Internal Mammary to Pulmonary Artery Fistula Presenting as Early Recurrent Angina after Coronary Bypass

A 50-year-old man developed recurrent angina 1 year after coronary artery bypass surgery. The patient was found to have a large fistula involving branches of the internal mammary artery graft and the left pulmonary artery. In the absence of another clear cause for the patient's symptoms, we speculated that our patient's angina and abnormal stress nuclear study were due to coronary steal. In patients with a history of coronary bypass grafting, fistula formation between graft and native vessels should be considered as a possible cause of early recurrent angina.

Myocardial Bridges and their Relationship to the Anterior Interventricular Branch of the Left Coronary Artery

OBJECTIVE: To analyze the relationship between myocardial bridges and the anterior interventricular branch (anterior descending) of the left coronary artery. METHODS: The study was carried out with postmortem material, and methods of dissection and observation were used. We assessed the perimeter of the anterior interventricular branch of the left coronary artery using a pachymeter, calculated its proximal and distal diameters in relation to the myocardial bridge, and also its diameter under the myocardial bridge in 30 hearts. We also observed the position of the myocardial bridge in relation to the origin of the anterior interventricular branch. RESULTS: The diameters of the anterior interventricular branch were as follows: the mean proximal diameter was 2.76±0.76 mm; the mean diameter under the myocardial bridge was 2.08±0.54 mm; and the mean distal diameter was 1.98±0.59 mm. In 33.33% (10/30) of the cases, the diameter of the anterior interventricular branch under the myocardial bridge was lower than the diameter of the anterior interventricular branch distal to the myocardial bridge. In 3.33% (1/30) of the cases, an atherosclerotic plaque was found in the segment under the myocardial bridge. The myocardial bridge was located in the middle third of the anterior interventricular branch in 86.66% (26/30) of the cases. CONCLUSION: Myocardial bridges are more frequently found in the middle third of the anterior interventricular branch of the left coronary artery. The diameter of the anterior interventricular branch of the left coronary artery under the myocardial bridge may be smaller than after the bridge. Myocardial bridges may not provide protection against the formation of atherosclerotic plaque inside the anterior interventricular branch of the left coronary artery.

Detection of Altered Risk Factors in Hospitalized Patients with Coronary Artery Disease

OBJECTIVE: To assess biochemical, anthropometric, and dietary variables considered risk factors for coronary artery disease. METHODS: Using anthropometrics, dietary allowance, and blood biochemistry, we assessed 84 patients [54 males (mean age of 55± 8 years) and 30 females (mean age of 57±7 years)], who had severe ( > or = 70% coronary artery obstruction) and nonsevere forms of coronary artery disease determined by cardiac catheterization. The severe form of the disease prevailed in 70% of the males and 64% of the females, and a high frequency of familial antecedents (92% ' 88%) and history of acute myocardial infarction (80% ' 70%) were observed. Smoking predominated among males (65%) and diabetes mellitus among females (43%). RESULTS: Males and females had body mass index and body fat above the normal values. Females with nonsevere lesions had HDL > 35 mg/dL, and this constituted a discriminating intergroup indicator. Regardless of the severity of the disease, hyperglycemia and hypertriglyceridemia were found among females, and cholesterolemia > 200 mg/dL in both sexes, but only males had LDL fraction > 160 mg/dL and homocysteine > 11.7 mmol/L. The male dietary allowance was inadequate in nutrients for homocysteine metabolism and in nutrients with an antioxidant action, such as the vitamins B6, C, and folate. Individuals of both sexes had a higher lipid and cholesterol intake and an inadequate consumption of fiber. The diet was classified as high-protein, high-fat, and low-carbohydrate. CONCLUSION: The alterations found had no association with the severity of lesions, indicating the need for more effective nutritional intervention.

Anomalous origin of the left pulmonary artery from the ascending aorta: successful surgical correction in an infant with fallot's tetralogy

We describe the case of a 40-day-old female patient with a history of breathlessness since birth who was referred to our hospital for surgical correction of common arterial trunk. The invasive investigation disclosed a Fallot¢s tetralogy anatomy associated with an anomalous origin of the left pulmonary artery from the ascending aorta. Immediately after diagnosis, the patient underwent a successful total surgical correction of the defect, including simultaneous anastomosis of the left pulmonary artery to the pulmonary trunk.

