BACKGROUND The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon. OBJECTIVE To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study. PATIENTS AND DESIGN All patients < 76 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of > 3.0 mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60 patients. RESULTS Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (p = 0.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65) ml v 157 (62) ml (p < 0.001), respectively. No major adverse cardiovascular events had occurred by 30 days. CONCLUSIONS The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.

In Carney's syndrome, the association of cardiac myxomas, spotty pigmentation and endocrine over activity, the myxomas are usually multiple and have atypical locations. The authors report a case in which an accurate diagnosis of these multiple myxomas was made by transoesophageal echocardiography, although transthoracic echocardiography had missed the diagnosis.

The authors report 4 cases of aortic dissection after aortic valve replacement. The aorta was dilated in all four cases before surgery. Two patients died within hours of the dissection, illustrating the poor prognosis of this complication and the difficulties of surgical management. The features of these four cases were compared to those of 29 other cases reported in the last ten years. The initial surgical indication for valve replacement was equally divided between aortic stenosis and regurgitation. The onset of dissection after surgery was very variable, ranging from a few hours to several years after valve replacement. Abnormalities of the aortic wall and peroperative trauma play an important role in the pathogenesis of this complication. The prognosis is very poor, which underlines the importance of preventive measures and regular follow-up of these patients.

The authors report 4 cases of aortic dissection after aortic valve replacement. The aorta was dilated in all four cases before surgery. Two patients died within hours of the dissection, illustrating the poor prognosis of this complication and the difficulties of surgical management. The features of these four cases were compared to those of 29 other cases reported in the last ten years. The initial surgical indication for valve replacement was equally divided between aortic stenosis and regurgitation. The onset of dissection after surgery was very variable, ranging from a few hours to several years after valve replacement. Abnormalities of the aortic wall and peroperative trauma play an important role in the pathogenesis of this complication. The prognosis is very poor, which underlines the importance of preventive measures and regular follow-up of these patients.

In Carney's syndrome, the association of cardiac myxomas, spotty pigmentation and endocrine over activity, the myxomas are usually multiple and have atypical locations. The authors report a case in which an accurate diagnosis of these multiple myxomas was made by transoesophageal echocardiography, althouth transthoracic echocardiography had missed the diagnosis.

Calcium channel blockers are now recommended for the treatment of stable angina but few studies have been carried out comparing the efficacy of verapamil and diltiazem in this indication. The short-term efficacy of these two drugs was compared in a double-blind crossover trial in 12 patients. The following protocol was used, 24 hour selection period followed by two crossover treatment periods versus double placebo. Exercise stress tests were performed 2 hours after the last dose at the end of each treatment period. Each patient underwent 3 stress tests: the first during the selection period whilst taking verapamil and diltiazem placebo (ET0), the second after the first treatment period at day 7 (ET1) and the third after the second treatment period at day 14 (ET2). A comparison of exercise capacity (ET0 to ET1 and ET2) showed improved effort tolerance and an increase in the ischaemic threshold with calcium blocker therapy. The duration of effort, the maximum sustained load, the rate-pressure product and the time to ST depression were all significantly increased. On the other hand, there were no significant changes in the percentage theoretical maximum heart rate attained, the heart rate at which ST depression occurred, the maximum ST depression and the incidence of angina. A comparison between ET1 and ET2 did not show any difference in the parameters of maximum effort or of the appearance of myocardial ischaemia. The comparison of exercise stress tests performed after treatment with verapamil and after diltiazem showed that the total duration of exercise, the maximum sustained load (in watts) and the rate-pressure product were identical.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of immediate percutaneous transluminal coronary angioplasty (PTCA) (260 +/- 167 minutes after onset of pain and an average of 56 minutes after thrombolysis) and deferred PTCA (average 9.6 days, range 1 to 30 days after infarction) were compared in 118 consecutive patients with acute myocardial infarction. The overall primary success rate of PTCA was 82.2 per cent; it was higher in those patients undergoing deferred angioplasty (96% vs 78%; p less than 0.05). The primary success rate of immediate PTCA was related to the severity of the stenosis before dilatation: 75 per cent success in occluded compared to 84 per cent in suboccluded vessels (over 90% stenosis) and 100 per cent success in vessels with under 90 per cent stenosis. Eighty one per cent of failed angioplasties occurred in patients with occluded arteries, the majority being left anterior descending (LAD) arteries (71.4%). The incidence of restenosis was 13.4 per cent. This complication was diagnosed at coronary arteriography performed 40 days after PTCA in 1 case, 47 days after PTCA in another case and at the 6 month control in 11 cases. Reocclusion was observed in 21 patients (21.7% of immediate successes). The occlusion was diagnosed at the first control after an average of 8 days in 15 cases. The interval between the onset of pain and thrombolysis and dilatation was significantly longer in the group with reocclusion compared with patients without reocclusion (314 minutes vs 193 minutes for thrombolysis, p less than 0.01; and 356 minutes vs 204 minutes fort PTCA, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

