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Improved resting asynergy after coronary bypass: Relationship to perfusion
ABSTRACTS
CARDIOVASCULAR EFFECTS OF THE CONVERTING ENZYME INHIBITOR IN HYPERTENSION ASSOCIATED WITH CORONARY BYPASS SURGERY. A.P. Niarchos, MD, A.J. Roberts, MD, D.B. Case, MD, W.A. Gay, MD, J.H. Laragh, MD, FACC. Hypertension Center and Division of Cardiothoracic Surgery, New York HospitalCornell Medical Center, New York, N. Y. The possible role of the renin system and the cardiovascular effects of converting enzyme inhibitor (CEI, SQ20881) were evaluated in 13 patients who developed post coronary artery bypass hypertension. Eight patients who responded to CEI had control PRA of 8.8!2 ng/ml/h, and showed a 23+--4 mmHg decrease in MAP (p<0.005), due to a decrease (p
IMPROVED RESTING ASYNERGYAFTER CORONARYBYPASS: RELATIONSHIP TO PERFUSION. Bruce Brundage, M.D., FACC; Barry Massie, M.D.; Elias Botvinick, M.D.; Harris Gelberg, M.D., University of California, San Francisco, California
ELECTROCARDIOGRAPHIC-ISOTOPIC PREDICTION OF SUCCESSFUL CORONARY BYPASS Sergio E. Schabelman, MD; Winston A. Mitchell, MD; Eloy E. Schulz, MD; William H. Willis, Jr., MD, FACC; Melvin P. Judkins, MD, FACC; Loma Linda University, Loma Linda, California.
HEMODYNAMIC AND SCINTIGRAPHIC DEMONSTRATION OF TRANSIENT RIGHT VENTRICULAR DYSFUNCTION IMMEDIATELY AFTER UNCOMPLICATED CORONARY ARTERY BYPASS GRAFT SURGERY. ~amshid Maddahi, M~D,, Richard Gray, M.D., Daniel Berman, M.D., FACC, Marjorie Raymond, R.N., Alan Waxman, M.D., Jack Matloff, M.D., FACC, William Ganz~ M.D., FACC, HJC Swan, M.D., FACC. Cedars-Sinai Medical Center, Los Angeles, Ca.
Biplane ventriculography in 50 patients (pts) assessed post-operative differences in wall motion in 9 segments. Pre-operative isotopic perfusion scans (IPS) in 44 pts (Tc99 for left coronary, 1131 for right) were (I) predictive when (a) adequate perfusion was paired with unchanged or improved contractility, (b) absent perfusion was confirmed as scar at surgery; (2) inconclusive when (a) deterioration occurred in grafted segments, with or without graft occlusion, or (b) when normal, nongrafted myocardium deteriorated without angiographically discernible cause. EKG-angiographic agreement occurred in 41 pts (82%), 20 normal and 21 with Q wave markers for proved scar. Normal EKG-abnormal angiography in 7 pts (14%) was resolved in 6 by improved contractions after bypass, but not in one with scar. Abnormal EKGabnormal IPS-normal angio occurred in one pt.(2%). One EKG (2%) was inconclusive (LBBB). IPS correctly predicted the fate of 349 segments (90.2%) and was inconclusive in 38 (9.8%). One scan was technically deficient. IPS-EKG correctly forecast the results of coronary bypass (characterized by 94.4% patency at 3 months) in 41 of 42 pts (97.6%). IPS-EKG were normal in 15 pts and abnormal in 20 pts; abnormal IPS-normal EKG occurred in 7 pts. In conclusion, EKG and IPS are complementary: lack of Q waves usually signals a good prospect for improving motion in deficient ventricular segments. IPS proved more sensitive in detecting and quantifying scar.
