Angina pectoris and intermittent claudication.
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Adult↗
Biomedical subjects
R I Hamby
Publications and source records attributed to R I Hamby.
Effects of contrast medium on left ventricular pressure and volume with emphasis on coronary artery disease.
Forty-one patients had left ventricular angiography repeated 3 minutes after an initial study in order to evaluate the effect of angiographic contrast medium on left ventricular end-diastolic pressure (EDP) and volume (EDV). Seven patients had no evidence of heart disease (normal group) and 34 patients had coronary artery disease. Single-vessel diseae was present in 10, double-vessel disease in 10, and triple-vessel disease in 14 patients. Seven other patients with radiopague epicardial clips previously attached to the left ventricle underwent cinefluorographic studies to determine end-diastolic intraclip distance at various intervals after a left ventricular angiogram. In all the groups studied there was a significant increase (p less than 0.005) in both the left ventricular EPD and EDV in the second angiographic study as compared to the first. This increase in EDV (deltaV) was similar in all groups. However, the increase in EDP (deltaP) was significantly greater (p less than 0.01) in patients with double- and triple-vessel disease as compared to the normal and single-vessel disease groups. Ejection fraction, per cent shortening of the heart axis, and contractile pattern in the normal subjects were not singnificantly different when the second angiographic study was compared to the first. In nine of 34 patients with coronary artery disease the second angiographic study demonstrated impairment in left ventricular contractile pattern not present in the first angiographic study. Cinefluorographic study demonstrated an increase in end-diastolic intraclip distance after the left ventricular angiogram. The change in intraclip distance corresponded directionally and temporally to the changes in left ventricular EDP. The present study revealed that the increase in left ventricular end-diastolic press-re associated with the injection of angiographic contrast medium can be explained by an increase in EDV and that such changes last for over 15 minutes and may be associated with alterations in the contractile pattern of the left ventricle.
Adult↗
Comparative study of the postoperative flow in the saphenous vein and internal mammary artery bypass grafts.
Postoperative coronary bypass flow was evaluated in two groups of randomly selected patients with grafts to the left anterior descending artery (LAD). Saphenous vein bypass grafts were placed in 27 patients and internal mammary artery grafts in 25 patients. Postoperative flow studies were performed in both groups with roentgendensitometric methods based on the transit time of radiopaque media along the graft plus the mean graft diameter. There was no significant difference between the two groups of patients for age, duration of symptoms, or the frequency of hypertension, diabetes mellitus, prior myocardial infarction, or cardiomegaly. Intraoperative bypass flows were 75+/-27 and 77+/-24 ml. per minute for the saphenous vein group (SVG) and internal mammary artery group (IMAG), respectively. There was no significant difference in the heart rate or mean aortic pressure at the time of the roentgendensitometric flow study. The mean graft diameters were 3.0+/-0.5 and 1.9+/-0.3 mm. for the SVG and IMAG, respectively (p less than 0.001). The ratios of graft diameter to LAD diameter were 1.9+/-0.3 and 1.2+/-0.2 for the SVG and IMAG, respectively (p less than 0.001). The roentgendensitometric postoperative flows were 68+/-27 ml. per minute in the SVG and 46+/-16 ml. per minute in the IMAG (p less than 0.01). The present study indicates that flow in significantly higher in saphenous vein than in internal mammary artery bypasses and that the difference in flow may in part be explained on the basis of the graft diameter.
Angina Pectoris↗
Isolated aortic valve stenosis in the eighth decade.
Aortic valve stenosis was evaluated in 26 patients in the eighth decade of life, representing 20% of all patients referred for aortic valve stenosis. There were no clinical features which distinguished this older group from younger patients. Coronary artery disease was present in 46% of the older group, 30% in the younger. Angina pectoris or an infarction pattern on the electrocardiogram was not useful in predicting coronary artery disease in either group. A dominant left coronary circulation was more frequent (22%) in the younger than the older group. This was related to the higher incidence of congenitally deformed aortic valves (55%) found in the younger, compared in the advanced age group (5%). The surgical mortality in the younger and advanced age group was 8 and 20%, respectively. Mortality in both groups was related in more than half the patients to coronary artery disease.
Age Factors↗
Angina pectoris: a clinical-electrocardiographic-angiographic correlative study in 510 patients.
