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Isolated bilateral coronary ostial stenosis in Takayasu's arteritis
962
-- ---Brie/Communications
relative increase in both h e a r t rate and blood pressure were noted. Therefore intravenous propranolol and sublingual nitroglycerin were administered in order to reduce myocardial oxygen demand. H e a r t rate and systolic blood p r e s s u r e declined, with immediate relief of the p a t i e n t ' s angina and resolution of pulsus alternans. In conclusion, myocardial ischemia should be recognized as a potential causative factor in the development of pulsus alternans. Although negative inotropic drugs are generally contraindicated in patients with this hemodynamic finding, fl-adrenergic blockade can have a paradoxic salutary effect in the setting of acute myocardial ischemia. P r e s u m a b l y this beneficial effect is m e d i a t e d through an effect on the rate-pressure product and a reduction in myocardial oxygen demand. REFERENCES
1. Braunwald E. Heart disease. Philadelphia: W.B. Saunders Co, 1988:481. 2. Traube L. Ein fall yon pulsus bigeminus nebst bemerkungen uber die leberschwellungen bei klappenfehlern und uber acute leberatrophic. Berl Klin Wochenschr 1872;9:185. 3. Gleason WL, Braunwald E. Studies on Starling's law of the heart. Circulation 1962;25:841-8. 4. Cohn KE, Sandler H, Hancock EW. Mechanisms of pulsus alternans. Circulation 1967;36:372-80. 5. Hess OM, Surber EP, Ritter M, Krayenbuehl HP. Pulsus alternans: its influence on systolic and diastolic function in aortic valve disease. J Am Coll Cardiol 1984;4:1-7. 6. Hashimoto H, Suzuki K, Miyake S, Nakashima M. Effects of calcium antagonists on the electrical alternans of the ST segment and on associated mechanical alternans during acute coronary occlusion in dogs. Circulation 1983;68:667-72. 7. Elbaum DM, Banka VS. Pulsus alternans during spontaneous angina pectoris. Am J Cardiol 1986;58:1099-100.
Isolated bilateral coronary ostial stenosis in Takayasu's arteritis Y0shiharu Emi MD, Tetsu Yamakado MD, Yasuo F u t a g a m i MD, T a k u y a T a m a i MD, You Hasegawa MD, Takao K o y a m a MD, Masayuki H a m a d a MD, and Takeshi Nakano MD. Tsu, J a p a n
Coronary ostial stenosis is usually associated with either multivessel atherosclerotic coronary artery disease or syphilis. Nonatherosclerotic or nonsyphilitic isolated coronary ostial stenosis is a rare disease of unknown etiology, usually occurring in premenopausal women. 1 In this report, we present the case of young girl with Takayasu's arteritis in which bilateral coronary ostial stenosis was demonstrated
From The First Department of Internal Medicine, Mie University. Reprint requests: Tetsu Yamakado, MD, The First Department of Internal Medicine, Mie University, Edobashi 2-174, Tsu 514, Japan. 4/4/18629
April 1990 American Heart Journal
by angiography, and anginal pain was relieved by coronary bypass surgery. A 17-year-old girl had been well until 3 months prior to admission, when she noted chest pains on exertion t h a t increased progressively. She had no family history of premature coronary artery disease. She did not smoke and did not take contraceptive pills. On physical examination, the patient a p p e a r e d healthy and had no abnormal finding and no evidence of systemic disease. Her blood pressure was 128/ 76 m m Hg. Her peripheral arteries were easily palpable, and there was no inequality of the pulses. Laboratory studies revealed an elevated erythrocyte sedimentation rate (ESR) (54 m m in 1 hour) and C-reactive protein (CRP), suggesting acute inflammatory changes. The Venereal Disease Research L a b o r a t o r y (VDRL), Treponema pallidum hemagglutination test (TPHA), rheumatoid factor, and antinuclear factor were negative. Serum triglyceride and cholesterol levels were within the normal range. The resting electrocardiogram, chest x-ray film, and echocardiogram were all normal. On treadmill testing, she developed chest pain during mild exercise (1.7 m p h at a grade of 10 % ), associated with significant S T segment depression of 2 to 4 m m in leads II, III, aVF; and V2 to V6, together with a decrease in systolic blood pressure. On cardiac catheterization, the left ventriculogram showed a normal