This report describes the first clinical experience with ultrafast (cine) computed tomography for evaluating intracardiac masses. Two patients had a left atrial myxoma that was comprehensively described (size, location, site of attachment and relation to the mitral valve) preoperatively by cine-computed tomography. The information content of the studies exceeded that of two-dimensional echocardiography, and both patients were operated on without invasive cardiac catheterization. This early experience with a new minimally invasive high temporal and spatial resolution technology suggests that cine-computed tomography may be uniquely suited for precise evaluation of intraatrial masses.

Twenty-five consecutive patients with 68 independent (single distal anastomosis) saphenous vein aortocoronary and 12 internal mammary bypass grafts (27 to left anterior descending, 10 to diagonal, 23 to left circumflex, 20 to right coronary artery) entered a reader-blinded, prospective, standardized study to establish the accuracy of ultrafast (cine) cardiac computed tomography (CT) for determining graft patency compared with invasive angiography. All patients underwent imaging after injection of 35 to 45 ml of meglumine diatrizoate (Renografin-76; 7 to 9 ml/sec for 5 sec) into an arm vein. Electrocardiographically triggered images were acquired over eight to 16 tomographic levels at 1 cm intervals from aortic arch to mid left ventricle. Criteria for graft patency were contrast opacification on at least two noncontinguous levels and contrast density-time curves morphologically similar to that of the aorta. Ultrafast CT correctly determined that 46 of 48 bypass grafts were patent and 31 of 32 were occluded (sensitivity, specificity, and accuracy 96%, 97%, and 96%); there were no interpretation errors in 23 (92%) of the 25 patients. Accuracy was independent of vessel bypassed and not different for saphenous veins (96%) compared with internal mammary bypasses (100%). This study establishes a 20 min outpatient intravenous injection technique that is highly accurate for determining patency of coronary artery bypass grafts.

3 malades de chirurgie coronaire. Les mecanismes qui ont contribue a cet effet incluent l'injection rapide de sufentanil chez des malades recevant des betabloquants et des antagonistes du Ca en l'absence de support vagolytique associe au vecuronium

Coronary sinus catheter techniques for evaluation of coronary flow and myocardial metabolism have the drawback that a global sampling method is used to evaluate a regional disease (coronary artery disease). Studies on the coronary circulation are further limited by the fact that interventions acting on the coronary bed may simultaneously modify several of the principal determinants of coronary blood flow. Results are also influenced by differences among species, and whether the coronary vascular bed is normal or pathologically narrowed. Because coronary flow is intimately coupled to myocardial oxygen demand, interpretation of values as abnormal require simultaneous evaluation of some index of myocardial oxygen consumption. Under normal conditions, myocardial flow is predominantly in diastole, and is subject to compromise by factors that abbreviate diastole (e.g., tachyarrhythmias). Autoregulation maintains constant coronary blood flow over a range of perfusion pressures (60-130 mm Hg), and increased flow demands are normally met by coronary vasodilation (coronary flow reserve). In proximal coronary stenosis, this capacity for additional vasodilation may be significantly reduced, and flow to potentially ischemic beds beyond the stenosis may be maintained by collaterals. Pharmacologic coronary vasodilation in this situation can result in coronary steal. When perfusion pressure decreases below the autoregulatory range, or when coronary flow reserve is exhausted early, as in coronary stenosis, flow becomes dependent on mechanical factors including duration of diastole and the perfusion pressure. In these situations, monitoring heart rate and diastolic pressure would allow reasonable assessment of adequacy of coronary flow and myocardial perfusion.

Received from the Department of Anaesthesia, Dalhousie University and Maritime Heart Centre, Victoria General Hospital, Halifax, Nova Scotia; and the Department of Cardio-Thoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio. Address correspondence to Dr. Moffitt, Department of Anesthesia, Victoria General Hospital, Halifax, Nova Scotia, Canada, B3H 2Y9. Accepted for publication October 30, 1985.

Dobutamine is frequently used in the early postoperative period following myocardial revascularization to improve cardiac output. Seven postoperative adult patients with low output syndrome were studied before and during intravenous dobutamine (mean ± SD: 5.1 ± 2.5 μg/kg/min) infusion. The metabolic effects were evaluated and related to hemodynamic changes. Cardiac index increased 40% (p < 0.05) with an increase in heart rate (p < 0.05) and decreases in systemic vascular resistance and right atrial pressure (p < 0.05). No significant changes occurred in arterial or pulmonary capillary wedge pressures or in stroke volume index. Dobutamine produced a 29% increase in myocardial oxygen consumption which, in these revascularized patients, was accompanied by a 35% increase in coronary blood flow. No significant alteration was observed in coronary sinus oxygen content or in global myocardial lactate extraction. Thus, despite the increased metabolic cost of dobutamine, global myocardial ischemia was not observed.

Although intravenous nitroglycerin has been used to control the hypertensive response during sternotomy in patients undergoing myocardial revascularization, the effects of the drug on myocardial oxygen supply and demand have not been anesthetized for coronary artery bypass, were studied before and after administration of intravenous nitroglycerin (mean dose 12 microgram/kg in 6 minutes). Evaluation of myocardial metabolism showed an increase in coronary sinus oxygen content (p less than 0.05) and a reduction in myocardial oxygen consumption (p less than 0.05). Although mean myocardial lactate extraction and coronary sinus blood flow were not significantly altered in the group as a whole, variations in individual patient responses were observed and are discussed. These direct observations of global myocardial metabolism observed in this study group are similar to the conclusions reached by other investigators using indirect indices of myocardial oxygen supply and demand.

