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The use of electronic ÒfilmlessÓ media for long-term archiving of coronary angiograms has been impeded by the problems of image storage and data transfer among institutions. Although long-term analogue storage of the images is presently feasible, and much less costly than digital storage, processing has been limited to a 625 lines video format, not optimal for high quality images. We developed a bi-directional 1249/625 lines converter, able to store and to replay high resolution (1249 lines) video images, from Component Record Video (CRV) Optical Laser (Analogue) Videodisks. Image quality and medical relevance were evaluated five ways: 1) Outside experts compared 593 static images stored on CRV discs to the same images stored in a high-resolution digital format blinded to source of image. The four experts found no visual or medical difference in 98% of evaluated images and minor differences in the remainder. The differences in the remaining images were not consistent among experts. 2) Two of the experts also compared the enhanced CRV optically stored image to the image obtained on simultaneously recorded 35mm cine film, and found the enhanced CRV stored image to be superior or similar, but never inferior to the film image. 3) 90 representatives from 63 outside institutions compared images from both a digital hard drive and the enhanced CRV optical (analogue) storage displayed at a Windows based digital workstation. During the test they were blinded as to the source of the images. The representatives found no difference in image resolution, quality, diagnostic accuracy, and medical relevance. 4) We evaluated quantitative coronary angiography (QCA) on standard coronary test phantoms using enhanced CRV stored images digitally processed. The correlation of the enhanced CRV image to the actual size of the phantom vessels was similar to the results obtained in the literature from digitally stored images. 5) 78 arterial measurements ranging 0.65 to 4.85 mm were evaluated both from the digital hard disc (D) and the CRV optical disc (CRV), using the same QCA analytical package. The correlation coefficient and the Standard Error of the Estimate between D and CRV values were respectively 0.997 and 0.076, no systematic over or underestimation occurred, and the mean variability was inferior to 0.1 mm. CONCLUSION: High-Resolution CRV-optical storage represents a cost-effective solution for excellent image quality equivalent to digitally stored images, permitting permanent electronic archiving inside the cath-lab, and allowing digital image processing and digital image communication.

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BACKGROUND: Stenting reduces both acute complications of coronary angioplasty and restenosis rates but increases subacute thrombosis rates and hemorrhagic complications when used with coumadin anticoagulation. METHODS AND RESULTS: To simplify postcoronary stenting treatment and to reduce these drawbacks, we evaluated the 1-month outcome of a prospective registry of 2900 patients in whom successful coronary artery stenting was performed without coumadin anticoagulation. Patients received 100 mg/d aspirin and 250 mg/d ticlopidine for 1 month. Low-molecular-weight heparin (LMWH) treatment was progressively reduced in four consecutive stages, from 1-month treatment to none. Event-free outcome at 1 month was achieved in 2816 patients (97.1%). Major stent-related cardiac events were subacute closure in 51 patients (1.8%), including death in 12 (0.5%), acute myocardial infarction in 17 (0.6%), and coronary artery bypass graft surgery in 9 (0.3%). Stent thrombosis was more frequent with balloon size of < 3.0 mm (< or = 2.5 mm, 10%; 3.0 mm, 2.3%; > or = 3.5 mm, 1.0%; P < .001), bail-out situations (6.67% versus 1.38%, P < .001), and patients with unstable angina or acute myocardial infarction (2.2% versus 1.12%, P = .02). Bleeding complications that required transfusion, surgical repair, or both occurred in 55 patients (1.9%). Bleeding complications were related to female gender (4.0% versus 1.51%, P < .001), duration of LMWH treatment (3.83% in phase II/III versus 0.69% in phase IV/V, P < .001), sheath size (6F, 0.52%; 7F, 1.04%; > or = 8F, 4.23%; P < .001), bail-out situations (4.76% versus 1.67%, P < .01), and saphenous graft stenting (4.38% versus 1.75%, P = .04). CONCLUSIONS: These results suggest that poststenting treatment by ticlopidine/aspirin is an effective alternative to coumadin anticoagulation, achieving low rates of subacute closure and bleeding complications. LMWH treatment does not improve subacute reocclusion rates but increases bleeding complications. Furthermore, as bleeding complications were independently related to sheath size, we suggest that stenting with 6F guiding catheters may prevent local complications. Furthermore, the ticlopidine/aspirin combination allows a low-cost stenting strategy without ultrasound assessment of stent deployment and permits short inhospital stay.