The results obtained in a series of 142 patients operated upon, between December 1978 and December 1987, for infective endocarditis on native valve are reported. 61 patients (group 1) had acute progressive endocarditis and 81 patients (group 2) had subacute old-standing endocarditis. In group 1 patients, hospital mortality (i.e. occurring during the first 30 post-operative days) was 11.5 p. 100. During a mean follow-up period of 37.6 months (1.5 to 104.5 months), the survival rates were 52 p. 100 at 72 months and 37.4 p. 100 at 104.5 months. Mechanical desinsertion without persistence or relapse of the infective process, and recurrent endocarditis accounted for 27.8 p. 100 of deaths of known cause. Prognosis was better in group 2 patients. Hospital mortality was 4.9 p. 100, and during a mean follow-up period of 58 months (2 to 124 months) the survival rates were 84 p. 100 at 72 months and 73.4 p. 100 at 124 months. 60 p. 100 of late deaths of known cause were due to heart failure. In native valve infective endocarditis the post-operative diagnosis depends upon the pre-operative haemodynamic status, and the assessment of this status (notably with echocardiography) is a crucial element in the decision to operate.

The results obtained in a series of 142 patients operated upon, between December 1978 and December 1987, for infective endocarditis on native valve are reported. 61 patients (group 1) had acute progressive endocarditis and 81 patients (group 2) had subacute old-standing endocarditis. In group 1 patients, hospital mortality (i.e. occurring during the first 30 post-operative days) was 11.5 p. 100. During a mean follow-up period of 37.6 months (1.5 to 104.5 months), the survival rates were 52 p. 100 at 72 months and 37.4 p. 100 at 104.5 months. Mechanical desinsertion without persistence or relapse of the infective process, and recurrent endocarditis accounted for 27.8 p. 100 of deaths of known cause. Prognosis was better in group 2 patients. Hospital mortality was 4.9 p. 100, and during a mean follow-up period of 58 months (2 to 124 months) the survival rates were 84 p. 100 at 72 months and 73.4 p. 100 at 124 months. 60 p. 100 of late deaths of known cause were due to heart failure. In native valve infective endocarditis the post-operative diagnosis depends upon the pre-operative haemodynamic status, and the assessment of this status (notably with echocardiography) is a crucial element in the decision to operate.

Pericarditis is frequent in patients with rheumatoid arthritis. It is usually asymptomatic, but cases of constrictive pericarditis or, more rarely, tamponade have been reported. In such cases, the study of pericardial fluid is of special interest for the aetiological diagnosis. Early medical treatment with or without pericardiocentesis is effective in most cases of tamponade, but constrictive pericarditis demands pericardiectomy. We report here three cases of pericarditis responsible for cardiac compression: two cases of tamponade and one case of constrictive pericarditis.

Les auteurs rapportent les résultats d'une série de 142 patients opérés pour endocardite infectieuse sur valve native entre décembre 1978 et décembre 1987. 61 patients (groupe 1) avaient une endocardite aiguë, évolutive et 81 patients (groupe 2) une endocardite subaiguë, ancienne. Dans le groupe 1, la mortalité hospitalière (30 jours postopératoires) est de 11,5 p. 100. Avec un suivi moyen de 37,6 mois (1,5–104,5 mois), le pourcentage de survie est de 52 p. 100 à 72 mois et de 37,4 p. 100 à 104,5 mois. Les désinsertions mécaniques, sans persistance ou reprise du processus infectieux, et les récidives d'endocardite sont responsables de 27,8 p. 100 des décès de cause connue. Dans le groupe 2, le pronostic est meilleur. La mortalité hospitalière est de 4,9 p. 100. Sur un suivi moyen de 58 mois (2–124 mois) le pourcentage de survie est de 84 p. 100 à 72 mois et de 73,4 p. 100 à 124 mois. Les décès tardifs, de cause connue, sont liés dans 60 p. 100 des cas à une insuffisance cardiaque. Le pronostic postopératoire dépend essentiellement de l'état hémodynamique préopératoire, dont l'estimation (intérêt de l'échocardiographie) est un élément prépondérant de la décision chirurgicale.

The authors present 5 cases of coronary artery ectasia discovered on coronary angiography and review the literature on the subject. The aetiology of these coronary aneurysms is discussed: coronary atherosclerosis seems to be the most common cause of this condition which some authors consider to be a variant of coronary atheroma. The therapeutic management is controversial. The indications for surgery are rare and should be carefully considered. Long term anticoagulant therapy, however, appears to be essential.