Novel X-ray image noise reduction technology reduces patient radiation dose while maintaining image quality in coronary angiography

AIMS

The consequences of high radiation dose for patient and staff demand constant improvements in X-ray dose reduction technology. This study assessed non-inferiority of image quality and quantified patient dose reduction in interventional cardiology for an anatomy-specific optimised cine acquisition chain combined with advanced real-time image noise reduction algorithms referred to as 'study cine', compared with conventional angiography.

METHODS

Fifty patients underwent two coronary angiographic acquisitions: one with advanced image processing and optimised exposure system settings to enable dose reduction (study cine) and one with standard image processing and exposure settings (reference cine). The image sets of 39 patients (18 females, 21 males) were rated by six experienced independent reviewers, blinded to the patient and image characteristics. The image pairs were randomly presented. Overall 85 % of the study cine images were rated as better or equal quality compared with the reference cine (95 % CI 0.81-0.90). The median dose area product per frame decreased from 55 to 26 mGy.cm(2)/frame (53 % reduction, p < 0.001).

CONCLUSION

This study demonstrates that the novel X-ray imaging technology provides non-inferior image quality compared with conventional angiographic systems for interventional cardiology with a 53 % patient dose reduction.

Percutaneous revascularization of coronary chronic total occlusion

Percutaneous coronary intervention for chronic total occlusions is the most challenging and time consuming intervention in Cardiology. It is evolving rapidly, well documented by a success rate that in the hands of specifically trained operators recently increased from about 60% to 90% and longterm patency because of drug eluting stents from 50% to 90%. These results are comparable or even superior to surgical revascularisation. Sophisticated techniques unique to CTO interventions were developed and the need for specific training is emphasised so that the success rate of at least 80% as claimed by the ESC guidelines on myocardial revascularization can be met and patients with CTO who deserve revascularization no longer be denied appropriate treatment.

[The QuIK-Registry of the German Society of Cardiologists in private practice: countrywide and benchmarking quality assurance in invasive cardiology]

QuIK is the German acronym for QUality Assurance in Invasive Cardiology. It describes the continuous project of an electronic data collection in Cardiac catheterization laboratories all over Germany. Mainly members of the German Society of Cardiologists in Private Practice (BNK) participate in this computer based project. Since 1996 data of diagnostic and interventional procedures are collected and send to a registry-center where a regular benchmarking analysis of the results is performed. Part of the project is a yearly auditing process including an on-site visit to the cath lab to guarantee for the reliability of information collected. Since 1996 about one million procedures have been documented.

[5th Report of the German Association of Cardiologists in Private Practice (BNK) on Quality Assurance in Cardiac Catheterization and Coronary Intervention 2003-2005]

On behalf of the German Association of Cardiologists in Private Practice (BNK) the Steering Committee of the QuIK Registry reports on the results of the voluntary quality assurance in invasive cardiology in 2003-2005 and compares it to other data collections. In 2005 more than 70% of diagnostic (LHK) and 78% of therapeutic (PCI) cardiac catheterization procedures in private practice were entered into the registry. Altogether 229,462 LHK and 64,818 PCI were documented over the 3 years. In the reported period age of patients, percentage of acute coronary syndromes and three-vessel coronary artery disease increased in LHK as well as in PCI while consumption of contrast media and fluoroscopy time decreased. By implemented possibility of follow-up, a high rate of external auditing (monitoring) and certification QuIK remains a worldwide unique quality assurance project in cardiology. On a stable data basis over 10 years the QuIK Registry enables the implementation of quality indicators for future quality assurance purposes.

Percutaneous in situ coronary venous arterialization: report of the first human catheter-based coronary artery bypass

Diffuse coronary artery disease is frequently untreatable by coronary artery bypass or angioplasty. Many such "no-option" patients have been subjects for trials of angiogenesis using growth factor manipulation or laser injury. We think these novel revascularization strategies are limited by insufficient inflow to putative areas of new microvasculature and thus seek a more mechanical solution. We report the use of a catheter-based system for arterializing the adjacent anterior cardiac vein in a patient with chronic total occlusion of the left anterior descending coronary artery. A composite catheter system (phased-array ultrasound imaging system mounted on a catheter with extendable nitinol needle) was used to deliver an exchange-length intracoronary guidewire from the proximal left anterior descending coronary artery into the parallel anterior interventricular vein. Using standard angioplasty techniques, a fistula was then constructed from the proximal artery to the coronary vein using a self-expanding connector. The proximal vein was blocked with a novel self-expanding "blocker," thus precluding "steal" through the coronary sinus and forcing retroperfusion of the anterior wall. The procedure was completed without complication, and a follow-up angiogram at 3 months confirmed continued patency of the arteriovenous connection. This patient, who had severe angina before the procedure, has been asymptomatic for 12 months. Percutaneous in situ venous arterialization may be an effective therapy for diffuse, "untreatable" coronary disease by supplying a robust inflow of arterialized blood via retroperfusion to severely ischemic myocardium.

[Carotid percutaneous transluminal angioplasty in cardiological patients with increased surgical risk]

Carotid angioplasty is a revascularisation procedure introduced more than 20 years ago and that is still not widely accepted. Most institutions perform this intervention only under a study protocoll or in patients with high risk for carotid surgery. We performed angioplasty of the extracranial internal carotid artery in 50 patients with increased risk for surgery: 43 men, 7 women, 19 older than 75 years, 42 with significant coronary artery disease and 25 prior to CABG. Eight patients presented with an LVEF < 40%, 13 were neurologically unstable, 6 had a recurrence after endarterectomy and 1 patient had a lesion induced by radiotherapy. After predilatation with a 3.5 mm balloon via 8 F guiding catheter we implanted 21 JJ biliary stents, 25 Jostent Carotid, 2 Wallstents und 4 coronary stents.

RESULTS

47/50 patients were dilated successfully with a reduction of the stenosis from 82 +/- 12% to 6 +/- 8%. Three patient experienced a severe acute complication: 1 severe intracerebral bleeding after 5 hours, most likely due to abciximab, and 2 minor cerebral strokes. After 6 months 1 patient had died after CABG, 1 patient experienced a TIA and another developed restenosis (2.4%).

CONCLUSION

Carotid angioplasty with stenting is a valuable alternative to Carotis-TEA or medical therapy, especially in patients with significant comorbidity, who present with increased risk for vascular surgery.

