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Background: The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis.Methods: We conducted a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.Results: The rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis (overall P=0.004). The adjusted hazard ratio for the occurrence of the primary end point for repeated thrombolysis versus conservative therapy was 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69), as compared with adjusted hazard ratios of 0.43 (95 percent confidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95 percent confidence interval, 0.28 to 0.79; P=0.004) for rescue PCI versus conservative therapy. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05).Conclusions: Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between hematological inflammatory signs, cardiovascular risk (CV) factors and prognosis in patients presenting with acute myocardial infarction (AMI) and coronary artery ectasia (CAE)., Design: We investigated 3321 AMI patients who required urgent primary percutaneous intervention in two centres in the United Kingdom between January 2009 and August 2012. Thirty patients with CAE were compared with 60 age- and gender-matched controls. Blood was collected within 2 h of the onset of chest pain. CV risk factors were assessed from the records. Major acute cardiac events and/or mortality (MACE) over 2 years were documented., Results: CAE occurred in 2.7% and more often affected the right (RCA) (p = 0.001) and left circumflex artery (LCx) (0.0001). Culprit lesions were more frequently related to atherosclerosis in non-CAE patients (p = 0.001). Yet, CV risk factors failed to differentiate between the groups, except diabetes, which was less frequent in CAE (p = 0.02). CRP was higher in CAE (p = 0.006), whereas total leucocyte, neutrophil counts and neutrophil/lymphocyte ratio (N/L ratio) were lower (p = 0.002, 0.002 and 0.032, respectively) than among non-CAE. This also was the case in diffuse versus localised CAE (p = 0.02, 0.008 and 0.03, respectively). The MACE incidence did not differ between CAE and non-CAE (p = 0.083) patients, and clinical management and MACE were unrelated to the inflammatory markers., Conclusion: In AMI, patients with CAE commonly have aneurysmal changes in RCA and LCx, and their inflammatory responses differ from those with non-CAE. These differences did not have prognostic relevance, and do not suggest different management.

We describe the case of a 48-year-old patient who presented with an out-of-hospital cardiac arrest due to an acute ST-elevation myocardial infarction. Left ventriculography performed during the initial coronary angiography revealed the presence of structural abnormalities in the myocardial wall which subsequently, with the use of contrast echocardiography and cardiac magnetic resonance imaging, were confirmed to represent ventricular clefts. We reviewed the pathophysiological significance of these defects and compared them with similarly looking abnormalities such as aneurysms, pseudoaneurysms, and diverticula. In conclusion, recognition of ventricular clefts is needed to allow clinicians to differentiate them from other myocardial wall defects with different pathological profile and clinical significance. .

Coronary artery ectasia (CAE) is defined as localized coronary dilatation, which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. The pathophysiology of CAE remains unclear as its relationship with atherosclerosis remains only modestly established. The histological variances and conflicting reports of the role of traditional cardiovascular risk factors, also, weakens the significance of such association. The slow coronary flow (CSF) of CAE may lead to ischemic and thrombotic events, a mechanism that has never been fully elucidated, but may play a fundamental role in its pathogenesis. While pure, non-atherosclerotic, CAE is believed to have better prognosis when compared to atherosclerotic obstructive CAE, it is thought that CAE is not a simple condition but rather has an adverse clinical course. Nevertheless, long-term prognosis and outcome of CAE is similar to atherosclerotic-non-CAE. Since CAE was first described, oral anticoagulants have been considered as a valid treatment option. Dual antiplatelet therapy is widely employed in acute coronary syndrome (ACS), which also applies to CAE patients presenting with ACS. However, there is a significant uncertainty about the best treatment strategy for CAE in acute myocardial infarction. We hereby report a variety of presentations of CAE complicated with ST elevation myocardial infarction (STEMI). Pathophysiological and anatomical varieties of ectatic coronary culprit lesions represent clinical challenges in uniformly managing this condition. Our review is unique in critically showing the pathophysiology, available controversial evidence upon management and prognostic features of CAE with STEMI.

A 53-year-old man presented with cardiac tamponade due to direct invasion of left atrium by a large cell neuroendocrine metastatic lung adenocarcinoma. Direct invasion of left atrial cavity by this type of lung tumour is rare. When cardiac involvement is suspected, two-dimensional echocardiography is the first-line diagnostic tool. Computerized tomography and magnetic resonance imaging can provide additional anatomical information and, as in this case, further delineation of the relation between intracavity masses and normal structures, including the mural site of attachment and tumour extension.

