Adv. Cardio!., vo!. 26, pp. 121-124 (Karger, Basel 1979)
Progressive Coronary Artery Disease with Sudden Death in a Marathoner: Results of Internal Mammary Artery Bypass Case Report
JOHN H.K. VOGEL, R. BRUCE Mc FADDEN, and GEORGE U. FISHER
This 64-year-old white male had been running the marathon for 2 years and had completed the Santa Monica Marathon on January 12, 1974 without difficulty. A rhythm strip at the end of that race was said to be normal. He had been running approximately 70 miles a week. On February 7, 1974 he was awakened with a nightmare, not associated with pain or other sensations. He fell asleep within a few minutes only to be awakened again. On the third occasion, some 15-20 min later, his wife took him to the Emergency Room whereupon, within 5 min, he developed ventricular fibrillation. During the next 2 h he had 14 episodes of ventricular fibrillation. With intravenous Lidocaine, Inderal, Pronestyl and intramuscular Quinidine it was possible to stabilize his rhythm with only paroxysmal ventricular tachycardia. He was transferred from Lompoc Hospital to the Goleta Valley Community Hospital where he underwent cardiac catheterization. Left ventricular enddiastolic pressure was normal, being 8 mm Hg, and stroke index was normal at 74 mllm 2 • However, his VCF was reduced to 0.56 circumferences/sec and systolic ejection fraction was 66% (table I). His anterolateral wall was hypokinetic. Coronary cineangiography revealed 90% segmental narrowing in the proximal third of the left anterior descending coronary artery. No collateralization was noted to the distal vessel. The diagonal and circumflex vessels appeared free of significant disease. A 30% localized obstruction was present in the proximal third of the right coronary artery. On February 9, 1974 the left internal mammary artery was anastomosed to the left anterior descending artery. The postoperative course was unremarkable and the arrhythmias were abolished. 10 days postoperatively, on February
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Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, Calif.
122
VOGEL/McFADDEN/FISHER
SEF,% EDV,mllm2 VCF, circumference/SEC
2/8/74 (pre) 2119/74 (post)
5/28/76
66 79 73
112 92 77
0.56 1.54 1.60
SI
LVEDP
74 74 56
8 12 15
19, 1974, he underwent repeat studies (table I). The ejection fraction had increased to 79% and the VCF to 1.54 circumferences/sec. The left internal mammary artery was widely patent with excellent run-off into the left anterior descending coronary artery. His end-diastolic volume was smaller, being 92 mllm2 compared to 112 preoperatively. He was started on a progressive exercise program, and on April 11, 1974 performed a normal, maximal treadmill stress test. He was able to run 7 miles an hour on a 20% grade without difficulty and without abnormalities on his electrocardiogram. Blood pressure response was normal and no abnormal sounds were noted on auscultation. He increased his exercise to 70 miles a week and in October of 1974 ran the Santa Barbara Marathon in 3 hand 59 min. An electrocardiogram immediately after the race was normal, as was his cardiovascular examination. His only problem was a 'bum' foot. On May 3,1976, a routine treadmill was positive electrocardiographically although he experienced no pain. He had been running in his usual routine without difficulty and without arrhythmias. Because of his desire to continue running it was recommended that he undergo recatheterization to determine the reason for the change in his exercise electrocardiogram. His resting electrocardiogram was normal. On May 21, 1976 he ran the 8-mile Dipsy Doodle in San Francisco in 68 min without difficulty. Thus, on May 28, 1976 he underwent restudy. At that time, the physiologic data were essentially the same as those obtained shortly postoperatively, with an ejection fraction of 73% and a VCF of 1.6 circumferences/sec. His left ventricular end-diastolic pressure was slightly elevated at 15. Coronary cineangiography revealed his left internal mammary artery to be slightly larger with excellent run-off into the left anterior descending artery and in addition, for the first time, large collaterals were noted to the distal right coronary artery with filling up to its proximal third where it was totally occluded. Injections of the native right coronary artery showed occlusion in the proximal third at the site of the minor lesion noted preoperatively. However, there was no electro-
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Table I
Sudden Death in a Marathoner
123
cardiographic evidence of infarction and biplane left ventricular cineangiography revealed no segmental abnormalities [2]. Currently, he runs 6-7 miles a day, occasionally 10 miles. This past year he has run in six races, 5-8 miles in length, limiting himself to somewhat shorter races because of bad knees. He has had no chest pain and works full time at the post office. This normotensive, lean, athletic gentleman has a fasting blood sugar of 95, a cholesterol of 185, triglycerides of 125 and normal serum lipoproteins. He does not drink or smoke and is on no medications. He does admit to chewing tobacco. Family history is negative for coronary artery disease. Physical examination is unremarkable. Chest X-ray is normal and his electrocardiogram remains normal.
