To assess visual interpretation of the coronary arteriogram as a means of predicting the physiologic effects of coronary obstructions in human beings, we compared caliper measurements of the degree of coronary stenosis with the reactive hyperemic response of coronary flow velocity studied with a Doppler technique at operation, after 20 seconds of coronary arterial occlusion. In 39 patients (44 vessels) with isolated, discrete coronary lesions varying in severity from 10 to 95 per cent stenosis, measurement of the percentage of stenosis from coronary angiograms was not significantly correlated (r = -0.25) with the reactive hyperemic response. Results were the same for obstructions in the left anterior descending, diagonal, and right coronary arteries. Underestimation of lesion severity occurred in 95 per cent of vessels with >60 per cent stenosis of the diameter by arteriography. Both overestimation and underestimation of lesions with <60 per cent stenosis were common. These results, together with...

Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis

Procedure Appropriateness Category Relative Radiation Level Radiography area of interest Usually Appropriate Varies CT area of interest with IV contrast Usually Not Appropriate Varies CT area of interest without and with IV contrast Usually Not Appropriate Varies CT area of interest without IV contrast Usually Not Appropriate Varies FDG-PET/CT whole body Usually Not Appropriate ☢☢☢☢ MRI area of interest without and with IV contrast Usually Not Appropriate O MRI area of interest without IV contrast Usually Not Appropriate O Bone scan whole body Usually Not Appropriate ☢☢☢ US area of interest Usually Not Appropriate O

The American College of Radiology. ACR Appropriateness Criteria project.

Myocardial 'stunning' in man.

We have shown improvement in collateral filling immediately after sudden controlled coronary occlusion in human subjects undergoing elective coronary angioplasty. It has been suggested but not proved that collateral circulation can limit myocardial ischemia. We prospectively studied 23 patients with isolated left anterior descending (n = 14) or right coronary (n = 9) disease and normal left ventriculograms during elective coronary angioplasty. A second arterial catheter was used for injection of the contralateral artery to assess collateral filling before balloon placement and during coronary occlusion by balloon inflation. Left ventriculography was performed during another inflation. Grading of collateral filling was as follows: 0 = none, 1 = filling of side branches only, 2 = partial filling of the epicardial segment, 3 = complete filling of the epicardial segment. Indexes of myocardial ischemia included percent of the left ventricular perimeter showing new hypocontractility and the sum of ST segment elevation measured on a simultaneous 12-lead electrocardiogram recorded during each inflation. Collateral filling during balloon occlusion and indexes of ischemia were assessed at 30 to 40 sec into inflation. Aortic pressure and heart rate did not correlate with the percent hypocontractile perimeter nor the sum of ST segment elevation. There was a significant correlation between the grade of collateral filling during inflation and both percent hypocontractile perimeter (r = -.85) and the sum of ST segment elevation (r = -.87). Anginal pain occurred in all patients with grade 0 or 1 collateral filling but in only 36% of patients with grade 2 or 3 collaterals. In conclusion, collateral circulation limits myocardial ischemia as assessed by the extent of new ventricular asynergy and electrocardiographic changes during coronary occlusion in patients.

Limitation of myocardial ischemia by collateral circulation during sudden controlled coronary artery occlusion in human subjects: a prospective study.

After an introduction dealing with the "historical evolution" of the Noonan syndrome (NS), we try to define the NS phenotype based on clinical descriptions published since 1883. The theories concerning the cause of the NS are discussed fully. The peculiar cardiac involvement deserves special attention and raises the question of whether the Watson and LEOPARD syndromes are indistinguishable from NS. Finally, the recent contributions to the variability of the NS phenotype (reports on lymphatic dysplasia, partial deficiency of factor XI, malignant hyperthermia, perceptual-motor disabilities, and endocrine evaluation) are also described.

Noonan syndrome: a review.

Acute massive gastrointestinal hemorrhage can be intermittent from minute to minute. This phenomenon is documented by arteriography in three patients. Failure to demonstrate active bleeding by angiography therefore may not prove cessation of bleeding or indicate an inadequate examination.

Intermittent bleeding from minute to minute in acute massive gastrointestinal hemorrhage: arteriographic demonstration.

Two cases of pulmonary lymphangiectasia associated with Noonan's syndrome are described. Chest films showed diffuse pulmonary intersitial infiltrates from infancy. Lymphangiograms demonstrated obstructive changes and collateral formation in the retroperitoneal, mediastinal, pulmonary, and cervical lymphatics and extensive opacification of the pulmonary and visceral pleural lymphatics. Possible mechanisms and causes of the lymphatic malformation are discussed.

Pulmonary lymphangiectasia demonstrated by lymphangiography in 2 patients with Noonan's syndrome.

The effects of obstructing coronary artery lesions upon regional left ventricular contractility were studied angiographically in 200 patients with significant coronary artery disease. The arteries were graded according to degree of obstruction and adequacy of distal runoff flow beyond the lesion. The corresponding regional myocardial contractility was evaluated by ventriculography.Left ventricular contractility was found to be determined not primarily by the degree of arterial obstruction but rather by the adequacy of runoff flow in the distal segment of the diseased vessel. In cases of complete occlusion, the adequacy of distal runoff flow is determined directly by the degree of development of collateral circulation. Normal or mildly impaired contractility was present in most instances where distal runoff was adequate; regional akinesia or dyskinesia occurred in most instances where distal runoff was inadequate.Collateral circulation and distal coronary runoff are thus felt to be the key factors in prese...

Coronary collateral circulation and distal coronary runoff: the key factors in pre-serving myocardial contractility in patients with coronary artery disease.

Ventricles of 21 patients with coronary artery disease examined by coronary angiography and left ventriculography were studied histologically. The amount of fibrosis was compared to the decrease in function indicated by ventriculography, elevation of left ventricular end diastolic pressure (LVEDP), and reduction of ejection fraction. In 51% of ventricular segments dysfunction paralleled the presence or absence of fibrosis. In 42%, dysfunction, more severe than the fibrosis, was due to ischemia or coronary steal. Patchy fibrosis in 7% did not significantly decrease function. Severe decrease in ejection fraction and elevation of LVEDP may be due to ischemia not fibrosis.

Impaired Left Ventricular Contractility in Ischemic Heart Disease: Angiographic and Histopathologic Correlations

Two new lordotic oblique projections of the left coronary artery are described.When the LAO view of the left coronary artery is obtained with the horizontal beam angled 45° cephalad, the main left coronary artery, the proximal left anterior descending coronary artery, and the diagonal branches may be optimally seen.When the angulated horizontal beam is used to obtain the RAO view of the left coronary artery, the proximal LAD is seen with the diagonal branches projected away from it.The roentgenographic technique of the lordotic views is discussed. Coronary arteriograms are presented to demonstrate the usefulness of these new views.

/pdf/new-lordotic-projection-for-improved-visualization-of-the-50wwoiql74.pdf

New lordotic projection for improved visualization of the left coronary artery and its branches.

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