Eighteen patients having coronary artery bypass grafts were randomly anesthetized with morphine (1 mg/kg) or halothane and oxygen. Central and peripheral pressures were measured serially, plus cardiac output and total coronary sinus blood flow, both by thermodilution catheters, starting before induction of anesthesia and continuing until completion of sternotomy. No significant differences in hemodynamic responses were seen between the two anesthetic techniques during induction: blood pressure and peripheral vascular resistance decreased significantly, but not cardiac output or coronary flow. Myocardial oxygen consumption decreased significantly with induction as oxygen content of coronary sinus blood increased, indicating preservation of oxygen balance. Heart rate and blood pressure increased after sternotomy in the patients given morphine, with the myocardium producing lactate in two of six patients and with nitroprusside being required in four patients to decrease arterial pressure. Halothane-oxygen anesthesia effectively controlled autonomic responses to sternotomy, although one of 12 patients had myocardial lactate production at that time. Neither rate-pressure product or ST segment changes were useful predictors of the ratio between myocardial oxygen consumption and supply. Myocardial oxygen balance can be maintained in coronary patients before cardiopulmonary bypass if pulse rate and blood pressure are kept at less than awake levels.

Large doses of morphine sulfate have been reported to cause myocardial lactate production and reduction in coronary blood flow in animals. Similar effects with clinical doses in man would significantly alter the management of cardiac patients. Eleven adult patients with significant coronary arterial disease and normal left ventricular ejection fraction were studied before and 30 minutes after infusion of morphine (0.25 mg/kg IV). Evaluation of myocardial metabolism showed an increase in coronary sinus oxygen content (p less than 0.001) and a reduction in myocardial oxygen consumption. Myocardial lactate extraction was not altered. No change in coronary sinus blood flow was seen. It is concluded that infusion of morphine sulfate, 0.25 mg/kg IV, does not produce global myocardial ischemia in patients with coronary artery disease and normal ventricular function.

Although the antiarrhythmic effects of verapamil (V) have been studied widely, its role in the treatment of atrial tachyarrhythmias after open-heart surgery (OHS) has not been defined. Accordingly, 22 patients were studied using a double-blind randomized crossover protocol 1 to 6 days after OHS, except for one patient, who was studied 90 days after OHS. Atrial fibrillation was seen in 18 and atrial flutter was observed in four patients. Two doses were used, 0.075 and 0.15 mg/kg (not exceeding 10 mg per dose), depending on the response. A positive response consisted of: conversion to sinus rhythm or heart rate less than 100 beats/minute (bpm). Eleven patients received V as the first drug; the remaining 11 received placebo first. Digoxin had been given to 20 patients (0.5 mg average dose) prior to inclusion in the study. Four patients converted to sinus rhythm within 30 minutes after V and one additional patient did so within 10 seconds of placebo administration. The post treatment heart rate combining both low and high dose response was 85 ± 18 compared to 128 ± 23 bpm for placebo (m ± SD, p < 0.01). The heart rate remained lower than control 30 minutes after V. Transient hypotension required intravenous fluid in one patient. Thus, V safely and rapidly controls heart rate but is not likely to result in immediate conversion to sinus rhythm in patients after OHS.

The effect of protamine sulfate on myocardial oxygen supply and demand was studied under clinical conditions in nine patients following cardiopulmonary bypass. Before surgery, the patients had severe coronary artery disease with good ventricular function. The patients required no vasoactive drugs, but only blood volume adjustments when weaned off bypass, and were hemodynamically stable at the time of study. The protamine dose of 196 mg (2.5 mg/kg) was infused over 4 +/- 1 minutes. Although modest variation in hemodynamic function occurred in individual patients after administration of protamine, there were no significant hemodynamic alterations for the group. No significant alteration in global myocardial metabolism was observed. Protamine caused a small decrease in measured coronary blood flow, resulting in a corresponding reduction in calculated myocardial oxygen consumption as coronary sinus oxygen content remained unaltered. Myocardial lactate extraction showed no significant alteration. It is concluded that protamine sulfate, given at rapid infusion rates in hemodynamically stable patients, is not associated with an adverse alteration in hemodynamics or global myocardial metabolism.

Myocardial beta-adrenoceptor binding was investigated, with (-)3H dihydroalprenolol as radioligand, in microsomes derived from anterior (ALV) and inferior (ILV) myocardial wall sections of the canine left ventricle. Characterisation of specific binding sites revealed a hierarchy of myocardial beta-adrenoceptor binding with greater binding occurring to the anterior than the inferior wall of the left ventricle, under identical experimental conditions. Equilibrium analysis by Scatchard plots suggested a significant (P less than 0.01) difference in the number of receptors (Bmax ALV = 70 fmol . mg-1 protein vs Bmax ILV = 37 fmol . mg-1 protein) with no alteration in the binding affinity of the receptors (KDALV = 10.1 nmol . litre-1 vs KDILV = 6.7 nmol . litre-1). Such differences in the extent of binding of beta-adrenoreceptors in cardiac muscle may be of physiological and pathological significance and may account for the heterogeneity of regional autonomic responses in the heart.