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Unstable angina represents an indication for percutaneous transluminal coronary angioplasty (PTCA) provided it is based on a significant fixed lesion. A primary success rate of about 90% can be expected, but in 5% to 10% the intervention will cause a myocardial infarction. Mortality is higher than in patients with stable angina and does not differ from that of bypass surgery; however, it is still below 1%. At 1 year, 50% to 90% of the patients treated with initial success are asymptomatic if redilatations for recurrences (occurring in about one third) are included. - Acute myocardial infarction was introduced as an indication for PTCA in about 1980. PTCA was first used for failures, then for incomplete successes of intracoronary streptokinase therapy, and finally in patients without pretreatment. Currently, PTCA is being evaluated in multicenter studies as an adjunct to early intravenous fibrinolysis with clot specific agents (e.g., tissue-type plasminogen activator). PTCA achieves adequate initial reperfusion in about 80% irrespective of concomitant fibrinolytic therapy. It is complicated by occlusion of an already partially recanalized vessel in 4%. Late reocclusions occur in 15%, half of them accompanied by reinfarction. Intrahospital mortality is about 5% and increases by 1% up to 1 year. PTCA has its place in the treatment of unstable angina and acute infarction. In the latter it may be advantageous to precede it with early intravenous fibrinolysis.

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In 100 consecutive patients undergoing multivessel percutaneous transluminal coronary angioplasty (PTCA), dilation was attempted in 207 arteries. Primary success was achieved in 85 patients. Complications occurred in 8 patients: acute myocardial infarction in 5 and need for emergency coronary artery bypass surgery in 5. Control angiography was done in 77 of 85 patients (91%) with primary success at a mean of 12 +/- 6 months. Complete revascularization had been achieved in 59 patients and incomplete revascularization in 18. Angiographic restenosis was found in 39 of 77 patients (51%) and in 47 of 143 arteries (33%) at 9 +/- 7 months. The restenosis rate was 57% for chronic total occlusions (8 of 14) and 30% for stenoses (39 of 129). The restenosis rate was significantly higher for the left anterior descending coronary artery (40%) than for the left circumflex coronary artery (21%). However, the significance was lost after exclusion of chronic total occlusions. A higher residual stenosis and a high coronary wedge pressure were predictors for restenosis. Restenosis was clinically silent in 14 patients (18%). Repeat PTCA was done in 19 patients with recurrence and elective surgery in 8. Clinical follow-up was available in all patients at 24 +/- 12 months. Patients with incomplete revascularization had less favorable clinical follow-up results than patients with complete revascularization: 44% (8 of 18) vs 81% (48 of 59) were asymptomatic (p less than 0.005), and 28% (5 of 18) vs 5% (3 of 59) had undergone elective bypass surgery during follow-up (p less than 0.005). Most patients with restenosis after multivessel PTCA had only 1-vessel restenosis and only 7% had restenosis of all lesions.

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A videodensitometric method for quantification of aortic regurgitation which requires neither measurement of cardiac output nor determination of enddiastolic and endsystolic left ventricular volumes has been developed. The injection of 20 ml of contrast medium into the left ventricle is digitally recorded at 25 images s-1 during 20 s using an equipment for digital subtraction angiography (Digitron 2, Siemens). The Digitron computes 2 'time dilution curves' (TDC) from the unsubtracted image sequence, for 2 regions of interest drawn around the angiographic enddiastolic and endsystolic left ventricular silhouettes. Enddiastolic and endsystolic points of the TDC are then entered into a VAX-750 computer, which calculates the ejection fraction (EF), the forward ejection fraction (FEF) and the regurgitant fraction (RGF). This is performed by a complex fitting algorithm based on a physical model of the washout process of contrast medium, which reconstructs the two best enddiastolic and endsystolic baselines in the washout parts of the two TDC. The EF, FEF and RGF obtained in 9 regurgitant and 11 nonregurgitant patients have been compared with the corresponding values EFv, FEFv and RGFv obtained by a conventional technique (Cardiogreen and biplane LV area-length volumetry). Regression analysis yielded: EF = 0.88 X EFv (regression line forced through the origin), r = 0.77, FEF = 0.76 X FEFv + 3, r = 0.96, RGF = 0.94 X RGFv + 5, r = 0.98 (v stands for volumetry).

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Between August 1983 and October 1984, 44 patients (39 male and 5 female, mean age 53 years) underwent multivessel percutaneous transluminal coronary angioplasty involving 2 vessels in 37 (84%), 3 vessels in 4 (9%), 4 vessels in 1 (2%) and coronary artery bypass graft plus 1 or 2 vessels in 2 (5%). A mean of 2.2 vessels per patient were attempted. Dilatations of multiple stenoses in the same vessel were not included. Primary success was achieved in 87 of 97 vessels (90%) and in 37 of 44 (84%) patients. Primary success per patient was defined as primary success in all or at least in the strategic lesions associated with clinical improvement of the patient. Complications included one death (2%), emergency coronary artery bypass surgery in one (2%) and myocardial infarction in 2 (4%) patients. Five other patients underwent elective coronary artery bypass surgery. Recurrence of lesion was 14% (5/37 patients) during a follow-up period of 3 to 12 months. Repeat angioplasty was successful in 4 patients (80%) and unsuccessful in 1 patient who underwent elective surgery. It is concluded that, in selected cases, multivessel percutaneous transluminal coronary angioplasty is a feasible alternative to coronary artery bypass surgery, with comparable risks. A satisfactory long-term amelioration without coronary artery surgery can be obtained in 2/3 of patients.

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