Interventricular septal motion in patients with proximal and distal left anterior descending coronary artery lesions

In order to evaluate the ability of the echocardiogram to detect and localize left main or left anterior descending (LAD) coronary artery lesions, 43 patients were studied. The systolic excursion of the left side of the septum and the ratio of posterior wall to septal excursion were measured. Seventeen patients had no LAD lesions; all had systolic septal excursion of 3 mm or greater. Twelve patients with septal excursion of 2 mm or less all had left main or LAD lesions, but 14 other patients with LAD lesions had septal excursions of 3 mm or greater. Nine of 16 patients with LAD lesions proximal to the first septal branch had reduced or absent septal excursion, as did three of ten with LAD lesions distal to the first septal branch. In a setting of coronary artery disease reduced or absent septal motion on echocardiography suggests involvement of the left main or left anterior descending coronary. However, the technique is relatively insensitive, with 54% of the LAD patients having normal septal motion.     

Primitive hypoglossal artery associated with basilar artery aneurysm

A case of persistent primitive hypoglossal artery, accompanied by a basilar bifurcation aneurysm, is reported. The persistent primitive hypoglossal artery was seen on the right side and the left vertebral artery was hypoplastic. The right vertebral artery was absent, while a normal sized posterior communicating artery was seen on the right side at the operation on the aneurysm. The combination of a basilar bifurcation aneurysm and a persistent primitive hypoglossal artery is rare. A review of related reports has been made.     

Isradipine lowers human arterial low density lipoprotein retention in vivo

An 84-year-old woman was admitted to our hospital because of left heart failure of acute onset. Transthoracic echocardiography showed diffuse hypertrophy of the normal sized hyperkinetic left ventricle and chordae-like fluttering echoes attached to the mitral valve with severe mitral regurgitation signals. Mosaic flow signals were seen at the left ventricular outflow tract, but the velocity could not be measured. Emergent transesophageal echocardiography detected no obvious mitral valve prolapse. Cardiac catheterization showed greater than 100 mmHg pressure gradient between the left ventricle and femoral artery. Pressures in the femoral artery and pulmonary capillary wedge changed reciprocally in the intensive care unit; a bisferient narrow pulse pressure of the femoral artery was associated with increased v wave of the pulmonary capillary wedge pressure, and a wide pulse pressure of the femoral artery with absent v wave of the pulmonary capillary wedge pressure. Pressure monitoring in the intensive care unit, catheterization laboratory and transesophageal echocardiography were useful to understand the pathophysiology of the patient.     

Thallium-201 myocardial perfusion imaging in infants and children. Value in distinguishing anomalous left coronary artery from congestive cardiomyopathy

In infants and children, anomalous origin of the left coronary artery (ALCA) from the pulmonary artery may be difficult to distinguish from congestive cardiomyopathy (CCM) of other causes. We performed thallium-201 myocardial perfusion imaging in seven children with ALCA and in nine with CCM to study the usefulness of this technique in distinguishing between these lesions. Localized abnormalities of thallium uptake were present in each of the seven patients with ALCA, including two asymptomatic 4-year-old children. Thallium distribution was normal in five patients with CCM, diffusely irregular in three, and was absent in the lateral and posterobasal portions of the left ventricle in one patient. We conclude that thallium-201 imaging is a sensitive noninvasive method of detecting ALCA. However, perfusion abnormalities are not limited to patients with coronary artery abnormalities, and may be present in patients with myocardial ischemia or infarction of other causes.     

Cerebral aneurysm associated with persistent primitive olfactory artery aneurysm

Persistent primitive olfactory artery is a rare vascular anomaly but has a clinical importance because of its high association with cerebral aneurysm. We describe a patient with bilateral persistent primitive olfactory arteries associated with an unruptured saccular aneurysm on the left persistent primitive olfactory artery. Seven reported cases with this anomalous artery including ours are reviewed and classified into two variants. This anomalous artery arises from the terminal portion of the internal carotid artery and courses anteromedially along the ipsilateral olfactory tract and makes a hair-pin curve posterior to the olfactory bulb, becoming the distal anterior cerebral artery (variant 1) or the ethmoidal artery (variant 2). Out of 7 reported cases, 4 cases are associated with saccular aneurysms. The aneurysm in variant 1 is located on the hair-pin curve at which an apparent arterial branch is sometimes absent. Two patients suffer from anosmia. Persistent primitive olfactory artery should be kept in mind because of its high association with intracranial saccular aneurysms and unique clinical presentation.     

