LETTERS
have occurred before coronary arteriography or spasm could have occurred at the time of arteriography. In their Case 2 the left circumflex artery appeared on aortograms, but was occluded at the time of left coronary arterial injection with the Judkins technique. As with Case 3 of Cheng et al.,3 selective injection of the left anterior descending artery with this technique can lead to spasm of the left circumflex artery. The lack of tapering at the site of occlusion in these two cases is a point against spasm, but previous reports have emphasized lumen irregularity after recanalization of thromboembolism. Finally, a few minor editorial changes in our report may have given the impression that we definitely ruled out thromboembolism, which was not our original intention. Lewis Sass&
California
Los Angeles,
S.D.Moulopoulos, Department University Athens,
MD, FACC
Department of Intemal So&her6
aortic pressure. He concludes that afterload is not reduced except when blood is withdrawn from the aorta during cardiac systole. With respect to the intraaortic balloon,2 there is much evidence that end-diastolic pressure is significantly reduced after balloon deflation. Thus, when the aortic valve opens, the left ventricle is indeed facing a reduced central aortic pressure and hence a reduced afterload. When the systolic aortic pressure is not appreciably reduced, it is because of changes in volume of cardiac output. I see no difference in this respect between intraaortic balloon pumping and counterpulsation by drawing and reinjecting blood into the aorta.
Medical
Group
References
1.
California
1. Bruschke AVG, Bruyneel KJ, Bloch A, et al: Acute myocardial infarction without obstructive coronary artery disease demonstrated by selective cmearieriography. Br Heart J 33585-594. 1971 2. Lynch RP, Edwards JE: Pathology of coronary atherosclerosrs and its Complicatrons In. The Heart. second edition (Hurst JW. Logue RB. ed). New York. McGraw-Hill, 1970. 914 3. Cheng TO, Bashhour T. Slngh EK, et al: Myocardial infarction in (he absence of coronary arteriosclerosis. Result of coronary spasm(?). Am J Cardiol 30:680-682. 1972
p
Cokklnos OV: Edal counterpulsation and aoitic balloon pumping. Am J Cardioi 35:59 1, 1975 2. MOUlOpoulos SD, Topaz SR, Kofff WJ: Diastolic balloon pumping (with carbon dloxlde) in the aorta-a mechanical assistance to me failing circulation. Am Heart J 63:669-675. 1962
PULMONARY AFTER
THROMBOSIS
MUSTARD OF
BALLOON
of Athens
Greece
Medicine
Permanente
References
INTAAAORTIC
MD
of Clinical Therapeutics
PUMPING
AND
COUNTERPULSATION
In a recent letter Cokkinos’ states that neither of these techniques [sequenced external counterpulsation and intraaortic balloon pumping] should cause a reduction of systolic central
AND
OPERATION GREAT
VASCULAR FOR
DISEASE
TRANSPOSITION
ARTERIES
We read with interest the report by Rosengart et al.’ of progressive pulmonary vascular disease after the Mustard operation for transposition of the great arteries since we described* a similar occurrence in a patient with transposition, intact ventricular septum and subpulmonary stenosis. In our case preoperative cardiac catheterization at age 1 year revealed
FGURE 1. Lung biopsy specimens. A, at Mustard operation. Arrow points to cushion lesion of patchy intwflal fibrosis. 6 to 0. 18 months after operation. sbowng a plexiform lesion arising from an artery with medial hypertrophy (B and enIbraed In D) and an arteriole with marked medial hypertrophy and ¢rnc intimal fibrosis resulbng from an organizing thrombus (C).
June 1976
The American
Journal
of CARDIOLOGY
Volume 37
1115
have occurred before coronary arteriography or spasm could have occurred at the time of arteriography. In their Case 2 the left circumflex artery appeared on aortograms, but was occluded at the time of left coronary arterial injection with the Judkins technique. As with Case 3 of Cheng et al.,3 selective injection of the left anterior descending artery with this technique can lead to spasm of the left circumflex artery. The lack of tapering at the site of occlusion in these two cases is a point against spasm, but previous reports have emphasized lumen irregularity after recanalization of thromboembolism. Finally, a few minor editorial changes in our report may have given the impression that we definitely ruled out thromboembolism, which was not our original intention. Lewis Sass&
California
Los Angeles,
S.D.Moulopoulos, Department University Athens,
MD, FACC
Department of Intemal So&her6
aortic pressure. He concludes that afterload is not reduced except when blood is withdrawn from the aorta during cardiac systole. With respect to the intraaortic balloon,2 there is much evidence that end-diastolic pressure is significantly reduced after balloon deflation. Thus, when the aortic valve opens, the left ventricle is indeed facing a reduced central aortic pressure and hence a reduced afterload. When the systolic aortic pressure is not appreciably reduced, it is because of changes in volume of cardiac output. I see no difference in this respect between intraaortic balloon pumping and counterpulsation by drawing and reinjecting blood into the aorta.
Medical
Group
References
1.
California
1. Bruschke AVG, Bruyneel KJ, Bloch A, et al: Acute myocardial infarction without obstructive coronary artery disease demonstrated by selective cmearieriography. Br Heart J 33585-594. 1971 2. Lynch RP, Edwards JE: Pathology of coronary atherosclerosrs and its Complicatrons In. The Heart. second edition (Hurst JW. Logue RB. ed). New York. McGraw-Hill, 1970. 914 3. Cheng TO, Bashhour T. Slngh EK, et al: Myocardial infarction in (he absence of coronary arteriosclerosis. Result of coronary spasm(?). Am J Cardiol 30:680-682. 1972
p
Cokklnos OV: Edal counterpulsation and aoitic balloon pumping. Am J Cardioi 35:59 1, 1975 2. MOUlOpoulos SD, Topaz SR, Kofff WJ: Diastolic balloon pumping (with carbon dloxlde) in the aorta-a mechanical assistance to me failing circulation. Am Heart J 63:669-675. 1962
PULMONARY AFTER
THROMBOSIS
MUSTARD OF
BALLOON
of Athens
Greece
Medicine
Permanente
References
INTAAAORTIC
MD
of Clinical Therapeutics
PUMPING
AND
COUNTERPULSATION
In a recent letter Cokkinos’ states that neither of these techniques [sequenced external counterpulsation and intraaortic balloon pumping] should cause a reduction of systolic central
AND
OPERATION GREAT
VASCULAR FOR
DISEASE
TRANSPOSITION
ARTERIES
We read with interest the report by Rosengart et al.’ of progressive pulmonary vascular disease after the Mustard operation for transposition of the great arteries since we described* a similar occurrence in a patient with transposition, intact ventricular septum and subpulmonary stenosis. In our case preoperative cardiac catheterization at age 1 year revealed
FGURE 1. Lung biopsy specimens. A, at Mustard operation. Arrow points to cushion lesion of patchy intwflal fibrosis. 6 to 0. 18 months after operation. sbowng a plexiform lesion arising from an artery with medial hypertrophy (B and enIbraed In D) and an arteriole with marked medial hypertrophy and ¢rnc intimal fibrosis resulbng from an organizing thrombus (C).
June 1976
The American
Journal
of CARDIOLOGY
Volume 37
1115