Evidence indicating improved ventricular function after coronary bypass surgery (CBS) is conflicting. The existence of a chronic ischemic state producing resting asynergy is also controversial. This study evaluates the relationship between myocardial perfusion and segmental wall motion (SWM) before and after CBS. Nine patients had myocardial perfusion scintigraphy (MPS) by thallium-201 during exercise and cardiac cath before and several months after CBS. Biplane ventriculograms were done to assess SWMof 8 regions by a previously reported quantitative area ejection fraction technique. A normal range (mean + 2 SD) was established from 17 normal ventricles. Changes of I SD from abnormal into the normal range or vice versa were considered significant. Increases of I SD within the abnormal range were called improvement. Exercise-induced HPS defects occurred in 32 segments before surgery and were related to normal SWMin 21. After surgery, 20/21 showed continued normal SWM in the presence of improved MPS (15) or unchanged MPS (6). In the 11 asynergic segments with preop exercise-induced HPS defects, 7 showed improved MPS postop, all with normal (6) or improved (1) SWM, while 4 segments without improved MPS showed no change in SWM. (p
Right ventricular (RV) function was assessed by hemodynamic and scintigraphic (Sc) measurements before, immediately (2-6 hrs) and up to 3 days after coronary artery bypass graft surgery (CABG) in 20 pts, RV ejection fractions (EF) were obtained with Tc-99m RBC's and a new method using LAO multiple gated equilibrium Sc with multiple RV regions of interest. Left ventricular segmental wall motion was evaluated semi-quantitatively. No pt had perioperative myocardial infarction. The pericardium was left open in 13 pts; surgically closed in 7 pts. Immediately after CABG a decrease was seen in RVEF (46 ~= 13 to 34 i 10%) (mean ~ SD), RV stroke work index (SWI) (7.4 2.7 to 5.7 i 2.4 gm.m/m 2) and cardiac index (CI) (2.39 * .33 to 2.13 @ .43 L/m/m 2) (all p<.05). Mean pulmonary artery pressure increased (15 _+ 4 to 20 _+ 4 mmHg) as did total pulmonary resistance (TPR) (264 ~: 84 to 405 ~ 128 dyne.sec.cm -5) and right atrial pressure (RA) (5 * 2 to ii ± 3 mmHg) (all p<.01). The increase in RA pressure was greater in the pts with closed pericardium ( 8 , 2 vs 5 ± 3 mmHg, p~.05). RVEF, RVSWI and CI improved by postoperative day (POD) 2. End diastolic RV volume increased by 30% and remained enlarged. Septal wall motion deteriorated and remained abnormal at POD 2 (p<.01). Thus: i) RV function transiently deteriorates immediately after uncomplicated CAGB. 2) Pericardial closure adds further to the elevation of RA pressure. 3) RV enlarges and septal motion is uniquely impaired through POD 2. 4) Spontaneous improvement was seen by POD 2.
February 1979
The American Journal of CARDIOLOGY
Volume 43
423
CARDIOVASCULAR EFFECTS OF THE CONVERTING ENZYME INHIBITOR IN HYPERTENSION ASSOCIATED WITH CORONARY BYPASS SURGERY. A.P. Niarchos, MD, A.J. Roberts, MD, D.B. Case, MD, W.A. Gay, MD, J.H. Laragh, MD, FACC. Hypertension Center and Division of Cardiothoracic Surgery, New York HospitalCornell Medical Center, New York, N. Y. The possible role of the renin system and the cardiovascular effects of converting enzyme inhibitor (CEI, SQ20881) were evaluated in 13 patients who developed post coronary artery bypass hypertension. Eight patients who responded to CEI had control PRA of 8.8!2 ng/ml/h, and showed a 23+--4 mmHg decrease in MAP (p<0.005), due to a decrease (p
IMPROVED RESTING ASYNERGYAFTER CORONARYBYPASS: RELATIONSHIP TO PERFUSION. Bruce Brundage, M.D., FACC; Barry Massie, M.D.; Elias Botvinick, M.D.; Harris Gelberg, M.D., University of California, San Francisco, California
ELECTROCARDIOGRAPHIC-ISOTOPIC PREDICTION OF SUCCESSFUL CORONARY BYPASS Sergio E. Schabelman, MD; Winston A. Mitchell, MD; Eloy E. Schulz, MD; William H. Willis, Jr., MD, FACC; Melvin P. Judkins, MD, FACC; Loma Linda University, Loma Linda, California.
HEMODYNAMIC AND SCINTIGRAPHIC DEMONSTRATION OF TRANSIENT RIGHT VENTRICULAR DYSFUNCTION IMMEDIATELY AFTER UNCOMPLICATED CORONARY ARTERY BYPASS GRAFT SURGERY. ~amshid Maddahi, M~D,, Richard Gray, M.D., Daniel Berman, M.D., FACC, Marjorie Raymond, R.N., Alan Waxman, M.D., Jack Matloff, M.D., FACC, William Ganz~ M.D., FACC, HJC Swan, M.D., FACC. Cedars-Sinai Medical Center, Los Angeles, Ca.
