Soluble P-selectin is released into the coronary circulation after coronary spasm

BACKGROUND: The glycoprotein P-selectin is an adhesion molecule involved in the property change of leukocytes at the initiation of the inflammatory process. The purpose of the present study was to determine whether acute myocardial ischemia induced by coronary spasm causes an acute inflammatory response in the coronary circulation. METHODS AND RESULTS: We examined plasma soluble P-selectin levels in the coronary sinus and the aortic root simultaneously in 16 patients with coronary spastic angina before and after left coronary artery spasm induced by intracoronary injection of acetylcholine and in 15 patients with stable exertional angina before and after acute myocardial ischemia induced by rapid atrial pacing. Ten control patients with chest pain but normal coronary arteries and no coronary spasm also received intracoronary acetylcholine. Plasma soluble P-selectin levels were increased significantly in the coronary sinus (32.8 +/- 3.6 to 52.8 +/- 5.9 ng/mL, P < .001) and in the aortic root (34.6 +/- 3.7 to 41.9 +/- 4.4 ng/mL, P < .05) after the attacks in the coronary spastic angina group but remained unchanged in the stable exertional angina group after the attacks and in the control group after the administration of acetylcholine. Furthermore, the coronary sinus-arterial difference of soluble P-selectin increased significantly after the attacks in the coronary spastic angina group (-1.8 +/- 2.2 to 10.9 +/- 2.7 ng/mL, P < .001). CONCLUSIONS: Our data indicate that soluble P-selectin is released into the coronary circulation after coronary artery spasm. We conclude that coronary artery spasm may induce the leukocyte adhesion in the coronary circulation and may lead to myocardial damage.     

Right coronary artery cirsoid with fistulous connection to the coronary sinus

A 61-yr-old woman was referred to our hospital for evaluation of a suspected right atrial myxoma. The transesophageal echocardiogram suggested the presence of an anomalous right coronary artery with fistulous connection to the coronary sinus. At cardiac catheterization, an oxygen step-up in the right atrium indicated a 1.3:1.0 left-to-right shunt. Aortic root angiography showed a large and calcified right coronary artery cirsoid draining to the coronary sinus, which appeared remarkably dilated. In this rare anomaly, cardiac catheterization is necessary, not only to quantify the magnitude of the left-to-right shunt, which is an important requirement for the indication to surgical treatment, but also to confirm the echocardiographic diagnosis.     

Anomalous origin of the right coronary artery from the left anterior descending coronary artery

A 77-year-old male presented with a recent posterior myocardial infarction for coronary angiography. This angiogram revealed a rare, previously unreported anomalous origin of the right coronary artery from the proximal left anterior descending coronary artery distal to the first major diagonal branch.     

Aortic dissection extending from the left coronary artery during percutaneous coronary angioplasty

A 72-year-old woman with acute aortic dissection as a complication of percutaneous coronary angioplasty was successfully treated. She received a graft replacement of the ascending aorta as well as triple coronary artery bypass grafts. The dissection had extended from the left coronary artery. Although acute aortic dissection is a rare complication of percutaneous coronary angioplasty, physicians and cardiac surgeons should keep its potential occurrence in mind.     

Complete occlusion of the left main coronary artery and the importance of coronary collateral circulation

Study of four patients who survived complete occlusion of the left main coronary artery forms the basis of conclusions concerning the functional significance of coronary collateral circulation. Each of these patients had prominent collateral circulation from the right coronary artery. Global left ventricular function was maintained to the extent that congestive heart failure did not occur; the biplane ejection fraction was normal in the two patients where measurement was possible. The peak rate of systolic wall thickening by roentgen videometry in anterior left ventricular segments was normal in one patient and mild to moderately depressed in another. Experience with the patients described herein indicates that coronary collateral flow can provide critically needed circulatory support for the patient with coronary artery disease.     

