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Occlusive coronary disease in the transplanted denervated heart: Assessment by exercise electrocardiogram and coronary arteriography
ABSTRACTS
these same factors on arrival time at the medical facility was studied. The mean arrival time for the group was 285 + 39 minutes, The mean arrival time for patients with angina was 465 f 125 minutes, for those with prodromal symptoms 381 + 83 minutes, and for those with a history of acute myocardial infarction was 259 2 73 minutes. Thus, patients with a history of angina or prodromal symptoms had a prolonged arrival time and those with a history of acute myocardial infarction did not shorten their arrival time. In this population sudden death was the overwhelming event of acute coronary mortality. The same factors that appear to predispose to sudden death also result in a prolonged arrival time, thus suggesting that although death due to acute myocardial infarction may be sudden, it does not occur without warning. The Transition from Double Outlet Right Ventricle to Complete Transposition. A Pathologic Study D. A. GOOR, MD; JESSE E. EDWARDS, York, and St. Paul, Minnesota
MD, FACC, New York,
New
Ninety-four heart specimens of complete transposition of the great vessels (TGV) and 40 of double outlet right ventricle (OBGRV) were studied. Correlations were made with embryonic developments involving the conotruncus in 54 normal human embryonic hearts. The conal septum is identically completely inverted and the great vessels are identically interrelated in TGV, OBGRV and Taussig-Bing anomaly. The conal septal inversion is probably due to lack of counterclockwise torsion of the ostium bulbi during the formation of the loop of the heart tube. The riding position of the pulmonary artery (PA) over the left ventricle (LV) differs almost from one case of OBGRV to another. In specimens with OBGRV with the PA arising only from the right ventricle (RV), leftward shift of the conoventricular flange did not occur. In those with Taussig-Bing anomaly, in which the PA mostly rides over the LV, a “normal” leftward shift of the conoventricular flange probably occurred. Intermediate positions of the PA account for the great variety of patterns of OBGRV. The absence of pulmonary conus, and the presence of pulmonary mitral fibrous continuity, is a characteristic feature of TGV. It is assumed that absorption of the pulmonary conus obliterates the conus tunnel (subpulmonic ventricular septal defect) and brings the PA to the mitral valve, thus transforming the Taussig-Bing anomaly to TGV. Photomicrographs of the conotruncal torsion and the conus absorption will be shown, and photographs of heart specimens showing the spectrum of anomalies leading from OBGRV to TGV will be demonstrated. Cardiac Effects of a Cocktail LAWRENCE A. GOULD, MD, FACC’; MOHAMMAD ROBERT F. GOMPRECHT, MD, FACC; ANTHONY MD, Bronx, New York
ZAHIR, MD; DeMARTlNO,
The hemodynamic effects of a cocktail during cardiac disease is unknown. Ten patients with cardiac disease and 4 normal subjects underwent cardiac catheterization. Hemodynamic measurements were obtained before and 30 minutes after oral ingestion of 2 ounces of Canadian Club whiskey. In the 10 abnormal subjects the average cardiac index decreased with alcohol
VOLUME
29, FEBRUARY
1972
from 3.3 to 2.7 liters/min per mz, the stroke index decreased from 41 to 33 ml/beat per mz, the arteriovenous oxygen difference increased from 4.9 to 6.2 vol %, the left ventricular end-diastolic pressure increased from 10 to 12 mm Hg, and the pulmonary arterial mean pressure and cardiac rate were unchanged. In the 4 normal subjects the average cardiac index increased with alcohol from 3.2 to 4.5 liters/min per mz, the stroke index increased from 49 to 68 ml/beat per m2, the pulse rate increased from 79 to 80 beats/min, and the arteriovenous oxygen difference decreased from 4.5 to 3.4 vol %. With alcohol all of the patients with cardiac disease demonstrated a fall in the cardiac index and stroke index. In the normal subjects, alcohol produced an increase in these indexes. The different hemodynamic response in the 2 groups was statistically significant (P
MD; DONALD
Since January 1968, 34 cardiac transplant operations have been performed at Stanford, and 14 patients are presently alive. Actuarial statistics show 45% survival at 1 year, 30% at 2 years and approximately 30% at 3 years. Since patients with denervated hearts would not be thought to experience angina pectoris as a manifestation of ischemia, routine exercise electrocardiography has been performed regularly, in an attempt to diagnose ischemic changes in all long-term survivors of transplantation. Correlation with hemodynamic studies and coronary arteriography has been performed at yearly intervals. Four patients with normal exercise studies have had completely normal coronary arteriograms and hemodynamic status at 1 year. Two other patients have had abnormal exercise electrocardiograms. One had a positive test at 28 months, with S-T segment depression and ventricular ectopic beats. Coronary arteriography showed a blocked left circumflex artery, and cardiac catheterization showed a poor exercise response. The other had a positive exercise electrocardiogram at 35 months, and this correlated with diffuse small vessel disease on the coronary arteriogram. Both patients remain asymptomatic and have never had angina. All other survivors have negative exercise studies. Long-term cardiac transplant survivors are susceptible to the development of occlusive coronary artery disease without evidence of chest pain. These changes can be reliably detected by exercise electrocardiography and confirmed by coronary arteriography. Results of Early Surgical Repair of Ventricular Septal Defects Following Myocardial Infarction ANTHONY F. GRAHAM, DONALD C. HARRISON,
MD’; NORMAN E. SHUMWAY. MD, FACC, Stanford, California
MD, FACC;
A ventricular septal defect (VSD) occurring as a complication of acute myocardial infarction has been associated with a poor prognosis if treated medically. Surgical closure of the defect, if carried out at least 6
