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This study analyses the immediate outcome and the risk of recurrent restenosis in patients who, at the time of repeat coronary angioplasty for a first restenosis, had unstable (n = 50), 19%) or stable (n = 218, 81%) angina. Successful angioplasty was accomplished in 250 (93%) patients, 222 (89%) of whom had follow-up angiography. Mean time from initial to repeat angioplasty was shorter (P = 0.0002) and angiographic evidence of thrombus was commoner (P = 0.0001) in the unstable group. Major complications (coronary artery bypass grafting or myocardial infarction) were more frequent (P < 0.01) in the unstable group (6% vs 0.5%); no procedure-related deaths occurred. The angiographic rate of restenosis was significantly higher in the unstable group (61% vs 43%, P < 0.05). Despite this high rate of recurrent restenosis, most of the patients in both groups were either asymptomatic or had atypical chest pain at follow-up. Repeat coronary angioplasty, in patients with unstable angina, has a high primary success rate but a higher risk of acute complications than in patients with stable angina. The angiographic rate of restenosis was significantly higher in unstable than in stable patients; however, the clinical status of most patients was improved at follow-up.

Restenosis is the main complication of coronary angioplasty. Many experimental models have been developed over the last few years, reflecting very active research work in this field. The value of experimental models may be discussed under two headings: improvement in our understanding of the mechanisms of restenosis and the development of preventing strategies. The smooth muscle cell is the main cause of restenosis, experimental models having demonstrated a triple response which has been observed clinically: proliferation, migration to the intima and synthesis of the extracellular matrix. The mechanisms controlling this response are not fully understood, the most likely candidates being desendethelialisation, platelets and other circulating components of the blood, vasopressive hormones especially the renin-angiotensin system, growth factors and finally the degree of direct trauma to the smooth muscle cells. Experimental models also allow evaluation of therapeutic strategies elaborated to reduce the frequency of restenosis in clinical practice: three strategies are identifiable: systemic treatment, local treatment and genetic therapy. At the present time, none of these approaches has been clearly shown to be effective clinically though some positive results have been observed in the animal.

The ability to accurately estimate the severity of epicardial coronary stenoses is critical in the assessment of the immediate and long-term results of percutaneous transluminal coronary angioplasty (PTCA). We prospectively compared visual estimates, performed by experienced interventional cardiologists, with computerized quantitative angiographic measurements of stenosis severity in a group of patients (n = 305) before, immediately after and 6 months after PTCA. Before PTCA the visual estimate of the mean (+/- SD) percentage stenosis severity, 80.6 (+/- 9.7)%, was significantly (P < 0.001) higher than the equivalent value, 73.4 (+/- 11.1)%, obtained with use of quantitative angiography. Immediately after PTCA the visual estimate of the mean residual stenosis, 18.8 (+/- 12.3)%, was significantly (P < 0.0001) lower than the equivalent quantitative estimate, 37.4 (+/- 14)%. Additionally, the residual stenosis was more frequently (18% vs. 3%) classified as significant (> 50%) by quantitative angiography. At follow-up, quantitative measurements of stenosis severity showed a Gaussian distribution with a mean of 54.8 (+/- 21)%, whereas visual estimates had a bimodal distribution with populations greater than 70% and less than 50%. Visual estimates provide an inaccurate assessment of the immediate and medium term results of PTCA. Quantitative measurements suggest that the immediate results of PTCA are frequently misclassified as successful by the operator. Conversely, restenosis rates are underestimated by the operators suggesting that a more objective method must be used in trials to assess the impact of new therapies on the rate of restenosis.

This report summarises the authors' experience of 421 patients treated for a first restenosis by repeat conventional balloon angioplasty with a high 6 months angiographic follow-up (84%). The immediate results were significantly less than those obtained during the same period with initial angioplasty procedures (94.5% success and 0.9% complications without any deaths during the hospital period). The 39.9% recurrent restenosis rate, on the other hand, is the same as observed after a first procedure. The risk factors of a second restenosis seem to be different from those of a first restenosis. A shorter interval between the first and second angioplasty (< 3 months) was associated with a 55% risk of restenosis compared with only 36% when the interval was > 3 months. Two operative factors were associated with a high risk of recurrent restenosis: a maximum inflation pressure > 7 atm and > or = 3 balloon inflations. These results seem to be important and should be taken into consideration when deciding on the management of patients presenting with a first restenosis.

Objective: The aim of this study was to analyze the angiographic rate of recurrent restenosis in patients who underwent repeat coronary angioplasty for a first restenosis within 3 months or greater than 3 months after the first procedure., Background: Several studies that have examined risk factors for restenosis after coronary angioplasty have suggested that a short interval between a first angioplasty and a repeat procedure is associated with an increased risk for a second restenosis., Methods: Between January 1981 and December 1990, 423 patients underwent a repeat coronary angioplasty procedure because restenosis had occurred at the site of a successful first angioplasty procedure. The clinical characteristics, immediate outcome and angiographic rate of recurrent restenosis were compared in patients who underwent repeat dilation within 3 months (early redilation group, n = 77) or greater than 3 months (late redilation group, n = 346) after the first procedure., Results: The incidence of unstable angina at the time of the repeat procedure was significantly higher in the patients who underwent early redilation (42% vs. 8%, p = 0.0001). The procedural success rate (95%) and complication rate were similar in both groups. Follow-up angiography was performed in 86% of patients with an initially successful procedure. The incidence of restenosis was significantly higher in the group that underwent early redilation (56% vs. 37%, p = 0.007) and was similar in patients in this group who presented with stable (55%) or unstable (57%) angina., Conclusions: Rapidly recurring coronary stenoses have an extremely high rate of restenosis when again treated by coronary angioplasty, irrespective of the clinical presentation at the time of repeat dilation. The outcome in patients with early restenosis who have stable angina might be improved by delaying the repeat procedure.