ejection fraction (0.66). W i t h right ventricular pacing of 150/min for 3 minutes, the left ventriculogram disclosed an area of severe anteroseptal hypokinesis. Coronary angiography after intracoronary nitroglycerin administration d e m o n s t r a t e d a 90 % left coronary ostial stenosis (Fig. 1, A) with collateral flow from the right coronary artery to the anterior descending coronary artery. A pressure drop was noted as the catheter tip entered the left coronary ostium. There was also a 75% right coronary ostial stenosis (Fig. 1, B). The remainder of the coronary arterial tree was normal. Coronary bypass surgery was carried out with an internal m a m m a r y a r t e r y graft to the anterior descending artery and a saphenous vein graft to the right coronary artery. During operation, a specimen of the ascending thoracic aorta showed fibrotic thickening of intima and inflammatory infiltration of the adventitia and vasa vasorum with lymphocytes and plasma cells (Fig. 2). Clinical and histologic findings were consistent with Takayasu's arteritis. Corticosteroid t h e r a p y (prednisone, 10 to 30 m g / d a y for 6 months) was begun, with resultant normalization of the E S R and CRP. Repeat angiography 6 months after surgery demonstrated p a t e n t grafts (Fig. 1, C and D). However, there was no regression of either the left or right coronary ostial stenosis (Fig. 1, C and D). There was no abnormal angiographic finding in the thoracic and abdominal aorta or pulmonary arteries. Although Takayasu's arteritis is rarely complicated by coronary artery disease, there are some case reports of isolated coronary ostial stenosis in Takayasu's arteritis, e4 In these patients, however, the ostial stenosis was associated with stenosis of the aortic arch or peripheral vessels. In Contrast, our p a t i e n t had a unique clinical feature in that anginal pain was associated with isolated, bilateral coronary ostial stenosis without any other significant arterial involvement.
V o l u m e 119
Brief Communications
Number 4
963
Fig. 1, Coronary angiograms and aortogram before and after coronary artery bypass grafting (CABG). Before CABG, the left coronary angiogram (A) shows significant 90% ostial stenosis (arrow). Aortogram (B) showed a 75 % stenosis of the right coronary ostium (arrow). After CABG ( a and D), both coronary bypass grafts to the left anterior descending (C, arrows) and right coronary artery (D, arrows) were patent. However, there is no angiographic regression of left (C, arrow) or right (D, arrow) coronary ostial stenosis.
Coronary ostial stenosis in T a k a y a s u ' s arteritis carries the same serious prognosis as does left main coronary artery disease. 2 In fact, most of these patients die of cardiac causes. 2-4 Therefore we elected to perform bypass surgery. Corticosteroid t h e r a p y has sometimes been recommended for the t r e a t m e n t of Takayasu's arteritis, 5 but we could not confirm any angiographic regression of the coronary ostial stenosis by long-term corticosteroid t h e r a p y despite normalizing E S R and CRP. This case suggests t h a t in patients
with anginal pain in T a k a y a s u ' s arteritis, coronary ostial stenosis should be kept in mind. Early diagnosis and surgery are essential to avoid serious cardiac complications. REFERENCES
1. Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol 1986;7:997. 2. Cipriano PR, Silverman JF, Perlroth MG, Griepp RB, Wexler L. Coronary arterial narrowing in Takayasu's aortitis. Am J Cardiol 1977;39:744.
964
April 1990 American Heart Journal
Brief Communications
Fig, 2. Histologic section of the ascending thoracic aorta obtained at cardiac surgery, showing a prominent mononuclear cell infiltrate of the adventitia and vasavasorum.
3. Chun MPKC, Jones CR, Robinowitz M, Davia CJE, Lawrence CPJ. Coronary ostial stenosis in Takayasu's aortitis. Chest 1980;78:330. 4. Morgan JM, Honey M, Gray HH, Belcher P, Paneth M. Angina pectoris in a case of Takayasu's disease: revascularization by coronary ostioplasty and bypass grafting. Eur Heart J 1987;8:1354. 5. Hayashi K, Fukushima T, Matsunaga N, Hombo Z. Takayasu's arteritis: decrease in aortic wall thickening following steroid therapy, documented by CT. Br J Radiol 1986;59:281.