267
these same factors on arrival time at the medical facility was studied. The mean arrival time for the group was 285 + 39 minutes, The mean arrival time for patients with angina was 465 f 125 minutes, for those with prodromal symptoms 381 + 83 minutes, and for those with a history of acute myocardial infarction was 259 2 73 minutes. Thus, patients with a history of angina or prodromal symptoms had a prolonged arrival time and those with a history of acute myocardial infarction did not shorten their arrival time. In this population sudden death was the overwhelming event of acute coronary mortality. The same factors that appear to predispose to sudden death also result in a prolonged arrival time, thus suggesting that although death due to acute myocardial infarction may be sudden, it does not occur without warning. The Transition from Double Outlet Right Ventricle to Complete Transposition. A Pathologic Study D. A. GOOR, MD; JESSE E. EDWARDS, York, and St. Paul, Minnesota
MD, FACC, New York,
New
Ninety-four heart specimens of complete transposition of the great vessels (TGV) and 40 of double outlet right ventricle (OBGRV) were studied. Correlations were made with embryonic developments involving the conotruncus in 54 normal human embryonic hearts. The conal septum is identically completely inverted and the great vessels are identically interrelated in TGV, OBGRV and Taussig-Bing anomaly. The conal septal inversion is probably due to lack of counterclockwise torsion of the ostium bulbi during the formation of the loop of the heart tube. The riding position of the pulmonary artery (PA) over the left ventricle (LV) differs almost from one case of OBGRV to another. In specimens with OBGRV with the PA arising only from the right ventricle (RV), leftward shift of the conoventricular flange did not occur. In those with Taussig-Bing anomaly, in which the PA mostly rides over the LV, a “normal” leftward shift of the conoventricular flange probably occurred. Intermediate positions of the PA account for the great variety of patterns of OBGRV. The absence of pulmonary conus, and the presence of pulmonary mitral fibrous continuity, is a characteristic feature of TGV. It is assumed that absorption of the pulmonary conus obliterates the conus tunnel (subpulmonic ventricular septal defect) and brings the PA to the mitral valve, thus transforming the Taussig-Bing anomaly to TGV. Photomicrographs of the conotruncal torsion and the conus absorption will be shown, and photographs of heart specimens showing the spectrum of anomalies leading from OBGRV to TGV will be demonstrated. Cardiac Effects of a Cocktail LAWRENCE A. GOULD, MD, FACC’; MOHAMMAD ROBERT F. GOMPRECHT, MD, FACC; ANTHONY MD, Bronx, New York
ZAHIR, MD; DeMARTlNO,
The hemodynamic effects of a cocktail during cardiac disease is unknown. Ten patients with cardiac disease and 4 normal subjects underwent cardiac catheterization. Hemodynamic measurements were obtained before and 30 minutes after oral ingestion of 2 ounces of Canadian Club whiskey. In the 10 abnormal subjects the average cardiac index decreased with alcohol
VOLUME
29, FEBRUARY
1972
from 3.3 to 2.7 liters/min per mz, the stroke index decreased from 41 to 33 ml/beat per mz, the arteriovenous oxygen difference increased from 4.9 to 6.2 vol %, the left ventricular end-diastolic pressure increased from 10 to 12 mm Hg, and the pulmonary arterial mean pressure and cardiac rate were unchanged. In the 4 normal subjects the average cardiac index increased with alcohol from 3.2 to 4.5 liters/min per mz, the stroke index increased from 49 to 68 ml/beat per m2, the pulse rate increased from 79 to 80 beats/min, and the arteriovenous oxygen difference decreased from 4.5 to 3.4 vol %. With alcohol all of the patients with cardiac disease demonstrated a fall in the cardiac index and stroke index. In the normal subjects, alcohol produced an increase in these indexes. The different hemodynamic response in the 2 groups was statistically significant (P
MD; DONALD
Since January 1968, 34 cardiac transplant operations have been performed at Stanford, and 14 patients are presently alive. Actuarial statistics show 45% survival at 1 year, 30% at 2 years and approximately 30% at 3 years. Since patients with denervated hearts would not be thought to experience angina pectoris as a manifestation of ischemia, routine exercise electrocardiography has been performed regularly, in an attempt to diagnose ischemic changes in all long-term survivors of transplantation. Correlation with hemodynamic studies and coronary arteriography has been performed at yearly intervals. Four patients with normal exercise studies have had completely normal coronary arteriograms and hemodynamic status at 1 year. Two other patients have had abnormal exercise electrocardiograms. One had a positive test at 28 months, with S-T segment depression and ventricular ectopic beats. Coronary arteriography showed a blocked left circumflex artery, and cardiac catheterization showed a poor exercise response. The other had a positive exercise electrocardiogram at 35 months, and this correlated with diffuse small vessel disease on the coronary arteriogram. Both patients remain asymptomatic and have never had angina. All other survivors have negative exercise studies. Long-term cardiac transplant survivors are susceptible to the development of occlusive coronary artery disease without evidence of chest pain. These changes can be reliably detected by exercise electrocardiography and confirmed by coronary arteriography. Results of Early Surgical Repair of Ventricular Septal Defects Following Myocardial Infarction ANTHONY F. GRAHAM, DONALD C. HARRISON,
MD’; NORMAN E. SHUMWAY. MD, FACC, Stanford, California
MD, FACC;
A ventricular septal defect (VSD) occurring as a complication of acute myocardial infarction has been associated with a poor prognosis if treated medically. Surgical closure of the defect, if carried out at least 6
267