Anatomical types of coronary circulation and various lesions of the right coronary artery

The data on coronarography, conducted in clinic to 1249 patients in 1994-1996 yrs., and intraoperative data, obtained in the patients with a coronaris dextra (ACD) affection and its concurrent affection with a coronaris sinistra (ACS) operated on in clinic in 1974-1996 yrs., were analyzed. It was established that the frequency of severe affection of endothelium of ACD while the existence of the left coronary blood circulation (CBC) type 2.5 times as higher than that while the presence of its right or balanced kinds. The most frequent atherosclerosis occurrence in the proximal ACD portion creates the anatomical prerequisites for the broad application of surgical treatment methods of coronary insufficiency.     

Anomalous origin of the left coronary artery from the pulmonary artery in an adult: tubular reconstruction of the left main coronary artery under coronary perfusion

A 38-year-old female with anomalous origin of the left coronary artery (LCA) from pulmonary artery was surgically corrected by tubular reconstruction of the left main coronary artery (LMCA) using the pulmonary artery wall, and this repair was performed under beating heart. Thus, the pulmonary artery was divided above the orifice level and just above the pulmonary valve, and the commissure between nonfacing and left side sinuses was dissected away from the pulmonary artery wall to obtain lateral flaps. The pulmonary artery defect was reconstructed with a roll using an autologous pericardial patch, while the detached commissure was suspended on the pericardial patch. The long tube constructed using pulmonary artery tissue was anastomosed to the anterior aspect of the ascending aorta. These procedures were performed under beating heart simply by clamping the LMCA, since the preoperative myocardial contrast echocardiography confirmed the adequate coronary collateral flow from the right circulation. The postoperative course was uneventful, and a coronary artery angiogram demonstrated a widely patent LMCA. Our experience suggests that, in adult cases, this procedure could be performed without myocardial ischemia simply by clamping the LMCA because of well-developed coronary collateral arteries. The safety of this technique could be confirmed by myocardial contrast echocardiography.     

Comparison of transesophageal coronary sinus and left anterior descending coronary artery Doppler measurements for the assessment of coronary flow reserve

Genetic variation in correlations among size-related traits of head, thorax, and wings was examined in Drosophila buzzatii, by comparing the pattern of the Phenotypic Correlation Matrix (Rp) between inversion karyotypes of the second chromosome. No similarity in Rp was observed between some karyotypes in a natural population. The pattern of Rp in wild-reared heterokaryotypes, but not in homokaryotypes, was similar to the whole population represented by laboratory-reared flies. While phenotypic correlations in wild-reared flies were found to be larger than in laboratory-reared flies, similarity in the pattern of Rp was very high for one homokaryotype reared in both environments: the relatively homogeneous lab environment and the more variable field environment. While no such a similarity across environments was detected between different karyotypes, the pattern of Rp was similar for a same homokaryotype in different populations. Thus, the lack of karyotypic similarity in Rp is, at least partially, genetic. These results indicate that chromosomal inversions are factors affecting genetic correlations among traits known to be phenotypically correlated with adult fitness components in this species.     

Assessing the coronary circulation in hypertension

Systemic arterial hypertension is one of the major risk factors for coronary artery disease, coronary microangiopathy, and left ventricular hypertrophy, all of which can potentially lead to cardiac failure and sudden cardiac death. Coronary flow reserve is defined as the maximal increase in coronary flow above its resting, autoregulated level for a given perfusion pressure. In arterial hypertension functional and structural alterations are observed at the level of epicardial vessels as well as in resistive vessels requiring sophisticated approaches to assess coronary flow reserve and thus myocardial perfusion. Electrocardiographic tests and echocardiography can be regarded as monitoring and screening methods. Myocardial scintography is useful to semiquantitatively estimate hypertension-associated perfusion abnormalities, whereas positron emission tomography provides the only quantitative approach of a non-invasive technique for myocardial blood flow measurement. Invasive methods for the assessment of coronary blood flow need cardiac catheterization procedures, such as techniques requiring catheterization of the coronary sinus, angiographic methods, and guidewire based methods. Thermodilution and venous oxymetry in the coronary sinus systematically underestimate coronary flow reserve and are thus considered as only semiquantitative approaches. In contrast, the gas chromatographic argon method allows a quantitative measurement of coronary blood flow at baseline and during maximum vasodilation; thus it is possible to distinguish between an altered autoregulated and maximal flow as the major cause of a reduced coronary flow reserve and to evaluate long-term therapeutic interventions in hypertensive hearts. Videodensitometric and angiographic methods should be restricted only to patients with coronary microangiopathy or with coronary single-vessel disease. Guidewire-based Doppler techniques are suitable to semiquantitatively assess coronary flow reserve with a considerable spatial and time resolution. Myocardial biopsies may gain insight into hypertension-associated structural alterations in small arterioles. Long-term treatment of hypertensive heart disease aims to normalize blood pressure, to reduce left ventricular hypertrophy and to achieve cardioreparation including reversal of the abnormal structure and function of coronary circulation. Based on the different methods for assessment of coronary circulation the therapeutic value of different classes of antihypertensive therapeutics will be evaluated in this overview.     

