Physiologic assessment of the coronary collateral circulation in transplanted human hearts.
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Coronary arteries
Collateral circulation
Coronary occlusion
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Until recently, the measurement in man of left ventricular geometry and hemodynamics and the assessment of alteration in myocardial metabolism early after an abrupt occlusion of a major coronary artery were not feasible. Percutaneous transluminal coronary angioplasty (PTCA), however, now provides a unique opportunity to study the time course of these variables during the transient interruption of coronary flow in the balloon occlusion sequence in patients with single-vessel disease and without angiographically demonstrable collateral circulation [1, 2].
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The unique observations of contralateral and ipsilateral coronary artery collateral supply before and after angioplasty suggest highly responsive conduits to hemodynamic conditions. The study of collateral supply system is not only significant for our current understanding of the dynamic behavior of the collateral circulation, but may also have important clinical implications for the treatment of patients with a chronic coronary occlusion.
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We explored the role of microcirculation integrity following the chronic occlusion of an infarct-related artery to assess the behaviour of collateral circulation during and after reperfusion by coronary angioplastyEighteen patients with a proximally occluded left anterior descending artery and firm evidence of intercoronary collateral circulation were studied with selective coronary angiography and selective intracoronary myocardial contrast echocardiography, before coronary angioplasty, and at 5 and 15 min and 12 h later. Myocardial enhancement during myocardial contrast echocardiography was evaluated with a semiquantitative score (0-3), which was correlated to basal and 6 months' regional left ventricular wall motion results. 16/18 procedures were successfully performed; four patients with an inadequate acoustic window were excluded. Restenosis was evident at the 6 months' follow-up in two patients. Basal myocardial contrast echocardiography indicated that 81/192 segments from the left anterior descending coronary artery and 90/192 from the right coronary artery were perfused; no perfusion was observed in 21 segments either before or after coronary angioplasty. After coronary angioplasty, the angiographic intercoronary collateral circulation immediately disappeared, and myocardial contrast echocardiography revealed that there was a progressive reduction of segments perfused by the right coronary artery and an increase in segments perfused by the left anterior descending coronary artery. Regional left ventricular wall motion analysis demonstrated that there was abnormal motion in 51/192 segments. There was no improvement in segments with score 0 and abnormal motion after 6 months (100% sensitivity), but 16/17 segments with score 3 did show an improvement (98% specificity). The predictive value of intermediate scores (1-2) in detecting long-term improvement, was only 43%.These data show that the adaptive mechanism observed in the behaviour of epicardial and microvascular circulation after reperfusion of a chronic occluded infarct-related artery can vary. In addition, this study clearly shows that microvascular integrity detected by myocardial contrast echocardiography can provide myocardial viability.
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The results of 126 consecutive balloon dilatations of coronary arteries, carried out in 110 patients between 1980 and the end of 1983, are reported. The follow-up periods ranged from one to 47 months. The primary success rate was 74%, and the long-term success rate was 65%. In successful cases, the diameter of stenosis was changed, on average, from an initial 88% to 33%. Acute occlusion of the vessel occurred on 13 occasions (10%). Of these, myocardial infarction occurred in eight (6%), and emergency bypass grafts were performed in nine (7%). One of these 13 patients died (case fatality rate, 0.8%). Occlusion of the dilated vessels did not occur after the patients were discharged from hospital. However, stenosis recurred in 20 of 80 patients with successfully dilated arteries (25%). Dilatation was repeated in 16 of these, and stenosis had not recurred at the three-months’ follow-up. There has been a marked improvement in the success rate of this procedure over the years. It is concluded that balloon dilatation is an effective and safe alternative to bypass graft surgery in selected patients with coronary artery disease.
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