The coronary vasodilator properties of isosorbide dinitrate are well established but the doses generally used (1,000-2,000 micrograms) are still empirical. We studied, with the use of quantitative coronary arteriography (CAESAR System), the response of smooth vessel segments (greater than 1.85 mm diameter), preconstricted with methylergometrine (400 micrograms i.v.), to intracoronary injections of graded doses (5-100 micrograms) of isosorbide dinitrate and the effects of these injections on systemic hemodynamic parameters in 10 patients undergoing diagnostic coronary angiography. Six further patients, in whom the injections of isosorbide dinitrate were replaced by equivalent volumes of normal saline, served as controls. Relative to the diameter 5 min after injection of methylergometrine, the diameter increased by a mean +/- SD of 9 +/- 7, 26 +/- 12, 33 +/- 15, 38 +/- 14, and 39 +/- 16% after injections of 5, 15, 60, 240, and 1,000 micrograms, respectively, of isosorbide dinitrate. After a cumulative dose of 80 micrograms, subsequent doses did not cause further significant increases in diameter. Injection of saline in the control group did not alter the coronary diameter. A significant fall in systolic arterial pressure, compared to the control group, occurred at a cumulative dose of 320 micrograms. The mean arterial pressure and heart rate were unchanged. Significant coronary vasodilation occurs with intracoronary doses of isosorbide much smaller than those currently employed. Cumulative doses of 320 micrograms or more cause systemic hemodynamic changes without producing additional coronary vasodilation. During interventional cardiac procedures, where systemic hypotension is undesirable, the use of smaller doses of intracoronary isosorbide dinitrate than currently employed may be feasible and should be investigated further.

To investigate the prognostic value of exercise-induced changes in R-wave amplitude and their relation to other exercise and angiographic variables, 303 consecutive patients who underwent maximal exercise testing and coronary angiography within 2 months of a first acute myocardial infarction were studied. R-wave amplitude at peak exercise increased or was unchanged in 159 patients (57.4%) and decreased in 118 (42.6%). Increased R-wave amplitude was significantly related to underlying 3-vessel disease (p = 0.0001), the extent of ST-segment depression on exercise (p = 0.0001), and the time to 1 mm ST depression (p less than 0.05). Follow-up information was available in 285 patients (86.4%) at a mean of 4 +/- 1.8 years. Death from cardiac causes occurred in 25 patients (9%); 18 (6.5%) developed recurrent myocardial infarction, and 32 (11.6%) developed angina. Variables with a predictive value for cardiac death were maximal exercise heart rate (p = 0.0005), occurrence of exercise-related supraventricular arrythmia (p = 0.02), and number of diseased vessels (p = 0.02). R-wave changes had no predictive value. No variable had a predictive value for recurrent infarction. Maximal exercise heart rate (p = 0.02) and increased R-wave amplitude (p = 0.0001) were significantly related to the occurrence of angina at follow up. Exercise-related R-wave increases were associated with the presence of angina at follow-up, but had no predictive value for cardiac death or recurrent infarction; their association with subsequent angina appears to reflect an association with more severe underlying coronary disease.

Background: Serotonin, released by aggregating platelets, may contribute to or cause myocardial ischemia by constricting epicardial vessels. Experimental studies suggest that this constriction is mediated by two distinct serotonin receptor subtypes: 5-hydroxytryptamine1-like (S1-like) and 5-hydroxytryptamine2 (S2)., Methods and Results: To determine the relative contribution of S1-like and S2 receptors to the vasoconstrictor effects of serotonin, we studied the effect of ketanserin (0.75 mg, intracoronary), a selective S2 receptor antagonist, on the constrictor response of human coronary vessels to intracoronary infusions of serotonin. In control patients (n = 7), serotonin (10(-4) mol/l) caused significant (p less than 0.05) constriction only in distal segments, which was significantly (p less than 0.05) inhibited by ketanserin. In stable angina patients (n = 8), serotonin (10(-4) mol/l) caused significant constriction in proximal (p less than 0.01) and distal (p less than 0.01) segments, which was significantly inhibited by ketanserin in proximal (p less than 0.05) but not distal (p = 0.30) segments. In patients with variant angina (n = 3), epicardial occlusion at the site of preexisting stenoses in proximal locations occurred at infused concentrations of 10(-6) (one patient) or 10(-5) (two patients) mol/l. The infusion of the same concentration of serotonin after ketanserin again caused epicardial occlusion., Conclusions: Our results suggest that functionally important S1-like receptors that mediate vasoconstriction exist in the epicardial vessels of patients with stable or variant angina. Their activation, either at hyperreactive sites in patients with variant angina or in the distal epicardial vessels of patients with chronic stable angina, may contribute to or cause myocardial ischemia when serotonin is released after the intracoronary activation of platelets.

The object of this study of 30 patients with an anomalous origin of the left circumflex coronary artery was to define the clinical and angiographic features of this condition and to assess its influence on morbidity and survival. The 30 patients were 24 men and 6 women with ages ranging from 29 to 76 years. An anomalous origin of the left circumflex coronary artery should be suspected when two angiographic signs are present: firstly, the visualisation of a spur of opacification in the 30 degrees LAO view of left ventriculography, present in 93% or our patients; secondly, during selective left coronary angiography in the transverse view, an ascular zone is observed where the normal left circumflex artery should be. Confirmation of the diagnosis depends on opacification of the left circumflex arising from the right anterior sinus of Valsalva with a separate (37%) or common (23%) orifice with the right coronary artery or arising from a proximal segment of the right coronary artery/(40%). Five patients (17%) had a significant stenosis of the anomalous left circumflex coronary artery but this was always associated with lesions of the other coronary narrowing was observed. Of these patients, one had electrocardiographic signs of myocardial ischaemia and no other cause apart from the anomalous origin of the left circumflex to explain this ischaemia. The 30 patients were followed up for an average of 6.1 +/- 3.9 years. During this period, 1 cardiac death, 1 infarction, 5 cases of angina, 4 coronary bypass procedures, and 6 coronary angioplasties were observed. Nine patients (30%) had no cardiac event during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1980 and 1990, 1,664 coronary angioplasty procedures were performed in 1,307 patients (86.6% male) with multivessel disease. The average age was 57 +/- 3 years (range 29 to 83 years). There was a previous history of infarction in 40.1% of patients and 22.4% of the procedures were performed for unstable angina. Catheter and 58.2%, 1,220 double vessel and 444 triple vessel diseases. A total of 2,509 lesions were dilated (1.5 stenoses/patient). The primary success rate was 81.9% with 3.2% of infarcts and 3.5% emergency bypass procedures and a global mortality of 2%. The factors responsible for death in the acute and hospital phases were unstable angina, age > 70 years, and ejection fraction < 35%. Complete revascularisation was achieved in 14.3% of cases: the only predictive factor for complete revascularisation on multivariate analysis was double vessel disease. A 6 months clinical and angiographic control was obtained for 83.8% of controllable procedures (965 dilatations). The restenosis rate was 47.9%. Univariate analysis of the factors of restenosis identified clinical parameters (age > 58 years, triple vessel disease, diabetes and unstable angina), parameters related to the lesion (length of stenosis > 1 cm, percentage stenosis > 80%) and to the procedure (residual stenosis > 20%): 68.4% of patients with restenosis underwent repeat angioplasty with a significantly superior primary success rate 88.7% vs 81.9% of global successes (p < 0.001). With a 82% primary success rate with few major complications, coronary angioplasty is a safe and effective therapeutic alternative. The extent of the lesions and the presence of chronic occlusion are the main limitating factors of revascularisation.(ABSTRACT TRUNCATED AT 250 WORDS)