Biplane ventriculography in 50 patients (pts) assessed post-operative differences in wall motion in 9 segments. Pre-operative isotopic perfusion scans (IPS) in 44 pts (Tc99 for left coronary, 1131 for right) were (I) predictive when (a) adequate perfusion was paired with unchanged or improved contractility, (b) absent perfusion was confirmed as scar at surgery; (2) inconclusive when (a) deterioration occurred in grafted segments, with or without graft occlusion, or (b) when normal, nongrafted myocardium deteriorated without angiographically discernible cause. EKG-angiographic agreement occurred in 41 pts (82%), 20 normal and 21 with Q wave markers for proved scar. Normal EKG-abnormal angiography in 7 pts (14%) was resolved in 6 by improved contractions after bypass, but not in one with scar. Abnormal EKGabnormal IPS-normal angio occurred in one pt.(2%). One EKG (2%) was inconclusive (LBBB). IPS correctly predicted the fate of 349 segments (90.2%) and was inconclusive in 38 (9.8%). One scan was technically deficient. IPS-EKG correctly forecast the results of coronary bypass (characterized by 94.4% patency at 3 months) in 41 of 42 pts (97.6%). IPS-EKG were normal in 15 pts and abnormal in 20 pts; abnormal IPS-normal EKG occurred in 7 pts. In conclusion, EKG and IPS are complementary: lack of Q waves usually signals a good prospect for improving motion in deficient ventricular segments. IPS proved more sensitive in detecting and quantifying scar.
Evidence indicating improved ventricular function after coronary bypass surgery (CBS) is conflicting. The existence of a chronic ischemic state producing resting asynergy is also controversial. This study evaluates the relationship between myocardial perfusion and segmental wall motion (SWM) before and after CBS. Nine patients had myocardial perfusion scintigraphy (MPS) by thallium-201 during exercise and cardiac cath before and several months after CBS. Biplane ventriculograms were done to assess SWMof 8 regions by a previously reported quantitative area ejection fraction technique. A normal range (mean + 2 SD) was established from 17 normal ventricles. Changes of I SD from abnormal into the normal range or vice versa were considered significant. Increases of I SD within the abnormal range were called improvement. Exercise-induced HPS defects occurred in 32 segments before surgery and were related to normal SWMin 21. After surgery, 20/21 showed continued normal SWM in the presence of improved MPS (15) or unchanged MPS (6). In the 11 asynergic segments with preop exercise-induced HPS defects, 7 showed improved MPS postop, all with normal (6) or improved (1) SWM, while 4 segments without improved MPS showed no change in SWM. (p
Right ventricular (RV) function was assessed by hemodynamic and scintigraphic (Sc) measurements before, immediately (2-6 hrs) and up to 3 days after coronary artery bypass graft surgery (CABG) in 20 pts, RV ejection fractions (EF) were obtained with Tc-99m RBC's and a new method using LAO multiple gated equilibrium Sc with multiple RV regions of interest. Left ventricular segmental wall motion was evaluated semi-quantitatively. No pt had perioperative myocardial infarction. The pericardium was left open in 13 pts; surgically closed in 7 pts. Immediately after CABG a decrease was seen in RVEF (46 ~= 13 to 34 i 10%) (mean ~ SD), RV stroke work index (SWI) (7.4 2.7 to 5.7 i 2.4 gm.m/m 2) and cardiac index (CI) (2.39 * .33 to 2.13 @ .43 L/m/m 2) (all p<.05). Mean pulmonary artery pressure increased (15 _+ 4 to 20 _+ 4 mmHg) as did total pulmonary resistance (TPR) (264 ~: 84 to 405 ~ 128 dyne.sec.cm -5) and right atrial pressure (RA) (5 * 2 to ii ± 3 mmHg) (all p<.01). The increase in RA pressure was greater in the pts with closed pericardium ( 8 , 2 vs 5 ± 3 mmHg, p~.05). RVEF, RVSWI and CI improved by postoperative day (POD) 2. End diastolic RV volume increased by 30% and remained enlarged. Septal wall motion deteriorated and remained abnormal at POD 2 (p<.01). Thus: i) RV function transiently deteriorates immediately after uncomplicated CAGB. 2) Pericardial closure adds further to the elevation of RA pressure. 3) RV enlarges and septal motion is uniquely impaired through POD 2. 4) Spontaneous improvement was seen by POD 2.
February 1979
The American Journal of CARDIOLOGY
Volume 43
423