Coronary artery disease is a progressive process adversely affecting the integrity of the coronary vasculature. In the past years, most studies have focused on the morphological changes leading to compromised coronary blood flow in atherosclerosis. In recent years however, it has become apparent that abnormal coronary vasomotor regulation may precede or accompany gross morphological changes in coronary atherosclerotic disease. In fact, the pathophysiology of angina pectoris in many patients with risk factors for atherosclerosis and minimally obstructive disease may involve abnormal coronary vasomotor regulation. This article will review the current knowledge of the physiologic assessment of both native coronary artery disease and the adequacy of percutaneous coronary interventions.

Background and Methods We reviewed our eleven-year experience in cardiac transplantation. From January 1988 through July 1999, we performed 212 heart transplants (HT) in 210 patients at our Institution. Indications for HT included dilated cardiomyopathy in 102 patients (48.11%), coronary artery disease in 74 (34.91%), heart valve disease in 21 (9.9%), myocarditis in 6 (2.83%), hypertrophic cardiomyopathy in 3 (1.42%), restrictive cardiomyopathy in 3 (1.42%), allograft coronary artery disease (ACAD) in 2 (0.94%), and congenital heart disease in 1 (0.47%). Patients were followed up for 138 months. During the follow-up period, 1659 endomyocardial biopsies (EMBs) were performed. Diagnosis and grading of rejection were reported according to the guidelines of the 1990 Working Formulation in the diagnosis of heart and lung rejection. For each patient, we evaluated the evolution of rejection in order to establish whether further immunosuppressive treatment was indicated. Results EMBs showed no sign of rejection (grade 0) in 806 (48.58%) cases, grade 1A rejection in 581 (35.02%), grade 1B in 123 (7.42%) cases, grade 2 in 45 (2.72%). Such degrees of rejection usually regressed spontaneously or remained stable over time. Grade 3A rejection was found in 37 (2.23%) biopsies, grade 3B in 6 (0.36%), therefore additional immunosuppressive treatment was performed only in 43 cases. No case of severe rejection (grade 4) has been observed to date. Sixty-one biopsies (3.67%) were considered inadequate. Conclusions During the follow-up period, 71 patients died (mortality rate 33.81%). Postoperative mortality after HT was high within the first postoperative month, and slightly lower between the 1st and the 6th postoperative month. The survival curve shows a better trend after the 6th postoperative month. Causes of death included acute graft failure in 31 patients, sudden death in 11, infections in 10, chronic rejection (ACAD) in 5, neoplastic complications in 4, acute rejection in 3, other causes in 7. A strong association was found between ACAD (5 patients) and HCV (4/5 patients) and HCMV (5/5 patients) positivity, confirming the opinion that such viruses could play a role in the development of chronic rejection.

Background Sustained ventricular tachyarrhythmias (VT) such as monomorphic or polymorphic ventricular tachycardia and ventricular fibrillation represent the most dreadful arrhythmic events that can complicate the postoperative course of coronary artery bypass grafting (CABG). The perioperative factors that are potentially associated with the onset of post-CABG sustained VT have not been deeply investigated. Hence, the aim of our paper was to identify which perioperative variables might predict post-CABG VT occurrence. Methods and Results One hundred fifty-two consecutive patients who underwent CABG surgery at our institution between September and December 1997 comprised the study population. Post-CABG VT occurred in 13 (8.5%) out of 152 patients (6 cases of monomorphic ventricular tachycardia and 7 cases of ventricular fibrillation). Using univariate analysis, VT patients were compared with those who remained in sinus rhythm (SR). VT patients were significantly younger (54.8 ± 6.6 vs. 60.1 ± 8.8, p=0.038), had more severe coronary artery disease (CAD) (No. of diseased vessels 2.92 ± 0.3 vs 2.45 ± 0.7, p=0.023), had a higher incidence of three-vessel CAD (91.7% vs 57.3%, p=0.043), and received a greater number of CABGs (% of patients receiving three or more CABGs 76.9% vs. 38.8%, p=0.018). VT patients were found to developed intra- or post-operative myocardial infarction more frequently (total CK > 1000 76.9% vs. 38%, p= 0.016; and MB-CK > normal range 72.7% vs 30.7%, p= 0.014), had a higher incidence of electrolyte derangement (84.6% vs 45.6%, p=0.017) and more severe hemodynamic impairment (need of IABP 23% vs 2.9%, p=0.009). At multivariate analysis, total CK > 1000, postoperative electrolyte imbalance, the need of three or more CABGs and use of IABP were found to be independent correlates for VT. Conclusions Post-CABG VT seem to be related to the pre-existence of severe underlying coronary artery disease and to triggering factors such as acute ischemia, electrolyte disorders, and a sudden hemodynamic impairment that might precipitate the onset of VT.

Early postoperative arrhythmias have a great influence on the hemodynamic stability of patients in the early postoperative hours and days. Diagnostic and therapeutic equipment must be available at all times to prevent potential adverse complications. Accurate diagnosis of an arrhythmia and knowledge of its mechanism are extremely important in planning a therapeutic strategy. The most frequent arrhythmias and their management is described