Audit and quality control in angioplasty in Europe: procedural results of the AQUA Study 1997: assessment of 250 randomly selected coronary interventions performed in 25 centres of five European countries. AQUA Study Group, Nucleus Clinical Issues, Working Group Coronary Circulation, of the European Society of Cardiology

AIMS

Percutaneous transluminal coronary angioplasty (PTCA) has become the most widely used major intervention in western medicine. However, there is disparate use of this technique among different European countries and the U.S.A. In an attempt at quality assurance, the working group Coronary Circulation of the European Society of Cardiology has carried out a study on appropriateness, necessity, and performance of PTCA in Europe. The present paper reports on the procedural results of this survey.

METHODS

In a multicentre case-control study in Europe, 750 patients (544 men, 206 women) with documented vascular disease of the From the countries participating in the European Registry of Coronary Intervention, the three countries with the highest absolute PTCA volume (Germany, France, and the United Kingdom) and two randomly selected countries (Belgium and Italy) were chosen for investigation. In these countries, five centres were selected at random according to the following criteria: one centre with >1000, three centres with 300-1000, and one centre with <300 procedures per year. In each of these, 10 cases from the first half of 1997 were randomly identified and all pertinent documentation was collected.

RESULTS

In 250 cases, 325 stenoses were addressed as target lesions. Single vessel disease was present in 41%. History included stable angina in 49%, unstable angina in 32%, atypical chest pain in 6%, no anginal pain in 12%, and acute/subacute myocardial infarction in 13%. The percentage of patients with either positive stress test and/or unstable angina, acute/subacute infarction, previous infarction (within 6 months) or coronary revascularization amounted to 98%. Single vessel intervention accounted for 90%. In 41% balloon-only angioplasty was performed and in 54% at least one stent was implanted with considerable variation among countries. The use of other new devices amounted to only 3%. In 92%, the operators documented a successful procedure. Major complications (myocardial infarction, emergency bypass surgery, or death) were found in 4.8%.

CONCLUSIONS

Based on scrutinized hospital and operator data, the present study revealed a satisfactorily high percentage of justifiable indications, an adequate procedural success rate, and an acceptably low complication rate. Further analysis by an expert panel will address appropriateness, necessity, and procedural performance of the individual cases.

A novel stent delivery catheter: the Intella Trinity balloon

The Trinity catheter is a novel multiballoon device designed to facilitate stent delivery by providing for predilatation, stent deployment, and further expansion on a single shaft. The device was tested extensively in a canine model with a variety of stents before being used in a limited human feasibility trial in Europe. A description of the device and its initial human application is presented.

Transvenous closure of patent ductus arteriosus with Ivalon plugs. Multicenter experience with a new technique

RATIONALE AND OBJECTIVE

The authors assess the clinical efficacy of transvenous closure of patent ductus arteriosus (PDA) with a new plug consisting of Ivalon foam and a platinum/iridium frame with four aortic and two pulmonary nitinol struts. The most widely used devices for transcatheter treatment of PDA (Porstmann plug, Rashkind umbrella, Botallo occluder, coils) have specific limitations inherent to their design (e.g., transarterial approach, residual shunts, limited retrieval).

METHODS

Between 1994 and 1997, PDA closure was attempted in 33 children and 67 adolescents and adults in 7 clinical centers; PDA diameter was 2 to 11 mm. Plug diameter was 6 to 20 mm, and 8 to 16 F venous sheaths were used for insertion.

RESULTS

Placement was successful in 98% (with a single plug in 88%, and a second or third plug in 10%) and unsuccessful in 2%. Plugs were retrieved after malpositioning in 12 of 12 patients and after pulmonary embolization in 2 of 3 patients. One patient underwent surgery for removal of an embolized plug. Complete PDA closure was proved by aortography and color Doppler echocardiography in 85% (40 of 43 patients with a PDA 2-3.9 mm, 30 of 36 patients with a PDA 4-5.9 mm, and 15 of 21 patients with a PDA 6-11 mm). During a median follow-up interval of 16 months, there were no complications (infection, hemolysis, fracture, embolization).

CONCLUSION

The new plug device can be used successfully in patients with a PDA diameter up to 11 mm. Further investigations are underway to determine the definite clinical value of this technique.

[Balloon angioplasty of stent restenosis: early and late results of first and second PTCA in focal and diffuse stenosis]

From January 1996 until February 1997 6,376 patients were treated by our group with PTCA and 3,859 (60.5%) received one or several stents. An angiographic followup was achieved in 63% of the patients with 1,267 experiencing restenosis (32.8%). Of those being treated with re-PTCA 302 were randomly selected for further analysis. In-stent-restenosis was treated with rotablator in 8 patients (2.7%), with eximer laser in 21 (7.0%) and with another stent in 48 patients (15.9%). 225 patients (74.4%) of this subselection were treated with balloon-angioplasty only. Mean patient age was 63 +/- 10.2 years, 401 stents had been implanted (42.5% Wiktor, 13.7% Jomed Sito, 12.3% ACS Multlink, 9.5% GR II, and some others), the number of stents per patient was 1.68, mean stent length 28.5 mm, mean stent diameter 3.01 +/- 0.3 mm, the time since implantation 142 +/- 76 days. The recurrence appeared as restenosis in 199 patients (88.4%) and as a chronic stent occlusion in 26 (11.6%). In-stent-restenosis was discovered in 94.7% within the stent and was of focal appearance (restenosic lesion of < or = 5 mm) in 28.5% and diffuse (> 5 mm) in 71.5%. Balloondilatation (balloon:artery = 1:1; maximal pressure 11.7 +/- 3.3 bar) was successfull in 98% of the stenotic lesions and in 18/26 of the chronically occluded stents (definition of success: residual stenosis < 50%, no major complications). The stenosis decreased from 82.2% to 20.5% (12.8% in focally stenosed vessels and 23.6% in diffuse restenosis). Complications were death in 0.9%, Q-MI in 0% CABG in 0.9%, Non-Q-MI in 2.4%, subacute stent thrombosis in 0.5% and groin bleeding in 1.8%. A clinical follow up after 151.7 +/- 87.7 days was achieved in 98.6% and an angiographic follow up in 69.1% of the patients: 1.9% had died (2/4 due to noncardiac disease), no MI, 6.2% CABG and 31% PTCA (TLR 37.2%). A second restenosis within the stents ocurred in 27.9% of those with focal disease and in 44.3% of those with diffuse in stent restenosis.