The action of nitrate derivatives on the coronary arterioles is weak and very short lasting which avoids the phenomenon of a coronary steal syndrome. Investigations of the epicardial coronary vessels require vasoconstriction stress tests, usually using ergometrine, and vasodilatation tests, mainly using isosorbide dinitrate (ISDN). The combination of the two tests allows evaluation of global coronary vasomotricity which is less than 100% variation of diameter. In coronary spasm, ISDN relieves the stenosis in less than 2 minutes in nearly all cases. An infusion of ISDN also prevents most cases of arterial spasm. In effort angina, it has been possible to demonstrate paradoxal vasoconstriction during exercise due to endothelial dysfunction. The direct action of nitrate derivatives on smooth muscle which is not endothelium dependent, prevents the vasoconstriction and increases oxygen supply during exercise.

The coronary vasodilator properties of isosorbide dinitrate (ISDN) are well known but the dosage remains empirical. The aim of this study was to construct a dose-response curve to ISDN with respect to vasoconstriction induced by ergometrine. The heart rate, aortic pressure and coronary angiography were analysed before and 3 and 5 minutes after I.V. injection of 0.4 mg of methylergometrine and 3 minutes after intracoronary injection of 5, 15, 60, 240 and 1,000 micrograms of ISDN in 10 patients with an average age of 53.2 +/- 10.8 years (ISDN group). Six other patients with an average age of 56.5 +/- 12.8 years comprised the control group and only received ergometrine. The coronary diameters were measured by quantitative coronary angiography using the CAESAR system of automatic contour detection. Three coronary segments with angiographically normal appearances and a resting diameter greater than or equal to 1.85 mm were analysed in each patient. With respect to the maximal constriction observed 5 minutes after the injection of methylergometrine, the percentage increase in coronary diameter was 9 +/- 7%, 26 +/- 12%, 33 +/- 15%, 38 +/- 14% and 39 +/- 16% after 5, 15, 60, 240 and 1,000 micrograms of ISDN respectively (p less than 0.005 vs control). A plateau effect was observed after a cumulative dose of 80 micrograms and administration of higher doses of 240 and 1,000 micrograms only caused mild nonsignificant additional increase in vessel diameter. In comparison with the control group, the systolic blood pressure only fell significantly with doses greater than 240 micrograms of ISDN (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

In order to study the earliest phenomenons occurring in the arterial wall after balloon angioplasty, the level of expression of the proto-oncogenes, c-fos and c-myc, was studied in rabbit aorta after balloon denudation by using Northern blot analysis. Both c-fos and c-myc are rapidly and transitorily induced (maximal at 30 min and 2 h after mechanical injury for c-fos and c-myc respectively). By comparison, infusion of norepinephrine increases oncogene expression in normal non-denuded rabbit aorta after 1 h, but the combination of both mechanical and hormonal stimuli do not lead to a more important induction than balloon denudation alone.

The coronary stent has been investigated as an adjunct to percutaneous transluminal coronary angioplasty to obviate the problems of early occlusion and late restenosis. From March 1986 to March 1990, 265 patients (308 lesions) were implanted with the coronary Wallstent in 6 European centers. For this study, the patients were analyzed according to date of implantation (group 1, March 1986 to January 1988; group 2, February 1988 to March 1990) and vessel type (native arteries versus bypass grafts). Quantitative angiographic follow-up was performed in 82% of the study patients. The early in-hospital occlusion rate in the overall group was 15%. Group 1 patients had a 20% rate in contrast to 12% rate in group 2 (p = not significant [NS]). The early occlusion rate in native vessels and bypass grafts was 19 and 8%, respectively (p = 0.019). Restenosis was determined by 2 criteria (criterion 1, greater than or equal to 0.72 mm loss in minimal luminal diameter from poststent to follow-up; criterion 2, greater than or equal to 50% diameter stenosis at follow-up) within the stent and in the segments immediately proximal and distal to the stent. The restenosis rate with criterion 1 was 43% in the overall group of patients, 35% in group 1 versus 49% in group 2 (p = NS), and 34% in native vessels versus 54% in bypass grafts (p = 0.016). The second criterion was met by 27% of patients in the overall group, 21% in group 1 versus 32% in group 2 (p = NS), and 18% in native vessel versus 39% in bypass grafts (p = 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

This study reports the results from 3 European centers using rotary ablation with Rotablator, a device that is inserted into the coronary artery and removes atheroma by grinding it into millions of tiny fragments. Rotary ablation was performed in 129 patients. Primary success (reduction in percent luminal narrowing greater than 20%, residual stenosis less than 50%, without complications) was achieved by rotary angioplasty alone in 73 patients (57%). An additional 38 patients (29%) had successful adjunctive balloon angioplasty. Thus primary success was achieved in 111 patients (86%) at the end of the procedure. Acute occlusion occurred in 10 patients (7.7%). Recanalization was achieved by balloon angioplasty in 7: urgent bypass grafting was undertaken in 2. Q-wave and non-Q-wave myocardial infarction occurred in 3 and 7 patients, respectively. No deaths occurred. Follow-up angiography was performed in 74 patients (60%). Restenosis, defined as the recurrence of significant luminal narrowing (greater than 50%) occurred in 17 of 37 patients (46%) who underwent rotary ablation alone, and 11 of 37 patients (30%) who had adjunctive balloon angioplasty. The overall angiographic restenosis rate was 37.8%. In conclusion, rotary ablation is technically feasible, and relatively safe in the coronary circulation. The low primary success rate reflects the limited size of the device, which can be introduced through available guiding catheters, and limits the use of rotary ablation as a stand-alone procedure to lesions in small arteries or in distal locations. No reduction in restenosis was seen, but the role of this device combined with balloon angioplasty in larger arteries needs to be further defined.