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A 20 year old woman with acute myocardial infarction exhibited a huge aneurysm of the left main coronary artery that was occluded by a large intraluminal thrombus. After exclusion of other vascular or systemic diseases, atypical Kawasaki syndrome was diagnosed. Other major symptoms usually required for this diagnosis were absent. As patients with Kawasaki syndrome in childhood are surviving longer, acute coronary symptoms may occur in young adults, and coronary aneurysms might be the only symptom of atypical Kawasaki syndrome.     

Age specific prostate specific antigen reference ranges: population specific

BACKGROUND: Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA). METHODS: From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting. RESULTS: All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%. CONCLUSIONS: The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.     

Diabetes mellitus accompanied by nonocclusive colonic ischemia

A 70-year-old man with diabetic triopathy was hospitalized with left lower quadrant abdominal pain and tenderness, muscle guarding and absent bowel sounds. Three hours after admission, creatine phosphokinase (CPK) was elevated and an abdominal plain film X-ray showed intestinal gas retention, indicating paralytic ileus due to inferior mesenteric artery occlusion. Urokinase (60,000 units/day) and heparin (10,000 units/day) were administered. Angiography showed no occlusion in the mesenteric artery. On the 16th day, the abdominal signs had disappeared and CPK was normalized. We diagnosed this case as nonocclusive colonic ischemia because of the hemorheological abnormalities due to diabetic triopathy and the hypercoagulable state.     

Hepatic artery: effect of a meal in healthy persons and transplant recipients

Thirty healthy volunteers and 12 liver allograft recipients (two with cirrhotic changes seen at microscopy) were given a standard meal. Doppler sonography of the right and left hepatic arteries, the superior mesenteric artery, and the portal vein was performed. The change in hepatic arterial resistance was evaluated with the resistive index (RI). After the standard meal, portal venous flow increased in both the healthy volunteers and allograft recipients (more so in the latter group). Superior mesenteric arterial RI decreased in all subjects. A postprandial increase in hepatic arterial RI, likely reflecting constriction of the hepatic artery, was seen in both groups. It was absent in the two patients with recurrent transplant cirrhosis. These results show the importance of examining hepatic arterial flow in the fasting subject, since high resistance after a meal may be falsely interpreted as a sign of disease. Absence of a postprandial change in resistance of the hepatic artery could signal abnormal liver function.     

Imaging of electromagnetic resonances in a YBa2Cu3O7- delta bicrystal grain-boundary Josephson junction

The diagnosis of a discontinuous left pulmonary artery arising from a left ductus arteriosus was made by two-dimensional and Doppler echocardiography in an infant with recurrent pneumonia. The diagnosis was later confirmed at cardiac catheterization and surgery. The suprasternal notch views were especially useful for the identification of the left pulmonary artery. In this patient with a right aortic arch, the left pulmonary artery was supplied by a left ductus arteriosus that arose from the innominate artery. This case report describes the echocardiographic diagnosis of discontinuous left pulmonary artery as an isolated lesion, an unusual lesion that can easily be missed. It emphasizes the necessity of a careful and complete examination with particular emphasis on pulmonary artery continuity in patients suspected of having congenital heart disease or respiratory compromise as a result of a cardiovascular cause.     