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Adult↗
Reappraisal of the functional significance of the coronary collateral circulation.
A review of data in 465 patients with complete obstruction of either the left anterior descending or right coronary artery was undertaken to evaluate the functional role of the collateral circulation. Complete obstruction of a dominant right coronary artery was observed in 288 patients, 83 percent with distal filling and visualization of the posterior descending artery by way of collateral vessels. Complete obstruction of the left anterior descending artery was noted in 177 patients, 71 percent with filling and visualization distal to the obstruction by way of collateral vessels. Among patients with obstruction of the left anterior descending artery, there was a significantly greater frequency of congestive heart failure and cardiomegaly in those without collateral vessels than in those with collateral vessels. The former also had a significantly greater frequency of both electrocardiographic evidence of an anterior wall myocardial infarction and angiographic findings of anterior wall asynergy. The frequency of inferior myocardial infarction and inferior wall asynergy was not influenced by the presence of collateral vessels. These observations indicate that the collateral circulation plays a significant protective role in the presence of obstruction of the left anterior descending artery, which is not apparent with obstruction of the right coronary artery.
Adult↗
Correlation of heart size with clinical and hemodynamic findings in patients with coronary artery disease.
The clinical, hemodynamic, and angiographic findings were correlated with the heart size in 207 patients with proved coronary artery disease. Cardiomegaly was noted in 34 patients and normal heart size in 173. In these two groups, the patients' age range, duration of disease, and history of myocardial infarction were similar. There was no statistical difference in incidence of shortness of breath, hypertension, left ventricular hypertrophy, or abnormal glucose tolerance. Patients with cardiomegaly had a significantly higher incidence of congestive heart failure (26 per cent) as compared to patients with normal heart size (2.9 per cent) (P less than 0.001). Patients with enlarged heart presented a high incidence of anterior wall or multiple myocardial infarction (73 per cent) (P less than 0.001). The cardiomegaly group had a high incidence of elevated end-diastolic volumes, elevated end-diastolic pressures, and diminished ejection fractions when compared to patients with normal heart size (P less than 0.01). Double and triple coronary artery disease was more frequent in patients with cardiomegaly and total coronary score was also higher in this group (P less than 0.005). Asynergy was present in 55 per cent of patients with normal heart size but in 82 per cent of those with enlarged hearts (P less than 0.01). The group of patients with cardiomegaly and documented congestive heart failure had ejection fractions less than 0.30. Cardiac catheterization is probably not advisable in these patients in the absence of associated significant mitral regurgitation, ventricular septal defect, or ventricular aneurysm.
Cardiomegaly↗
Anterior conduction delay: a possible cause for prominent anterior QRS forces.
Prominently anterior QRS forces often present a diagnostic dilemma. Frequently, right ventricular forces may be eliminated on clinical grounds and dorsal infarction is therefore suspected, especially in a clinical setting of coronary artery disease. In five such patients studied angiographically, the coronary disease was concentrated in the left anterior descending artery and the ventricular dysfunction confined to the anterior wall of the left ventricle. In a sixth case, the prominent anterior forces were observed intermittently together with left anterior hemiblock. These observations, in addition to serial studies following surgery, strongly suggest that the mechanism for prominent anterior QRS forces in these cases is conduction delay in an anterior division of the left bundle branch system.
Adult↗
New Q waves after bypass grafting: correlations between graft patency, ventriculogram and surgical venting technique.
New Q waves were observed in 35 (11%) of 321 patients undergoing saphenous vein bypass grafting with an overall mortality rate of 1.1%. Twenty-eight (80%) had postoperative arteriograms and ventriculograms and are reported. Ventricular venting was used intra-operatively in 17 patients and atrial venting in 11. The incidence of new Q wave was 22% in patients with ventricular venting and 5.5% in those with atrial venting (p less than 0.05). Complete or incomplete revascularization did not affect the incidence of new Q waves. New Q waves appeared in a zone of myocardium supplied by a grafted artery in all except two patients with ventricular venting in whom Q waves occurred within the zone of myocardium supplied by diseased ungrafted vessels. In the ventricular venting group, seven (41%) demonstrated an improved or unchanged postoperative ventriculogram and ten (59%) had deteriorated ventriculograms. In 11 patients with atrial venting, nine (82%) showed improved or unchanged postoperative ventriculograms and two (18%) had deteriorated ventriculograms. Ventricular venting patients with improved or unchanged postoperative ventriculograms had 7% graft closure as compared to 5% of those with atrial venting (pNS). Graft closure rate was 44% in ventricular venting and 20% (pNS) of patients with atrial venting who had deteriorated left ventriculograms. These findings indicate poor correlation between new Q waves and graft closure. Improved postoperative ventriculograms corrleated well with graft patency despite new Q waves. The etiology of new post bypass graft Q waves are varied. They include ventricular trauma and conduction delays resulting from surgery or venting, as well as infarction. This may be due to compromised arterial inflow either in nonoperated vessels or in the vessels distal to the anastomosis with patent grafts, or due to occluded grafts.