Can patients with left main coronary artery disease wait for myocardial revascularization surgery?

OBJECTIVE: To assess the occurrence of cardiac events in patients diagnosed with left main coronary artery disease on diagnostic cardiac catheterization and waiting for myocardial revascularization surgery. METHODS: All patients diagnosed with left main coronary artery disease (stenosis > or = 50%) consecutively identified on diagnostic cardiac catheterization during an 8-month period were selected for the study. The group comprised 56 patients (40 males and 16 females) with a mean age of 61±10 years. The cardiac events included death, nonfatal acute myocardial infarction, acute left ventricular failure, unstable angina, and emergency surgery. RESULTS: While waiting for surgery, patients experienced the following cardiac events: 7 acute myocardial infarctions and 1 death. All events occurred within the first 60 days after the diagnostic cardiac catheterization. More patients, whose indication for diagnostic cardiac catheterization was unstable angina, experienced events as compared with those with other indications [p=0.03, relative risk (RR) = 5.25, 95% confidence interval = 1.47 - 18.7]. In the multivariate analysis of logistic regression, unstable angina was also the only factor that independently contributed to a greater number of events (p = 0.02, OR = 8.43, 95% CI =1.37 - 51.7). CONCLUSION: Unstable angina in patients with left main coronary artery disease acts as a high risk factor for cardiac events, emergency surgery being recommended in these cases.

Risk factors, biochemical markers, and genetic polymorphisms in early coronary artery disease

OBJECTIVE: To assess the risk factors, lipid and apolipoprotein profile, hemostasis variables, and polymorphisms of the apolipoprotein AI-CIII gene in early coronary artery disease (CAD). METHODS: Case-control study with 112 patients in each group controlled by sex and age. After clinical evaluation and nutritional instruction, blood samples were collected for biochemical assays and genetic study. RESULTS: Familial history of early CAD (64 vs 39%), arterial hypertension (69 vs 36%), diabetes mellitus (25 vs 3%), and previous smoking (71 vs 46%) were more prevalent in the case group (p<0.001). Hypertension and diabetes were independent risk factors. Early CAD was characterized by higher serum levels of total cholesterol (235 ± 6 vs 209 ± 4 mg/dL), of LDL-c (154 ± 5 vs 135 ± 4 mg/dL), triglycerides (205 ± 12 vs 143 ± 9 mg/dL), and apolipoprotein B (129 ± 3 vs 105 ± 3 mg/dL), and lower serum levels of HDL-c (40 ± 1 vs 46 ± 1 mg/dL) and apolipoprotein AI (134 ± 2 vs 146 ± 2mg/dL) [p<0.01], in addition to an elevation in fibrinogen and D-dimer (p<0.02). The simultaneous presence of the rare alleles of the APO AI-CIII genes in early CAD are associated with hypertriglyceridemia (p=0.03). CONCLUSION: Of the classical risk factors, hypertension and diabetes mellitus were independently associated with early CAD. In addition to an unfavorable lipid profile, an increase in the thrombotic risk was identified in this population. An additive effect of the APO AI-CIII genes was observed in triglyceride levels.

Effect of arginine vasopressin on the canine epicardial coronary artery: experiments on V1-receptor-mediated production of nitric oxide