The recurrence of angina-type pain within a few months of successful coronary angioplasty usually indicative of a diagnosis of coronary re-stenosis. A control coronary artery angiograph sometimes eliminates this diagnosis by detecting a fresh coronary stenosis. The authors report a case of a tight stenosis of the left major coronary trunk a few months after angioplasty of the circumflex artery. The onset of a stenosis of this type leads to the discussion of the possible role of a traumatic lesion of the wall of the major trunk by the catheter-guide.

The efficacy of nicorandil was compared with that of nifedipine in 13 patients with vasospastic angina enrolled in a randomized, placebo-controlled, crossover study. All patients had a coronary spasm during coronary arteriography, either spontaneously or ergometrine-induced. During two consecutive periods of 2 days, patients received active drugs or placebo in a randomized order. Each patient received single oral doses of 30 mg nicorandil, 10 mg nifedipine, and, on 2 days, a placebo. One hour after drug intake, patients underwent an ergometrine test with increasing doses of Methergin (ergometrine) (0.05, 0.10, 0.20, and 0.40 mg every 5 min). After placebo, the tests always were positive, and the ECG changes occurred at the same +/- 1 dose of ergometrine in 10 cases, showing good reproducibility. After nicorandil, the tests were negative in nine patients and positive for a higher or lower dose of ergometrine in three and one patient, respectively (p = 0.0034 vs. placebo). After nifedipine, the tests were negative in five patients and positive for a higher or the same dose of ergometrine in four and four patients, respectively (p = 0.0039 vs. placebo). Nifedipine (10 mg) and nicorandil (30 mg) were equally effective in eight patients; in the remaining five patients, nicorandil had better results (p = 0.06). Nicorandil (30 mg) prevents ergometrine-induced coronary spasm. This compound may be beneficial in patients with vasospastic angina.

To study the sequential changes of an atherosclerotic narrowing after repeated balloon dilatation, we reviewed the coronary angiograms of 11 patients who underwent at least 3 percutaneous transluminal coronary angioplasties of the same coronary segment for two restenoses. No significant changes in reference and stenosis diameters were found when comparing the three successive stenosis, but lesion length and stenosis area progressively increased. The identification of these morphological changes after repeated angioplasties may be of interest in the management of recurrent restenosis.

Background: Late angiographic narrowing has been observed following coronary implantation of the Wallstent. To identify the angiographic variables that predict restenosis within the stented segment, a retrospective study of data from the European Wallstent core laboratory was performed., Methods and Results: Follow-up angiograms (excluding patients with in-hospital occlusions) were analyzed for 214 lesions in 176 patients (78% restudy rate). The incidence of restenosis within the stented segment was 35% by lesion and 35% by patient for criterion 1 (greater than or equal to 0.72 mm loss in minimal luminal diameter) and 24% by lesion and 24% by patient for criterion 2 (diameter stenosis greater than or equal to 50% at follow-up). The association between 16 variables and restenosis was determined by a relative risk ratio assessment. Variables with significant risk ratios for restenosis with criterion 1 were use of multiple stents/lesion (relative risk, 1.56; 95% confidence interval [CI], 1.08-2.25) and oversized (unconstrained stent diameter exceeding reference diameter greater than 0.7 mm) stents (relative risk, 1.64; 95% CI, 1.10-2.45), and for criterion 2, oversizing by more than 0.70 mm (relative risk, 1.93; 95% CI, 1.13-3.31), bypass grafts (relative risk, 1.62; 95% CI, 0.98-2.66), use of multiple stents/lesion (relative risk, 1.61; 95% CI, 0.97-2.67) and residual diameter stenosis more than 20% post stenting (relative risk, 1.51; 95% CI, 0.91-2.50)., Conclusions: It is concluded that several angiographic variables are significantly associated with late angiographic narrowing after stenting in the coronary arteries. We suggest that stent operators avoid excessive oversizing in the selection of stent diameter and the use of multiple stents per lesion to lessen the risk of late restenosis.

To determine the procedural variables associated with eventual long term angiographic success in patients with recurrent restenosis, we compared two successive PTCAs on the same segment, in the same 16 patients, where the first led to recurrent restenosis but the second to successful long term angiographic result. A long interval since previous PTCA and low inflation pressure are associated with long term success after repeated PTCA; other procedural variables are not linked with long term outcome. This study may help us to predict long term success after a repeated angioplasty procedure.

A fiber-optic tip catheter has been developed for treating coronary and peripheral atherosclerosis percutaneously. The catheter is coupled to an ionised Argon laser emitting at an optical power of 1 to 7 Watts. It is designed to follow a guide wire and to perform tissue ablation by a new concept combining the effects of central vaporisation and peripheral thermal remodelling of the obstructed artery. This mode of function should considerably reduce the risks of false route previously encountered with laser angioplasty. The optical and thermic properties of the catheter prototypes were determined by physical methods. These experiments showed that the temperature of the metallic component of the catheter tip did not exceed 30 degrees C at a continuous power of 6 laser Watts when the flush was functioning. It attained 400 degrees C in the absence of the flush. The performances of the catheter were then tested in a number of in vitro experiments. First of all, the catheter tip was placed perpendicularly to atheromatous cadaver aortae to study the effect of vaporisation with respect to the laser power. The threshold of vaporisation was 1 Watt (irradiance: 1100 Watts/cm2). The catheter was then introduced into plastic tubes obstructed by atheromatous plaques. This experiment demonstrated the mechanical solidity of the catheter and its flexibility in difficult operating conditions: diameter 2mm, 45 degrees angles, irregular calcified plaques. It also showed that the optimal safety-efficacy laser power was 3 laser Watts and that the exposure times varied with respect to the nature of the plaques tested.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to identify the parameters of exercise stress testing with a predictive value of cardiac death after myocardial infarction and to determine their importance with respect to clinical and coronary angiographic data. Three hundred and three patients, average age 48.9 +/- 9.2 years, surviving primary myocardial infarction, underwent a symptoms-limited exercise stress test and coronary angiography four to seven weeks after infarction. The average follow-up period was 48 +/- 22 months. Eighteen patients (5.9%) were lost to follow-up. Global mortality was 11.6% (33/285) and cardiac mortality was 8.8% (25/285) including 14 sudden deaths (56%) and 17 deaths during the first three years of follow-up (68%). A univariable analysis identified the following parameters of exercise stress testing as predictive of cardiac mortality. The duration of exercise, the maximal rate-pressure product, inconclusive test, the maximal heart rate, and occurrence of supraventricular arrhythmias. Only the last two parameters remained significant after a discriminant analysis and their combination with clinical variables (age and ventricular fibrillation during the hospital phase) enabled accurate classification of 79% of patients, which was significantly better than when clinical features were used alone (p 0.01). On the other hand, adding the data of coronary angiography (number of diseases vessels, absence of an Ergometrine test) only moderately improved this score (82%, NS). This study suggests that the results of the post-infarction exercise stress test enables identification of patients with a low or, on the contrary, with a high risk of cardiac death. The prognostic value of this investigation is better than simple clinical evaluation, especially in stable or asymptomatic patients. In this selected group of patients, coronary angiography did not provide additional prognostic information.