CONCLUSIONS

Restenosis within stents may occurr in about 30% of unselected patients. In 2/3 these stenoses appear diffuse and in 10% they appear as chronic occlusions. Re-PTCA with balloons is rather simple with a high success rate (even in chronic stent occlusions) and a low complication rate. The incidence of a second restenosis is acceptably high in focal lesions but appears unacceptable in patients with diffuse in-stent-restenosis. Thus the indication for stenting should be restricted to patients with clear cut advantage over balloon-angioplasty alone, e.g. threatening closure, chronic occlusion, old savenous veingraft and proximal LAD stenosis.

[From surgical to interventional standby?]

Life threatening Q-infarction because of bypassgraft occlusion may occurr in 5-8% of the patients during the first days after CABG, and most patients are treated by immediate reoperation. This treatment may however be delayed because operating rooms might not be available immediately. We prospectively studied the feasability and safety of immediate coronary angiography and PTCA, if appropriate, in patients with severe ischemic in-hospital complications after CABG. From January till December 1995 1263 patients had CABG: mean age 64.9 +/- 10 y, 24% female, 7.1% emergencies (CABG < 24 h after coronary angiography). A 24 hours interventional standby was provided to perform immediate catheterization and PTCA in patients with signs of evolving myocardial infarction after CABG (ST-elevation in > or = 2 leads and hemodynamic compromise or new LV hypocinesia in the transoesophageal echocardiogramm).

RESULTS

3/1263 patients had immediate reoperation without angiography. 55/1263 patients were catheterized, all within 1 hour after the onset of Stelevation. 14/1263 had normal grafts and complete revascularization. Their ischemia was either transient (spasm) or the ECG was misinterpreted (pericarditis). Catheterization caused no severe complications. 2 patients had major bleeding at the puncture site. 41 patients presented with envolving Q-MI: 1 patient had immediate reoperation, 29 patients received immediate PTCA and 11 patients were treated medically. 8/29 PTCA-patients were in cardiogenic shock. We dilated 4 IMA-anastomoses, 3 distal veingraft anastomoses, 18 native vessels with occluded veingrafts and 4 native vessels, having not been grafted. Angiographic success was achieved in 20/29 (69%), clinical success in 65% (residual stenosis < 50%, no severe complications during hospital stay). 2 patients died during the first 30 days (none due to the PTCA procedure or PTCA-related delay of reoperation), Q-MI occurred in 2/29, NonQ-MI in 7/29, reoperation appeared necessary in 4/29, no bleeding complications were noticed.

CONCLUSIONS

Immediate coronary angiography after CABG is feasable and safe. Salvage-PTCA early after CABG is an alternative treatment in patients with evolving Q-MI. Interventional standby might therefore be useful for institutions with a busy cardiac surgical program.

Direct coronary stenting without predilatation: a new therapeutic approach with a special balloon catheter design

Coronary stenting is the primary therapeutic option for many coronary lesions, after the risk of subacute stent thrombosis and bleeding complications has been reduced by antithrombotic regimens and improved stent expansion. It would be desirable to shorten the procedure and the duration of ischemia, and to reduce the risk of ischemic complications during balloon inflation by implanting the stent without previous dilatation of the lesion. This is not possible with the presently available stent delivery systems. This new therapeutic concept was tested with a specially designed balloon catheter, on which slotted-tube stents can be fixed between two conical radiopaque markers. Sixty-one patients eligible for angioplasty underwent direct stent implantation without predilatation. Four procedures were performed for acute myocardial infarction, and two as high-risk PTCA. Single slotted-tube stents (Palmaz-Schatz, NIR, or JOStent) of 14-16-mm length were mounted between the conical radiopaque markers of a special balloon which provided a fixation for the crimped stent. The direct implantation was successful in 80% of all patients, while in 10% the stent could be deployed after predilatation of the lesion. In 10% of lesions a stent could not be implanted with this and any other delivery system. When patients with successful direct stenting were compared with those with indirect (after predilatation) or unsuccessful stent deployment, the presence of angiographically visible calcification was higher in the unsuccessful cases (75% vs. 19%; P < 0.01), and the patients were older (72+/-8 vs. 61+/-12 years; P < 0.01). Radiation exposure time was only 8.7+/-5.1 min as compared with 12.6+/-7.6 min in conventional stent procedures with predilatation (P < 0.05). The number of balloons used per lesion was also lower than with conventional stenting. Stent dislocation was observed in 5%, and no embolization occurred. The new therapeutic approach of direct stenting without predilatation proved to be a safe and successful procedure in this initial series of coronary angioplasties. When calcified coronary lesions are avoided, it provides a way to rationalize stent implantation with shorter radiation exposure times, fewer balloons, and the potential advantage of fewer ischemic complications as no balloon predilatation is required.

[First annual report of practitioners of interventional cardiology in private practice in Germany. Results of procedures of left heart catheterization and coronary interventions in the year 1996]

The German Society for Cardiac Angiography and Interventions in Private Practice has started a registry of cardiac procedures since 1996 in order to establish a standard for performance. Although quality management for the cath lab makes sense and is also legally required, there is no generally recommended infrastructure for quality assurance existing in Germany at this time. Therefore, the German Society of Cardiologists in Private Practice (BNK) initiated a project in 1994 to develop a computer program for paperless documentation of diagnostic cardiac catheterizations and coronary interventions (PTCA) using a minimal data set. In 1996, 8 private associated groups participated in this project. The (anonymous) analysis of 10,316 diagnostic cardiac catheterizations and 2597 PTCA yielded the following results: In 95% of the patients, diagnostic cardiac catheterization was performed using the femoral and in 5% the brachial/radial approach. The mean volume of administered contrast medium was 164 +/- 138 ml/patient. The mean LV-EF was greater than 50% in 58.4% of the patients and between 30% and 50% in 10.1%. Coronary artery disease was diagnosed in 69.6% of the patients and valvular/congenital heart disease in 8.5%. In 18.4% of the patients undergoing diagnostic cardiac catheterizations no significant heart disease was identified. Mortality in the cath lab as well as the rate of cerebral insults was 0.05%. In 22.9% and 19% of the patients PTCA and cardiac surgery respectively was recommended. In patients undergoing PTCA, stable angina was present in 74.4% and unstable angina in 13.1%. Of the total number of PTCA procedures, 5.8% were performed in the setting of acute myocardial infarction. The PTCA lesion success rate was 96%, the mean diameter stenosis was 81% pre and 6% post-intervention. The mortality rate at 1 month post-PTCA was 0.4%, and myocardial infarction 1.0%. An acute occlusion occurred in 1.3% of the PTCA patients; 0.6% had to be transferred for emergency bypass surgery. None of the cath labs had on-site surgery. In comparison to other registries, our data show some similarities but also some different trends. Thus, our newly developed software proved to be reliable, fast and easy to use. Participating centers receive immediate feedback regarding their position within the whole group.