200/40 mmHg - 1
x4
Intrapericardial "negative" cannon waves during atrioventricular dissociation in large pericardial effusion Chalapathirao V. Gudipati, MD, Ubeydullah Deligonul, MD, Denise Janosik, MD, Michel Vandormael, MD, and Morton J. Kern, MD.
St. Louis, 114o. l n t r a p e r i c a r d i a l pressure closely follows the changes in right atrial pressure and volume during the cardiac cycle. 13 We observed an unusual hemodynamic p a t t e r n during pericardiocentesis in which intrapericardial "negative" pressure waves mirrored right atrial cannon waves in a patient with ventricular pacing. A 64-year-old woman was a d m i t t e d to the hospital for elective pericardiocentesis. A DDD pacemaker had been
From the CardiologyDivision,St. Louis UniversityHospital Reprint requests: Morton J. Kern, MD, Cardiac Catheterization Laboratory, St. Louis University Hospital, 3635 Vista Ave.,St. Louis, MO 63110. 4/4/18659
2
x
JM
o Fig. 1. Hemodynamic d a t a during DDD pacing before pericardiocentesis. Ao, Femoral artery pressure; RA, right atrial pressure; PERI, pericardial pressure. Scale-200/40 m m Hg for aortic, RA, and P E R I pressures, respectively.
initially implanted for complete heart block and syncope 3 months previously, A procedure including implantation of a t e m p o r a r y pacemaker at t h a t time was complicated by perforation of the right ventricle and development of echocardiographically documented pericardial effusion. The p a t i e n t was a s y m p t o m a t i c and initially was managed conservatively. However, during follow-up, because of an increasing pericardial effusion with symptoms of fatigue with echocardiographic evidence of t a m p o n a d e physiology, a pericardiocentesis was performed. A 7F balloon-tipped flotation catheter was inserted into the pulmonary artery
-- ---Brie/Communications
relative increase in both h e a r t rate and blood pressure were noted. Therefore intravenous propranolol and sublingual nitroglycerin were administered in order to reduce myocardial oxygen demand. H e a r t rate and systolic blood p r e s s u r e declined, with immediate relief of the p a t i e n t ' s angina and resolution of pulsus alternans. In conclusion, myocardial ischemia should be recognized as a potential causative factor in the development of pulsus alternans. Although negative inotropic drugs are generally contraindicated in patients with this hemodynamic finding, fl-adrenergic blockade can have a paradoxic salutary effect in the setting of acute myocardial ischemia. P r e s u m a b l y this beneficial effect is m e d i a t e d through an effect on the rate-pressure product and a reduction in myocardial oxygen demand. REFERENCES
1. Braunwald E. Heart disease. Philadelphia: W.B. Saunders Co, 1988:481. 2. Traube L. Ein fall yon pulsus bigeminus nebst bemerkungen uber die leberschwellungen bei klappenfehlern und uber acute leberatrophic. Berl Klin Wochenschr 1872;9:185. 3. Gleason WL, Braunwald E. Studies on Starling's law of the heart. Circulation 1962;25:841-8. 4. Cohn KE, Sandler H, Hancock EW. Mechanisms of pulsus alternans. Circulation 1967;36:372-80. 5. Hess OM, Surber EP, Ritter M, Krayenbuehl HP. Pulsus alternans: its influence on systolic and diastolic function in aortic valve disease. J Am Coll Cardiol 1984;4:1-7. 6. Hashimoto H, Suzuki K, Miyake S, Nakashima M. Effects of calcium antagonists on the electrical alternans of the ST segment and on associated mechanical alternans during acute coronary occlusion in dogs. Circulation 1983;68:667-72. 7. Elbaum DM, Banka VS. Pulsus alternans during spontaneous angina pectoris. Am J Cardiol 1986;58:1099-100.
