Doty D B, Eastham C L, Hiratzka L F, Wright C B, Marcus M L
Circulation. 1982 Aug;66(2 Pt 2):I186-92.
Coronary reserve in patients with supravalvular aortic stenosis may be limited by coronary artery ostial obstruction or left ventricular hypertrophy. To assess the relative effect of these two factors on coronary reserve, seven patients with supravalvular aortic stenosis were studied intraoperatively before and after repair. Six patients who underwent elective cardiac surgery for conditions that did not involve the left ventricle or the left anterior ascending coronary artery served as controls (control group 1). Four patients were studied before and after cardiopulmonary bypass to determine if cardiopulmonary bypass altered coronary reserve in normal vessels perfusing normal ventricle (control group 2). Using a pulsed Doppler probe to determine coronary velocity, coronary reactive hyperemia was induced in the left anterior descending coronary artery (patients with supravalvular aortic stenosis and group 1 controls) or right ventricular branches of the right coronary artery (group 2 controls) during maximal coronary dilation produced by a 20-second coronary occlusion. All patients with supravalvular aortic stenosis underwent patch aortoplasty to relieve left coronary artery ostial obstruction and outflow tract obstruction; three patients also underwent aortic valvotomy and one patient also underwent valve replacement. Coronary reactive hyperemia was calculated as the ratio of peak to resting velocity. This ratio was 5.0 +/- 0.6 (mean +/- SEM) preoperatively and 3.6 +/- 0.3 postoperatively in control group 2. Thus, coronary reserve was only modestly reduced after cardiopulmonary bypass. Before repair, the ratio of peak to resting velocity was markedly reduced in patients with supravalvular aortic stenosis compared with control group 1 (1.8 +/- 0.3 vs 4.9 +/- 0.5, p less than 0.05) and did not change after repair (1.7 +/- 0.2), even though the aortic gradient was reduced (80 +/- 14 vs 38 +/- 6 mm Hg, p less than 0.05) and real or potential coronary ostial obstruction was eliminated by the operation. Because coronary reserve did not improve after surgery in patients with supravalvular aortic stenosis, we conclude that left ventricular hypertrophy is probably the primary determinant of decreased coronary reserve in these patients.
瓣上主动脉狭窄患者的冠状动脉储备可能受冠状动脉开口梗阻或左心室肥厚限制。为评估这两个因素对冠状动脉储备的相对影响，我们对7例瓣上主动脉狭窄患者在修复手术前后进行了术中研究。6例因不涉及左心室或左前降支冠状动脉的疾病接受择期心脏手术的患者作为对照（对照组1）。4例患者在体外循环前后接受研究，以确定体外循环是否改变灌注正常心室的正常血管的冠状动脉储备（对照组2）。使用脉冲多普勒探头测定冠状动脉血流速度，在20秒冠状动脉闭塞产生的最大冠状动脉扩张期间，于左前降支冠状动脉（瓣上主动脉狭窄患者和对照组1）或右冠状动脉的右心室分支（对照组2）诱导冠状动脉反应性充血。所有瓣上主动脉狭窄患者均接受补片主动脉成形术以解除左冠状动脉开口梗阻和流出道梗阻；3例患者还接受了主动脉瓣切开术，1例患者还接受了瓣膜置换术。冠状动脉反应性充血以峰值速度与静息速度之比计算。对照组2术前该比值为5.0±0.6（均值±标准误），术后为3.6±0.3。因此，体外循环后冠状动脉储备仅轻度降低。修复前，瓣上主动脉狭窄患者的峰值速度与静息速度之比与对照组1相比明显降低（1.8±0.3对4.9±0.5，p<0.05），修复后未改变（1.7±0.2），尽管主动脉压差降低（80±14对38±6 mmHg，p<0.05），且手术消除了实际或潜在的冠状动脉开口梗阻。由于瓣上主动脉狭窄患者术后冠状动脉储备未改善，我们得出结论，左心室肥厚可能是这些患者冠状动脉储备降低的主要决定因素。