The effect of intravenous streptokinase therapy on the time course of functional recovery was investigated in a controlled study of 64 patients randomized within 3 hours after the onset of acute myocardial infarction (AMI). Contrast ventriculography was performed 1 to 4 days after AMI and repeated 5 weeks later. Wall motion was analyzed by the centerline method in the central infarct, peripheral infarct and noninfarct regions. In patients with ventriculographic data at the early catheterization, streptokinase-treated patients had less severe hypokinesia in the central infarct region than control patients (-2.9 +/- 0.9 [n = 29] vs -3.4 +/- 0.7 standard deviations below normal [n = 21], p less than 0.05). The benefit of streptokinase was more marked in the peripheral infarct region (-1.5 +/- 0.7 vs -2.1 +/- 0.6, p less than 0.001). As a result, the ejection fraction was slightly higher in treated versus control groups (46 +/- 10 vs 43 +/- 7%, respectively; difference not significant). At 5 weeks, function in the streptokinase and control groups had diverged further because of continued improvement in the streptokinase-treated patients. This study shows that streptokinase benefits left ventricular (LV) function by 1 to 4 days after AMI, earlier than previously reported. The benefit was not limited to the peripheral infarct region, where ischemia might have been less severe, but was also seen in the central infarct region. The implication is that thrombolytic therapy can improve LV function during the period of myocardial stunning, while myocardial function is still recovering.

Background: The placement of stents in coronary arteries after coronary angioplasty has been investigated as a way of treating abrupt coronary-artery occlusion related to the angioplasty and of reducing the late intimal hyperplasia responsible for gradual restenosis of the dilated lesion., Methods: From March 1986 to January 1988, we implanted 117 self-expanding, stainless-steel endovascular stents (Wallstent) in the native coronary arteries (94 stents) or saphenous-vein bypass grafts (23 stents) of 105 patients. Angiograms were obtained immediately before and after placement of the stent and at follow-up at least one month later (unless symptoms required angiography sooner). The mortality after one year was 7.6 percent (8 patients). Follow-up angiograms (after a mean [+/- SD] of 5.7 +/- 4.4 months) were obtained in 95 patients with 105 stents and were analyzed quantitatively by a computer-assisted system of cardiovascular angiographic analysis. The 10 patients without follow-up angiograms included 4 who died., Results: Complete occlusion occurred in 27 stents in 25 patients (24 percent); 21 occlusions were documented within the first 14 days after implantation. Overall, immediately after placement of the stent there was a significant increase in the minimal luminal diameter and a significant decrease in the percentage of the diameter with stenosis (changing from a mean [+/- SD] of 1.88 +/- 0.43 to 2.48 +/- 0.51 mm and from 37 +/- 12 to 21 +/- 10 percent, respectively; P less than 0.0001). Later, however, there was a significant decrease in the minimal luminal diameter and a significant increase in the stenosis of the segment with the stent (1.68 +/- 1.78 mm and 48 +/- 34 percent at follow-up). Significant restenosis, as indicated by a reduction of 0.72 mm in the minimal luminal diameter or by an increase in the percentage of stenosis to greater than or equal to 50 percent, occurred in 32 percent and 14 percent of patent stents, respectively., Conclusions: Early occlusion remains an important limitation of this coronary-artery stent. Even when the early effects are beneficial, there are frequently late occlusions or restenosis. The place of this form of treatment for coronary artery disease remains to be determined.

Unlabelled: To improve the result of peripheral laser recanalization (less perforation with wider tunnels of vaporization), we used the technique of sapphire laser angioplasty. A Nd:YAG laser with continuous emission was connected to a catheter with a 600 mum fiber and a sapphire probe to its extremity (1.8-3 mm in diameter). Treatment was performed on 127 patients with severe stenosis or occlusion of peripheral arteries (iliac, femoral, or popliteal arteries). Recanalization was obtained in 102 cases (80%) and was further embellished by balloon dilatation. The rate of success decreased proportionally with the length of occlusions (93% for 3 cm, 33% for 15 cm and more). Most failures were due to wall perforation or wall entry of the probe; passage of the sapphire tip was rarely blocked by the occlusion. At follow-up, 26.4% of arteries were reoccluded after 2 months., In Conclusion: laser angioplasty with a sapphire tip can totally recanalize occluded arteries with low rate of failure and complications.

During the last few years several new instruments have been added to the armentarium of endovascular procedures. They are aimed at destroying atheromatous plaques and recalibrating the arteries. The plaque destruction techniques include atherectomy which may be directional (as with Simpson's Atherocath) and applicable only to very proximal vascular segments, or rotational, pulverizing the plaques with a bur. In this category are the flexible Auth's rotablator and Stack's transluminal extraction catheter (TEC) where planning is combined with extraction. To traverse complete occlusions, Kaltenbach's rotating guide increases the success rate, but its use must always be completed by conventional angioplasty. Vascular recalibration can be achieved by stents or heating balloons. Numerous types of stent are now available. The best known are the Medivent stent which is self-expansive and stents with expanding balloons, such as the Palmaz Schatz stent or the radio-opaque Wiktor stent made of tantalum. These stents require an important anticoagulant therapy. These technique have widened the limits of angioplasty by tackling stenoses that have long been regarded as inaccessible. They have also made it possible to treat a number of acute occlusions. On the other hand, none of them has yet proved effective in the prevention of restenosis.