Objective: To report our experience with a new thrombectomy device (X-SIZER(TM)) in patients with angiographically visible thrombus or total coronary occlusion in the setting of acute coronary syndromes., Design: A safety and feasibility study in the use of the X-SIZER during intervention in patients with acute coronary syndromes., Patients: 35 patients, age range 31 to 83 years (mean 60)., Setting: University Hospitals of Coventry and Warwickshire NHS Trust (tertiary referral centre)., Interventions: The indication for intervention was primary or salvage percutaneous coronary intervention for acute myocardial infarction in 17 of the 35 patients; unstable angina or non-ST-elevation myocardial infarction in 10; and unstable postinfarct angina in eight. Abciximab was given in 11 patients., Main Outcome Measures: Device success (successful deployment of the device at the site of the lesion with resultant improvement in TIMI flow); clinical success (no residual stenosis at the end of the procedure with no in-hospital major adverse coronary events)., Results: Successful use of the device was achieved in 26 of the 35 cases. It failed to cross the lesion in five and failed to improve TIMI flow despite crossing the lesion in four. Clinical success was achieved in 30 of the 35 cases. Device related complications occurred in two cases (vessel perforation) and there was one intraprocedural death (acute myocardial infarction with cardiogenic shock)., Conclusions: Thrombectomy with the X-SIZER catheter system appears promising in percutaneous coronary intervention where thrombus extraction is considered necessary before stent implantation.

We report the case of a 60-year-old female with a history of hypertension who was admitted with an acute inferior myocardial infarction. She received rescue percutaneous transluminal coronary angioplasty/stenting of an occluded right coronary artery for failed thrombolysis with a good initial result. However, this was immediately complicated by cardiogenic shock characterized by left ventricular outflow tract (LVOT) gradient. She was treated with intravenous fluids and adrenaline. Predischarge echocardiography showed no LVOT gradient and features of left ventricular hypertrophy that mainly affected the septum.

Objectives: To evaluate patient characteristics and utilisation of invasive cardiac procedures in a UK ethnic population with unstable angina pectoris (UAP)., Design: Retrospective, observational study., Setting: Tertiary referral cardiology centre in the United Kingdom serving a large Asian ethnic population., Subjects: White and Asian patients undergoing PTCA for UAP over a 2.5-year period at a UK referral cardiology centre from a comprehensive PTCA database. Data were also collated for all emergency admissions with unstable angina, or angina (type unspecified), to our institute., Main Outcome Measures: Demographic and angiographic characteristics of patients undergoing PTCA. Frequency of usage of invasive cardiac procedures was determined in emergency angina admissions., Results: From January 1997 to July 1999, 435 White and 36 Asian patients underwent PTCA for UAP at our institute. Asian patients were on average 4.4 years younger (P=0.015), had 19.3% more diabetes (P=0.003) and 19.7% less smoking (P=0.007). Trends to more single vessel disease in Whites and more double vessel disease in Asians were observed, with similar rates of triple vessel disease. Interestingly, Asians also had trends towards more left-sided coronary artery disease and revascularisation, smaller vessels and less bail-out stenting. Asian patients were significantly less likely to undergo coronary angiography, OR 0.64 (CI 0.45-0.91, P=0.012), during the index admission, and showed a trend to less PTCA., Conclusions: Asian patients with unstable angina pectoris appear to have clinical and angiographic differences from their White counterparts, and are less likely to have invasive cardiac procedures deployed. The reasons for these observations require elucidation and the prognostic significance of these findings is uncertain.

Objective: To compare early complication rates in unselected cases of coronary artery stenting in patients with stable v unstable angina., Setting: Tertiary referral centre., Patients: 390 patients with stable angina pectoris (SAP) and 306 with unstable angina (UAP). Patients treated for acute myocardial infarction (primary angioplasty) or cardiogenic shock were excluded., Interventions: 268 coronary stents were attempted in 211 patients (30.3%). Stents used included AVE (63%), Freedom (14%), NIR (7%), Palmaz-Schatz (5%), JO (5%), and Multilink (4%). Intravascular ultrasound was not used in any of the cases. All stented patients were treated with ticlopidine and aspirin together with periprocedural unfractionated heparin., Results: 123 stents were successfully deployed in 99 SAP patients v 132 stents in 103 UAP patients. Failed deployment occurred with nine stents in SAP patients, v four in UAP patients (NS). Stent thrombosis occurred in four SAP patients and 11 UAP patients. Multivariate analysis showed no relation between stent thrombosis and clinical presentation (SAP v UAP), age, sex, target vessel, stent length, or make of stent. Stent thrombosis was associated with small vessel size (p < 0.001) and bailout stenting (p = 0.01) compared with elective stenting and stenting for suboptimal PTCA, with strong trends toward smaller stent diameter (p = 0.052) and number of stents deployed (p = 0.06). Most stent thromboses occurred in vessels < 3 mm diameter., Conclusions: Coronary artery stenting in unstable angina is safe in vessels >/= 3 mm diameter, with comparable initial success and stent thrombosis rates to stenting in stable angina.

