Myocardial imaging with intravenous thallium-201 (201Tl) was performed at rest and following maximal treadmill exercise in 101 patients with suspected coronary artery disease. Results were interpreted from Polaroid scintiphotos by three independent observers with complete interobserver agreement in 79%. Of 25 patients with no or insignificant coronary artery disease (less than 50% diameter stenosis), one (4%) had a resting 201Tl image defect, one (4%) had an exercise 201Tl defect, none had an ECG Q wave, and four (16%) had exercise ST-segment depression. Among 76 patients with coronary artery disease (greater than or equal to 50% diameter stenosis), 58 (76%) had a defect on either the rest or exercise 201Tl image. The proportion of patients with an exercise image defect (50/76, 66%) was greater than the proportion with exercise ST depression alone (34/76, 45%; P less than 0.02). Overall, 69 of the 76 (91%) patients with coronary artery disease had either a positive rest or exercise myocardial image and/or a positive rest (ECG Q waves) or exercise (ST depression) electrocardiogram. This exceeded the proportion with only rest or exercise electrocardiographic abnormalities (50/76, 65%; P less than 0.001). We conclude that rest and exercise myocardial imaging with 201Tl is easily accomplished with readily available imaging equipment. The image data enhanced the diagnostic sensitivity of stress electrocardiography, and provided spatial identification of the abnormal segment(s) of myocardium.

Myocardial imaging with thallium-201 at rest and during exercise. Comparison with coronary arteriography and resting and stress electrocardiography.

Current complications of diagnostic and therapeutic cardiac catheterization

Nineteen patients, aged 58-80 years, with severe isolated aortic valve stenosis, severely reduced ejection fraction and clinical heart failure underwent aortic valve replacement between January 1970 and April 1977. Ten had concomitant coronary artery disease (all underwent additional coronary bypass surgery), 17 had angina pectoris and four had syncope. Aortic valve area index was 0.32 +/- 0.03 cm2/m2 (mean +/- SEM); left ventricular (LV) end-diastolic volume index was 117 +/- 9 ml/m2 and LV ejection fraction was 0.37 +/- 0.02. There were four operative deaths and one late death. The follow-up time ranged from six to 74 months (38 +/- 6 months). Actuarially determined three-year survival is 74 +/- 10%; the expected five-year survival is the same. One patient had a serious cerebrovascular accident. Of the remaining survivors, seven were initially Functional Class IV and six Class III; currently, six are Class I and seven Class II (New York Heart Association classifications). The cardiothoracic ratio has decreased from 0.54 +/- 0.03 to 0.49 +/- 0.03. Repeat hemodynamic evaluation has been performed in 10 patients, 22 +/- 6 months after surgery. In these 10 patients, the aortic valve gradient decreased from 55 +/- 7 11 +/- 1.3 mm Hg; LV end-diastolic pressure from 22 +/- 2.4 to 9 +/- 1.9 mm Hg; LV end-diastolic volume index from 119 +/- 16 ml/m2 to 107 +/- 11 ml/m2. LV ejection fraction has increased dramatically from 0.34 +/- 0.03 to 0.63 +/- 0.05 and mean velocity of circumferential fiber shortening from 0.57 +/- 0.08 to 1.3 +/- 0.18 circ/sec. The encouraging long-term survival, improved functional class and the marked improvement in left ventricular function that occurred in our patients indicate that all patients with severe aortic stenosis in clinical heart failure should be offered aortic valve replacement.

Severe aortic stenosis with impaired left ventricular function and clinical heart failure: results of valve replacement.

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.

https://www.ccsenet.org/journal/index.php/gjhs/article/download/13987/9702

Risks and Complications of Coronary Angiography: A Comprehensive Review

Distressing rates of embolic complications from coronary arteriography performed by the percutaneous femoral approach have been reported since 1972. From 1970-1974, 5250 patients underwent coronary arteriography in our laboratory by the same percutaneous femoral technique with preformed polyethylene catheters and no systemic heparinization. Data were recorded during and for 24 hours postcatheterization. The annual mortality rate averaged 0.23% and remained relatively stable. Our incidence of embolic complications was very low. In patients with normal coronary arteries, no fatal or serious nonfatal complications occurred. Left main coronary artery disease was present in all cases of mortality and greater than or equal to 60% stenosis was shown in nine of 12 instances. Thus major risk was proportional to the severity of disease in the left coronary system. The use of more aggressive supportive measures in these high-risk cases appears essential to reduce the total complication rate from coronary arteriography significantly.

Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique.

STARTLING FACTS about the incidence of complications of coronary arteriography in the U. S. during the years 1970 and 1971 emerge from the study reported by Adams et al. in the September 1973 issue of Circulation. The following findings seen nationally are most significant. (1) Death or the serious nonfatal complications of myocardial infarction and/or cerebral embolus occur in an unacceptable 1.5% of all patients examined; the occurrence is ten times higher in institutions performing fewer than 100 examinations/year than in those doing more than 400/year. Reported death rates vary more than one hundred fold, from 0.05% to 8%.1, 2 (2) The serious complications, primarily thrombotic, occur eight times more frequently when the percutaneous transfemoral approach is used. (3) Fifty-five percent of laboratories using a femoral method do fewer than 50 cases/year. As volume increases, the complication disparity between the brachial and the femoral approach dramatically narrows to near equality. The reported complication rates are unacceptably high. Two clearly evident factors emerge: (1) the competence of the operator (training and main-

Prevention of complications of coronary arteriography.

Macroaggregates of albumin labeled with 99mTc and 131I were injected into the coronary arteries in 400 patients undergoing coronary arteriography. The three major coronary artery systems were divided into six groups, based upon coronary arteriography and myocardial perfusion color scintigraphy. Myocardial perfusion could not be predicted uniformly by angiography alone. Myocardial perfusion patterns of each group are presented, together with cases illustrating collateral perfusion, myocardial aneurysms, cardiomyopathy, and venous by-pass grafts. If the size and number of particles injected are carefully controlled, the procedure involves insignificant morbidity and no mortality. Myocardial perfusion scintigraphy with radioactive particles reflects the status of the myocardium beyond diseased coronary arteries.

Myocardial perfusion color scintigraphy with MAA.

Macroaggregates of albumin (MAA) labeled with /sup 131/I and /sup 99m/Tc were injected into the right and left coronary arteries, respectively, of 800 patients at the time of cororary angiography. Microspheres of albumin (HAM labeled with /sup 99m/Tc were substituted for macroaggregates in the last 400 patients and injected into the left coronary artery. The radiopharmaceutical was carefully prepared with strict limitation of the number and size of particles and total amount of carrier protein. The electrocardiogram and aortic blood pressure were monitored following the injection of labeled particles. No significant electrocardiographic or aortic pressure changes occurred secondary to the radioactive microemboli. There was no mortality and no demonstrable morbidity. It was concluded that the intracoronary injection of labeled particles is safe in humans when performed under carefully controlled conditions. (auth)

http://jnm.snmjournals.org/content/15/1/2.full.pdf

Martin P. Gander

Papers

Prevention of complications of coronary arteriography.

Myocardial perfusion color scintigraphy with MAA.

Safety of the direct coronary injection of radiolabeled particles.