Discussion
This remarkable gentleman indicates that sudden death is possible in spite of the ability to run the marathon, having run it several times in the past 2 years and regular running of approximately 70 miles a week. Fortuitously, his wife saved his life by bringing him to the Emergency Room at the time when he developed ventricular fibrillation. The internal mammary artery bypass has been successful in eliminating his arrhythmias and the excellent run-off into the distal left anterior descending artery has provided excellent flow into collaterals to the distal right coronary artery, thus avoiding muscle damage, consequent to the occlusion of his right coronary artery. Of note is that the right coronary artery proceeded to total occlusion in spite of little in the way of predisposing factors and excellent physical exercise. The functional capacity of the internal mammary artery to provide excellent flow in response to heavy demands is well illustrated in this marathoner.
1
2
VOGEL, J. H. K.; McFADDEN, R. B.; SPENCE, R.; JAHNKE, E. J., jr., and LOVE, J. W.: Quantitative assessment of myocardial performance and graft patency following coronary bypass with the internal mammary artery. J. thorac. cardiovasc. Surg. 75: 487-498 (1978). VOGEL, J. H. K.; CORNISH, D., and McFADDEN, R. B.: Underestimation of ejection fraction with single plane angiography in coronary artery disease. Role of biplane angiography. Chest 64: 217 (1973).
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References
VOGEL/McFADDEN/FISHER
124
Addendum
J. H. K. VOGEL, MD, Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, 351 South Patterson Avenue, Santa Barbara, CA 93111 (USA)
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In July he increased his running to 10-15 miles daily in preparation for the October Marathon. On the morning of 9-1-78 he collapsed after breakfast before his run. Although his ventricular fibrillation was corrected and CPR given, he never awoke and died 9-18-78. Postmortem examination revealed the internal mammary artery to be normal and widely patent. However, a new occlusion was noted in the circumflex coronary artery with acute lateral wall myocardial infarction.
Progressive Coronary Artery Disease with Sudden Death in a Marathoner: Results of Internal Mammary Artery Bypass Case Report
JOHN H.K. VOGEL, R. BRUCE Mc FADDEN, and GEORGE U. FISHER
This 64-year-old white male had been running the marathon for 2 years and had completed the Santa Monica Marathon on January 12, 1974 without difficulty. A rhythm strip at the end of that race was said to be normal. He had been running approximately 70 miles a week. On February 7, 1974 he was awakened with a nightmare, not associated with pain or other sensations. He fell asleep within a few minutes only to be awakened again. On the third occasion, some 15-20 min later, his wife took him to the Emergency Room whereupon, within 5 min, he developed ventricular fibrillation. During the next 2 h he had 14 episodes of ventricular fibrillation. With intravenous Lidocaine, Inderal, Pronestyl and intramuscular Quinidine it was possible to stabilize his rhythm with only paroxysmal ventricular tachycardia. He was transferred from Lompoc Hospital to the Goleta Valley Community Hospital where he underwent cardiac catheterization. Left ventricular enddiastolic pressure was normal, being 8 mm Hg, and stroke index was normal at 74 mllm 2 • However, his VCF was reduced to 0.56 circumferences/sec and systolic ejection fraction was 66% (table I). His anterolateral wall was hypokinetic. Coronary cineangiography revealed 90% segmental narrowing in the proximal third of the left anterior descending coronary artery. No collateralization was noted to the distal vessel. The diagonal and circumflex vessels appeared free of significant disease. A 30% localized obstruction was present in the proximal third of the right coronary artery. On February 9, 1974 the left internal mammary artery was anastomosed to the left anterior descending artery. The postoperative course was unremarkable and the arrhythmias were abolished. 10 days postoperatively, on February
Downloaded by: University of Cambridge 131.111.164.128 - 2/1/2019 9:14:32 AM
Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, Santa Barbara, Calif.