New lesions appearing during coronary angioplasty may be due to a number of causes including spasm, dissection, embolisation, thrombosis and creation of a pseudo-lesion. The term "coronary pseudo-lesions" has been given to describe artefactual lesions occurring during percutaneous transluminal coronary angioplasty and induced by the angioplasty guide-wire and/or balloon as a result of straightening of the vessel's curvature. No specific treatment is required as they resolve completely on removal of the angioplasty wire. Few modern texts of interventional cardiology contain description of this important phenomenon and we suspect that they pass largely unrecognised. All angioplasty operators should become familiar with this complication as failure to do so may lead to inappropriate intervention with attendant increase in risk to the patient. We report three cases of coronary pseudo-lesion. In two cases affecting the right coronary artery and in the third the left anterior descending coronary artery. Pseudo-lesions affecting the right coronary artery have been previously reported in the literature however pseudo-lesion affecting the left anterior descending artery has not been described. The possible mechanisms of this phenomenon and its management are discussed.

A 30 year old man had an acute anterolateral myocardial infarction following which he developed unstable angina requiring percutaneous transluminal coronary angioplasty. He subsequently developed further angina with recurrence of coronary artery lesions that were reversed by intracoronary nitrate. A diagnosis of prinzmetal (vasospastic) angina was made and this had been the apparent cause of his myocardial infarction. He was treated with a calcium antagonist and an oral long acting nitrate with resolution of symptoms. He remained well and symptom free, and was reviewed in the outpatient clinic six weeks after discharge without problems.

Background: Unfractionated heparin and its low molecular fragments possess antiproliferative effects and have been shown to reduce neointimal smooth muscle cell migration and proliferation in response to vascular injury in experimental studies., Objectives: The specific objective of the REDUCE trial was to evaluate the effect of a low molecular weight heparin on the incidence and occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty., Methods: The REDUCE trial is an international prospective, randomized, double-blind, multicenter study. Twenty-six centers in Europe and Canada enrolled 625 patients with single lesion coronary artery obstructions suitable for PTCA. Three hundred and six patients received reviparin as a 7000 U bolus before PTCA followed by 10,500 U as an infusion over 24 hours and then twice a day 3500 U s.c. application for 28 days. The 306 patients in the control group received a bolus of 10,000 U unfractionated heparin followed by an infusion of 24,000 U over 24 hours. These patients then received 28 days of s.c. placebo injections. The primary endpoints were efficacy (defined as a reduction in the incidence of major adverse events, i.e., death, myocardial infarction, need for reintervention or bypass surgery), absolute loss of minimal luminal diameter, and incidence of restenosis during the observation period of 30 weeks after PTCA., Results: Using the intention-to-treat analysis for all patients, 102 patients (33.3%) of the reviparin group and 98 patients (32%) of the control group have reached a primary clinical endpoint (relative risk = 0.98; 95% confidence limit, 0.88-1.09; p = 0.707). Likewise, no difference in late loss of minimal luminal diameter was evident for either group. Acute events within 24 hrs occurred in 3.9% of the reviparin group and in 8.2% of the control group (relative risk = 0.49; 95% confidence limit, 0.26-0.92; p = 0.027) during or immediately after the initial procedure. In the control group, 8 major bleedings occurred, and in the reviparin group, 7 major bleeding complications were observed within 35 days after PTCA., Conclusions: Reviparin use during and after coronary angioplasty did not reduce the occurrence of major clinical events or the incidence of angiographic restenosis over 30 weeks.

