SUMMARY Hemodynamically significant primary anomalies of the coronary arteries are those which alter myocardial perfusion. There are four major types: coronary artery fistulae, origin of the left coronary artery from the pulmonary artery, congenital coronary stenosis or atresia, and origin of the left coronary artery from the right sinus of Valsalva, with subsequent passage of the vessel between the aorta and right ventricular infundibulum. Tbc-angiographic features of these lesions are discussed.PRIMARY CONGENITAL ANOMALIES of the coronary arteries (that is, those which can occur as isolated anomalies and are not necessarily associated with other types of congenital heart disease) can be divided into hemodynamically significant and insignificant lesions.The hemodynamically insignificant anomalies are principally those of abnormal aortic origin or distribution of the coronary arteries. They occur in slightly less than 1% of adult patients undergoing coronary arteriography and in children with certain forms of congenital heart disease, such as d-and 1-transposition, tetralogy of Fallot, double outlet right ventricle and single ventricle. Myocardial perfusion is not altered in these individuals.The hemodynamically significant anomalies of the coronary arteries are characterized by abnormalities of myocardial perfusion. There are four major types: 1) coronary fistulae, 2) origin of the left coronary artery (LCA) from the pulmonary artery (PA), 3) congenital coronary stenosis or atresia and 4) origin of the LCA from the right sinus of Valsalva, with subsequent passage of the vessel between the aorta and right ventricular infundibulum. Although angiography provides the key to diagnosis, there have been no previous comprehensive discussions of the radiologic aspects of these lesions. In this paper we review their angiographic appearance, based upon a survey of previously published reports and our own experience with 34 cases. Twenty-one of our patients had coronary artery fistulae, 12 had anomalous origin of the LCA from the PA and one had atresia of the origin of the LCA. Coronary Artery Fistulae A pre-capillary fistula connecting a major coronary artery directly with a cardiac chamber, coronary sinus, superior vena cava or PA, is the most common form of hemodynamically significant coronary anomaly. Physiologically, a left-to-right shunt exists in such cases, except in the rare instances when the termination is in a left heart chamber. Approximately half of these patients are asymptomatic and undergo cardiac catheterization because of a continuous precordial murmur.' The rest may develop congestive heart failure, subacute bacterial endocarditis, myocardial ischemia or infarction resulting from a "steal" phenomenon, or rupture of an aneurysmal fistula.2 The symptoms, murmur, plain radiographic findings and electrocardiographic changes of coronary fistulae may closely resemble those of other lesions, such as patent ductus arteriosus, aorticopulmonary window, ventricular septal defect with aortic regurgitation, rupture ...

Two hundred coronary arteriograms and left ventriculograms of patients having significant coronary artery disease were reviewed. Collateral circulation was seen only when the degree of arterial narrowing exceeded 90%. Ten different collateral pathways were noted in patients having right coronary obstruction; seven different pathways were noted in left anterior descending obstruction; five different pathways were noted in left circumflex obstruction. The role of collateral circulation in preserving myocardial function was assessed by comparing regional left ventricular contractility in 86 instances of total arterial occlusion and adequate collateral circulation with that in 80 instances of total arterial occlusion and inadequate collateral circulation. Among the group with adequate collaterals, regional left ventricular contraction was normal in 43%, mildly impaired (hypokinetic) in 52% and severely impaired (akinetic or dyskinetic) in only 5%. Among the group lacking adequate collaterals, regional contraction was normal in 11%, mildly impaired in 16% and severely impaired in 73%. Chi square analysis reveals that the difference between the two groups is significant at the .01 level. These data indicate that collateral circulation plays an important role in preserving myocardial contractility in patients with coronary artery disease.

Pathologic studies have shown that acute occlusive thrombosis of a coronary artery is usually associated with complicated atherosclerotic stenoses. Thus, complicated lesions represent a greater risk factor for acute myocardial infarction or sudden death than do uncomplicated lesions. This study suggests that coronary stenoses characterized angiographically by irregular borders or intraluminal lucencies are probably the clinically more dangerous "complicated" type.IN REVIEWING and interpreting coronary angiograms, it is customary for the angiographer to describe a focal lesion only in terms of the percent luminal diameter or area narrowing it produces. This practice is uniformly adhered to both in published series and in the dictation, coding and scoring of individual angiographic reports. Virtually no attempt has been made to characterize the morphology of coronary lesions by their arteriographic appearance.Atherosclerotic coronary artery narrowing is a comple-and dynamic process. According to Roberts,'

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Previous research has demonstrated neuropsychological deficits in moderately to severely hypoxemic chronic obstructive pulmonary disease (COPD) patients. The present article reports on the neuropsychological functioning of mildly hypoxemic COPD patients. One hundred patients and 25 controls matched on relevant variables were given extensive neuropsychological tests. Mild neuropsychological impairment was observed in the COPD patients with overall indexes of neuropsychological dysfunction correlating with resting partial pressure of oxygen. Depression and motivation to perform could not account for the results. Long-term reduced oxygen supply to the brain may account for these observed deficits.Patients with chronic obstructive pulmonary disease (COPD) and hypoxemia have been reported to show neuropsychological impairment (Grant, Heaton, McSweeney, Adams, & Timms, 1980;Krop, Block, & Cohen, 1973). They also have complaints of depression and associated worries about bodily functioning (Cummings, Godfrey, & Burrows, 1969; DeCensio, Leshner, & Leshner, 1968). Presumably, chronic reduction of the partial pressure of oxygen (PaO 2 ) significantly contributes to these psychiatric com-

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