Summary: Adaptation of the circulation to pregnancy occurs via a complicated series of changes not yet completely understood. To define pertinent alterations, echocardiographic measurements of left ventricular function were performed every 4 weeks in 13 normal pregnant women. Six weeks postpartum each woman was reexamined; thus each woman served as her own nonpregnant control. Left ventricular dimensions, left ventricular wall thickness, shortening fraction, and rate of change of these measurements were recorded. As expected, cardiac output was increased throughout pregnancy. Up to 20 weeks gestation this occurred via an increased heart rate. After 20 weeks gestation stroke volume increased significantly, with 20% at 20-26 weeks up to 30% at term (p < O.OI). With the end-diastolic wall thickness remaining equal, myocardial hypertrophy occurred. This was corroborated by an increase in end-systolic left ventricular wall thickness towards term: from 13.8 mm (S.D. ± 1.73) in early pregnancy to 16.6 mm (S. D. ± 1.62) at term, with end-systolic left ventricular dimension unchanged. It was concluded that during pregnancy the mechanism to produce a higher cardiac output shifts from an increase in cardiac frequency to elevation of stroke volume with concomitant myocardial hypertrophy. Due to changes in heart rate and afterload, no conclusions could be drawn regarding myocardial contractility.

Reintervention was required in 123 (12%) individuals during a follow up (mean 7-5 years, range 5-14-5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5-6%) than at the primary operation (1 2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1-82) and with extent of vascular disease (rate ratio 1 80) but not with reintervention (rate ratio 1 45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention.Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.Coronary artery bypass grafting has been used successfully to treat angina pectoris since 1968.1 It is now clear that it is not a definitive treatment. Most patients experience an improvement in symptoms but this relief decreases with time.24 Both Campeau et al and Lytle et al reported an accelerated loss of graft patency after five years or more.5 6 Moreover, atherosclerosis is a progressive disease. As a result, reoperations after coronary artery bypass grafting are increasingly performed7 and angioplasty has been introduced to improve myocardial blood flow either by dilatation of a stenosed bypass graft or by dilatation of an unbypassed narrowed native artery.'0 'To assess the frequency of re-revascularisation achieved by re-grafting or angioplasty, we studied a group of consecutive patients who had isolated coronary artery bypass grafting before July 1980. We looked especially at symptomatic improvement after both these procedures, the timing, the procedure Requests for reprints to

To examine whether coronary angioplasty has a different effect on work resumption than has coronary artery bypass surgery, we studied the work status of patients before and at least 1 year after either intervention. The population consisted of men aged less than 60 years, submitted to these procedures from September 1983 to July 1984. Of the 261 eligible patients, 219 (84%) participated, 94 after an angioplasty and 125 after a bypass procedure. 6 months preceding the intervention, 52% of the men were working. This had decreased to 47% at follow-up. Multiple logistic regression analysis showed that failure to resume work was correlated with bypass surgery vs balloon dilatation (rate ratio 1.8; 95% CI, 1.0-3.4), not working beforehand (rate ratio 6.5; 1.2-4.3), age greater than 55 years vs less than or equal to 50 years (rate ratio 2.6; 1.3-5.4) and with angina at follow-up (rate ratio 1.8; 1.0-3.3). Taking these additional risk factors into account permits a prediction of the probability of a return to work.

The angiotensin-converting enzyme inhibitor, captopril, was given to 19 patients with severe heart failure. Seven patients had acute myocardial infarction and the remainder had chronic myocardial damage caused by ischaemia or valvular disease. Cardiac filling pressures were raised in all, the pulmonary capillary "wedge" pressure being 17 mmHg or more. Captopril, 50 mg orally, raised stroke volume and cardiac output, and reduced heart rate, cardiac filling pressures, systemic arterial pressure, and the plasma concentrations of aldosterone and noradrenaline. These changes were attended by clinical improvement. Decrements in cardiac filling pressures, systemic arterial pressure, and total peripheral resistance were positively correlated with pretreatment plasma renin. Long-term treatment with captopril was offered to 14 patients. Four patients with severe coronary disease died suddenly after initial clinical improvement. In nine patients haemodynamic measurements were repeated after three months. The results showed sustained effects on cardiac output and filling pressures but there was no loss of body weight. The haemodynamic effects were at least as good as with previous vasodilators. The fall in systemic arterial pressure, however, was greater with captopril. Captopril may become a valuable adjunct to the treatment of acute and chronic heart failure, but more information about its effect on coronary blood flow is required.

suMMARY Angiographically demonstrable changes in bypass status and their relation to the disease in the native coronary circulation were studied in 221 patients one year and three years after coronary artery bypass graft surgery. The extent of coronary artery disease was scored according to the recommendations of the American Heart Association and quantified following the method of Leaman. Patency in 570 grafts at one year was 79-6% and at three years 76-5%. The majority of grafts (83-5%) showed no change from one year to three years, 1144% showed progression in disease, and 5-1% showed regression. The majority of grafts which occlude do so in the first year after surgery. After the first year, the graft attrition rate is 1*6% of grafts per year.The coronary score (0, no disease; >30, serious three vessel disease) before surgery was 14 2+ 1.92 (mean +95% confidence) and dropped to 5 3+0 76 at one year when corrected for patent grafts. The coronary score remains greater than zero because of early graft closure and/or untreated lesions. By three years the corrected coronary score increased to 7-2 t1*06 primarily because of progression of disease in the native coronary circulation. Two subgroups, formed on the basis of angina pectoris at three years, showed that progression of disease in the native circulation was identical, but that return of angina was highly correlated with whether or not this disease occurred in segments perfused by patent grafts. Those This study was made possible by the existence of a large data bank designed for the three year follow-up of patients after bypass grafting. ' The pertinent aspects of this data bank are that it specifies recatheterisation at one year and three years after Accepted for publication 10 March 1983 bypass surgery with complete scoring of the coronary angiogram and bypass graft status. A complete physical examination and history are also obtained at these points. The development in this laboratory of a coronary scoring system to quantify the extent of coronary artery disease and its changes over the follow-up period has been previously reported.2 This method is also applied here in this study. MethodsThe selection criteria for this study was the availability in Rotterdam of selective graft and coronary angiograms at one year and three years after coronary artery bypass graft surgery. All patients were also evaluated before surgery. In total 221 patients met 42