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Several new techniques have been developed to get round the limitations of conventional coronary angioplasty. Most entail ablation of the atheromatous plaques by mechanical (atherectomy) or photochemical (laser excimer) means, whilst others (stents) shore up the vascular walls. Their use with conventional coronary balloon angioplasty optimises the results of treatment of complex lesions. This report describes the authors' experience in 1,266 patients (1,668 lesions) treated between January 1992 to December 1993. The new techniques were used in 33% of patients and 30% of lesions (rotational) atherectomy: 20%; stents: 5%; directional atherectomy: 3%; laser excimer: 2%) because of the defavourable angiographic characteristics of the lesions (eccentricity, calcification, bifurcation, length, chronic total occlusion, thrombosis, ostial stenosis, ulceration, saphenous vein graft). The primary success rate was 91% in the whole group (94 to 97% for the patients treated by the new techniques). The global major complication rate was 1.7%. The multi-instrumental revascularization adjusted to the coronary lesions (MIRACLE) gives a high primary success rate in patients with coronary lesions difficult to treat by conventional angioplasty. Randomised trials will be necessary to determine the precise indications of each technique with respect to the morphological characteristics of each lesion.

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The use of Digital Subtraction Angiography in coronary applications is restricted by the difficulty in: 1. Obtaining a good resolution of the distal branches. 2. Avoiding, for the purpose of subtraction, the motion artifacts induced by artery and background displacement during the cardiac and respiratory cycles. 3. Preserving the dynamic vascular motion. 4. And storing the digital dynamic information on a permanent support. We used for this study an angiography system, based upon a high resolution 45 MIPS-32 Mbyte image processor, interfaced with a 2.75 Gbyte Winchester drive allowing the real time storage of either 30 frames/s in the 512*512*8 bits matrix or of 7.5 f/s in the 1024*1024*8 bits matrix. To preserve the most important dynamic informations on the basis of the 7.5 f/s maximal storage rate, we developed a synchronization device able to recognize in real time, from chronologic delays derived by using both ECG and Aortic Pressure curves, the functional End-Diastolic (ED) and the End-Systolic (ES) positions, even in the case of heart rates varying during the procedure. The ED and the ES images are stored together with the Mid-Systolic (MS), the 1/3-Diastolic (1/3D) and 2/3-Diastolic (2/3D) images. To establish the validity of this sampling method, which uses a reduced number of frames per cardiac cycle, 7200 coronary injections performed during 450 routine coronary angiographies were compared by two independent observers (A and B), using: first a Digital (D) 5 frames/cycle sequence, and secondly a cine Film (F) 50 frames/s sequence acquired immediately after the corresponding D injection. The D technique resulted in the best image and diagnostic quality, particularly when the F quality was estimated 'fair' or 'poor' by both observers, and in an important reduction on X-Ray doses. The visualisation of the sequential ED, MS, ES, 1/3D and 2/3D frames gives the possibility: 1. of saving the dynamic information, as a regular sample of functional images can be displayed with a cine loop technique. 2. of facilitating cardiac synchronized subtractions. 3. of reducing the amount of frames per cycle, thus allowing an important reduction of X-ray doses and the digital and permanent storage of the most important cardiac cycles.

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We report two cases of multiple aneurysm complicating bacterial endocarditis and involving the hepatic, renal and superior mesenteric arteries. The aneurysms were treated by the superselective embolization technique hitherto restricted to cerebral arteries. The first patient had been operated upon for mitral valve endocarditis. Because of a persistent anicteric cholestasis, repeat ultrasonography and computerized tomographic scan were performed which revealed two intrahepatic aneurysms associated, at arteriography, with an aneurysm of the superior mesenteric artery. The patient underwent superselective embolization of one of the intrahepatic aneurysms, then of the superior mesenteric artery aneurysm. Angiographic cure was obtained and persists after a 17-month follow-up. In the second patient, persistent clinical and biochemical hepatic abnormalities after mitral and aortic valve replacements for endocarditis prompted us to perform an ultrasonography which showed a large hepatic aneurysm, and an abdominal arteriography which disclosed the presence of several aneurysms. Because of its size and suspected fissuration, the hepatic aneurysm was treated by superselective embolization, and this was followed by embolization of a renal artery. The immediate post-treatment period was uneventful, and complete angiographic cure was confirmed after 6 months. Superselective embolization seems to give good results at mid-term and should therefore be considered for fragile patients with multiple abdominal aneurysms.

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The case of a 77-year old woman who died of refractory pulmonary oedema 36 hours after percutaneous valvuloplasty for tight calcified aortic valve stenosis is reported. Post-mortem examination showed satisfactory opening of the aortic orifice but also rupture of an aberrant chorda which crossed the outflow tract below the aortic sigmoid valves, between the mitral valve and the interventricular septum. This case suggests that before all aortic valvuloplasties the absence of aberrant chorda or suspicious subaortic acceleration should be confirmed by Doppler echocardiography; moreover, during the procedure the balloon should not be inserted too deeply into the left ventricle.

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