Yasuo Matsuda

Progression of coronary atherosclerosis.

Two hundred sixty-two patients with 50% or greater obstruction of at least one coronary artery on the initial study underwent recatheterization 2–182 months later and were evaluated for progressive arterial changes. Progression was considered present if (1) a change from less than total obstruction to total obstruction occurred in any vessel; (2) a change from 70% or less to 90% or more occurred in any vessel; (3) a change from 30% or less to 50% or more occurred in any vessel not initially obstructed by 50%; or (4) a 20% or more increase in obstruction was noted in any vessel already narrowed 50% or more. Of the 262 patients, 116 of 238 men (49%) and 12 of 24 women (50%) met the criteria for progression. Risk factors determined at the time of the initial catheterization in patients who met the criteria for progression were compared with risk factors in patients who did not. No significant difference could be found between the groups in relation to family history, blood pressure, diabetes, smoking habits, weight, cholesterol levels, triglyceride values, initial ECG and initial catheterization findings.The frequency of detecting progressive arterial changes tended to increase as the interval between studies increased (p < 0.001). The frequency of multiple vessel progression increased as the interval between studies increased. Progression was more frequent in patients younger than 50 years than it was in patients 50 years and older.

Progression and regression of coronary atherosclerosis: Relation to risk factors

Epidemiologic studies have recognized the association of certain clinical characteristics, called “risk factors,” with the incidence and prevalence of coronary artery disease. l-lo Although association does not imply causation, an assumption of “probable cause” has been made by some2 and extraordinary efforts have been undertaken to favorably alter these factors in affected “high-risk” individuals and in society at large (primary prevention).” Similar measures have been recommended for patients with proved disease (secondary prevention).“. l2 In the patient with angiographically documented disease, death can be related to the number of coronary arteries involved, to the severity of involvement, and to left ventricular function.13-‘7 Risk factors are less clearly related to prognosis.‘“’ 14, l6 In the patient with disease, it can also be demonstrated that progression occurs in relation to time, increasing vessel involvement and left ventricular dysfunction.18,1g Risk factors at initial catheterization have not been found helpful in determining which cases will progress. 18-20 There has been little evidence to suggest that alteration of these risk factors in the individual who already has disease either retards or reverses the disease, thereby altering the risk of death.

Segmental analysis of the rate of progression in patients with progressive coronary atherosclerosis.

Bruschke et al.’ have shown that the likelihood of finding progressive coronary atherosclerosis at second catheterization increases in relation to time and severity of the initial lesion. Defining a rate of progression, however, has been difficult. Sudden, unpredicted events intermittently punctuate the clinical course of patients with coronary atherosclerosis, suggesting that there may be more than one rate of progression (fast versus slow), or that there may be some events occurring independently of time as a function of other variables.

Angiographic Follow-up of Internal Thoracic Artery for Free Bypass Grafting

BACKGROUND The use of free internal thoracic artery (ITA) grafts in patients with smaller body surface areas has been questioned because of technical difficulties and inadequate graft flow. METHODS To evaluate postoperative changes in the diameter of free ITA grafts, we performed coronary angiography immediately after coronary artery bypass grafting and then again at a mean of 42 +/- 6 months later. In 20 consecutively treated patients, 21 free ITAs were used as bypass conduits. Two ITA grafts that were patent at the time of the first angiography had closed at the second angiography. Postoperative changes in ITA graft diameter were measured in the 19 patent ITA grafts. RESULTS At the first angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.28 +/- 0.45 mm, 2.34 +/- 0.39 mm, and 2.12 +/- 0.38 mm, respectively. At the second angiography, the mean diameters of the proximal, middle, and distal ITA grafts were 2.85 +/- 0.50 mm, 2.89 +/- 0.53 mm, and 2.72 +/- 0.53 mm, respectively. All segments of the ITA grafts had dilated significantly between the first and second angiographic evaluations (p < 0.01). The percentage change in graft diameter was greater when the initial ITA diameter was less than 2.3 mm (32.0% +/- 28.0%) than when it was 2.3 mm or more (18.8% +/- 11.3%) (p < 0.05). CONCLUSIONS The postoperative increase in free ITA graft diameter depends on coronary blood flow requirements.

Unroofed coronary sinus demonstrated by two-dimensional echocardiography

Fig. 2. Left panel, Two-dimensional echocardiogram in parasternal, long-axis view demonstrates a mass (T) in the left atrium (LA). Right panel, The left atrium is shown at necropsy with thrombus (T), measuring 3 cm in length and 1 cm in width, attached to the interatrial septum. AV = aortic valve; FO = foramen ovale; LVFW = left ventricular free wall; MV = anterior leaflet of mitral valve; VS = ventricular septum.

Thallium-201 myocardial scintigraphic evidence of ischemia in a patient with angina pectoris and normal coronary arteriogram: Significance of thallium-201 washout analysis

We present a patient who had anginal pain and an abnormal exercise electrocardiogram but a normal coronary arteriogram. We thought that myocardial ischemia was responsible for this symptom in view of the exercise left ventriculogram, exercise thallium-201 myocardial scintigraphy and effect of nitroglycerin on the anginal pain. The left ventriculogram at rest was normal but exercise worsened the entire left ventricular wall motion. Exercise thallium-201 myocardial images showed minimal reduction of radio-activity in the anterior, apical, antero-lateral and postero-lateral wall. Myocardial thallium-201 washout analysis revealed washout abnormalities all over the left ventricular myocardium similar to those of triple vessel disease, supporting the exercise left ventriculographic finding. Myocardial thallium-201 washout analysis as well as the visual method should be performed in patients with angina pectoris and normal coronary arteriograms.

Left ventricular motion after bypass operation for coronary artery disease with collaterals

Left ventricular ejection changes obtained from left ventricle roentgenograms were analyzed before and after coronary artery bypass grafting in 22 consecutive patients with chronic obstructive left anterior descending coronary artery disease receiving collaterals before surgical revascularization. The collateral vessels all disappeared after surgical revascularization. After operation, ejection changes of anterobasal, anterolateral and apical walls supplied by the left anterior descending coronary artery improved from 43.6% +/- 9.7% to 48.5% +/- 8.6% (p < 0.05), from 35.2% +/- 10.9% to 39.4% +/- 9.5% (p < 0.05), and from 46.0% +/- 10.6% to 50.0% +/- 8.7% (p < 0.05), respectively. The improvement in left ventricular wall motion did not appear to be related to the extent of preoperative collateralization. Thus, left ventricular wall motion was impaired in the area supplied by collaterals and was improved by myocardial revascularization. These results suggest that coronary blood flow, even through well-developed collaterals, may not be sufficient, which may produce chronic active ischemia and impaired left ventricular wall motion.

Release of intracoronary thrombus during coronary arteriography in a patient with unstable angina.

SummaryA case of release of an intracoronary thrombus in a patient with unstable angina is presented. The thrombus was observed in the right coronary artery just distal to the severe stenosis and was released during coronary arteriography.

Progression of Coronary Atherosclerosis in Nonoperated Patients: Relation to Risk Factors

Important determinants of progression have recently been described by Bruschke and colleagues (1981). Careful analysis of sequential coronary cineangiograms obtained in 256 nonoperated patients with significant coronary atherosclerosis showed time to be the most important determinant of progression. In addition, the initial severity of disease could be correlated to progression, whereas risk factors at first study could not. If progressive coronary atherosclerosis occurs in relation to time and initial severity of disease independently of risk factors, “secondary prevention” by risk-factor modification may not be possible. We studied 302 patients to determine the relation of progression to risk factors.