OBJECTIVE: To determine whether arginine vasopressin releases endothelium-derived nitric oxide (EDNO) from the epicardial coronary artery. METHODS: We studied segments of canine left circumflex coronary arteries suspended in organ chambers to measure isometric force. The coronary artery segments were contracted with prostaglandin F2alpha (2 x 10-6M) and exposed to a unique, strong arginine vasopressin concentration (10-6M) or titrated concentrations (10-9 a 10-5 M). RESULTS: The unique dose of arginine vasopressin concentration (10-6M) induced transient, but significant (p<0.05), relaxation in arterial segments with endothelium, and an increase, not significant, in tension in arteries without endothelium. Endothelium-dependent relaxation to arginine vasopressin was inhibited by Ng-monomethyl-L-arginine (L-NMMA, 10-5M) or N G-nitro-L-arginine (L-NOARG) (10-4M), 2 inhibitors of nitric oxide synthesis from L-arginine. Exogenous L-arginine (10-4M), but not D-arginine (10-4M), reversed the inhibitory effect of L-NMMA on vasopressin-mediated vasorelaxation. Endothelium dependent relaxation to vasopressin was also reversibly inhibited by the vasopressin V1-receptor blocker d(CH2)5Try(Me) arginine vasopressin (10-6M) (n=6, P<0.05). CONCLUSION: Vasopressin acts through V1 endothelial receptors to stimulate nitric oxide release from L-arginine.

Dual anterior descending coronary artery associated with coronary artery disease

The patient is a male with risk factors for coronary artery disease, who was referred for cardiac catheterization after acute myocardial infarction in the inferior wall. The patient underwent transluminal coronary angioplasty in the right coronary artery with successful stent implantation.

Distribution of risk factors in parents and siblings of patients with early coronary artery disease

OBJECTIVE: Early coronary artery disease (CAD) is associated with risk factors (RF). Offspring of parents with a RF have a greater prevalence of them. However, the distribution of RF in parents and siblings of patients with early CAD is unknown. METHODS: The study comprised the parents and siblings of 42 patients with early CAD (< 45 years), 29 males. Their mean age was 39.5±3.7 years. The following major RF were analyzed: smoking (> 5 cigarretes/day), hypercholesterolemia (total cholesterol > 200 mg/dL), hypertension (diastolic blood pressure > 90 mmHg), and diabetes (glycemia > 126 mg/dL). RESULTS: Of a total of 102 RF, 4, 3, 2, and 1 were observed in, respectively, 5, 15, 15, and 7 patients with early CAD, the most prevalent being smoking (86%) and hypercholesterolemia (83%). Diabetes was observed in 15 (36%) and hypertension in 16 (38%) patients. Smoking was more prevalent in the fathers (76%) and hypercholesterolemia in the mothers (30%). In 183 siblings, 131 RF were observed (1 patient with the disease had a mean of 4.7 siblings). The prevalences of smoking, hypertension, hypercholesterolemia, and diabetes in the siblings were, respectively, 32%, 18%, 14%, and 9%. The incidence of RF was as follows: 72 (39%) siblings had 1 RF, 25 (14%) siblings had 2 RF, and 3 (2%) siblings had 3 RF. In parents and their offspring, smoking was moderately correlated (r=0.43; P=0.02) with CAD. CONCLUSION: Smoking habit of parents is passed on to offspring, and, in association with hypercholesterolemia, it was the major cause of early CAD in offspring. High prevalence of smoking in offspring shows the potential responsibility of parents in the incidence of the disease in offspring.

Cellular cholesterol efflux mediated by HDL isolated from subjects with low HDL levels and coronary artery disease

OBJECTIVE: The aim of this study was to verify whether HDL particles isolated from patients with coronary artery disease (CAD) and low HDL-C had diminished ability to promote cholesterol efflux from cultured cells compared with HDL isolated from subjects without CAD and with normal HDL-C. METHODS: Smooth muscle cells isolated from human aortas cultured and radiolabeled with ³H-cholesterol were loaded with cholesterol and incubated with increasing concentrations of HDL isolated from 13 CAD patients with low HDL-C (CAD group) or from 5 controls without CAD (C group). Efflux of cellular cholesterol was measured by cellular depletion of radiolabeled cholesterol and by the appearance of ³H-cholesterol into experimental medium expressed as a percentage of total labeled cholesterol. RESULTS: Cholesterol efflux increased with the amount of HDL present in the medium, and no difference was found between groups at various HDL protein concentrations: efflux was 28 ± 6.3% (C) and 25.5 ± 8.9% (CAD) with 25 mg/mL; 34 ± 4.3% (C) and 31.9 ± 6.6% (CD) with 50 mg/mL and 39.5 ± 3.5% (C) and 37.1 ± 4.4% (CAD) with 100 mg/mL, HDL. CONCLUSION: Because the HDL fraction of CAD patients with low HDL-C have normal ability to extract cholesterol from cells of the vessel wall, it is suggested that low HDL-C atherogenicity should be ascribed to diminished concentrations of HDL particles rather than to the qualitative properties of the HDL fraction.