Objectives: The specific objective of the REDUCE trial was to evaluate the effect of low molecular weight heparin on the incidence and occurrence of restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA)., Background: Unfractionated heparin and its low molecular weight fragments possess antiproliferative effects and have been shown to reduce neointimal smooth muscle cell migration and proliferation in response to vascular injury in experimental studies., Methods: The REDUCE trial is an international prospective, randomized, double-blind, multicenter study. Twenty-six centers in Europe and Canada enrolled 625 patients with single-lesion coronary artery obstructions suitable for PTCA. Three hundred six patients received reviparin as a 7,000-U bolus before PTCA, followed by 10,500 U as an infusion over 24 h and then twice-daily 3,500-U subcutaneous application for 28 days. The 306 patients in the control group received a bolus of 10,000 U of unfractionated heparin followed by an infusion of 24,000 U over 24 h. These patients then underwent 28 days of subcutaneous placebo injections. The primary end points were efficacy (defined as a reduction in the incidence of major adverse events [i.e., death, myocardial infarction, need for reintervention or bypass surgery]), absolute loss of minimal lumen diameter and incidence of restenosis during the observation period of 30 weeks after PTCA., Results: Using the intention to treat analysis for all patients, 102 (33.3%) in the reviparin group and 98 (32%) in the control group have reached a primary clinical end point (relative risk [RR] 1.04, 95% confidence interval [CI] 0.83 to 1.31, p = 0.707). Likewise, no difference in late loss of minimal lumen diameter was evident for both groups. Acute events within 24 h occurred in 12 patients (3.9%) in the reviparin group and 25 (8.2%) in the control group (RR 0.49, 95% CI 0.26 to 0.92, p = 0.027) during or immediately after the initial procedure. In the control group, eight major bleeding complications occurred, and in the reviparin group, seven were observed within 35 days after PTCA., Conclusions: Reviparin use during and after coronary angioplasty did not reduce the occurrence of major clinical events or the incidence of angiographic restenosis over 30 weeks.

We report on the development of features of the postpericardiotomy syndrome following coronary perforation during balloon angioplasty, in a patient that was managed conservatively. The case illustrates that while cardiac tamponade does not invariably follow coronary perforation, late consequences derived from this complication may occur. It also widens the spectrum of conditions where the postpericardiotomy syndrome has been observed.

Objective: To assess the sensitivities of Doppler indices to changes in global cardiac function during and after controlled myocardial ischaemia induced by coronary angioplasty., Design: Continuous wave Doppler signals of aortic flow were recorded during coronary angioplasty. The following Doppler indices of cardiac function were measured before, during, and after balloon inflation: V (peak velocity), MA (mean acceleration), V2/T (T = time from onset to peak ejection), and MD (minute distance corrected for baseline heart rate)., Setting: A tertiary care cardiological unit in a university hospital., Patients: Sixteen patients undergoing coronary angioplasty of the left anterior descending coronary artery. Eight patients had multivessel disease., Main Outcome Measures: The primary outcome measures were planned before data collection began., Results: 12 patients showed a significant fall of three or more Doppler indices from their baseline values during balloon inflation. This occurred in all patients with multivessel disease. The Doppler indices V2 T, MD, V, and MA fell by 43.7%, 37.7%, 27.4%, and 23% respectively from their baseline values (p less than 0.0001). The relative sensitivities of the Doppler indices to ischaemia were V2/T greater than MD (p less than 0.02), MD greater than (p less than 0.001), and V greater than MA (p less than 0.01). The impairment of global left ventricular function resulting from brief balloon inflation during single vessel angioplasty was reversible in all the patients., Conclusions: The Doppler indices V2/T, MD, V, and MA are all sensitive, in order of magnitude, to falls in global cardiac function resulting from ischaemia. They may prove useful for assessing cardiac function during ischaemia in the clinical setting.

A theoretical formula for calculation of peak dP/dt was derived using parameters obtained from continuous wave Doppler echocardiography signals of aortic blood flow. The direct proportional relationship between the main variables of this formula and invasively measured peak dP/dt was validated in 20 patients undergoing routine diagnostic cardiac catheterization. Doppler signals of aortic flow were obtained simultaneously to invasive pressure recordings with a 2 MHz continuous wave transducer via the suprasternal echocardiographic window. The Doppler signals were recorded on magnetic tape and measurements were made with digital calipers by two independent, blinded observers. The following parameters were measured: peak velocity (V) and time from onset of ejection to peak velocity (T). V2/T, the variable of the derived formula, was calculated for each of the observer's measured parameters and showed a very high interobserver correlation. The two observers' measurements of each parameter were averaged for each patient and the resulting mean was used in calculating the V2/T and mean acceleration. 4. A good correlation of V2/T with invasively measured peak dP/dt was obtained. Our derived index of left ventricular function showed a higher correlation with peak dP/dt compared to other Doppler indices of ventricular function. V2/T may provide a noninvasive method for estimating peak dP/dt.