Results of Micro stent implantations in coronary lesions of various complexity

Micro stents appear to be especially suitable for the safe treatment of complex coronary lesions and adverse vessel morphology. Stenting of lesions with type C morphology is associated with a higher restenosis rate than stenting of less complex coronary obstructions.

Recanalization of total coronary occlusions using a laser guidewire (the European TOTAL Surveillance Study)

The success rates of coronary angioplasty for the treatment of chronic total occlusions are less favorable than for coronary stenosis. Therefore, a new laser guidewire (LW) was designed to facilitate the crossing of chronic total occlusions. We report on the results of a European multicenter surveillance study, evaluating the laser guidewire performance. Between May 1994 and July 1996, 345 patients (age 59 +/- 10 years, 291 men) with chronic total occlusions were enrolled in 28 European centers. The median age of occlusion was 29 weeks (range 2 to 884), the occlusion length 19 +/- 10 mm. LW recanalization was successful in 205 patients (59%/). LW perforation occurred in 73 patients (21%), with hemodynamic consequences in 4 (1%). There were no deaths, emergency coronary artery bypass graft surgery, or Q-wave myocardial infarctions. In a multivariate regression analysis an occlusion age of <40 weeks (p = 0.001, RR = 1.34) and an occlusion length <30 mm (p = 0.01, RR = 1.59) were independent predictors of success. Results indicate that the LW is an effective and safe tool in the treatment of chronic total occlusion refractory to conventional guidewires.

[The reliability of a new 12-channel ECG with telephone transmission]

BACKGROUND AND OBJECTIVE

Different from the situation in the USA, Canada, Israel, Italy and Great Britain transmission of electrocardiograms (ECG) by telephone plays an unimportant part in Germany because existing technology is at best adequate for the diagnosis of arrhythmias. A new simple system, the size of a mobile phone (P12, Aerotel, Israel), was tested: for the first time in Europe it allows patients themselves to obtain a 12-lead ECG and transmit it via any telephone to a centre for analysis. This system was evaluated for its reliability when used by lay persons.

PATIENTS AND METHODS

Qualitative and quantitative parameters of a conventional 12-lead ECG obtained in 217 patients (86 women, 131 men) were compared with those of 12-lead ECGs recorded and stored by lay persons, transmitted via telephone to a computer and then printed out.

RESULTS

All ECGs transmitted with the P12 were analysable: quality was good or very good in 86%. Heart rate, transmission time and the various durations agreed with the conventional leads, while P12 underregistered amplitudes by about 15%. This difference was correctable by a constant or by adjusting the ECG machine. Atrial fibrillation (in eight of eight cases), infarct changes (40 of 40), ST elevations or depressions (15 of 15) and T negativities (80 of 82) were also reliably recognized.

CONCLUSIONS

The described method proved simple and reliable. Clinically significant information in the ECG can be transmitted within minutes and with high diagnostic reliability to a central station via any telephone. P12 is thus suitable for self-recording of ECGs by patients with potentially dangerous cardiac conditions. However a centre with cardiologically trained personnel should be available where telephone transmission of the ECGs and dialogue with the patients is possible around the clock.

Randomized comparison of angioplasty of complex coronary lesions at a single center. Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison (ERBAC) Study

BACKGROUND

The purpose of this study was to test whether coronary revascularization with ablation of either excimer laser or rotational atherectomy can improve the initial angiographic and clinical outcomes compared with dilatation (balloon angioplasty) alone.

METHODS AND RESULTS

At a single center, a total of 685 patients with symptomatic coronary disease warranting elective percutaneous revascularization for a complex lesion were randomly assigned to balloon angioplasty (n = 222), excimer laser angioplasty (n = 232), or rotational atherectomy (n = 231). The primary end point was procedural success (diameter stenosis < 50%, absence of death, Q-wave myocardial infarction, or coronary artery bypass surgery). The patients who underwent rotational atherectomy had a higher rate of procedural success than those who underwent excimer laser angioplasty or conventional balloon angioplasty (89% versus 77% and 80%, P = .0019), but no difference was observed in major in-hospital complications (3.2% versus 4.3% versus 3.1%, P = .71). At the 6-month follow-up, revascularization of the original target lesion was performed more frequently in the rotational atherectomy group (42.4%) and the excimer laser group (46.0%) than in the angioplasty group (31.9%, P = .013).

CONCLUSIONS

Procedural success of rotational atherectomy is superior to laser angioplasty and balloon angioplasty; however, it does not result in better late outcomes. The role of plaque debulking before balloon dilatation in percutaneous coronary revascularization remains to be fully defined.

New double wire technique to stent ostial lesions

We describe a new fast technique to precisely deploy J&J Stents in ostial lesions using two guide wires. The second guide wire is inserted through the proximal stent strut and simultaneously advanced together with the stent on the balloon serving as a position marker that guides stent placement. This technique has been applied in 10 cases with 100% success and with no major complications.

[Thoracic radiography as routine within cardiological diagnosis?]

OBJECTIVE

As chest radiography is still frequently used routinely in patients suspected of heart disease, the study was undertaken prospectively to assess its value in view of the potentials of modern noninvasive methods.

PATIENTS AND METHODS

History, physical examination, electrocardiography, ergometry, echocardiography and colour Doppler echocardiography as well as chest radiography were undertaken in 201 consecutive patients (113 men, 88 women, age 60 [3-88] years) with known or suspected cardiac valvular defects or heart failure. Subsequently invasive investigations were performed in 92 of these patients.

RESULTS

The value of chest radiography depended on the nature and severity of the particular cardiac disease. The diagnosis was established without chest radiography in all defects (40 patients) of grade III or IV (New York Heart Association) or NYHA class III or IV heart failure (30 patients). Chest radiography provided no additional prognostic or therapeutic information.