Coronary Artery Bypass↗
Results of open heart surgery in the septuagenarian.
Open heart surgery has been extended to the septuagenarian. At the Long Island Jewish-Hillside Medical Center, 42 patients 70 to 79 years old underwent 43 open heart procedures in the past 7 years. Their average age was 73 years and 62% were male. Eighteen underwent aortic valve replacement; 7 had mitral valve replacement; 18 had coronary bypasses (3 with valve replacement); exploration for pulmonary embolism was done in 1; 1 patient had tricuspid replacement with mitral commissurotomy; 17% (7/42) died during hospitalization or within 30 days of surgery. Mean follow-up is 25 mo., and an additional 19% (8/42) have died at an average of 27 mo. after surgery. Open heart surgery is feasible for the elderly, but at an increased risk when compared to the younger patient submitted to the same procedure.
Age Factors↗
Multiple infarction pattern and fascicular block in prolapsed mitral valve syndrome. Case report.
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Angiography↗
Endocarditis in prosthetic valves.
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Adult↗
Medical-surgical aspects of left main coronary artery disease.
Disease of the left main coronary artery compromises circulation to the major part of the left ventricle and thus threatens massive myocardial infarction and sudden death. Cardiac catheterization and coronary bypass surgery, in previous reports, have been associated with high mortality and morbidity rates. We report 50 patients with over 50 per cent narrowing of the left main coronary artery. The clinical pattern in these patients was variable and a left main coronary artery lesion could not be predicted before coronary angiography. There was only one death during cardiac catheterization. One patient died while waiting for elective surgery. Coronary bypass surgery was performed in 42 patients; one died during surgery. Forty-one patients are alive at 2 to 39 months follow-up (mean, 19 months). Thirty-six patients are asymptomatic or have minimal symptoms. Compared to the prognosis in patients with left main coronary artery stenosis treated medically, coronary bypass surgery performed on urgent basis offers a much better prognosis. Both coronary angiography and bypass surgery can be performed in these patients with a very low risk.
Adult↗
Hpertrophic subaortic stenosis is not rare in the eighth decade.
During a five year period, idiopathic hypertrophic subaortic stenosis was diagnosed in nine patients 70 to 79 years of age and in 26 patients 20 to 66 years of age who were referred to the cardiology division of the Long Island Jewish-Hillside Medical Center because of symptomatic heart disease. Only one of the older patients, compared with 19 of the younger ones, was referred with the correct diagnosis. Coronary artery disease with papillary muscle dysfunction was incorrectly diagnosed in four of the older patients. Cardiac catheterization confirmed the diagnosis of idiopathic hypertrophic subaortic stenosis in all of the 26 younger patients and in five of the nine older ones; diagnosis was based on typical echocardiographic features in the other four patients. Symptoms, physical findings, and electrocardiographic observations were similar in both groups. Aortic valve calcification was found in one younger patient and three older ones. The ratio of women to men was higher in the older group (7:2) than in the younger group (12:14). Coronary artery disease was more frequent in the older patients (three of five, compared with six of 26). Our experience indicates that idiopathic hypertrophic subaortic stenosis is not rare during the eighth decade. The diagnosis should be considered in any patient with an unexplained appropriate heart murmur, and definitive studies, such as echocardiography, should be done. As with any condition, proper management depends on accurate diagnosis.
Adult↗
Preoperative coronary angiographic prediction of bypass flow and short-term patency.