Isolated bilateral coronary ostial stenosis in Takayasu's arteritis Y0shiharu Emi MD, Tetsu Yamakado MD, Yasuo F u t a g a m i MD, T a k u y a T a m a i MD, You Hasegawa MD, Takao K o y a m a MD, Masayuki H a m a d a MD, and Takeshi Nakano MD. Tsu, J a p a n
Coronary ostial stenosis is usually associated with either multivessel atherosclerotic coronary artery disease or syphilis. Nonatherosclerotic or nonsyphilitic isolated coronary ostial stenosis is a rare disease of unknown etiology, usually occurring in premenopausal women. 1 In this report, we present the case of young girl with Takayasu's arteritis in which bilateral coronary ostial stenosis was demonstrated
From The First Department of Internal Medicine, Mie University. Reprint requests: Tetsu Yamakado, MD, The First Department of Internal Medicine, Mie University, Edobashi 2-174, Tsu 514, Japan. 4/4/18629
April 1990 American Heart Journal
by angiography, and anginal pain was relieved by coronary bypass surgery. A 17-year-old girl had been well until 3 months prior to admission, when she noted chest pains on exertion t h a t increased progressively. She had no family history of premature coronary artery disease. She did not smoke and did not take contraceptive pills. On physical examination, the patient a p p e a r e d healthy and had no abnormal finding and no evidence of systemic disease. Her blood pressure was 128/ 76 m m Hg. Her peripheral arteries were easily palpable, and there was no inequality of the pulses. Laboratory studies revealed an elevated erythrocyte sedimentation rate (ESR) (54 m m in 1 hour) and C-reactive protein (CRP), suggesting acute inflammatory changes. The Venereal Disease Research L a b o r a t o r y (VDRL), Treponema pallidum hemagglutination test (TPHA), rheumatoid factor, and antinuclear factor were negative. Serum triglyceride and cholesterol levels were within the normal range. The resting electrocardiogram, chest x-ray film, and echocardiogram were all normal. On treadmill testing, she developed chest pain during mild exercise (1.7 m p h at a grade of 10 % ), associated with significant S T segment depression of 2 to 4 m m in leads II, III, aVF; and V2 to V6, together with a decrease in systolic blood pressure. On cardiac catheterization, the left ventriculogram showed a normal ejection fraction (0.66). W i t h right ventricular pacing of 150/min for 3 minutes, the left ventriculogram disclosed an area of severe anteroseptal hypokinesis. Coronary angiography after intracoronary nitroglycerin administration d e m o n s t r a t e d a 90 % left coronary ostial stenosis (Fig. 1, A) with collateral flow from the right coronary artery to the anterior descending coronary artery. A pressure drop was noted as the catheter tip entered the left coronary ostium. There was also a 75% right coronary ostial stenosis (Fig. 1, B). The remainder of the coronary arterial tree was normal. Coronary bypass surgery was carried out with an internal m a m m a r y a r t e r y graft to the anterior descending artery and a saphenous vein graft to the right coronary artery. During operation, a specimen of the ascending thoracic aorta showed fibrotic thickening of intima and inflammatory infiltration of the adventitia and vasa vasorum with lymphocytes and plasma cells (Fig. 2). Clinical and histologic findings were consistent with Takayasu's arteritis. Corticosteroid t h e r a p y (prednisone, 10 to 30 m g / d a y for 6 months) was begun, with resultant normalization of the E S R and CRP. Repeat angiography 6 months after surgery demonstrated p a t e n t grafts (Fig. 1, C and D). However, there was no regression of either the left or right coronary ostial stenosis (Fig. 1, C and D). There was no abnormal angiographic finding in the thoracic and abdominal aorta or pulmonary arteries. Although Takayasu's arteritis is rarely complicated by coronary artery disease, there are some case reports of isolated coronary ostial stenosis in Takayasu's arteritis, e4 In these patients, however, the ostial stenosis was associated with stenosis of the aortic arch or peripheral vessels. In Contrast, our p a t i e n t had a unique clinical feature in that anginal pain was associated with isolated, bilateral coronary ostial stenosis without any other significant arterial involvement.