CONCLUSION

These data indicate that routine chest radiography is of no value as a screening method in patients with chronic heart failure or cardiac defects, except in a few clearly defined specific circumstances.

[Multiplicity of clinical symptoms and manifestations of unruptured aneurysms of the sinus of Valsalva--3 case reports]

Sinus Valsalva aneurysms belong to the less common congenital or acquired structural cardiac anomalies. However, in patients with known cardiac anomalies and uncertain or uncharacteristic cardiac symptoms the existence of a sinus Valsalva aneurysm must be taken into consideration. A sinus Valsalva aneurysm can be clinically silent as in the case of the 56-year-old patient with an accompanying bacterial endocarditis. An increasing aortic regurgitation after dilatation of a coarctation of the aorta can also proceed with an ecstasy of the ascending aorta and an aneurysm of the sinus Valsalva (case 2). Furthermore, a rapid dilatation of a non-ruptured sinus Valsalva aneurysm can cause a severe compression of coronary arteries with subsequent myocardial infarction, as in the 27-year-old patient with congenital aortic stenosis and acute endocarditis in case 3.

[Results after coronary bypass operation]

OBJECTIVE

To determine the influence of various risk factors on 30-day postoperative mortality rate of aortocoronary bypass operation at different centres.

PATIENTS AND METHODS

Data on 227 patients (179 men, mean age 63 [40-87] years; 48 women, mean age 68 [44-81] years), 219 first operations, 8 second operations) were retrospectively analysed. In all patients the indications for aortocoronary bypass surgery had been established in the last 3 months of 1993. The operations had been performed at six cardiac centres in Germany (five in Hessen [H1-H5]) and in three hospitals elsewhere in Europe outside of Germany (E1-E3).

RESULTS

The operative mortality was relatively high (5.3%), 152 patients (67%) presenting with one or more risk factors accounting for an increased perioperative mortality. The mortality rate was significantly higher for: clearly impaired left ventricular function (ejection fraction < 40%): 20 vs 3% with an ejection fraction > or = 40% (P < 0.001); emergency operation: 16.6 vs 2.7% for elective operation (P < 0.001); advanced age (> or = 70 years): 10.9 vs 3.1% for younger patients (P < 0.025); and unstable angina: 9.2 vs 2.9% with stable angina (P < 0.05). Most of the bypasses were done with the internal mammary artery (63.9%, usually combined with venous bypasses (exclusive use of venous bypasses in 35.2%), but the proportion of arterial bypasses differed greatly between centres (96% in H3, 19% in H4).

CONCLUSIONS

(1) Aortocoronary bypass operations are done on many patients with important risk factors, resulting in a relatively high 30-day postoperative mortality rate. (2) The proportion of internal mammary artery bypasses markedly differs between centres in Hessen.

Multicenter evaluation of the Strecker tantalum stent for acute coronary occlusion after angioplasty

The Strecker stent is a balloon-expandable, flexible endoprosthesis constructed of knitted tantalum wire and has been implanted successfully in peripheral arteries. This study presents the first multicenter experience with implantation of this radiopaque device in the coronary arteries in 64 patients of 6591 consecutive percutaneous transluminal coronary balloon angioplasty (PTCA) procedures complicated by abrupt closure. In all except 1 patient the stents (n = 72) were correctly placed, and flow could be reestablished immediately. During hospitalization 12 (19%) patients had stent closures; 5 (8%) patients had Q-wave myocardial infarctions; and 13 (20%) patients underwent bypass surgery (4 on an emergency basis). The in-hospital mortality was 9%: 2 patients died after thrombotic stent occlusions; 2 patients had fatal bleeding complications; and 2 patients died after bypass surgery. Major bleeding complications at the puncture site were observed in 8 (12.5%) patients. Angiograms (n = 45) after 17 +/- 5 weeks revealed a stent patency rate of 89%. Thus the Strecker coronary stent proved to be helpful in the management of acute vessel closure during PTCA. However, in this first series a high incidence of early thrombotic occlusions and bleeding complications warrants close anticoagulation monitoring and limits broader indications.

[PTCA or alternative techniques? Balloon angioplasty remains dominant]

The use of second generation devices like excimer laser, rotablator, directional atherectomy, and stents is increasing. It is noteworthy that they are used in most cases in combination with "balloon" dilatation. The application of these more expensive techniques requires more experience and skills than mere balloon dilatation. Today, however, only three randomized trials were able to document some advantage of alternative devices in comparison to the traditional lumen enlargement with balloons (BENESTENT, STRESS, ERBAC). The following paper reflects our experience with balloon angioplasty in more than 15,000 patients, as well a critical review of new devices that were used in 19% of our patients in 1993.

[The recanalization of chronic coronary artery occlusions: what factors influence success?]

Between January 1986 and June 1990, recanalization with guide-wire and balloon angioplasty (PTCA) was attempted in 509 patients (416 men, 93 women; mean age 57.5 +/- 9 years) with chronic coronary artery occlusions. The data recorded were analysed to determine the factors which influenced the outcome. The intervention was initially successful in 284 patients (55.8%; circumflex branch: 50%; right coronary artery: 52%; venous bypass graft: 50%; anterior interventricular branch: 64%). The success rate was markedly reduced if (1) the occlusion had persisted for more than 6 months (9.5%; P < 0.001); (2) occlusion had occurred at or after a vessel kink (28.5%; P < 0.001); (3) there had been no vessel "stump" (36%; P < 0.01) and (4) the occlusion was longer than 10 mm (40.7%; P < 0.05). The success-rate was higher if (1) intracoronary anastomoses were absent (61.2%); (2) occlusion had occurred in a straight vessel (62.6%); (3) there had been a vessel stump (64%); (4) the occlusion had persisted for less than 4 weeks (68.5%) and (5) the length of occlusion was < or = 10 mm (75.8%).-These data indicate that the success of PTCA after chronic coronary artery occlusion depended on the site of occlusion, its duration and length, absence of orthograde collaterals and the presence of a vessel stump. Knowing the extent of these factors helps in delineating the indications.

