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Cardiovascular disease is the major cause of death among patients with end stage renal disease and accounts for about half the deaths among the dialysis population. Several researchers have reported a high prevalence of coronary artery disease among diabetic patients with renal failure and coronary arteriography is often considered an integral part of the pre-transplant evaluation of diabetic patients with end stage renal disease. However, very few reports have addressed the question of coronary disease in non-diabetic patients, and the pattern and prevalence of coronary artery disease in non-diabetic patients with end stage renal disease are not well defined. We evaluated the clinical and coronary angiographic findings in 158 consecutive patients (84 diabetic and 74 non-diabetic) with end stage renal disease. The coronary arteries were divided into 16 segments and each segment was analyzed for the presence of coronary disease, which was defined as the presence of > or = 50% luminal diameter stenosis. Diabetic patients had more adverse risk factors for coronary artery disease, yet there was no significant difference in the prevalence of coronary artery disease between the diabetic and non-diabetic patients (67% vs. 55%, p = 0.15), or in the number of affected coronary artery segments (2.0 vs. 1.4, p = 0.05). Triple vessel coronary artery disease was however, significantly more common among the diabetic subjects (27% vs. 12%, p = 0.005). Non-diabetic patients with end stage renal disease also have a high prevalence of coronary artery disease and may merit as careful investigation of their coronary status as their diabetic counterparts.

Background: Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity., Hypothesis: The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock., Methods: We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock., Results: Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management., Conclusions: Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.

Background: Transmyocardial laser revascularization (TMLR) is advocated to offer relief of incapacitating angina for patients whose coronary vessels are poor targets for coronary artery bypass graft surgery (CABG) or balloon angioplasty and stenting. In spite of significant mortality and morbidity, the preliminary reports from centers performing the procedure were quite enthusiastic for a period of about 1 year following the procedure., Hypothesis: The study aimed to determine mortality, morbidity, and long-term results of TMLR., Methods: The study included 19 individuals with incapacitating angina not suitable for CABG or percutaneous balloon angioplasty. Patients were followed up clinically for death, myocardial infarction, heart failure, arrhythmia, and repeated hospital admissions for unstable angina or other conditions. Stress testing with radionuclide tracers was done following surgery in patients who were not unstable., Results: Of 19 patients, 8 experienced significant morbidity. There was one hospital death. Four died within 17 months. Relief from angina of two classes or more was present in 15 of 18 patients (83.3%) for a variable time period. Mean time for anginal relief was 8.0 months (range 1-30 months). At last follow-up, only two patients with a hybrid procedure (both CABG and TMLR in the same sitting) had mild angina for 17 and 29 months, respectively. All others with a mean follow-up period of 21.2 months (range 6-53 months) developed unstable angina or had a large area of ischemia on stress radionuclide studies. Despite a high incidence of significant angina in patients after TMLR, hospitalization was reduced from an average of 42.6 days pre procedure in the year before to 21 days during the follow-up period post procedure., Conclusion: Transmyocardial laser revascularization is associated with significant relief of angina pectoris in the majority of patients with severe diffuse coronary artery disease; however, this relief is short-lived in most. When mortality and morbidity are factored in, TMLR cannot be enthusiastically recommended.

Background: To lower costs, many centers around the world utilize previously used, resterilized balloon catheters to perform coronary angioplasty There are no controlled trials regarding their safety and efficacy., Methods and Results: We performed the first randomized, double-blind, controlled, single-center clinical trial comparing the safety (clinical success) and efficacy (angiographic success) of reused versus new coronary angioplasty balloon catheters. A total of 377 procedures were included, 178 in the reused catheter arm and 199 in the new catheter arm. There were no significant differences in clinical or lesion characteristics among the two arms. The incidence of first balloon failure in the reused catheter arm was similar to that of the new catheter arm (12 cases [7%] v. 10 cases [5%], respectively). The angiographic success rate was also similar-176 cases (98.9%) in the reused catheter arm and 196 cases (98.5%) in the new catheter arm. The number of balloon catheters used per lesion, amount of contrast, and procedural and fluoroscopy time were similar in the two arms. At 30 days, the incidence of major adverse cardiac events was similar in both arms, 8 cases (4.5%) in the reused catheter arm and 10 cases (5%) in the new catheter arm. The incidence of fever was also similar., Conclusions: When performing coronary angioplasty, reused catheters are as effective (similar angiographic success) and safe (similar clinical success) as new catheters.

