Echocardiographic measurements of left ventricular end-systolic dimension and fractional shortening obtained in the supine position before and immediately after maximal upright exercise were evaluated in 11 normal volunteers, 35 patients with coronary artery disease and 17 patients without coronary artery disease. The time course of recovery from acute exercise-induced changes in echocardiographic dimensions was analyzed using serial postexercise recordings from normal subjects. An exercise-induced decrease in end-systolic dimension (greater than or equal to 3 mm) and increase in fractional shortening (greater than or equal to 5%) persisted for 3 minutes or longer in the immediate postexercise period in each of the normal volunteers. With these criteria to separate normal from abnormal responses, abnormal responses were observed in 16 (94%) of 17 patients with coronary artery disease and in only 2 (6%) of 35 patients without coronary artery disease. Immediate postexercise echocardiography appears to be a practical and potentially valuable adjunct in the detection of coronary artery disease.

No abstract

A 65-year-old woman presented with intermittent left bundle branch block and angina pectoris. Cardiac catheterization demonstrated bilateral coronary artery fistulae entering diffusely into the left ventricle without evidence of major arterial-luminar shunt. A surgical procedure to reduce the arterial-to-cameral flow is discussed, and case reports are reviewed and discussed.

There have been many angiographic and necropsy reports focusing on left main coronary artery disease of greater than 50%.1-8 The degree of peripheral coronary disease in patients with this specific lesion is impressive. Bulkley et a1.9 reported a necropsy analysis of 152 patients with left main lesions. Thirtyfive patients had greater than 75% narrowing of the left main coronary artery, and 30 patients had 50 to 75% narrowing of the left main coronary artery. Of these patients, all had at least one other significantly involved vessel, and the majority of them had severe three-vessel coronary artery disease. The overall incidence of isolated left main disease in a combined analysis was 4%.9 Because of these data, it is tempting to diagnose single obstructions of the left main coronary artery without peripheral involvement as coronary artery spasm10,ll rather than as obstructive coronary artery disease.Over the last year and a half, in a large community hospital, we studied 38 patients with left main coronary artery stenosis. Of these patients, we found 2 with isolated fixed left main coronary artery stenosis (5.2%). In both cases there was skepticism about the absence of distal coronary involvement. However, at surgery both patients demonstrated palpable atherosclerotic lesions at the origin of the left main coronary artery, with no evidence of significant atherosclerotic involvement of the peripheral coronary vessels. Case 7A 52-year-old white woman had a hisLory of atypical chest pain for I 8 months before her initial hospitalization. This right-sided discomfort radiated to the right shoulder and back. The pain was atypical of angina in that it lasted at times for 45 minutes and was infrequently associated with exertion.We initially saw the patient in the hospital because of these complaints, and because of an abnormal electrocardiogram with repolarization changes over the anterior precordial leads. The patient underwent treadmill testing which was strongly positive in that her exercise performance was poor. Following exercise she became hypotensive and suffered prolonged chest pain. Coronary arteriography demonstrated left main coronary artery stenosis, which was partially relived following administration of nitroglycerine (90 to 75%) (Figure 1 ). No significant distal coronary disease was noted (Figure 2).

Over the past six months we have been using a new technique for imaging the pulmonic valve in patients with chronic obstructive lung disease. The technique employs the combination of twodimensional visualization for spatial orientation and M-mode recordings for assessment of valvular motion.Using the two-dimensional transducer, the aortic valve is visualized from the subxiphoid window long axis. The transducer is then angled anteriorly to visualize the right ventricular outflow tract and pulmonic valve (Figure 1 above). The cursor is then placed over the pulmonic valve and M-mode strips are recorded using the 2-D transducer for guidance (Figure 1 below).