Clinical and angiographic outcome following implantation of the new Less Shortening Wallstent in aortocoronary vein grafts: introduction of a second generation stent in the clinical arena

One of the factors felt to have contributed to the high rate of stent occlusion in the European registry of the coronary Wallstent in the 1980s was the frequent deployment of more than one stent to cover the target lesion. This resulted from a high degree of shortening of the Wallstent upon expansion. To overcome this limitation the design of the Wallstent was modified to reduce the degree of shortening. We report the results of a study of the first patients to undergo implantation of the new Less Shortening Wallstent. Thirty-five Wallstents were electively deployed in aortocoronary vein grafts in 29 patients. Stent deployment was successful in 35 of 36 attempts in 30 lesions. In five of the 30 lesions, a second stent was required to cover the proximal portion of the lesion. Angiographic success (< 50% residual diameter stenosis as determined by off-line quantitative coronary angiography) was achieved in all 29 patients. During the in-hospital phase, no major adverse cardiac event occurred (reintervention, re-CABG, myocardial infarction, or death) and five patients had hemorrhagic complications. Following hospital discharge, one patient had a subacute stent occlusion associated with symptoms and elevated cardiac enzymes at 11 days, another patient had symptoms and elevated cardiac enzymes (CK 300 U/I) at 22 days with a patent stent, five patients required balloon angioplasty within the 6 month follow-up period (four for restenosis and one for stent occlusion), one patient underwent re-CABG for a native artery stenosis distal to the anastomosis of the patent stented vein graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized trial comparing two devices: the Palmaz-Schatz stent and the Strecker stent in bail-out situations

To assess whether differences in design (geometry, flexibility) and material (electrostatic behavior) may influence the acute and late outcome following intracoronary stent implantation in the treatment of acute or threatened closure after prolonged balloon inflations, 50 patients were randomized to receive either a Palmaz-Schatz stent (n = 25) or a Strecker stent (n = 25).

RESULTS

[table: see text]

CONCLUSION

Both Palmaz-Schatz and Strecker stents are equally effective in restoring vessel patency in bail-out situations. The incidence of complications is high and similar for both stents if they were used after failed prolonged balloon inflations. Differences in design and material do not seem to influence the results.

Current status of the Strecker stent

Knitted flexible tantalum stents proved to be a valuable adjunct to percutaneous transluminal angiplasty (PTA) in the case of insufficient PTA results, and their use was established in the distal aorta, the iliac, the femoro-popliteal, the renal, and the coronary arteries. Recently, long arterial occlusions were defined as new indications for primary stenting; stent indications were further extended to the subclavian, the carotid, and the splanchnic arteries. Due to higher incidence of acute and late complications after stent treatment of small diameter arteries, patients have to be selected thoroughly. Newly designed drug-releasing stents tested in animal experiments promised to be suitable to diminish the incidence of late restenosis due to intinal hyperplasia, thus providing better long-term patency.

Clinical results of coronary excimer laser angioplasty: report from the European Coronary Excimer Laser Angioplasty Registry

From January 1991 to January 1993 the clinical and angiographic data of 470 patients were included in the European Coronary Excimer Laser Angioplasty Registry. Symptoms were CCS class 3 in 23% and CCS class 4 in 14.7%; unstable angina was present in 14.7% and 6.6% of patients had acute myocardial infarction. Of 477 treated lesions, 60% were type B2, and 19% type C. The lesion was located in the LAD in 61%, in the LCX in 16%, in the RCA in 20%, in a protected left main stem in 1.3% and in a saphenous vein graft in 2.5%, respectively. Failure of laser angioplasty occurred in 56 (12%) interventions. By multivariate analysis failure was associated with the intention to treat long segmental lesions (risk ratio (RR) 3.6, confidence interval (CI) 2.9 to 4.4; P = 0.0005), segments with severe prestenotic tortuosity (RR 3.5, CI 2.4 to 4.6; P = 0.02) and total occlusions (RR 2.1; CI 1.4 to 2.8; P = 0.05). Complications included vasospasm (13.4%), dissection (14.7%), flow limiting dissection (4%), reclosure (7.8%), and perforation (1.9%). Myocardial infarction occurred in 2.1%, CABG was requested in 1.9%, and the mortality was 1.5%. Procedural success was achieved in 89%. Individual morphological criteria for a reduced procedural success were the presence of a thrombus (RR 6.4; CI 5.0 to 7.7; P = 0.007) and vessel calcification (RR 2.6; CI 1.9 to 3.2; P = 0.005). Procedural success was slightly lower in type C lesions (86%) than in type B2 (88%) type B1 (95%), and type A lesions (92%), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[The long-term success after coronary angioplasty in old age]

Long-term results of coronary angioplasty (CAP) were compared between two age-groups of patients. Group 1 had 227 patients (158 men, 69 women) with a mean age of 70 (65-88) years, group 2 had 717 patients (611 men, 106 women), mean age 54 (20-64) years. Unstable angina was more common in group 1 than group 2 (48.9 vs 37.7%, P < 0.05). Multi-vessel disease was present in 50.7% of those in group 1 and 41.9% in group 2. Primary success of CAP was similar in the two groups (group 1: 88.1%, group 2: 90.5%). The long-term effect at the first follow-up angiography 3-4 months after CAP was slightly less favourable in group 1 than 2 (54.9 vs 58.3%; difference not significant). However, there were more patients with unstable angina in group 1. Thus the angiographic long-term results were worse in the older patients (44.6 vs 60.1%; P < 0.05), while there was no difference between the two groups as regards stable angina (64.7 vs 57.2%). After a second CAP (because of recurrence), the long-term angiographic effect was, if anything, slightly better in the older patients (87.0 vs 77.1%). The death-rate (cardiac causes of death) up to one year after CAP was comparable in the two groups (1.7 vs 0.8%), as was the rate of non-fatal myocardial infarction (2.2 vs 1.3%). These data indicate that clinical and angiographic long-term success after CAP is comparable in older and younger patient groups and age alone does not present a higher risk.

24-hour anti-ischaemic action with once daily nifedipine. Experience obtained with a fatty-alcohol matrix tablet in patients with coronary artery disease

The ability of a fatty-alcohol matrix, slow-release tablet of nifedipine 60 mg to maintain a 24-hour anti-ischaemic action in the fixed dose of 60 mg once daily has been investigated in a randomised, placebo-controlled, double-blind trial. 12 normotensive patients with angiographically proven coronary artery disease (stenosis of at least one major vessel > or = 70%) were studied. The anti-ischaemic response was assessed over a period of 4 days as changes in the exercise-induced ST-segment depression 6 h and 24 h post-dose, and ST-segment changes in 24-h ambulatory ECGs. A measurable anti-ischaemic response was observed in 8 of the 12 patients. Exercise-induced ST-segment depression 6 h after the administration of nifedipine was reduced by 30% compared to placebo, and there was still a measurable anti-ischaemic response 24-h post-dosing. Both responses were independent of changes in exercise blood pressure. In 7 patients with ischaemic episodes in the 24-h ECGs, nifedipine treatment had only a minor effect on the intensity and duration of ischaemia. It is concluded that a significant anti-ischaemic effect lasting 24 h could be demonstrated using effort-induced ST-segment changes in patients with angiographically proven coronary heart disease, who were treated once daily with nifedipine 60 mg as a fatty-alcohol slow release tablet.

