Functional Assessment of Coronary Artery Lesions—Old and New Kids on the Block

Angiography is inaccurate in assessing functional significance of coronary lesions, and often stenoses deemed severe on angiographic assessment do not restrict coronary blood flow at rest or with maximal dilatation. Angiography-guided revascularization has not shown improvement in hard clinical outcomes in stable ischemic heart disease (SIHD). Most current guidelines for SIHD recommend invasive functional assessment of lesions to guide revascularization if prior evidence of ischemia is not available. There has been several recent advances and development of novel methods in this arena. Various contemporary clinical trials have been undertaken for validation of these indices. Here we review the physiological basis, tools, techniques, and evidence base for various invasive (resting as well as hyperemic) and noninvasive methods for functional assessment of coronary lesions. Left main stenosis, bifurcation lesions, serial stenosis, and acute coronary syndrome each causes unique disequilibrium that may affect measurements and require special considerations for accurate functional assessment.

QUASICONFORMAL EXTENSIONS OF HARMONIC MAPPINGS WITH A COMPLEX PARAMETER

In this paper, we study quasiconformal extensions of harmonic mappings. Utilizing a complex parameter, we build a bridge between the quasiconformal extension theorem for locally analytic functions given by Ahlfors [‘Sufficient conditions for quasiconformal extension’, Ann. of Math. Stud.79 (1974), 23–29] and the one for harmonic mappings recently given by Hernández and Martín [‘Quasiconformal extension of harmonic mappings in the plane’, Ann. Acad. Sci. Fenn. Math.38 (2) (2013), 617–630]. We also give a quasiconformal extension of a harmonic Teichmüller mapping, whose maximal dilatation estimate is asymptotically sharp.

Validation of double vascular occlusion method for Pc,i in lung and skeletal muscle

Capillary pressures in isogravimetric lung and skeletal muscle measured with the double vascular occlusion technique (Pdo) were compared to those measured using the traditional gravimetric technique (Pc,i). Pressures were measured using both techniques in isolated blood-perfused canine lungs (n = 18), blood-perfused rat hindquarters before (n = 8) and after (n = 6) maximal dilatation with papaverine and in rat hindquarters perfused with an artificial plasma (n = 6). In both organs, regardless of vascular tone, the double vascular occlusion isogravimetric pressure was the same as the gravimetric Pc,i, and the two measurements were highly correlated. Lung: Pdo = -0.22 + 1.06 Pc,i (r = 0.85, P less than 0.01); hindquarter: Pdo = -1.03 + 0.99 Pc,i (r = 0.91, P less than 0.01). In addition, Pdo was the same at every combination of isogravimetric arterial and venous pressures tested. The results indicate that the more rapidly applied double vascular occlusion pressure yields an accurate measure of isogravimetric capillary pressure in isolated organs over a wide range of isogravimetric pressures.

Cerebral Hyperperfusion after Carotid Endarterectomy: A Cause of Cerebral Hemorrhage

Correction of a very high grade carotid stenosis by endarterectomy in a normotensive man was followed by the development of severe unilateral head, eye, and face pain, seizures, and on the 6th day a fatal intracerebral hemorrhage. Autopsy revealed changes in the cerebral hemisphere ipsilateral to the endarterectomy that resembled the changes seen in malignant hypertension, whereas the opposite hemisphere was normal. These changes included hypercellularity and edema of arterial and arteriolar walls, with necrosis, extravasation of erythrocytes, and exudation of fibrin. We propose that the clinical and pathological features in this case were due to relative hyperperfusion of a cerebral hemisphere in which autoregulation had been impaired because of preoperative chronic hypoperfusion with chronic maximal dilatation of its blood vessels. This state of relative hyperperfusion is probably similar to the normal perfusion pressure breakthrough that occasionally occurs after the resection of cerebral arteriovenous malformations. It is similar to the breakthrough perfusion that occurs in severely hypertensive patients and results in hypertensive encephalopathy.