Up to 20% of patients undergoing successful coronary angioplasty have been shown to have a mild elevation of creatine kinase-MB (CK-MB). The purpose of this study was to investigate the relationship between clinical and angioplasty procedural variables and circulating markers for cardiac injury. We measured both CK-MB and totally cardiac-specific troponin inhibitory protein (Tn-I) in 22 patients immediately before and at an average time of 10 h 36 min following successful angioplasty. Of these patients 16 had stable angina, six had unstable angina and none had recent myocardial infarction. Four patients had minor complications associated with the procedure (prolonged chest pain, limited coronary artery dissection) but none of these patients had increases in either CK-MB or Tn-I. In two patients there was a mild increase in enzyme-activity assayed CK-MB but none of the 22 patients had significant elevation of mass-assayed CK-MB or cardiac-specific Tn-I. This study supports the view that no significant myocardial damage occurs as a result of successful coronary angioplasty irrespective of the stability of the coronary artery disease. This study confirms the known discrepancies between results obtained by immunoassay and immunoinhibition enzyme assay, due to the false-positive results which can be yielded by the latter technique.

A case of Ebstein's anomaly associated with chronic right heart failure, hepatosplenomegaly, and the haematological features of hypersplenism is presented. The haematological abnormalities were corrected after tricuspid valve replacement but recurred with the reemergence of clinical features of right heart failure.

The short and long term effects of successful percutaneous transluminal coronary angioplasty on left ventricular function, at rest and on exercise were investigated in 49 patients. Thirty-four had had no previous infarction (group 1) and 15 had (group 2). Technetium-99m gated blood pool images were obtained at rest and during exercise before, six weeks after, and a mean of fifteen months after successful angioplasty. Before angioplasty the mean (SD) ejection fraction fell significantly on exercise in both groups from 58 (10)% to 53 (13)% in group 1 and from 48 (10)% to 40 (16)% in group 2. This change was paralleled by a worsening wall motion score (from 0.6 (0.4) to 1.6 (1.2) in group 1 and from 2.3 (1.9) to 3.3 (2.4) in group 2). Six weeks after the procedure there was little change in resting ejection fraction but it increased significantly on exercise (to 62 (11)% in group 1 and to 53 (13)% in group 2). There was a concomitant significant improvement in the exercise wall motion score (to 0.4 (0.6) in group 1 and to 1.8 (1.1) in group 2). This improvement in exercise ejection fraction and wall motion was maintained at later follow up with no significant deterioration in either variable and a clearly sustained improvement in ejection fraction (60 (10)% in group 1 and 51 (10)% in group 2) and wall motion score (0.2 (0.2) in group 1 and 1.3 (0.8) in group 2) compared with values before angioplasty. The initial improvement in left ventricular function on exercise after successful angioplasty was maintained for at least 9-24 months both in patients with previous myocardial infarction and in those without.

We have developed a low cost, clinically usable system for the objective assessment of the severity of coronary artery stenoses from single view angiograms. The system is based on a desktop computer with incorporated frame grabber. Images are captured by means of a video camera. The user selects a region of interest which encompasses the stenosis. Facilities are provided for automatic or manual definition of the artery centre line and edges. The computer then calculates the artery diameter and cross-sectional area by videodensitometry along profile lines which are orthogonal to the long axis of the artery. These results can be expressed numerically as a percentage stenosis when compared to a normal region of the artery. The image is corrected for geometric distortion using a grid test object. The image grey scale is corrected by means of a ramp test object such that a pixel value is proportional to the attenuator thickness. The ramp is placed on the patient during the X-ray examination and an iterative technique has been developed for subtracting the underlying structures from the superimposed ramp image. The system has been assessed using test objects constructed in Perspex which simulate arteries of known cross-sectional area and stenoses of known severity.

Many patients with coronary artery disease treated by percutaneous transluminal coronary angioplasty (PTCA) have a history of previous myocardial injury resulting in a reduced left ventricular ejection fraction (EF). The effects of successful PTCA on myocardial perfusion and left ventricular function in these patients were compared to treatment in patients with normal left ventricular EF. There were 21 patients with a normal EF (mean EF 59 +/- 2%) (Group I) and 15 patients with reduced EF (mean EF 43 +/- 1%) (Group II). Before PTCA a similar degree of reversible myocardial ischemia was present on thallium scintigraphy. At peak exercise left ventricular EF in the Group I patients decreased by 4 +/- 1% compared to 8 +/- 1% in Group II. At one month following successful PTCA there was resolution of reversible myocardial ischemia in both groups. No changes in EF at rest were observed. At the same level of exercise as before PTCA the mean EF was 5 +/- 1% higher than the pretreatment value in Group I and 10 +/- 1% higher in Group II. Thus in this study reversible myocardial ischemia was associated with severe compromise in the left ventricular response to exercise which was substantially improved by PTCA.