V o l u m e 119
Brief Communications
Number 4
963
Fig. 1, Coronary angiograms and aortogram before and after coronary artery bypass grafting (CABG). Before CABG, the left coronary angiogram (A) shows significant 90% ostial stenosis (arrow). Aortogram (B) showed a 75 % stenosis of the right coronary ostium (arrow). After CABG ( a and D), both coronary bypass grafts to the left anterior descending (C, arrows) and right coronary artery (D, arrows) were patent. However, there is no angiographic regression of left (C, arrow) or right (D, arrow) coronary ostial stenosis.
Coronary ostial stenosis in T a k a y a s u ' s arteritis carries the same serious prognosis as does left main coronary artery disease. 2 In fact, most of these patients die of cardiac causes. 2-4 Therefore we elected to perform bypass surgery. Corticosteroid t h e r a p y has sometimes been recommended for the t r e a t m e n t of Takayasu's arteritis, 5 but we could not confirm any angiographic regression of the coronary ostial stenosis by long-term corticosteroid t h e r a p y despite normalizing E S R and CRP. This case suggests t h a t in patients
with anginal pain in T a k a y a s u ' s arteritis, coronary ostial stenosis should be kept in mind. Early diagnosis and surgery are essential to avoid serious cardiac complications. REFERENCES
1. Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol 1986;7:997. 2. Cipriano PR, Silverman JF, Perlroth MG, Griepp RB, Wexler L. Coronary arterial narrowing in Takayasu's aortitis. Am J Cardiol 1977;39:744.
964
April 1990 American Heart Journal
Brief Communications
Fig, 2. Histologic section of the ascending thoracic aorta obtained at cardiac surgery, showing a prominent mononuclear cell infiltrate of the adventitia and vasavasorum.
3. Chun MPKC, Jones CR, Robinowitz M, Davia CJE, Lawrence CPJ. Coronary ostial stenosis in Takayasu's aortitis. Chest 1980;78:330. 4. Morgan JM, Honey M, Gray HH, Belcher P, Paneth M. Angina pectoris in a case of Takayasu's disease: revascularization by coronary ostioplasty and bypass grafting. Eur Heart J 1987;8:1354. 5. Hayashi K, Fukushima T, Matsunaga N, Hombo Z. Takayasu's arteritis: decrease in aortic wall thickening following steroid therapy, documented by CT. Br J Radiol 1986;59:281.
200/40 mmHg - 1
x4
Intrapericardial "negative" cannon waves during atrioventricular dissociation in large pericardial effusion Chalapathirao V. Gudipati, MD, Ubeydullah Deligonul, MD, Denise Janosik, MD, Michel Vandormael, MD, and Morton J. Kern, MD.
St. Louis, 114o. l n t r a p e r i c a r d i a l pressure closely follows the changes in right atrial pressure and volume during the cardiac cycle. 13 We observed an unusual hemodynamic p a t t e r n during pericardiocentesis in which intrapericardial "negative" pressure waves mirrored right atrial cannon waves in a patient with ventricular pacing. A 64-year-old woman was a d m i t t e d to the hospital for elective pericardiocentesis. A DDD pacemaker had been
From the CardiologyDivision,St. Louis UniversityHospital Reprint requests: Morton J. Kern, MD, Cardiac Catheterization Laboratory, St. Louis University Hospital, 3635 Vista Ave.,St. Louis, MO 63110. 4/4/18659
2
x
JM
o Fig. 1. Hemodynamic d a t a during DDD pacing before pericardiocentesis. Ao, Femoral artery pressure; RA, right atrial pressure; PERI, pericardial pressure. Scale-200/40 m m Hg for aortic, RA, and P E R I pressures, respectively.
initially implanted for complete heart block and syncope 3 months previously, A procedure including implantation of a t e m p o r a r y pacemaker at t h a t time was complicated by perforation of the right ventricle and development of echocardiographically documented pericardial effusion. The p a t i e n t was a s y m p t o m a t i c and initially was managed conservatively. However, during follow-up, because of an increasing pericardial effusion with symptoms of fatigue with echocardiographic evidence of t a m p o n a d e physiology, a pericardiocentesis was performed. A 7F balloon-tipped flotation catheter was inserted into the pulmonary artery