Progressive intracranial occlusive disease associated with deficiency of protein S. Report of two cases

BACKGROUND AND PURPOSE: Deficiency of the free fraction of protein S has been associated with arterial or venous stroke. The pathogenesis of vascular occlusion in patients with protein S deficiency is not known. We present two cases of cerebral infarction and deficiency of protein S in which the subjects had progressive intracranial occlusions. CASE DESCRIPTION: A 16-year-old girl was admitted because of left brain stem infarction and protein S deficiency. Cerebral angiography disclosed stenosis of the right intracranial vertebral artery and occlusion of the left posterior cerebral artery. A second angiogram performed 18 months later disclosed occlusion of the right vertebral intracranial artery. In the second case, a 17-year-old girl was admitted because of left hemispheric cerebral infarction and protein S deficiency. Cerebral angiography showed stenosis of the left anterior cerebral artery, left supraclinoid internal artery, and left middle cerebral artery. A second cerebral angiogram performed 5 months later disclosed occlusion of the left anterior cerebral artery and poor hemispheric perfusion through the left middle cerebral artery. CONCLUSIONS: Based on our cases, we postulate that some patients with prothrombotic states may develop progressive intracranial arterial occlusions, possibly secondary to a permanent thrombogenic stimulus. We suggest routinely searching for prothrombotic states in young patients with intracranial occlusion, especially if the occlusion is progressive and other causes are not obvious.     

Ultrastructural changes in cerebral blood vessels following prolonged administration of L-dopa to laboratory animals

Patients with anomalous left coronary artery arising from the pulmonary artery rarely survive to adult life. Those who attain adulthood may present with angina indistinguishable from coronary artery disease and are liable to sudden death. Myocardial infarction, though rare in young adults, may occur and may be due to coronary artery steal. Accurate diagnosis requires coronary arteriography. Two further cases of coronary artery steal in adults with anomalous origin of the left coronary artery from the pulmonary artery are presented. In both patients aortocoronary bypass grafting using a reversed autogenous saphenous vein with closure of the origin of the anomalous left coronary artery was successfully performed. This operation provided complete symptomatic relief and may protect patients against the risk of sudden death.     

Complete direct mammary harvest for minimally invasive coronary artery bypass

Minimally invasive coronary artery bypass has primarily involved left internal mammary artery grafting to the left anterior descending coronary artery through a small left anterior thoracotomy incision. Harvesting of the mammary artery has been accomplished completely using a video-assisted thoracoscopic technique or incompletely to the second interspace under direct vision. With a mammary retractor, the mammary artery can be dissected completely under direct vision, thus eliminating any criticism of an incomplete harvest and any increased difficulty or expense associated with the thoracoscopic harvest. In this series, all 17 mammary arteries were successfully harvested completely under direct vision and 16 patients underwent successful minimally invasive coronary bypass.     

Ischemic preconditioning attenuates postischemic coronary artery endothelial dysfunction in a model of minimally invasive direct coronary artery bypass grafting

OBJECTIVE: Unmodified reperfusion without cardioplegia in minimally invasive direct coronary artery bypass grafting procedures causes endothelial dysfunction that may predispose to polymorphonuclear neutrophil-mediated myocardial injury. This study tested the hypothesis that ischemic preconditioning in a minimally invasive direct coronary artery bypass grafting model attenuates postischemic endothelial dysfunction in coronary vessels. METHODS: In anesthetized dogs, the left anterior descending coronary artery was occluded for 30 minutes and reperfused for 3 hours without ischemic preconditioning (no-ischemic preconditioning; n = 7); in 7 dogs, the left anterior descending occlusion was preceded by 5 minutes occlusion followed by 5 minutes of reperfusion. Relaxation responses to stimulators of nitric oxide synthase were used to evaluate endothelial function in arteries from the ischemic-reperfused (left anterior descending) and nonischemic (left circumflex coronary artery) zones. RESULTS: Stimulated endothelial-dependent relaxation of epicardial left anterior descending artery to incremental concentrations of acetylcholine in the no-ischemic preconditioning animals was shifted to the right, and maximal relaxation was attenuated compared with the nonischemic left circumflex coronary artery (117% +/- 4% vs 138% +/- 5%). In contrast, acetylcholine-induced maximal relaxation was comparable in the left anterior descending artery versus left circumflex coronary artery in the ischemic preconditioning group (130% +/- 6% vs 135% +/- 5%). In 150- to 200- microm left anterior descending microvessels, 50% relaxation occurred with a lower concentration (log[M]) of acetylcholine in ischemic preconditioning versus no-ischemic preconditioning (-8.0 +/- 0.4 vs -7.0 +/- 0.1) with no group differences in smooth muscle relaxation to sodium nitroprusside, suggesting endothelial-specific damage. Adherence of fluorescent labeled polymorphonuclear neutrophils to epicardial coronary artery endothelium, used as an index of basal (unstimulated) anti-polymorphonuclear neutrophil function, was significantly attenuated by ischemic preconditioning versus no-ischemic preconditioning (293 +/- 25 polymorphonuclear neutrophils/mm2 vs 528 +/- 29 polymorphonuclear neutrophils/mm2). CONCLUSION: In this minimally invasive direct coronary artery bypass grafting model, both agonist-stimulated and basal postischemic endothelial dysfunction were attenuated by ischemic preconditioning.     

