Rutherford, Barry D.

The use of roentgen videometry as a means of studying regional left ventricular wall dynamics and performance was evaluated in 32 patients undergoing coronary arteriography. Nine patients had normal coronary arteriograms and hemodynamic findings (group 1), 8 patients had generalized decrease in left ventricular contraction and abnormal hemodynamic findings (group 2), and 15 patients with coronary artery disease had regional wall dynamics abnormalities (group 3). Sixty-per-second determinations of wall thickness were performed in selected sites of the left ventricle. Measurements performed included end-diastolic wall thickness (EDTw), mean and peak rates of systolic wall thickening (m and p dTw/dt), and fractional systolic increase in wall thickness (ΔTw/EDTw). In patients with uniformly performing ventricles (groups 1 and 2), these parameters correlated well with other parameters of ventricular function. Best distinction between the "normal" group (group 1) and the "abnormal" group (group 2) was achieved when the rates of thickening (m and p dTw/dt) were utilized ( P < 0.001). In patients of group 3, three types of abnormal regional wall dynamics could be determined and quantified objectively: hypokinesia (decreased p dTw/dt), akinesia (p dTw/dt = 0), and dyskinesia (p dTw/dt < 0). The severity of the abnormality of the wall dynamics correlated well with the presence or absence of a previous infarction on the electrocardiogram, and the anatomic location was strongly correlated with the distribution and severity of coronary artery lesions within a given ventricle.

Fifty patients underwent correction of one or two valvular lesions with concomitant insertion of one to three aortocoronary vein bypass grafts. Hospital mortality was 14% and late mortality was 10%. Factors influencing operative mortality were: (1) mitral valve replacement after myocardial infarction; (2) complete obstruction of a coronary artery preoperatively; (3) high left ventricular end-diastolic pressure at rest preoperatively in patients with mitral valve disease; and (4) use of a single aortocoronary graft in the presence of multiple-vessel disease. For patients with significant associated valvular and coronary artery disease, combined correction yields results that appear sufficiently encouraging, judged by mortality and follow-up, to warrant its continued use in selected cases.

The effect of oral aspirin in doses known to influence in vitro platelet aggregation was evaluated in patients undergoing brachial artery catheterization. Neither arterial thrombus formation nor pulse reduction was affected in patients given aspirin when compared to controls. Aspirin in small doses does not decrease the incidence of vascular occlusion after brachial artery catheterization.

Flow-directed catheters recorded serial changes in mean pulmonary artery pressure (PA) every 4 to 6 hours in 25 patients during the first 4 or 5 days following acute myocardial infarction. On the basis of the PA on admission, patients were divided into three groups. Patients in group 1 had normal PA (10-20 mm Hg) and maintained a stroke volume index (SVI)>35 ml/min/m 2 , a pulmonary artery oxygen saturation (MVSO 2 )>70%, and a normal cardiac index, arterial oxygen saturation, p H, and P CO CO2 . They developed only minor arrhythmias, no heart failure, and none died. Group 3 consisted of one patient with abnormally low PA (<10 mm Hg) who was hypovolemic. Group 2, those patients with elevated PA (>20 mm Hg) who maintained this elevation over the first 48 hours of monitoring, or showed progressive elevation prior to this, had SVI<35 ml/min/m 2 , MVSO 2 <70%, cardiac index<3 liters/min/m 2 , arterial desaturation, and respiratory alkalosis. They demonstrated clinical evidence of heart failure, had major arrhythmias, and 25% died. Three patients with elevated PA on admission spontaneously returned this pressure to normal over the first 48 hours of monitoring. Each of these patients maintained normal hemodynamics and had a good prognosis. PA was always elevated prior to the usual clinical signs of left ventricular failure. We conclude that PA provides a reliable early objective measure of left ventricular failure and is, therefore, an excellent guide to therapy.