Improving the results of coronary angioplasty

Coronary angioplasty has changed dramatically in the past three years with major reductions in suboptimal results and restenosis rates, and improvements in safety, efficacy and cost-effectiveness. Intracoronary stent implantation with optimisation of strut expansion and the abandonment of anticoagulants after deployment, have led to less entry-site complications, facilitated early hospital discharge, virtually abolished subacute stent thrombosis and resulted in a 50% reduction in target vessel revascularisation. Adjuvant medical treatment with anti-platelet agents, including glycoprotein IIb/IIIa receptor inhibitors, improves the safety of angioplasty and may further reduce the restenosis rate. Selective use of debulking devices has extended the indications for angioplasty. High resolution fluoroscopy, quantitative coronary angiography and intracoronary ultrasound leading to improved diagnosis, equipment selection and treatment have contributed to better outcomes. Further clinical trials will compare angioplasty and stent implantation with coronary bypass surgery in patients with multivessel coronary disease, and may extend the indications for percutaneous transluminal coronary angioplasty (PTCA) to selected patients with three vessel disease.     

Anatomic variations of the coronary arteries

PURPOSE: To study the coronary arteries and their main branches showing the aspects of source, trajectory and anastomoses of these vessels at the subepicardial level. METHODS: The study was carried out on 110 adult human hearts, of both sexes, fixed in 10% formaldehyde solution. The pericardium was removed to expose the coronary arteries and their branches at the subepicardial level. RESULTS: In 38.18% of the cases the left coronary artery presented a trifurcation into anterior interventricular, circunflex and left marginal branches (35.70%) and into anterior interventricular, circunflex and lateral branches (64.30%). In 60% of the hearts examined, the left coronary artery presented a bifurcation into anterior interventricular and circunflex branches. In 1.82% of the cases these two branches arise directly from the aorta. An anastomosis, at the subepicardial level, between the anterior and posterior interventricular branches was observed in 56.36% of the hearts. In 88.18% the posterior interventricular branch arised from the right coronary artery, whereas in 11.82% this vessel arises from the circunflex branch. Anastomoses between the right coronary artery and the circunflex branch were found in 10% of the hearts (crux cordis). The dominance of the right coronary artery was present in 69.09% of the cases, of the left coronary artery in 11.82% and in 19.09% of the hearts had balanced distribution. CONCLUSION: The coronary arteries and their main branches present a great quantity of variations with regard to source, trajectory and anastomoses. This knowledge is important for the interpretation of coronary angiography and surgical myocardial revascularization.     

Smokers undergoing percutaneous coronary revascularization present with fewer narrowings in the target coronary artery

Among patients undergoing percutaneous coronary revascularization, cigarette smoking remained associated with fewer lesions in the target artery even after adjusting for age, extent of coronary artery disease, diabetes mellitus, and hypertension. These findings support the hypothesis that smokers have less active, yet more active, coronary artery disease.     

Single coronary artery arising from the right coronary sinus. Report of two cases

The authors report two cases of single coronary artery arising from the right coronary sinus. Both patients had angina with reversible myocardial ischaemia on exercise Thallium scintigraphy. Coronary angiography showed single coronary artery arising from the right coronary sinus in both cases with severe stenosis of the right coronary artery in the first and occlusion of the right coronary artery in the second patient. Both underwent surgical revascularisation with a good result. Single coronary artery is a rare congenital abnormality (approximately 0.36 per 1,000) diagnosed at autopsy until 1963, and thereafter at coronary angiography. A review of the literature shows that an equal number of single coronary arteries arise from the right as from the left coronary sinus: there does not seem to be an increased risk of complication when a branch runs between the aorta and pulmonary artery. On the other hand, single coronary arteries arising from the right coronary sinus seem to be more commonly associated with atherosclerosis than a network with two coronary arteries, but when the lesions are proximal, the risk is high. Revascularisation is indicated only when myocardial ischaemia has been documented.     