A new echocardiographic index of mitral valve diastolic closure, based on the rate of diastolic apposition of the anterior and posterior mitral leaflet echoes, was measured in 40 patients with mitral stenosis. This mitral valve closure index correlated highly significantly with the mitral valve orifice area (calculated from the Gorlin formula) (r = 0-87). Correlation between the diastolic closure rate (based) on the EF slope) and the calculated valve area was poor (r = 0-37). It is proposed that the mitral valve closure index excludes movement extraneous to the mitral apparatus and expresses the actual rate of valve closure, thus avoiding some of the factors known to contribute to the poor specificity of the diastolic closure rate. The better correlation of the mitral valve closure index with the calculated valve orifice area makes it possible to assess the severity of mitral stenosis by echocardiogram with greater accuracy and confidence.

Mitral stenosis is a progressive lesion carrying a relatively high risk of sudden incapacitation from systemic embolus or the onset of atrial fibrillation. Since the condition is likely to be significant when diagnosed, it is not compatible with single-crew professional operations and requires careful supervision. The presence of mild mitral regurgitation where the aetiology has been shown not to be due to chordal rupture, papillary muscle dysfunction secondary to coronary artery disease, rheumatic mitral valve disease, or Marfan's disease, where left atrial and left ventricular dimensions are shown to be normal on the echocardiogram, and where follow-up over at least a year has shown no progression of disease, may be consistent with full certification. Regular cardiological review with echocardiography and exercise electrocardiography is required. Any departure from these guidelines may lead to restriction of flying status to multi-crew operations, or denial.

Carotid pulse tracings and M-mode echocardiography were recorded in 25 patients on maintenance haemodialysis pre- and post-dialysis. Myocardial function, as assessed by fractional shortening and velocity of circumferential fibre shortening, was depressed in 7 out of 25 patients pre-dialysis (28%). Acute Haemodialysis resulted in significant changes in body weight, mean arterial pressure, urea, creatinine and packed cell volumes in all patients. Left ventricular function, however, improved significantly only in that group of patients in which it was depressed prior to dialysis. Echocardiography provides a simple means for evaluating left ventricular function in patients on chronic haemodialysis and shows that cardiac performance improves with acute dialysis when it is depressed pre-dialysis.

The straight back syndrome, consisting of loss of normal upper thoracic spinal curvature associated with cardiac murmurs and radiographic cardiomegaly is considered a form of 'pseudoheart disease' which has been attributed to squashing of the heart in the reduced AP diameter of the chest. During an 18-month period 31 patients referred to a cardiologist were found to have a straight back. Forty-five relatives were subsequently examined and 27 were found also to have a straight back. Palpitations and chest pain were the commonest symptoms. On the lateral chest radiograph the distance from the middle of the anterior border T8 to a vertical line connecting T4 and T12 was found to be significantly reduced compared to controls, and a value less 1.2 cm is indicative of a straight back. Of the 58 subjects with the syndrome, 39 (67 per cent) had clinical and/or echocardiographic evidence of mitral valve prolapse. Respiratory function testing revealed no significant abnormality. HLA typing showed no association with an particular HLA antigen but indicates that the straight back syndrome is inherited as an autosomal dominant condition and suggested that the antigenic determinants may be located on chromosome 6. We conclude that the straight back syndrome should no longer be considered a form of pseudoheart disease and patients should be investigated for associated mitral valve prolapse and their relatives screened.

M-mode and cross-sectional echocardiography performed in a patient with acute pulmonary embolism showed a sausage shaped, mobile mass in the right ventricular cavity highly suggestive of a right ventricular myxoma. Emergency thoracotomy 24 hours later showed the right ventricle to be free of tumour but both pulmonary arteries contained embolised venous thrombi, one or more of which were thought to have given rise to the false echocardiographic diagnosis of a right ventricular tumour.

Prostaglandin E2 (PGE2) was administered orally, in doses of 12-65 microgram/kg at intervals of 1-4 hours, to 12 neonates in whom the pulmonary circulation depended on patency of the ductus arteriosus. After an oral dose, both oxygen saturation (SaO2) and plasma PGE2 concentration increased consistently within 15-30 minutes, reaching values comparable to those during i.v. infusions. Treatment continued for 5 days to 4 months. In eight infants, PGE2 withdrawal resulted in a decrease of SaO2, from a mean of 75 +/- 7% to 57 +/- 10% (+/- SD). The ductus remained responsive for long periods--in four infants, for over 3 months. Consequently, surgery could be delayed until the infants and their pulmonary arteries had grown. Side effects during oral therapy were similar to those during i.v. infusion but were less severe in this series. The effectiveness and simplicity of oral PGE2 administration have advantages over i.v. administration, especially for long-term treatment.