The rotablator is a high-speed rotating ablative system developed to grind obstructing atheromatous material into fine particles. It consists of a rotating burr attached to a long, flexible driving shaft with a central flexible guidewire. The device rotates with a speed of 190,000 r.p.m. In this study, after appropriate pretreatment, the atherectomy system was positioned over the guidewire, the steerable guidewire advanced to beyond the stenosis, the abrasive burr positioned at the stenosis and the rotation commenced. The abrasive burr was advanced until a resistance was experienced and then, with back and forth motion, further advanced until passage of the stenosis was achieved. The procedure was repeated six to eight times until no further mechanical resistance was encountered. Patients were maintained on aspirin and nifedipine. With a burr size between 1.5 and 2 mm, in 32 patients in the right coronary artery, twelve patients in the left anterior descending artery and eight patients in the circumflex artery, an average increase in diameter from 0.52 +/- 0.28 mm to 1.27 +/- 0.37 mm was achieved with respective reduction in the stenosis from 80 +/- 11% to 47 +/- 17%. Balloon dilatation was subsequently carried out in 19 patients in 15 of whom residual significant stenosis was due to the use of an inadequately large burr. There were no deaths. During ablation, in six patients evanescent (of few seconds in duration), spontaneously-reversible AV-block developed probably due to embolization of particles into the sinus node artery. Two patients developed coronary spasm, three had acute occlusion with subsequent myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

This study analyses the long-term prognosis of 210 patients with coronary spasm documented at coronary angiography. All patients with a previous history of myocardial infarction or who had undergone coronary angioplasty were excluded. The average follow-up was 55 months and only 11 patients were lost to follow-up. The actuarial survival figures showed the 1 year, 2 year and 5 year survival rates to be 95, 92 and 89 per cent respectively. Extracardiac mortality was mainly related to smoking (lung cancer, laryngeal cancer, etc.) and was higher than cardiac mortality. More than half of the cardiovascular events (sudden death, myocardial infarcts) occurred during the first year of follow-up. Ten patients (4.7%) died suddenly. The predictive factors of this event were: previous syncopal episodes or syncopal angina due to coronary spasm, percritical arrhythmias and the documentation of multiple spasms at coronary angiography. Myocardial infarction was observed in 10.6 per cent of patients. Only those with significant coronary arterial lesions developed this complication. At the end of the follow-up period, 75 per cent of patients were asymptomatic or had only atypical chest pain. No significant differences were observed between the two groups treated medically, by aortocoronary bypass or by the association of coronary bypass and plexectomy with the exception of non-lethal myocardial infarcts being significantly less common in patients treated medically. Therefore, the long-term prognosis of patients with coronary spams is relatively satisfactory.

The significance of U-wave inversion during coronary arterial spasm was investigated in 188 consecutive ergometric tests performed in 69 patients. All patients had previously undergone coronary arteriography which had clearly shown coronary spasm either at rest or after a single 0.4 mg injection of ergometrine. The ergometrine tests were then performed at the patient's bedside using a standard protocol with injection of incremental doses of ergometrine: 0.05, 0.1, 0.2 and 0.4 mg every 5 minutes with 12-lead ECG recordings every minute. Fifty of the 59 patients with positive tests had classical signs of spasms: ST elevation or depression and/or T wave inversion; the other 9 patients had inversion of the U wave alone (2 cases) or associated with classical ST segment changes in the remaining cases. The 10 other patients had no ECG changes although 2 of them suffered typical anginal pain. Negative U waves were observed in 4 of the 12 patients with spasm of the left anterior descending artery, accompanied by ST elevation in the anterior wall leads. A negative U wave would appear to be a sign of less ischaemia than the classical ECG changes because anginal pain is less common: 4 out of 9 cases in which U wave inversion was a very early change, 8 out of 9 cases in which it was the first or only abnormality. The recognition of a negative U wave increases the sensitivity of the electrocardiogram during resting angina and allows earlier treatment of coronary spasm with nitrate derivatives after an ergometrine test.

Pulsus alternans was observed during transluminal coronary angioplasty of the left anterior descending artery in a 48 year old man. Analysis of left ventricular pressures (Millar catheter) showed alternation of the parameters of relaxation. After the strong beats there was a lengthening of the relaxation constant T (78.8 +/- 3.9 ms compared to 72.9 +/- 4.4 ms, p less than 0.001), a widening of the negative deflection of dp/dt without a significant variation in amplitude and the point of minimal diastolic pressure was delayed. The first weak beat occurred after the longest constant of relaxation T and the lowest negative deflection of dp/dt. Regression of pulsus alternans was accompanied by a progressive decrease of T and an increase in amplitude and narrowing of the negative deflection of dp/dt. The increase in the constant of relaxation T and widening of the negative dp/dt, more apparent after the weak beats, could be signs of left ventricular asynchronism.

Among the hypertrophic non-obstructive cardiomyopathies, a particular group of patients with concentric apical hypertrophy can be described. We studied seven patients (five men and two women) who underwent heart catheterization because they had giant negative T waves in the precordial leads. M-mode and two-dimensional echocardiograms revealed no obstruction within the outflow tract of the ventricle. Coronary angiography was normal in all cases. None of these patients demonstrated any significant peak systolic pressure gradient in the outflow tract. A characteristic spade-like configuration (concentric apical hypertrophy) was observed in the right anterior oblique ventriculogram at end diastole. The apical thickness reached 17.2 +/- 0.85 mm and was significantly greater than mid-anterior wall thickness (9.8 +/- 2.14 mm). In five cases, atrial pacing with coronary arterial and venous lactate sampling revealed abnormalities in myocardial metabolism. With a mean follow up of 43 months, three patients remain asymptomatic and one had heart failure. ECG abnormalities were unchanged and echocardiograms showed an increase of the septal and posterior wall thickness, suggesting a transformation in concentric diffuse hypertrophic cardiomyopathy.