First-pass versus second-pass parsing processes in a Wernicke's and a Broca's aphasic: electrophysiological evidence for a double dissociation

The present paper is a first attempt to integrate the classical brain lesion behavioral impairment approach of functional neuroanatomy and the electrophysiological brain mapping approach in the domain of syntactic processing. In a group of normal age-matched controls we identified three electrophysiological components previously observed in correlation with language comprehension processes: an early left anterior negativity normally seen in correlation with syntactic first-pass parsing processes (ELAN), a centroparietal negativity seen in correlation with processes of lexical-semantic integration (N400), and a late centroparietal positivity observed in correlation with secondary syntactic processes of reanalysis and repair (P600). The early left anterior negativity was absent in a patient with an extended lesion in the anterior part of the left hemisphere sparing the temporal lobe, although the late centroparietal positivity and the centroparietal N400 were present. In a patient with a left temporal-parietal lesion the early left anterior negativity was found to be present, whereas the N400 component was absent. These findings suggest that first-pass parsing and secondary processes are subserved by distinct brain systems.     

A 23-year-old patient with neurofibromatosis associated with acute myocardial infarction, vasospasm and a coronary artery ectasis

We treated a 23-year-old male with neurofibromatosis with acute myocardial infarction. Cardiac catheterization revealed severe organic stenosis in the left anterior descending artery, an ectasic left circumflex artery and a small right coronary artery. Percutaneous transluminal coronary angioplasty (PTCA) was performed on the stenosis. In follow-up catheterizations, intracoronary administration of ergometrine induced vasospasm of the left coronary artery including at the PTCA site. An I 123 metaiodobenzylguanidine (MIBG) scintigram showed defects in the septum, inferior wall and apex. These findings suggest abnormality of the cardiac sympathetic nerve in neurofibromatosis.     

Study of the coronary flow with high resolution transthoracic echocardiography and nondirectional Doppler

Two-dimensional echocardiography allows to evaluate the effect of myocardial ischemia on left ventricular wall motion, but a direct measure of coronary flow by this method is still lacking. The aim of the present study was to evaluate the efficacy of a new, high-resolution echocardiographic equipment designed to image the epicardial and intramural coronary vessels by non directional Doppler. We studied 33 consecutive patients by transthoracic echocardiography in apical projections, to detect one or more segments of the left anterior descending coronary artery by non directional Doppler. Once the coronary artery has been imaged, pulsed Doppler was used to measure coronary blood flow velocity at rest. Peak and mean flow velocities were measured on the diastolic phase of the Doppler spectrum. In 25/33 patients (75.7%) the middle-distal tract of the left anterior descending coronary artery was imaged by non directional Doppler. In 15/33 patients (45.5%) the periapical tract of the left anterior descending coronary artery was imaged along with its perforating branches. In 2 out of 4 patients operated of coronary artery bypass grafting, the anastomosis between the left internal mammary artery and the left anterior descending coronary artery was imaged. In all 25 patients it was possible to measure by pulsed Doppler the coronary velocity flow pattern, characterized by a typical prevalent diastolic component. Peak diastolic flow velocity was 49.98 +/- 17.30 cm/s and mean diastolic flow velocity was 36.52 +/- 11.91 cm/s. The Doppler pattern of the grafted mammary artery was different from the native mammary flow. This new non invasive imaging technique of the coronary arteries promises to expand the field of diagnostic and experimental echocardiography and brings new insight into the pathophysiology of ischemic heart disease.     