Reproducibility of coronary arteriographic reading in the coronary artery surgery study (CASS)

Eight hundred seventy arteriograms from the Coronary Artery Surgery Study (CASS) were independently read by readers at two different clinics to evaluate the reproducibility of the interpretation of coronary arteriograms. Among proximal segments, the interpretation of lesions of the left main coronary artery were the least reproducible, P less than .02. When one angiographer reads a stenosis of 50% or more in the left main coronary artery, it is estimated that a second reader will report no lesion 18.6% of the time. In 94.7% of the films, the number of significantly (greater than or equal to 70% stenosis) diseased vessels was the same for both readers (72.1%) or differed by one vessel (22.6%). The reproducibility of interpretation of films of good or acceptable quality or completeness was better than the reproducibility of readings of arteriograms judged to be of poor quality or incomplete studies. The mean absolute difference between readings of the percent stenosis decreased over the time of the patient enrollment, 1975 to 1978. This may have resulted from major collaborative efforts made during the course of the study to improve the quality of angiography and to standardize the reading of the cine films.     

Ischemic heart disease in the elderly: the role of coronary angioplasty and coronary artery bypass grafting

Management of ischemic heart disease in the elderly is complex. Invasive therapies such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are associated with significant morbidity and mortality. The short-term advantage of PTCA is that its associated noncardiac morbidity and mortality are less than that of CABG, particularly in the incidence of stroke. Unfortunately, PTCA revascularization is less complete and less durable than CABG revascularization. The advantages of CABG are that cardiac revascularization is more complete, the result is more durable, and long-term results are improved over those of PTCA. Conversely, the initial morbidity and mortality are higher for CABG and are adversely affected by factors such as recent myocardial infarction, lung disease, and renal failure. We provide an overview of the results and outcomes of PTCA and CABG in the elderly, as well as suggestions for management.     

Heterogeneity of coronary flow reserve in the examination of multiple individual allograft coronary arteries

BACKGROUND: Epicardial and resistance vessel function in the transplanted heart has been evaluated primarily in regions supplied by a single vessel. Heterogeneity of flow among multiple perfusion fields as a marker of early endothelial dysfunction in the microcirculation has not been evaluated previously. This study tested the hypothesis that increased variability of coronary flow reserve (CFR) among multiple vascular regions would be associated with allograft coronary vasculopathy. METHODS AND RESULTS: One hundred six posttransplant patients undergoing cardiac catheterization had measurement of CFR in at least 3 major epicardial vessels. Patients were divided into those with minimal angiographic abnormalities (n=37) and those with no angiographic abnormalities (n=69). The ranges, coefficients of variation, and univariate and multivariate regression analyses of CFR were computed to determine the major clinical factors influencing the degree of variability. The abnormal angiographic group was older (54+/-11 versus 47+/-13 years; P<0.003), had older hearts (35+/-11 versus 27+/-10 years; P<0.005), and were further posttransplant (1626+/-1022 versus 931+/-984 days; P<0.0009). There was no difference in global CFR between groups (normal, 3.4+/-0.8 versus abnormal, 3.4+/-0.7; P=NS). The coefficient of variation of CFR was higher for the abnormal group (16.3+/-8.6% versus 11.0+/-5.5%; P<0. 0006). Univariate and multivariate predictors of increased variability in CFR included angiographic abnormalities, patient age, and body mass index. Both angiographic abnormalities and an elevated CV of CFR were predictive of a combined end point of death, congestive heart failure, or subsequent development of >/=50% coronary stenosis. CONCLUSIONS: These data demonstrate that increased variability of CFR is associated with discernible allograft coronary arteriopathy and is predictive of outcome in patients after heart transplantation.