A quantitative preoperative coronary angiographic index was defined in 148 patients undergoing coronary revascularization. Each diseased vessel was scored 0-3, for both diameter and quality of run-off. The sum of the scores for diameter and run-off constituted the numerical index for the diseased vessel. Correlations between the index and graft flow measured by electromagnetic flow meter at surgery were established in 259 bypassed vessels. The highest scores (5-6) were associated with higher flows, and the lower scores (0-4) with the lower flows (P less than 0.005). Repeat angiography performed 2 wk postoperatively in 110 patients demonstrated 174 graft patencies and 15 graft closures. Mean flow in open grafts was 82 +/- 41 ml/mn vs. 60 +/- 23ml/mn in closed grafts (P less than 0.005). It is concluded that graft flow is predictable from preoperative Coronary Angiographic Index and that higher flow and index scores are more likely to be associated with graft patency than low flows and index scores.
Angina Pectoris↗
Relation of left ventricular contractile patterns in coronary artery disease to the electrocardiogram and vectorcardiogram.
Two hundred thirty patients with coronary artery disease (CAD) were studied with left ventriculography, coronary arteriography, electrocardiography (ECG) and vectorcardiography (VCG) to determine how well left ventricular (LV) contractile defects could be predicted from the ECG-VCG patterns and how this was related to the coronary disease location and severity. Of 124 patients with infarction patterns on ECG-VCG about 50% had LV contractile defects localized to the corresponding ECG-VCG abnormalities, i.e., antero-apical asynergy with anterior infarction patterns, inferior asynergy with inferior infarction patterns, or antero-apical plus inferior asynergy with anterior plus inferior patterns. About 20% in each infarction group had unexpected synergy on ventriculography except for patients with dorsal infarction patterns (synergy in 68%) who are discussed as a special problem. Another 25-30% of patients had more extensive contractile abnormality than indicated by the ECG-VCG patterns. In 106 patients with left ventricular hypertrophy, normal QRS-abnormal T and normal QRS-T on ECG-VCG, 65-70% had synergy. However, 30-35% had asynergy in various combinations not suspected from the ECG or VCG. Coronary artery disease severity was less pronounced in patients with synergy than with asynergy and single vessel disease was more common in the former, 47% versus 18-30% in the latter. However, coronary artery disease severity was the same for all ECG-VCG groups except for anterior plus inferior infarction patterns where it was most severe.
Coronary Disease↗
Failure of the omnicardiogram to predict coronary artery disease in patients with normal resting electrocardiograms.
Seventy-two male patients over the age of 35 had normal resting twelve lead eletrocardiograms (ECG's). All patients were studied by invasive techniques including complete right and left sided cardiac catheterization, selective coronary arteriography, and left ventricular angiography. All patients had been referred because of chest pain with a presumed diagnosis of coronary artery obstruction and myocardial ischemia. Omnicardiograms were generated from the twelve lead ECG's and diagnosed as "abnormal" or "normal" by observers having no knowledge of the cardiac catheterization findings. Of 72 patients studied, 21 were free of coronary artery disease. Of these, 14 (66%) had "abnormal" omnicardiographic reports. Seven (33%) had "normal" omnicardiograms, indicating an incidence of false positive "abnormal" omnicardiographic reports as 66%. Fifty-one patients had hemodynamically significant coronary artery disease. In this group, 19 (38%) were reported as "normal" by omnicardiogram, an incidence of false negative diagnosis of 38%. When the patients with coronary artery disease were classified as to single, double, or triple coronary obstruction, it was evident that the omnicardiogram had failed to separate patients with more extensive disease. Of the 32 patients with "abnormal" omnicardiograms, 56% had double or triple vessel disease, while of the 19 patients with "normal" omnicardiograph reports, 78% had double or triple vessel disease. Similarly, the omnicardiograms failed to identify the patients with abnormal left ventricular angiography. Of 19 patients with coronary artery disease and "normal" omnicardiograms, only 8 (42%) had normal ventricular angiography. However, of the 32 patients with coronary disease and "abnormal" omnicardiograms, only 11 (34%) had abnormal ventriculogram. The omnicardiogram cannot be considered a useful technique for predicting the presence or severity of coronary artery disease or for the identification of abnormal left ventricular function in patients with known coronary artery disease.
Adult↗