Cross sectional echocardiographic studies were assessed prospectively in 58 infants in whom right ventricular outflow obstruction was subsequently shown angiographically. A subcostal cut was used to display simultaneously the short axis of the aortic root and the long axis of the right ventricular outflow tract. This facilitated the differentiation of the common right ventricular outflow tract obstructive lesions. Tetralogy of Fallot was diagnosed correctly in 22 of 26 infants; pulmonary atresia with intact septum in all of 14 neonates; isolated severe pulmonary valve stenosis in all of nine infants; and pulmonary atresia with ventricular septal defect in eight of nine infants. The subcostal approach is the technique of choice for evaluating right ventricular outflow tract obstruction as it is more reliable than the left parasternal approach.

One hundred and five patients with unstable angina and 175 with chronic stable angina were treated by primary percutaneous transluminal coronary angioplasty. Patients with unstable angina had had symptoms for a shorter time and were more likely to have angiographically complex lesions and lesions less than 10 mm in length than patients with chronic stable angina. Other baseline variables were not significantly different in the two groups. The overall primary success rate was similar in both groups (87% v 86%). Nine of the 14 unsuccessful procedures in those with unstable angina and nine of the 24 unsuccessful procedures in those with stable angina were the result of acute occlusion. These results led to a 9% frequency of procedure related myocardial infarction in patients with unstable angina and a 5% rate in those with stable angina (NS). The procedure related infarct rate tended to be higher in patients with unstable angina who had coronary angioplasty soon after an episode of unstable angina (mean 10 days) than in those in whom it was delayed (mean 35 days) (12% v 3%) (NS). In patients with unstable angina who had had a previous myocardial infarction procedure related infarction was significantly more common (18%) than in patients with no previous myocardial infarction (3%). The difference between those with and without previous infarction was also significant in patients with stable angina (10% v 3%).

Echocardiographic analysis of the movement of the posterior mitral valve leaflet in 60 patients with lone mitral stenosis, 35 patients with aortic stenosis, and 18 patients with aortic and mitral stenosis showed a spectrum of initial posterior mitral valve leaflet movement in early diastole. The classical anterior movement was seen in 36 out of 60 patients with mitral stenosis (60%), and 8 out of 16 patients with aortic and mitral stenosis (50%). Normal posterior movement was present in all patients with lone aortic stenosis but was also seen in 10 patients (17%) with mitral stenosis and 6 patients (33%) with aortic and mitral stenosis. The remaining patients with mitral stenosis or aortic stenosis and mitral stenosis showed a biphasic type of initial movement. Patients with anterior movement had a mean calculated mitral valve area from cardiac catheterisation significantly smaller than the rest (P less than 0.001), but neither biphasic nor posterior movement excluded severe mitral stenosis. The distinction between patients with mitral stenosis and initial movement of the posterior mitral valve leaflet and patients with left ventricular discompliance is possible when there is sinus rhythm. Late diastolic anterior movement of the posterior mitral valve leaflet during atrial contraction is diagnostic of true mitral stenosis.

Prenalterol, a beta-adrenergic agonist, was given to nine patients with angiographically proved coronary artery disease. Subjects were studied during chronic beta-adrenergic blockade. The adequacy of blockade was assessed by the exercise heart rate response and by plasma concentrations of blocking agents. After incremental doses of 2.5 mg, 5.0 mg and 7.5 mg of prenalterol, heart rate was increased by 20%, 24% and 38%, respectively, and left ventricular dP/dt max by 55%, 73% and 61%, respectively. Systolic and diastolic blood pressures did not change significantly; pulmonary artery wedge pressure fell from 10 +/- 0.5 mm Hg to 7.1 +/- 0.9 and 6.7 +/- 0.7 mm Hg after 2.5 mg and 5.0 mg, respectively (p less than 0.01 for both). The net inotropic response to prenalterol was assessed, independent of the chronotropic response, using incremental atrial pacing before and after drug infusion. At identical heart rates, left ventricular dP/dt max increased by 40%, 49% and 48% after 2.5 mg, 5.0 mg and 7.5 mg, respectively. Left ventricular cineangiography before and after infusion showed an increase in ejection fraction from 0.73 +/- 0.02 to 0.83 +/- 0.03 (p less than 0.001). Plasma prenalterol concentration estimations demonstrated a clear, dose-related inotropic response, the level of response in each patient being largely determined by the degree of beta-adrenergic blockade at the time of the study.