[Long-term results of coronary angioplasty in relation to vessel size]

Repeat angiography was performed after 3-4 months in 927 of 1386 consecutive patients (67%) who had a successful percutaneous coronary angioplasty (PTCA) between 1986 and 1988. The degree of coronary artery stenosis was determined angiographically before PTCA, immediately after and 3-4 months later. Patients were assigned to one of four groups according to balloon diameter at dilatation: Group 1: 1.5-2.0 mm; group 2: 2,5 mm; group 3: 3.0 mm; group 4: 3.4-4.2 mm. Vessel wall proliferation occurred in all four groups after PTCA. In patients with angiographically demonstrated recurrence (first recurrence: 308 patients, second recurrence: 43 patients) another balloon dilatation was undertaken and a repeat angiography 3-4 months later. Long-term success rate (less than 50% stenosis) differed significantly according to the post-PTCA vessel diameter: 48% in group 1, 63% in group 2, 66% in group 3 and 80% in group 4 (analysis of variance: P less than 0.001). PTCA thus produces better long-term results in large than in small vessels.

Dose-related antiarrhythmic effects of nicainoprol in patients with chronic ventricular arrhythmias--a double-blind, placebo-controlled, cross-over multicentre trial. Nicainoprol Study Group

One hundred and three patients with a history of ventricular arrhythmia were screened by baseline 24-h Holter monitoring for a minimal mean number of 30 premature ventricular beats (PVB) per hour. One hundred and one patients were subsequently enrolled in a double-blind, cross-over trial, including four 4-day periods with administration of placebo (PL) or nicainoprol (N.) in doses of 200, 400, 600 mg three times daily in randomized order. Antiarrhythmic efficacy could be evaluated in 61 patients who met all requirements of the protocol, including a complete sequence of valid Holter recordings (greater than 18 h each). Total PVBs were significantly reduced by the 400-mg dose (65%) and the 600-mg dose (71%) as compared to baseline. Two hundred mg N. and PL led to a non-significant reduction of PVBs by 41% and 24%, respectively. An individual response, assumed where there was simultaneous reduction of total PVBs greater than 75%, of ventricular pairs greater than 90% and elimination of ventricular runs, was found in 6 (10%), 10 (16%), 21 (34%), and 22 (36%) patients with PL, 200 mg N., 400 mg N. and 600 mg N., respectively. Four hundred and 600 mg N, significantly prolonged the PR interval (0.17 s and 0.18 s; median values) as compared with baseline (0.16 s), while the QRS duration was significantly increased only by the 600-mg dose (from 0.10 to 0.11 s). Heart rate, mean blood pressure, QT and JTc intervals were not significantly influenced by any dose of N.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute vascular occlusion caused by percutaneous transluminal coronary angioplasty: early and late results of repeat-PTCA]

Acute vascular occlusion after percutaneous transluminal coronary angioplasty (PTCA) often necessitates a prompt aortocoronary bypass-operation (CABG). Alternatively, a re-PTCA can be attempted. In 1500 consecutive patients there was acute symptomatic occlusion due to PTCA 5 min to 16 h after the operation in 47 cases (3.1%). An immediate re-PTCA was attempted in all cases.

RESULTS

Reopening was successful in 43 of 47 cases (91%): in 15 patients (30%) within 30 min, in 36 patients (68%) within 60 min and in 42 patients (89%) within 90 min. In eight patients there was early re-occlusion 30 min to 20 h after re-PTCA, necessitating acute CABG in four patients. In 35 patients with re-PTCA the vessel remained open. Re-stenosis occurred within 1 to 10 days in 10 patients, and in additional 12 patients after 2-4 months. In most cases an additional PTCA was successful.

COMPLICATIONS

Six patients had an emergency CABG (three with an exchange wire as a stent in the dissected coronary artery). Three patients died (one after CABG); 14 patients experienced myocardial infarction (30%) (in three of these 14 the infarct was large).

CONCLUSION

Acute vascular occlusion after PTCA can successfully be treated by re-PTCA in four of five cases. However a rate of re-stenosis of about 60% is to be anticipated. Reperfusion with re-PTCA is fast and in these patients with transmural ischemia there are obviously less complications in comparison to emergency CABG after PTCA. 60% of the patients remain symptom free or markedly improved and without infarction or emergency CABG after 4 months.

Clinical and Doppler echocardiographic follow-up after percutaneous balloon valvuloplasty for aortic valve stenosis

Percutaneous balloon valvuloplasty has been shown to increase the aortic orifice area and to improve clinical symptoms. However, there are only few data concerning long-term results after balloon valvuloplasty. In this study, 36 patients (11 men, 25 women, mean age 75 +/- 8 years) were followed after balloon valvuloplasty for a period of up to 18 months by means of clinical parameters and repeated Doppler echocardiographic measurements after 1, 3, 6, 12 and 18 months. Invasive measurements revealed a decrease of the systolic peak gradient from 78 +/- 24 to 38 +/- 13 mm Hg (p less than 0.001), and an increase in the aortic orifice area from 0.58 +/- 0.23 to 0.93 +/- 0.2 cm2 (p less than 0.001). The Doppler echocardiographic approach revealed that the maximal instantaneous gradient decreased from 96 +/- 26 to 67 +/- 22 mm Hg (p less than 0.001). The aortic orifice area increased from 0.49 +/- 0.16 to 0.73 +/- 0.21 cm2 (p less than 0.001). Three patients (8%) died in the hospital. After hospital discharge, 16 patients (44%) died and 8 patients (22%) underwent successful aortic valve replacement after a mean follow-up of 8 +/- 6 months. Nine patients (25%) were alive after a follow-up period of 18 months. Seven of these (19%) remained clinically improved. During follow-up, the Doppler echocardiographic results revealed a continuous trend toward the preprocedural severity of the aortic valve stenosis. Progression of restenosis assessed by Doppler echocardiographic measurements was accelerated in the group of patients who subsequently died or underwent repeat balloon valvuloplasty or aortic valve replacement.

