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Subendocardial ischemia without anatomic coronary artery obstruction may result from a discrepancy between metabolic needs and available blood supply. We studied this in open-chest anesthetized dogs and measured pressures in aorta and left ventricle (LV), phasic left coronary arterial blood flow (CBF) by electromagnetic flowmeter, total CBF and LV subendocardial (endo) and subepicardial (epi) flow with radioactive microspheres 8-10fi in diameter. Since LV subendocardial flow is mainly or entirely diastolic, it should depend on coronary driving pressure and duration of diastole (i.e., the area between aortic and left ventricular diastolic pressures). This diastolic pressure time index (DPTI) was varied by opening arteriovenous fistulas to lower aortic diastolic pressure, constricting the ascending aorta to raise LV diastolic pressure and pacing to shorten diastole. Myocardial oxygen needs were estimated from the tension time index (TTI). Normal endo-epi flow ratios per gram (1:1) fell to 0.1:1 with these procedures and paralleled a fall in diastolic flow fraction (often nearly zero) and postischemic coronary reactive hyperemic responses. These changes occurred despite normal or raised mean CBF and 300-500% increase in systolic CBF. The altered flow ratios were best predicted by relating them to the ratio of DPTI (supply) to TTI (demand). KEY WORDSregional coronary blood flow arteriovenous fistula subepicardial flow aortic constriction radioactive microspheres ventricular pacing reactive hyperemia tension time index phasic coronary blood flow diastolic pressure time index• Patchy necrosis and fibrosis of left ventricular subendocardial muscle occur in patients whose coronary arteries are normal or narrowed by atheroma (1-5). These changes could be due to a discrepancy between myocardial oxygen demand and available blood supply in subendocardial muscle, but this hypothesis has not yet been tested in

This study demonstrates that it is possible to design a terminal graft geometry for an end-to-side anastomosis that significantly reduces wall shear stress gradients. If the wall shear stress gradient is confirmed to be a major hemodynamic determinant of intimal hyperplasia and restenosis, these results may point to the design of optimal bypass graft geometries.

Patch angioplasty reconstruction of CEAs with arteriotomies that extend distal to the carotid bulb gives excellent early and long-term outcomes. Saphenous vein-patched CEAs are superior to synthetic patched CEAs for stroke and restenosis prevention. Primary closure is safe and durable when complete end points and arteriotomies are within the carotid bulb.

Chronically hypertrophied right ventricles function normally under high systolic pressures, whereas normal right ventricles fail when they are acutely subjected to similar pressures. This phenomenon may be partly due to adaptation of the coronary circulation as well as to hypertrophy. Knowledge of the magnitude and distribution of coronary blood flow and the degree of coronary vascular reserve are important in understanding the function of hypertrophied myocardium. We studied these variables in 16 awake, 5-12-week-old, tranquilized lambs; 9 of the lambs had had their main pulmonary artery banded at 2 days of age. Pressures, cardiac output, and coronary blood flow (radioactive microsphere method) were measured at rest and during two stress states-isoproterenol and dextran infusion. Ventricular function was similar in control and banded lambs. We found significant right ventricular hypertension and both right ventricular and septal hypertrophy in the banded lambs. Total coronary blood flow per gram was slightly higher in banded lambs in all states, and right ventricular flow per gram was significantly elevated at rest and during isoproterenol infusion. Right ventricular coronary resistance per gram was significantly lower in banded lambs in all states. These changes demonstrate that hypertrophied right ventricular tissue is not ischemic at rest, since there is vascular reserve. The changes also raise the question of increased vascularity in hypertrophied myocardium. Right ventricular oxygen supply per unit oxygen demand was increased in banded lambs at rest and during isoproterenol infusion. This finding suggests that hypertrophied myocardium has inefficient oxygen utilization, low oxygen extraction, or both. KEY WORDSradioactive microspheres coronary vascular resistance pulmonary stenosis subendocardial flow coronary blood flow Dextran 70 isoproterenol

To determine the benefit of carotid patch angioplasty, a retrospective study of 1000 consecutive carotid endarterectomies was done. Based on the type of carotid endarterectomy closure, patients were divided into four groups: 250 had primary closure, 250 had expanded polytetrafluoroethylene patch, 250 had Dacron patch, and 250 had saphenous vein patch. On the basis of operative technique or type of carotid artery closure, no statistical difference was found in the incidence of postoperative stroke (p greater than 0.25): primary closure 1.6% (4), expanded polytetrafluoroethylene 2.0% (5), Dacron patch 1.6% (4), and saphenous vein patch (0). Postoperative carotid patency was determined by B-mode ultrasonography, and 717 patients were evaluated in follow-up extending to 6 years (mean 37.8 months). Based on the method of carotid endarterectomy closure, no significant difference (p greater than 0.25) was found in the incidence of significant restenosis (greater than 50% diameter reduction): primary closure 4.0% (7), expanded polytetrafluoroethylene 4.0% (6), Dacron 5.4% (9), and saphenous vein 1.0% (2). Significant restenosis was most frequent in habitual smokers (93%, 25/28) and females (78%, 22/28) despite the method of carotid endarterectomy closure. No statistical difference was found in the incidence of late ipsilateral stroke either (p greater than 0.25): primary closure 2.9% (5), expanded polytetrafluoroethylene 2% (3), Dacron 5% (3), and saphenous vein 0%. These results indicate that the incidence of postoperative stroke, regardless of method of arterial closure, was not statistically different. The method of carotid closure did not appear to affect the occurrence of late ipsilateral stroke or restenosis; however, patch angioplasty with saphenous vein appears appropriate in habitual smokers, and likely in patients with small internal carotid arteries.

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These results indicate that flow disturbances in general and wall shear stress gradients in particular are markedly reduced in carotid artery bifurcations that are smooth and gradually tapered and do not have a bulb. Abrupt geometric wall changes such as those occurring in the normal carotid bulb and at the distal end of a patch-reconstruction after carotid endarterectomy are harbingers of disturbed flow and high wall shear stress gradients. These results suggest that carotid endarterectomy reconstruction geometry characterized by a gradually tapered internal carotid artery may minimize the hemodynamically induced component of early myointimal hyperplasia and thrombosis and late atherosclerotic restenosis.