Sixty patients less than 35 years with a first Q wave acute myocardial infarction were prospectively studied to evaluate their features, risk factors and evidence of any viral infection. Typical chest pain was present in 98.3% with Q waves and ST segment elevation in all. None had hypotension or cardiogenic shock. Smoking was the most common risk factor (81.7%). Mean total cholesterol was 5.74 (+/-1.42) mmol/l. History of a viral illness was present in 28.3%, severe emotional stress in 21.7% and exhausting physical activity in 18.3%. Mean left ventricular diastolic and end systolic volumes were increased (90.11+/-22.5 ml/m2) and (46.62+/-20.46 ml/m2), respectively. The ejection fraction was depressed (49.71+/-1.6%). Triple vessel disease was seen only in 6.8 and 26.7% had insignificant or no coronary artery disease. Left anterior descending artery was most frequently involved (66%). None had left main involvement. Coronary ectasia was present in 11.7%, intracoronary thrombus in 28.3% and 40% had collaterals. Patients with no significant disease had no diabetes, a smaller number had a raised total cholesterol or smoked and had a lower ejection fraction. Patients from the Indian subcontinent who had fewer conventional risk factors, had more severe disease than those from the Arab world suggesting that other etiological factors need investigation.

Unlabelled: Myocardial perfusion SPECT using the prone position improves inferior wall counts and decreases motion problems as compared with the usual supine position. Nonetheless, it is not suitable for women. In addition, it is associated with artifactual anteroseptal defects and hot spots., Methods: The right lateral (RL) position was evaluated instead of the prone position in 72 patients (26 women). RL imaging was performed immediately after the supine imaging during a routine 2-day 99mTc-sestamibi exercise protocol. The SPECT images were scored semiquantitatively by three physicians. Moreover, regional myocardial counts, as well as extent and severity of defects, were assessed by quantitative polar map analysis., Results: All patients tolerated the RL position well and there was no significant patient movement in either position. Higher inferior myocardial counts per pixel were observed in the RL than in supine images. Inferior wall defects (especially mild ones) were more common in the supine than the RL images, whereas defects in other regions were not different. Quantitative analysis confirmed these findings. Analysis of 34 patients with recent coronary arteriography revealed an overall coronary artery disease (CAD) supine- and RL-imaging specificity of 50% and 75%, respectively, and the sensitivities of both were 93%. Right CAD sensitivity, specificity and normalcy rates for the supine position were 100%, 44% and 55%, whereas those of the RL position were 94%, 75% and 90%, respectively., Conclusion: The RL position improves CAD diagnostic accuracy, particularly right CAD, without significant artifacts in other myocardial regions. Unlike the prone position, the RL position is well tolerated by both women and men.

Mitral balloon valvuloplasty (MBV) by Inoue technique was performed in 85 patients with symptomatic rheumatic mitral stenosis (MS). Twenty-eight patients were male and 57 patients were female. The age range was nine to 59 years (mean 28). All patients were subjected to echocardiographic and Doppler examinations before and one day after the procedure. The first 57 patients were subjected to exercise tolerance tests (ETT) a few days before and a few days after the procedure. An echocardiographic score was measured regarding valve thickening, leaflet mobility, degree of calcification and the severity of involvement of subvalvular apparatus. The mitral valve area (MVA) increased from 0.9 +/- 0.2 cm2 to 1.9 +/- 0.45 cm2, (P<0.0001). The mitral gradient (MG) decreased from 20 +/- 5.8 mm/Hg to 5.05 +/-+ 3.2 mm/Hg (P<0.0001). Mean left atrial pressure (LAP) dropped from 25.85 +/- 8.4 mm/Hg to 11.05 +/- 5.4 mm/Hg (P<0.0001). Exercise tolerance test (ETT) increased from 5.59 +/- 1.3 to 11.75 +/- 1.48 min. (P<0.0001). Complications included severe mitral regurgitation (MR) in two patients (2.3%). In the first 57 patients, mild left-to-right shunt measured by green dye dilution technique had occurred in 40% of patients. In conclusion, MBV by Inoue balloon is a good alternative to surgical commissurotomy and echocardiographic standby is very helpful when it is available. However, MBV can be safely performed if echocardiography is inaccessible.

Sixty cases of infective endocarditis were studied prospectively between May, 1985 and December, 1988. There were 40 males and 20 females with a mean age of 28 years. Endocarditis was found on normal valves in 13 patients, on rheumatic valves in 30, on congenital lesions in 8, on prosthetic valves in 4 and on mitral valve prolapse in 5 cases. Positive blood cultures were detected in 35 patients (58%). In addition bone marrow culture was positive in 1 and valves removed on surgery grew causative organisms in eight. Thus the total culture positive cases were 44 (73%). The commonest infective organism was Streptococcus viridans. Uncommon organisms accounted for 10 cases (17%). Two dimensional echocardiography (2D-Echo) was done in all cases and vegetations were detected in 48 patients (80%). 2 D-Echo was helpful not only in the detection of vegetations but also in the demonstration of other complications of endocarditis like ring abscesses, ruptured chordae, ulceration of aortic root, interventricular septum abscess, and mitral xenograft obstruction. Early surgery was performed in 31 patients. In this group of patients severe heart failure was present in 21, embolization in 10, persistence of fever in 15 and large vegetations in 19. Of the 29 patients treated medically, 2 died. The mortality in the surgical group was seen in 5 (16%) with a mean follow-up of 15 months. The major reason for a large number of our patients undergoing surgery is the fact that this is a referral Center and patients were sent later or when there was a failure of medical treatment.