Coronary arteriography remains the most precise clinical tool for diagnosis and therapeutical decision concerning patients with coronary artery disease; when performed during a short transient episode of myocardial ischemia, this investigation can afford interesting information. The first part of the paper describes the coronary arterial angiographic findings during ischemia related to increase in myocardial requirements. Thus, a vasoconstrictor reflex can decrease the area of narrowing during handgrip exercise. Other reports have described coronary arterial spasm during exercise in highly selected patients. Coronary arterial angiographic findings during transient decrease of coronary blood flow are described in the second part of this paper. They can rarely be detected spontaneously but most often are provoked. The results obtained with cold pressor, hyperventilation and ergonovine tests are discussed. In this latter provocative test, the incidence of spasm in a population of 2572 patients undergoing coronary angiography is described.

130 patients with recent transmural myocardial infarction were studied in order to evaluate changes in left ventricular compliance. Left heart catheterization and cineangiographic left ventriculography were performed. The modulus of chamber stiffness (K) was determined from the slope of the linear relation between volume stiffness (dP/dv) and pressure; the modulus of muscle stiffness was evaluated by the Laird index (asymptotic slope of logP vs log V). Patients were divided in 3 groups: Group A included 5 patients studied before and after myocardial infarction who experienced an increase in the modulus of chamber and muscle stiffness after infarction. Group B included 10 patients who were studied at the onset of infarct and 15 days later: this group demonstrated changes in LV compliance with, most often a rightwardshift of P-V curve in anterior infarct and inversely a leftward shift in posterior infarction. The 115 patients of Group B are roughly equally distributed in the areas of normal, increased or decreased compliance. Any correlation was found between the extent of asynergy and changes in modulus of chamber stiffness. However, ejection fraction or VCF were higher in patients with a reduction of compliance than in patients with an increase of compliance.

The methylergometrine test (ME) was performed during coronary angiography in 43 patients either by a single injection of 0,4 mg (34 cases) or by fractioned doses every 5 minutes of 0,1 mg, 0,2 mg, 0,3 mg, 0,4 mg (total 1 mg) (9 cases). Opacification of the coronary arteries was performed 1, 3 and 5 minutes after each injection; left ventricular pressures were recorded with a Millar catheter-tip transducer. The heart rate and first derivative of left ventricular pressure did not vary significantly after the 0,4 mg single dose ME. Left ventricular end systolic pressure rose by 11 p. 100 (p less than 0,001) and left ventricular end diastolic pressure from 18,3 to 23,1 mmHg (p less than 0,001). Myocardial oxygen consumption assessed by the TTI rose from 2873 +/- 896 to 3083 +/- 788 mmHg.s-1 .min (p less than 0,01), but myocardial contractility as assessed by the V max fell from 1,68 +/- 0,40 to 1,58 +/- 0,35 s-1 (p less than 0,001). The reduction in the calibre of the coronary lumen was identical after the single 0,4 mg dose and the 1 mg fractioned doses. In the later case, 50 p. 100 of the maximal response was observed after the first injection of 0,1 mg. After the single dose of 0,4 g ME the reduction in coronary lumen was very rapid over the first 3 minutes. Prolonged observation up to the 10th minute (7 patients) showed slight aggravation of the vasoconstriction between the 5th and 10th minutes, justifying an injection of a nitrate derivative before discontinuing surveillance. The vasoconstriction induced by ME seems to be within the physiological limits of vasoconstriction. The maximal overall decrease of the coronary diameter was 12,3 +/- 7,8 p. 100 and never exceeded 20 p. 100. There was a significant difference in the response of atheromatous patients in whom the vasoconstriction was greater in the presence of resting angina than in the absence of resting angina (16,4 +/- 8,7 p. 100 compared to 9,7 +/- 6,4 p. 100, p less than 0,01).

Left ventricular function during percutaneous transluminal coronary angioplasty was studied in 16 patients undergoing the procedure. All measurements were performed before and during the first episode of balloon coronary occlusion. In 16 patients (Group A), data were recorded before and 30 or 50 s after balloon inflation, and in 8 of these patients (Group B) data were also recorded 15 min after the complete procedure. Left ventriculograms indicated a marked dyskinesia of the anterior and apical wall in all patients. After balloon inflation, there was a marked depression in stroke index and ejection fraction and an increase in left ventricular end-diastolic pressure and the time constants of relaxation in all patients. Simultaneous recording of left ventricular pressure (Millar micromanometer) during cineangiography permitted the assessment of myocardial and chamber stiffness. Although there was a strong tendency for both myocardial and chamber stiffness to increase after 30 to 50 s of occlusion, these increases were statistically insignificant. In Group B, a third set of angiographic and pressure measurements obtained 15 min after completion of the coronary angioplasty procedure indicated no residual left ventricular dysfunction, and in this respect, the results are of added clinical importance.

This study comprised 165 cases of coronary artery spasm (147 men and 18 women) with an average age of 49,2 years (range 27 to 73 years). Smoking was a particularly significant risk factor. Symptoms were usually of recent onset (80%) and dominated by attacks of angina pectoris either at rest alone or associated with angina of effort. 14% of cases of spasm were observed during acute myocardial infarction. Some cases presented with syncope due to cardiac arrhytmias. The basal electrocardiogramme was normal in 53% of cases. Exercise stress testing may be normal (30/65 cases) or positive (ST depression recorded in 26/65 cases). In 5 cases, ST elevation was observed. Left ventricular function was usually normal: 115 patients (70%) had organic atherosclerotic lesions, with 1, 2 and 3 vessel disease in 40%, 18% and 22% respectively. Spasm was spontaneous in 24,2% of cases but most commonly provoked by ergometrine. Criteria of spasm only applied to focal spasm and exclused catheter--induced spasm. The most common site of spasm was the right coronary artery (50,3% of cases), followed by the left anterior descending (31% of cases) and left circumflex (10,3% of cases). The outcome of these 165 cases depended on the therapeutic options (surgical treatment in 48 cases). The medium term results were generally good with a low mortality rate and follow up showed that the calcium antagonists provided effective prophylaxis against recurrence of spasm.

The purpose of this study was to assess the early changes in stenosis geometry after insertion of intravascular stents in human coronary arteries. Morphologic changes were evaluated by quantitative coronary angiography (using automated edge detection) and by calculation of the theoretical pressure decrease across the dilated and stented stenosis from the Poiseuille and turbulent resistances assuming a coronary blood flow of either 1 or 3 ml/s. Twenty-six patients were studied before and after angioplasty, as well as immediately after stent implantation. The stented coronary artery was the left anterior descending artery in 19 cases, the circumflex artery in 2 cases, the right coronary artery in 2 cases and a coronary artery bypass vein graft in 3 cases. After stent implantation, an additional increase in minimal luminal cross-sectional area of the dilated vessel was observed, suggesting that the self-expanding stainless steel endoprosthesis used in this study has a dilating function in addition to its stenting role.