[The results after prosthetic aortic valve replacement. What effect does old age have?]

Data were retrospectively analysed of 149 consecutive patients with aortic valve stenosis (91 males and 58 females; mean age 64 [27-86] years) who had a prosthetic valve implanted between 1986 and 1988. The overall operative mortality rate was 3.4%, the one-year mortality rate was 4.7%. Operative mortality rate for those aged 27-74 years was 1.7% (2 of 120), but 10.3% (3 of 29) for those aged 75 to 86 years (P less than 0.05). None of the patients in clinical grade III (NYHA classification) died within 30 days of the operation. Among those in grade IV the operative mortality rate was 15.8% (3 of 19) for those aged 75-86, but 4.0% (2 of 50) for those aged below 75 years (P less than 0.05). Valve replacement in symptomatic aortic stenosis with a prosthetic valve is today the method of choice. Operative mortality rate is low, even for patients of advanced age, particularly if the operation is done early.

[Long-term success of coronary angioplasty after repeated treatment]

To ascertain the long-term results after second and third angioplasties for coronary stenosis the coronary angiograms from 1504 consecutive patients with coronary heart disease (1211 men, 293 women, mean age 57 [27-82] years) were retrospectively surveyed. A good initial response (at least 20% reduction in stenosis) was achieved in 295 out of 306 second angioplasties (95.5%), and in all 36 third angioplasties. Viewed overall, these results are significantly better (P less than 0.005) than those achieved at the initial angioplasty (1386 out of 1504 patients; 92.2%). The reduction in the severity of the stenosis achieved at the second angioplasty (from 86 to 24%) and at the third angioplasty (from 86 to 26%) was the same as at the first angioplasty (from 88 to 28%). Serious complications after the first angioplasty were infrequent (death in 0.2%, emergency bypass in 0.4%, myocardial infarction in 0.5%), and no complications were noted after second and third angioplasties. A good long-term outcome (at least 20% reduction in stenosis at 3-4 months) was slightly more frequent after the second and third angioplasties (103 out of 170 [60.6%] and 14 out of 17 patients, respectively) than after the first intervention (532 out of 926 patients; 57.5%). In keeping with these results, the degree of stenosis found at follow-up angiography was significantly lower (first intervention 54.8%, second intervention 50.3%, third intervention 36.9%). There were only 57 patients (3.8%) who ultimately required operative treatment. These figures indicate that the probability of a good long-term outcome from coronary angioplasty increases each time the stretching operation is repeated. Only a very small proportion of patients will require bypass surgery.

[Treatment of coronary heart disease in the aged. When balloon dilatation, when surgery?]

Data from 3029 consecutive patients (2474 men, 555 women, mean age 59 [20-88] years) in whom coronary heart disease had been diagnosed by coronary angiography were studied with the object of identifying those patients in the older age group who are suitable for treatment by balloon angioplasty. There were 884 patients with a mean age of 70 (65-88) years, and 2145 patients with a mean age of 54 (20-64) years. Single vessel disease was less common in older patients (30% vs 44%; P less than 0.001), double vessel disease was equally common in both groups (28% vs 30%) and triple vessel disease was commoner in the elderly group (42% vs 26%; P less than 0.001). For elderly patients with single vessel disease conservative treatment was chosen in 50%, angioplasty in 49% and operative treatment in only 1%. Of elderly patients with involvement of two arteries, 44% were treated conservatively, 40% by angioplasty and 16% surgically. Of elderly patients with triple artery disease, 23% were treated conservatively, 8% by angioplasty and 69% operatively. This pattern was similar to that among younger patients. The success rate and the incidence of complications after percutaneous transluminal coronary angioplasty were similar in both age groups. In elderly patients with disease of only one or two coronary arteries the prospects of success and the risks are comparable to those in younger patients, but patients with triple artery disease often need bypass surgery.

[Protective function of collaterals in percutaneous transluminal coronary angioplasty]

With increasing application of PTCA, it will become necessary to identify patients (p) who can be dilated without expensive surgical standby. In 82 p with angina pectoris and stress-induced ischemia and without transmural myocardial infarction, the following parameters were measured during coronary angioplasty (PTCA): angina pectoris (AP), epicardial ST-segment displacement (via long wire), and aortic pressure. In 26 p, the affected vessel showed retrograde filling (A) via collaterals (CL). In 24 p CL were identified without retrograde filling (B) and 32 p were without CL (C). The balloon was inflated three to eight times over periods of 30 to 90 s. [table; see text]

CONCLUSIONS

In vessel occlusion caused by PTCA, a myocardial infarction will occur in more than 80% of p without visible CL, and rarely in the presence of CL. Therefore, PTCA of vessels with retrograde filling appears safe. Furthermore randomized studies are necessary to determine if strict surgical standby is required in such cases.

[Echocardiographic functional parameters of the left ventricle as a prognostic indicator in coronary heart disease]

The value of two-dimensional cross-sectional echocardiography for the estimation of the left ventricular function had been investigated in 241 consecutive patients with suspected coronary artery disease (CAD). The day before left heart catheterization the left ventricular volumes (EDV, ESV) as well as the global left ventricular ejection fraction (EF) were calculated from the RAO-equivalent in the 2D-echo and in addition the classification of the EF was visually performed from different cross-sections. The coronary angiography showed in 208/241 patients hemodynamically effective stenoses (lumen restriction greater than 50%). For 192/208 patients there were diagnostically usable 2D-echograms as well as clinical data over an observation period of 3 years and 7 months. The 2D-echo correspond quite well to the levocardiography for the calculation of the EDV with r = 0.75, with r = 0.85 for the ESV, and with r = 0.80 for the EF. The mere visual evaluation of the EF out of the 2D-echo agreed well in 84% of the cases to the quantitative determination. During the observation period 18/192 patients died; 17/18 of these patients of cardial causes. Out of the patients with normal EF in the 2D-echo only 3.5% died, with slightly reduced EF 10% died. With highly reduced EF mortality was with 40% significantly increased (p less than 0.001). Thus in patients with CAD unfavourable long-time prognosis may be quickly recognized by their markedly reduced left ventricular function in the 2D-echocardiogram, which shows favourable correspondence to invasive data.