Comparative study of the use of diltiazem as an antispasmodic drug in coronary angiography via the transradial approach

OBJECTIVE: To evaluate the impact of the use, prior to the procedure, of injectable diltiazem to prevent complications. METHODS: Between September 2000 and July 2001, 50 patients underwent transradial coronary angiography and were randomized to receive placebo (GI) or diltiazem (GII) through a catheter inserted into the radial artery. All patients received isosorbide mononitrate. Ultrasound analyses of the radial artery were performed before examination, 30 minutes afterwards, and 7 days afterwards to evaluate the flow, the diameter, and the artery output. RESULTS: The radial artery diameter of GI was 2.4± 0.5 mm before the procedure and 2.3±0.5 mm after 30 minutes (NS), whereas in GII the diameter was 2.2±0.3 mm before the examination and 2.5±0.4 mm 30 minutes after it (P<0.001). Radial artery output in group 1 was 7.3±5.l2 mL/min before the examination and 6.1±3.5 mL/min 30 minutes after the examination (NS), and GII had an increase of 5.9±2.5 mL/min before examination to 9.05± 7.78 mL/min after the examination (P=0.04). Complications (spasm, occlusion, and partial obstruction) occurred in 4 patients (17.4%) in GI and did not occur in GII (P=0.04). CONCLUSION: The study suggests a decrease in vascular complications through the transradial access for coronary angiography with the use of diltiazem as an antispasmodic drug, resulting in the significant increase in the diameter of the radial artery and radial artery output.

Impact of cerebral cardiopulmonary resuscitation maneuvers in a general hospital: prognostic factors and outcomes

OBJECTIVE: To assess survival of patients undergoing cerebral cardiopulmonary resuscitation maneuvers and to identify prognostic factors for short-term survival. METHODS: Prospective study with patients undergoing cardiopulmonary resuscitation maneuvers. RESULTS: The study included 150 patients. Spontaneous circulation was re-established in 88 (58%) patients, and 42 (28%) were discharged from the hospital. The necessary number of patients treated to save 1 life in 12 months was 3.4. The presence of ventricular fibrillation or tachycardia (VF/VT) as the initial rhythm, shorter times of cardiopulmonary resuscitation maneuvers and cardiopulmonary arrest, and greater values of mean blood pressure (BP) prior to cardiopulmonary arrest were independent variables for re-establishment of spontaneous circulation and hospital discharge. The odds ratios for hospital discharge were as follows: 6.1 (95% confidence interval [CI] = 2.7-13.6), when the initial rhythm was VF/VT; 9.4 (95% CI = 4.1-21.3), when the time of cerebral cardiopulmonary resuscitation was < 15 min; 9.2 (95% CI = 3.9-21.3), when the time of cardiopulmonary arrest was < 20 min; and 5.7 (95% CI = 2.4-13.7), when BP was > 70 mmHg. CONCLUSION: The presence of VF/VT as the initial rhythm, shorter times of cerebral cardiopulmonary resuscitation and of cardiopulmonary arrest, and a greater value of BP prior to cardiopulmonary arrest were independent variables of better prognosis.

Anomalous origin of the left coronary artery from the pulmonary trunk in a 45-year-old woman

We report a rare case of anomalous origin of the left coronary artery from the pulmonary trunk in a 45-year-old woman. The approach and technique used for selective catheterization of an anomalous left coronary artery arising from the pulmonary trunk are described. Six years after diagnosis, echocardiography showed left ventricular disfunction, and surgical treatment was indicated again. The origin of the left coronary artery from the pulmonary trunk was closed, and the postoperative period was uneventful, with recovery of left ventricular function and disappearance of ischemic features on stress myocardial perfusion imaging with 99m Tc-sestamibi, performed 4 weeks after surgery.