Exercise electrocardiography with or without thallium-201 scintigraphy was performed (pre-hospital discharge) in 66 asymptomatic survivors of a first inferior myocardial infarction (IMI). Although coronary angiography revealed an 82% incidence of multivessel coronary artery disease (MV-CAD) in the total cohort, the sensitivity of exercise ECG for MV-CAD in the group with absent anterior ST-depression in the acute phase was low (11%). In contrast the presence of acute phase anterior ST-segment depression improved the yield for MV-CAD to 55%. Forty-six patients agreed to a symptom-limited exercise ECG plus/minus thallium imaging at 8-10 weeks post IMI. The sensitivity of detecting MV-CAD improved by 15% in patients with no acute phase anterior ST-segment depression and 16% in patients with acute phase anterior ST-segment depression. At each exercise protocol, thallium improved the sensitivity of exercise in detecting ischemia in the noninfarct zone. It is concluded that following IMI, a high percentage of asymptomatic patients whose acute phase ECG showed anterior ST-segment depression will have MV-CAD detected by heart-rate limited and, more so, by symptom-limited exercise ECG. The detection rate will double in patients with no anterior ST-segment depression if exercise testing is delayed until 8-10 weeks post IMI.

The aim of this study was to evaluate stress combining a cold pressor test and hand grip exercise during echocardiographic investigation of predominantly young asymptomatic patients with severe aortic regurgitation. Thirty five patients were catheterised and divided into two groups. Group A (16 cases) with abnormal ejection fraction by angiocardiography (less than 50%) and Group B (19 cases) with normal ejection fraction (greater than or equal to 50%). The above stress test altered significantly the blood pressure and heart rate in both groups. However, echocardiographic end systolic diameter, end diastolic diameter and fractional shortening were significantly worse during stress test only in Group A but not in Group B. In addition when an end systolic diameter greater than or equal to 48 mm is used as a predictor of abnormal ejection fraction, its sensitivity (100%) and specificity (83%) during stress is only marginally superior to the results obtained at rest. Similarly fractional shortening decrease of 10% or more during stress was no better than resting end systolic diameter parameter. The modified peak systolic pressure-end systolic volume slope demonstrated diminished systolic function in Group A in comparison to Group B. In conclusion, in young asymptomatic patients with severe aortic regurgitation, stress testing altered the echocardiographic parameters significantly in group A patients with abnormal ejection fraction but not in group B patients with normal ejection fraction. However, echocardiographic data during stress testing is not significantly superior to resting end systolic diameter in predicting abnormal ejection fraction.

Twenty-four male patients aged 18-30 (mean = 27.4) years were catheterized either after myocardial infarction (22 patients) or because of angina pectoris (2 patients). In this highly-selected group, 18 of 24 smoked but only 5 had elevated cholesterol levels. Of 14 patients with anterior myocardial infarction (AMI), 7 had a significant left anterior descending obstruction while the other 7 had nonsignificant or no coronary stenosis. In 8 patients with inferior MI (IMI), 4 had significant multivessel disease. Five of 6 patients with multivessel disease smoked while 4 had hypercholesterolemia. Risk factors were absent in 3 of 16 patients with single or no coronary lesions. We conclude that angina pectoris and inferior MI carry high risk of multivessel coronary disease; there is often one or more risk factor in this subgroup. Finally, routine catheterization in young patients with AMI is not warranted.

Rheumatic mitral valve disease is not infrequently associated with tricuspid regurgitation (TR). To determine the fate of TR following closed mitral valvotomy (CMV), we examined the records of 23 patients with variable degrees of TR and significant mitral stenosis (MS). Based on angiocardiographic assessment of TR, patients were divided into two groups: group 1 (15 patients) had mild-to-moderate TR, while group 2 (eight patients) had severe TR. After valvotomy, dyspnea lessened in all patients. Right ventricular (RV) failure signs (jugular venous distension and hepatomegaly) and the amounts of diuretics used diminished in 12 of 15 patients in group 1. Group 2 patients showed insignificant improvement at one-year follow-up period. Cardiac recatheterization was performed in four of group 2 patients three to five years later primarily for persistence of RV failure signs. The mitral valve areas varied from 1.4 to 2.7 cm2. There was mild mitral regurgitation in two patients. There was no deterioration of the left ventricular ejection fraction, but TR was at least moderate in all cases.