The hypothesis has been developed that increased coronary artery vasomotor tone superimposed on a preexisting obstruction is a possible mechanism responsible for resting and exertional angina. In 18 patients (22 stenotic lesions), the maximal changes in coronary artery diameter (mm) induced by an ergometrine test followed by an injection of isosorbide dinitrate were assessed by a quantitative computer-based angiographic system. If we assume that there is no change in the length of the artery as the result of changes in its diameter, then at any point of the artery the area of the arterial wall on a transverse cross section of the vessel will be constant regardless of its state of its contraction or dilatation. As vasoconstriction occurs, the luminal diameter decreases proportionally more than the outer diameter of the vessel and the wall thickness increases. Using elementary geometric principles, we calculated and reconstructed the changes that might occur at the stenotic sites as the result of vasomotion acting on the entire coronary segment. From the reference diameter in the control state (Ri:3.7 +/- 1.1 mm) and after vasoconstriction (Ric: 3.3 +/- 1.0 mm) and the obstruction diameter in the control state (ri: 2.2 +/- 0.9 mm), the minimal obstruction diameter after vasoconstriction (ric: 1.0 +/- 0.8 mm) was derived using the following equation: ric2 = ri2 - Ri2 + Ric2. In four of 22 lesions, the decrease in diameter of the lumen of the normal vessel was fully translated to the stenotic point and the decrease in diameter at the stenosis was correctly predicted.(ABSTRACT TRUNCATED AT 250 WORDS)

Since the introduction of intracoronary thrombolysis in the acute phase of myocardial infarction, all workers have observed a high incidence of coronary reocclusion (about 20%) essentially in the first hours and days after coronary recanalisation (CR). This had led to some groups carrying out transluminal coronary angioplasty (TCA) at the same time as CR by thrombolysis in situ to treat significant residual postthrombolysis stenosis. This french multicentre study carried out in 5 centres concerned 9 men (average age: 46.1 years) with 5 anterior infarcts (total thrombosis of the LAD artery) and 4 inferior infarcts (total thrombosis of the right coronary artery-RCA). Intracoronary trinitrate was ineffective in relieving the occlusion in all cases. In 5 cases, the thrombolytic protocol was streptokinase (SK) 3 000 u/min for 60 minutes; in the other 4 cases, the plasminogen-urokinase (Pg-UK) protocol was used. Thrombolysis was successful in all 9 cases. The results of TCA performed at the same time were also good (8/9 successes; 4 LAD and 4 RCA) without any complications during the procedure. There was only one immediate post-TCA reocclusion on a LAD artery. In all cases the initial ECG appearances of infarction remained, CR only appearing to prevent extension of the necrosis. The successful results of CR + TCA were maintained in 6 out of 7 patients reinvestigated 2 days to 6 months (average 6 months) after the initial procedure: the only case of reocclusion occurred after 48 hours on a RCA. The overall procedure never exceeded 2 hours.

Percutaneous coronary rotational angioplasty was attempted in 12 patients. The procedure was performed with a flexible rotating shaft with an abrasive tip, varying in diameter from 1.25 to 3.5 mm, tracking along a central guide wire. Among the 12 patients (mean age 58 years), 4 had a stenosis in the left anterior descending coronary artery and 8 a stenosis in the right coronary artery. After the guide wire crossed the stenosis, the abrasive tip was slowly advanced and several passes across the stenosis were made. The residual stenosis was measured with computerized automatic quantitative coronary angiography. Success was defined as a reduction of percent stenosis by greater than 20%. If residual stenosis remained significant (greater than 50%), the procedure was completed by balloon dilation. The device could not be inserted in 2 of the 12 patients. Five of the 10 patients underwent rotational angioplasty alone, and 5 had the procedure completed by balloon dilation. The stenosis was significantly enlarged from 0.56 +/- 0.31 mm to 1.26 +/- 0.28 mm. The outline of the vessel appeared smooth and regular. There were no complications related to the procedure and all patients were free of symptoms when discharged 2 to 3 days after the procedure. Thus, coronary rotational angioplasty is a simple and safe procedure allowing marked dilation of the narrowed segment. However, long-term follow-up is required for further evaluation.

Among 868 patients with successful percutaneous transluminal coronary angioplasty (PTCA), 437 were restudied angiographically and had a provocative test with ergonovine during coronary angiography performed before and 6 months after the procedure. The relation between provoked coronary artery spasm and restenosis was studied and 4 groups of patients were analyzed. Those in group 1 (n = 63) had spasm before and after PTCA and their rate of restenosis was high (55%), especially when spasm after PTCA was observed on the dilated coronary segment (restenosis rate 58%). Patients in group 2 (n = 78) had spasm before PTCA but without abnormal vasoconstriction at 6 months and their incidence of restenosis was 19%. Sixty-one patients in group 3 had no spasm before PTCA but developed spasm at restudy. The rate of restenosis was high (38%) in this group, especially when the spasm after PTCA was located on the dilated segment (43%). In group 4 (n = 235), patients had no spasm before or after PTCA and the restenosis rate was 20%. Thus, the presence of coronary artery spasm on the dilated coronary segment, 6 months after a successful PTCA, is frequently accompanied (43% in group 3 and 58% in group 1) by restenosis.

This study compares the results of percutaneous transluminal coronary angioplasty in a group of 132 patients (group A) with fixed atherosclerotic narrowing (no spontaneous or ergonovine-provoked spasm) and in a group of 97 patients (group B) with dynamic coronary stenosis (spasm superimposed on the stenosis). All these patients underwent complete follow-up angiography. The rate of restenosis (defined as a loss of 50% of the initial gain) was significantly higher in patients in group B (dynamic coronary stenosis) than in group A (fixed narrowing) (35 versus 22%, p less than 0.05). Despite treatment with a calcium antagonist, coronary artery spasm persisted in 44% of the patients in group B and was detected for the first time in 15% of the patients in group A. Thus, in patients with dynamic coronary stenosis, the results of coronary angioplasty were less satisfactory than in patients with fixed narrowing, and in both groups coronary artery spasm was frequently (64%) superimposed on the restenosis.