122
VOGEL/McFADDEN/FISHER
SEF,% EDV,mllm2 VCF, circumference/SEC
2/8/74 (pre) 2119/74 (post)
5/28/76
66 79 73
112 92 77
0.56 1.54 1.60
SI
LVEDP
74 74 56
8 12 15
19, 1974, he underwent repeat studies (table I). The ejection fraction had increased to 79% and the VCF to 1.54 circumferences/sec. The left internal mammary artery was widely patent with excellent run-off into the left anterior descending coronary artery. His end-diastolic volume was smaller, being 92 mllm2 compared to 112 preoperatively. He was started on a progressive exercise program, and on April 11, 1974 performed a normal, maximal treadmill stress test. He was able to run 7 miles an hour on a 20% grade without difficulty and without abnormalities on his electrocardiogram. Blood pressure response was normal and no abnormal sounds were noted on auscultation. He increased his exercise to 70 miles a week and in October of 1974 ran the Santa Barbara Marathon in 3 hand 59 min. An electrocardiogram immediately after the race was normal, as was his cardiovascular examination. His only problem was a 'bum' foot. On May 3,1976, a routine treadmill was positive electrocardiographically although he experienced no pain. He had been running in his usual routine without difficulty and without arrhythmias. Because of his desire to continue running it was recommended that he undergo recatheterization to determine the reason for the change in his exercise electrocardiogram. His resting electrocardiogram was normal. On May 21, 1976 he ran the 8-mile Dipsy Doodle in San Francisco in 68 min without difficulty. Thus, on May 28, 1976 he underwent restudy. At that time, the physiologic data were essentially the same as those obtained shortly postoperatively, with an ejection fraction of 73% and a VCF of 1.6 circumferences/sec. His left ventricular end-diastolic pressure was slightly elevated at 15. Coronary cineangiography revealed his left internal mammary artery to be slightly larger with excellent run-off into the left anterior descending artery and in addition, for the first time, large collaterals were noted to the distal right coronary artery with filling up to its proximal third where it was totally occluded. Injections of the native right coronary artery showed occlusion in the proximal third at the site of the minor lesion noted preoperatively. However, there was no electro-
Downloaded by: University of Cambridge 131.111.164.128 - 2/1/2019 9:14:32 AM
Table I
Sudden Death in a Marathoner
123
cardiographic evidence of infarction and biplane left ventricular cineangiography revealed no segmental abnormalities [2]. Currently, he runs 6-7 miles a day, occasionally 10 miles. This past year he has run in six races, 5-8 miles in length, limiting himself to somewhat shorter races because of bad knees. He has had no chest pain and works full time at the post office. This normotensive, lean, athletic gentleman has a fasting blood sugar of 95, a cholesterol of 185, triglycerides of 125 and normal serum lipoproteins. He does not drink or smoke and is on no medications. He does admit to chewing tobacco. Family history is negative for coronary artery disease. Physical examination is unremarkable. Chest X-ray is normal and his electrocardiogram remains normal.
Discussion
This remarkable gentleman indicates that sudden death is possible in spite of the ability to run the marathon, having run it several times in the past 2 years and regular running of approximately 70 miles a week. Fortuitously, his wife saved his life by bringing him to the Emergency Room at the time when he developed ventricular fibrillation. The internal mammary artery bypass has been successful in eliminating his arrhythmias and the excellent run-off into the distal left anterior descending artery has provided excellent flow into collaterals to the distal right coronary artery, thus avoiding muscle damage, consequent to the occlusion of his right coronary artery. Of note is that the right coronary artery proceeded to total occlusion in spite of little in the way of predisposing factors and excellent physical exercise. The functional capacity of the internal mammary artery to provide excellent flow in response to heavy demands is well illustrated in this marathoner.
1
2
VOGEL, J. H. K.; McFADDEN, R. B.; SPENCE, R.; JAHNKE, E. J., jr., and LOVE, J. W.: Quantitative assessment of myocardial performance and graft patency following coronary bypass with the internal mammary artery. J. thorac. cardiovasc. Surg. 75: 487-498 (1978). VOGEL, J. H. K.; CORNISH, D., and McFADDEN, R. B.: Underestimation of ejection fraction with single plane angiography in coronary artery disease. Role of biplane angiography. Chest 64: 217 (1973).
Downloaded by: University of Cambridge 131.111.164.128 - 2/1/2019 9:14:32 AM
References
VOGEL/McFADDEN/FISHER
124
Addendum
J. H. K. VOGEL, MD, Santa Barbara Heart and Lung Institute, Goleta Valley Community Hospital, 351 South Patterson Avenue, Santa Barbara, CA 93111 (USA)
Downloaded by: University of Cambridge 131.111.164.128 - 2/1/2019 9:14:32 AM
In July he increased his running to 10-15 miles daily in preparation for the October Marathon. On the morning of 9-1-78 he collapsed after breakfast before his run. Although his ventricular fibrillation was corrected and CPR given, he never awoke and died 9-18-78. Postmortem examination revealed the internal mammary artery to be normal and widely patent. However, a new occlusion was noted in the circumflex coronary artery with acute lateral wall myocardial infarction.