Hepatic artery aneurysm. Diagnosis and treatment

From 1990 until 1995, four patients were successfully treated for symptomatic aneurysm of the hepatic artery, with rupture in three of them. In two of the patients, the aneurysm was located in the common hepatic artery. In one patient it ruptured. Both aneurysms were resected. One patient also underwent vascular reconstruction. The other two aneurysms ruptured in the left and right hepatic artery respectively. The aneurysm in the right hepatic artery was treated by selective embolization. The aneurysm in the left hepatic artery was ligated, and the patient was subsequently reoperated on for septic necrosis of the left lobe of the liver.     

pH sensitive properties of Tc(V)-DMS: analytical and in vitro cellular studies

Coronary arteries anomalies may be part of complex congenital malformations of the heart or be an isolated defect. In our anatomic collection of congenital heart disease, an isolated anomalous origin of coronary arteries was observed in 27 of 1,200 specimens (2.2%): left coronary artery from pulmonary trunk in five, origin from the wrong aortic sinus in 12 (both right and left coronary artery from the right sinus in four and from the left sinus in seven, left coronary artery from the posterior sinus in one), left circumflex branch from right aortic sinus or from very proximal right coronary artery in three, high takeoff of right coronary artery in three, stenosis of the coronary ostia attributable to valvelike ridge in four. In 16 (59%) patients (12 males and 4 females, age ranging from 2 months to 53 years; median, 14), the final outcome was sudden death; it occurred in all cases of left coronary artery origin from right aortic sinus, in 43% of right coronary artery origin from left aortic sinus, and in 40% of the left coronary artery from the pulmonary trunk. Sudden death was precipitated by effort in eight (50%) and was the first manifestation of the disease in eight (50%); previous symptoms consisted of recurrent syncope in four, palpitations in three, and chest pain in one. Five patients who died suddenly during effort were athletes. In conclusion, (1) more than half of our postmortem cases with anomalous origin of coronary arteries died suddenly, (2) all but two patients with sudden death had anomalous coronary artery origin from the aorta itself, (3) the fatal event was frequently precipitated by effort, (4) palpitations, syncope, and ventricular arrhythmias were the only prodromic symptoms and signs. Recognition during life of these coronary anomalies, by the use of noninvasive procedures, is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.     

Minimally invasive coronary artery bypass grafting: port-access approach versus off-pump techniques

BACKGROUND: Within the past 5 years several surgical techniques have been developed for less invasive surgical treatment of coronary artery disease. The aim of this study was to define specific indications for the various minimally invasive coronary artery surgical procedures. METHODS: Minimally invasive direct coronary artery bypass grafting through a minithoracotomy was performed in 67 patients. The left internal mammary artery was anastomosed on the beating heart with the use of a pressure or suction stabilizer without the use of extracorporeal circulation. In 58 other patients with multivessel disease, the off-pump coronary artery bypass grafting technique through a sternotomy was applied with a left internal mammary artery to left anterior descending artery and additional vein grafts without extracorporeal circulation. In a third group, Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting was performed through a left minithoracotomy with the use of an endovascular extracorporeal circulation system and cardioplegic arrest. Angiographic follow-up was complete in 64% of the patients. RESULTS: There was minimal perioperative or postoperative mortality (0.5%). The medium surgical procedure time for all minimally invasive and off-pump procedures was 2.5 hours; it was 4.5 hours for Port-Access procedures. The median postoperative intensive care unit stay was 1.0 days, and the median hospitalization was 5.0 days. Overall graft patency was 97.3%; in 8 patients (4.1%) a stenosis either at or distal to the graft anastomosis was dilated with coronary angioplasty. CONCLUSIONS: For single-vessel disease of the left anterior descending artery, the minimally invasive coronary artery bypass grafting procedure can be performed safely without the use of extracorporeal circulation. In case of hemodynamic instability or anatomic variation, the Port-Access procedure can be applied without additional necessity for sternotomy. For multivessel disease, the off-pump bypass grafting procedure with sternotomy can be recommended depending on the coronary arteries involved. In case of necessary grafts to the lateral marginal or circumflex branches, Port-Access grafting can be recommended and may play an important role in the future for the development of fully endoscopic robot-assisted coronary artery bypass grafting.