Biomedical subjects
Publications and source records attributed to J B Partridge.
Although the risk of endocarditis from radiological instrumentation is low, it is recommended that antibiotic cover is used for certain invasive procedures in patients at high risk. The barium enema is, in this context, included in procedures requiring cover. Prosthetic heart valves are particularly liable to infection.
28 coronary grafts in 12 symptomatic patients were studied at the time of graft angiography at Prince Charles Hospital. The grafts were studied using the Toshiba 900S scanner with bolus injections of contrast agent into an anticubital vein. The assessment was carried out using fast incremental and continuous acquisition scanning with stepped reconstructions in the last 5 patients. Of the 27 grafts, 16 were shown at angiography to be patent and of good calibre. 14 of these were similarly assessed at CT. 11 were either diseased or blocked at angiography, and these were graded also as small, stenosed or blocked at CT. This early study would support previous reports that CT does offer a reliable method of diagnosing good patent grafts. The study also suggests that with conventional fast dynamic scanning some information regarding graft quality can be obtained.
'Dysmorphic lung' is introduced as a term to describe any complex congenital malformation which involves both abnormal vascular morphology and disordered growth of a whole lung. The major group within this definition is the scimitar syndrome, which we choose to mean a hypoplastic lung with anomalous venous drainage and various degrees of collateral arterial supply. Nine typical cases of scimitar are presented, with three closely related cases. Six other cases of dysmorphic lungs are also present. The relationships between the groups are discussed, and an effort is made to clarify the nomenclature used in this condition.
Minor variations in the position of the origin of the right coronary artery are not uncommon, but marked displacement is unusual. Three cases are presented in which the right coronary artery took origin from the middle third of the ascending aorta together with leftward displacement. Two cases were associated with valvar aortic stenosis. Selective catheterisation of this anomalous vessel can be difficult.
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A total of 125 patients undergoing aorta-coronary bypass grafting for disabling angina were randomized to receive either 330 mg of acetylsalicylic acid (aspirin) plus 75 mg of dipyridamole three times daily or a placebo for 6 months postoperatively. In addition, all patients were given warfarin for 3 months. Repeat angiography was performed at 6 months in 103 patients. In the treatment group 95 grafts were implanted in 48 patients, of which 87 were patent (91.6% patency rate). This figure compares with 88 grafts patent out of 118 implanted in 55 patients in the placebo group (74.6% patency rate) (p less than 0.01). We conclude that antiplatelet therapy improves the early patency of saphenous vein aorta-coronary bypass grafts.
In a series of 141 saphenous vein aortocoronary bypass grafts in 59 patients undergoing routine restudy of the coronary arteries within four weeks of operation, an overall graft occlusion rate of 12% was found. A trend towards a higher occlusion rate was seen in arteries that were small (19%), that had a limited run-off (15%), significant distal disease (24%) or severe atheroma at the graft site (22%). Statistically, these occlusion rates are not significantly different from the overall failure rate and do not give absolute contra-indications to grafting. A particular group of arteries which seemed underfilled in the pre-operative angiogram (1.5 mm or less in diameter but apparently healthy with smooth walls and supplying a larger area of myocardium than would be expected from their apparent size) was identified. These arteries showed a significant increase in diameter in the post-operative angiograms and had a low occlusion rate (1 of 15 grafts; 7%). When all grafts were patent, the mean post-operative left ventricular ejection fraction showed a significant increase over the pre-operative valve, but when one or more grafts were occluded there was no significant change.
A coronary arteriographic report presentation consisting of a diagram on which the radiologist draws the coronary arterial anatomy of each individual case is described. The diagram allows a clear visual presentation of all the information gained from the analysis of the original arteriographic study including anatomical variations, the position and importance of each artery in terms of the myocardium it supplies, the sites and severity of obstructions and the presence of collateral pathways. A myocardial scoring system which expresses the severity of left ventricular arterial obstructive disease is also presented. The myocardial score takes into account not only the degree of stenosis of any number of arterial branches, but also their importance in terms of the amount of myocardium supplied.
A retrospective study was made of 158 patients with unstable angina admitted to a coronary care unit over a 4-year period. Twenty patients (13 per cent) had myocardial infarcts while in hospital, and of these 3 died; three others died without preceding evidence of myocardial infarction. There was thus an acute mortality rate of 4 per cent. Patients with persisting angina after the first 24 hours and those without a previous history of myocardial ischaemia were more likely to develop a myocardial infarct or to die in hospital. Follow-up information, ranging from 3 to 7 years, was available in 144 of 152 hospital survivors. Patients older than 60 years (P less than 0-05), with cardiomegaly (P less than 0-01) and with pulmonary venous congestion (P less than 0-05) were found to have significantly increased long-term mortality. Long-term mortality was also found to rise with increasing coronary prognostic index. The average mortality rate for the whole group of hospital survivors was about 5 per cent per annum. Of the 111 patients who were alive at follow-up, 19 (17%) had had a myocardial infarct after leaving hospital, and a similar number had moderate or severe angina.
To correlate anatomy with hemodynamics, the angiocardiographic findings were reviewed in 42 patients with common ventricle (CV). Nine had normally related great arteries (NRGA), 12 d-malposition, 21 l-malposition and 5 a common atrioventricular valve. Selective outlet chamber (OLC) angiocardiograms were available in 14 out of 29 patients with OLCs. OLC position varied from anterior and to the right of the CV to posterior and to the left of it; two categories (anterior and lateral OLC) were delineated by a line 45 degrees to theleft of anterior in the horizontal plane. The OLC was anterior in all patients with NRGA, lateral in most l-malpositions, and almost equally divided between anterior and lateral in d-malposition (P less than 0.05). Complete hemodynamic data were obtained in 29 patients. Complete mixing of venous return occurred in four patients with atresia of one valve. In the remainder complete mixing occurred in 36%, unfavorable streaming in 12% and favorable streaming in 52%. Semilunar valve position and pulmonary stenosis did not affect the nature of mixing. Systemic arterial (SA) minus pulmonary arterial O2 saturation was positive and significantly higher in patients with malposition with lateral OLCs than anterior OLCs (P less than 0.001). However 79% of SA O2 saturation variation could be predicted from pulmonary and systemic blood flow alone.
When investigating complex congenital heart disease, determination of atrial situs is essential. Pathological studies have demonstrated that the best predictor of atrial situs is thoracic situs. To assess thoracic situs, bronchial tomography was performed in 92 patients with congenital heart disease. Sixty-four of these, without abnormalities of situs or cardiac position, formed 'normal' controls. The lengths of the left and right main bronchi were measured. When these were related to age, and the results analyzed statistically, linear discriminant equations resulted giving a chance of only 0.09% of misclassifying a bronchus of unknown morphology. The lowest ratio between bronchial lengths (BLR) in any individual was 1.71:1. These results were then used to assess thoracic situs in 17 patients with abnormal situs or CARDIAC POSITION. In 7 (2 with situs inversus), abdominal and thoracic situs agreed. Of 6 patients with bilateral left lung, 3 had an interrupted inferior vena cava. Of 4 patients with presumptive asplenia, 2 had bilateral right lung, but two had thoracic lateralization, one solitus and one inversus. The highest BLR in thoracic isomerism was 1.4:1. This emphasizes the complex interrelation of splenic status, thoracic, and abdominal situs, but demonstrates the value of bronchial measurement particularly in apparent situs indeterminatus.