction of modern electronic transducers, that dicrotism is again presenting itself for study. It should be recognized that many of the factors giving rise to dicrotism were known to writers of this earlier period.

Hemodynamic alterations in idiopathic myocardiopathy including cineangiography from the left heart chambers

Abstract Twenty-one patients with a diagnosis of idiopathic cardiomyopathy were studied clinically and hemodynamically. Catheterization of the right and left heart chambers with selective cineangiographic studies from the left ventricle and the aortic root are presented. The patients exhibited different patterns of failure that reflected more than one mode of adaptation of the circulation to left ventricular failure. All 12 patients in whom cineangiograms were performed demonstrated an increased transverse diameter of the left ventricle in end-systole and end-diastole. Three of these patients had normal pressures and flows at rest and on exercise. One of the 3 had never been clinically in failure, suggesting that ventricular dilatation as an isolated abnormality may precede the onset of other hemodynamic and clinical changes. An adequate appraisal of the hemodynamics should encompass ventricular volumes as well as filling pressures and flows.

The Influence of Medical and Surgical Therapy on Progression of Coronary Artery Disease - Insights From a Randomized Study

Controversies of efficacy (McIntosh and Garcia 1978) arising since the introduction of myocardial revascularization using saphenous vein grafts by Favaloro (1968) in 1967 have, for the most part, been resolved (Frye and Frommer 1982). Most rational interpretations of longevity studies have indicated the efficacy of this surgery in prolongation of life (Gunnar et al. 1980). The question of the effect of bypass grafting on native coronary disease progression has not yet been definitively answered, however, in spite of the many studies reported to date (Aldridge and Trimble 1971; Bourassa et al. 1973, 1978; Malinow et al. 1973; Maurer et al. 1974; Frick et al. 1975; Itscoitz et al. 1975; Robert et al. 1978; Levine et al. 1975; Glassman et al. 1974; Griffith et al. 1973; Benchimol et al. 1974; Gensini et al. 1974), and the influence of risk factors on this progression needs further study. The major shortcomings of previous studies have been that they were not prospective and that they lacked appropriately matched medically treated patients as a control group.

The effect of ventricular alternation on a summation gallop sound: Report of a case with left atrial and left ventricular intracardiac phonocardiograms

Abstract A patient with myocardial disease and pulsus alternans was found to have cyclic alternation in the intensity of a summation gallop sound recorded from the left ventricle. This sound was of greater amplitude immediately preceding the weaker beats. A reasonable explanation for the alternate waxing and waning of these vibrations makes use of the concept of Straub and the observations of more recent investigators that myocardial relaxation may be incomplete preceding the weaker beats of ventricular alternation.

Coronary embolism in primary myocardial disease

Abstract Two patients in whom coronary embolism occurred in association with primary myocardial disease are presented. In addition to coronary embolism, multiple systemic embolism occurred in both patients. In Patient 1, cerebral embolism preceded coronary embolism by a short period of time, and death resulted from myocardial infarction and cardiogenic shock. In Patient 2, the patient survived the episode of coronary embolism, but had episodes of precordial pain for some months following coronary embolism, and continued to have multiple systemic emboli. It is suggested that some instances of angina and sudden death in primary myocardial disease may be due to coronary embolism.