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Although greater than in patients with stabilised coronary insufficiency, the risks of carrying out coronary arteriography during the period of a threatened infarction are still modest in the hands of an experienced team. In a series of 66 such investigations under these conditions over an 18 month period, there were no deaths as immediate sequelae. Three myocardial infarctions occurred, one of which was probably encouraged by ceasing the propranolol prior to arteriography. Analysis of the results confirms the frequency of lesions affecting all three trunks (47% of cases), the anterior descending branch being the most commonly affected. A collateral circulation was established in 23% of cases. Ventriculography was normal in one third of cases. The mean value for the ventricular ejection fraction was 0.57 over the entire series. In 58% of cases, all the arteriographic and ventriculographic criteria of operability were satisfied. It therefore appears that coronary arteriography is justifiable during the period of threatened infarction; it may be undertaken at an early stage if the angina does not respond to medical treatment. It is always best to carry it out several days after cessation of the pain where possible. The investigation may lead to urgent surgical intervention.

The 19 coronary patients studied were found to have a "normalised" rigidity k = dp/(dVP) identical to that of normal subjects, and a lowered instantaneous end-diast-lic compliance (dV/dP)TD. The increase in end-diastolic pressure is due to a small increase in end-diastolic volume, and brings about Starling's phenomenon to compensate for a diminution in contractility. The maximimum speed of shortening of the myocardium (VCFmax) shows up the baseline contractility, and appears to be more sensitive than the mean speed of myocardial shortening (VCF) and the ejection fraction.

A cine-angiographic study was carried out in eleven patients with major aortic incompetence, in two of whom there was an associated aortic stenosis. The ventricular end-diastolic volume is always greatly increased, disproportionately to the modest increase in end-diastolic pressure. The pressure-volume relationship during filling is therefore altered, and makes it possible for a normal end-diastolic compliance (dV/dP) TD to be preserved. The indices of contractility are markedly altered, despite the recent appearance of signs of poor tolerance. These findings argue in favour of a full haemodynamic investigation and of early corrective surgery.

Advantage may be taken of the hyperaemic response to the iodine contained in the contrast medium injected during coronary angiography to assess the functional value of the coronary tree using radioactive microspheres. This series comprises 73 selective coronary scans performed in the resting state (113 m In marked microspheres) and during the hyperaemic phase (99 m TC marked microspheres) in 70 patients. A positive hyperaemic response distal to severe truncular stenosis indicates a good distal arteriolar bed and collateral circulation for aorto-coronary bypass grafting. After aorto-coronary bypass (23 cases), the hyperaemic response gives an indication of the functional value of the revascularised myocardium. In 71% cases, the results correlate well with the measurement of the peroperative blood flow through the graft. It is usually positive when the bypass graft is implanted with good distal arterial run off.

Aneurysms of Valvsalva sinus unruptured into a cavity, but developing into the membranous and even muscular interventricular septum are exceptional. Two cases illustrating this fact are reported. In one of them, a massive mitral incompetence by elongated chordae tendinae related to the presence of a voluminous intra-septal pouch. Atrio-ventricular and intraventricular conduction disturbances were present in both patients. The interest of supra-valvar angiography which makes it possible to advise operation before the eventual rupture is underlined.

The findings at coronary arteriography and ventricular angiography in 52 patients with a restricted myocardial infarct were compared with those of 106 patients with acute coronary insufficiency and 100 with transmural infarcts. Certain features place restricted myocardial infarction in an intermediate category when compared with the two other syndromes. The percentage of coronary occlusions was significantly higher in transmural infarction (23.5%) and in restricted infarction (16.6%) than in acute coronary insufficiency 6.8%). Study of the vessel beyond a tight stenosis (greater than or equal to 75% was particularly effective in clearly separating the three groups. As a result, 63% of patients with coronary insufficiency, 40% of these with restricted infarcts, and only 23% of patients with a transmural infarct could be referred for surgery. Ventricular angiography showed a close relationship between restricted infarction and acute coronary insufficiency because ventricular function appeared normal or subnormal (localised hypokinesia) in 69% and 81% of cases respectively, compared with 4% of cases of transmural infarction. Restricted myocardial infarction appears to resemble coronary insufficiency, but shows elevation of enzymes and often more marked disease of distal vessels.

One hundred and fifty-nine patients with aortic valve disease (86 cases), mitral valve disease (58 cases) or mitral and aortic disease (15 cases) underwent a pre-operative haemodynamic study, including coronary arteriography either as a routine (age greater than 50 years) or because of chest pains. Coronary arteriography is easy to do during left heart catheterisation and nowadays carries minimal risk. In the cases of chest pains, it showed stenotic lesions of the coronary vessels in 22% of patients with aortic valve disease and in 35% of those with mitral disease. In the absence of angina, coronary arteriography showed no evidence of coronary artery disease in the cases of mitral regurgitation and of aortic valve disease. In contrast, it showed stenotic lesions in three cases of mitral stenosis. In the whole of the series, coronary artery disease proved a contra-indication to surgery in three cases, and was an indication for aorta-coronary by-pass grafting, in addition to valve surgery, in seven other cases. In the absence of angina, coronary arteriography has only a slight influence on the decision to operate. It does however give additional security, which justifies its routine use in patients over 50 years of age, particularly those with mitral valve disease.