The effect of inspiration on pulmonary vein blood flow velocity and forward pressure gradient from pulmonary vein to left atrium was studied in seven patients with chronic constrictive pericarditis, five of whom had clinically obvious pulsus paradoxus. Compared to patients without pericardial disease, where inspiration produced no change, patients with pericardial disease showed an inspiratory fall in the forward pressure gradient and forward blood flow velocity in the pulmonary veins on inspiration. The mechanism of pulsus paradoxus in these patients can be explained by incomplete transmission of the inspiratory fall of intrathoracic pressure to the left atrium.

M-mode echocardiography was performed on 43 maintenance hemodialysis patients and 3 patients on continuous ambulatory peritoneal dialysis (CAPD). Only seven patients had completely normal echocardiograms. Nine patients (20%) had pericardial effusions and 20 patients (44%) had left ventricular dilatation. Left ventricular hypertrophy was present in 26 patients (57%): in 18 patients this took the form of concentric hypertrophy and in 8 patients there was asymmetric septal hypertrophy. Left ventricular function was depressed in 12 patients (27%). Left ventricular dilatation was more common in patients with multiple vascular accesses, who also tended to have lower hematocrit values. Left ventricular hypertrophy tended to be more common in patients with prolonged hypertension and with excessive inter-dialytic weight gains. Younger patients and those who had been on dialysis for a longer period had less cardiac abnormalities, suggesting that chronic dialysis might reverse these changes. Echocardiography was more sensitive than chest X-ray and ECG in detecting clinically unsuspected abnormalities and provides useful information in the overall evaluation of maintenance dialysis patients.

Two years after an orthotopic cardiac transplant a 28 year old man was found to have clinically significant stenosis of the right coronary artery at routine coronary angiography. This lesion was accompanied by a perfusion defect on exercise thallium scintigraphy. Percutaneous transluminal coronary angioplasty of the lesion improved the angiographic appearance of the stenosis and reduced the exercise thallium perfusion defect.

We describe a case in which the angiographic appearance of total occlusion of the left anterior descending coronary artery was not due to a complete anatomical obstruction, but due to competitive and retrograde flow in the distal segment of the artery from collaterals via the contralateral vessel. This case has implications on our current practice and results of coronary angioplasty in total coronary arterial occlusion.

Right atrial hypertension and pericardial effusion developed 2 years after mastectomy for fibrosarcoma. Clinical and echocardiographic features suggested right ventricular tumour. At catheterization the right ventricular cavity was almost obliterated, with an infundibular gradient of 13 mmHg, and biopsy of the mass was attempted. Post-mortem revealed extensive infiltrating and intracavitary right ventricular fibrosarcoma without extracardiac tumour.

A 67 year old woman with a permanent pacemaker was admitted with pulmonary oedema and mitral valve incompetence two months after a myocardial infarction. Echocardiograms showed good left ventricular function and a large coil of apparent thrombus in the right atrium prolapsing into the right ventricle. Intermittent loss of pacemaker sensing and capture was noticed on admission and probably caused the supraventricular tachycardia and ventricular fibrillation that occurred before an exploratory bypass operation. At operation rupture of the papillary muscle was found and the mitral valve was replaced. A large piece of thrombus was retrieved from the right pulmonary artery. The right heart contained no clot and the pacemaker wire was not displaced. It is envisaged that the strand of venous thrombus was caught in the permanent pacing wire at the tricuspid valve level resulting in an unusual case of pacemaker malfunction. The eventual poor outcome was almost certainly influenced by the arrhythmias and pulmonary embolism caused by the clot and might have been avoided by early operation.

Percutaneous transluminal coronary angioplasty was performed in a 56 year old man with postinfarction angina. During an otherwise uncomplicated dilatation of a left anterior descending artery with a 70% stenosis two diagonal branches, each measuring 1.5 mm in diameter, were occluded. The occlusions were not associated with any adverse clinical effects, though there was a small rise in plasma creatine kinase concentration. The patient became free of angina two weeks after angioplasty, and follow up angiography showed spontaneous reappearance of the occluded side branches. Redistribution of atheromatous material and its later reabsorption may have been the mechanism for the initial occlusion and later reappearance of the vessels.