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Restenosis rate after stent implantation for short lesions can be predicted using the variables percent diameter stenosis after the procedure and vessel size. This meta-analysis indicates that the concept of "the bigger the better" holds true for coronary stent implantation. Applicability of the model beyond short lesions should be tested.

Resting echocardiography is the most important tool for diagnosing valvular heart disease. However, treatment planning in valvular heart diseases may require additional information in some patients, particularly asymptomatic patients with severe valve disease or symptomatic patients with moderate disease. Stress echocardiography provides invaluable information in these situations and aids decision making. Stress echocardiography is performed using either physical stress or dobutamine stress and various valve parameters are monitored during the stress. Further, the ventricular performance, which is an important determinant of outcome in valve disease is also closely monitored during stress which helps immensely in planning the intervention. Lastly, possibility of associated coronary artery disease can also be evaluated, especially in the elderly. This article discusses the role of stress evaluation in assessment of valve disease in the commonly encountered clinical situations.

Glycoprotein IIb/IIIa inhibitor PCI Safety a b s t r a c t Aims: The aim of the study was to assess the safety and efficacy of Bivalirudin þ Glycoprotein (Gp) IIb/IIIa inhibitor as compared to unfractionated Heparin (UFH) þ Gp IIb/IIIa inhibitor in high risk patients undergoing elective percutaneous coronary intervention (PCI). The primary end point was time to sheath removal and ambulation where as periprocedure myocardial damage, access site bleeding and major adverse cardiac events (MACE) rates were secondary end points.Methods: One hundred and one high risk patients undergoing elective PCI were randomly assigned to either Bivalirudin þ GpIIb/IIIa inhibitor or UFH þ Gp IIb/IIIa inhibitor. PCI was performed by standard technique and activated clotting time was monitored immediately on arrival to recovery area and every 60 min thereafter. Sheath were pulled out once ACT was below 150 seconds and patients were mobilized 6hrs after sheath were removed. Periprocedure myocardial damage was assessed by serial Trop I levels.Results: Patient assigned to Bivalirudin þ Tirofiban has significantly reduced time to sheath removal and ambulation as compared to those who received UFH þ tirofiban (p < 0.0001) although peak Act did not differ in the groups. Peak Trop I levels were significantly lower in Bivalirudin þ Tirofiban group (p ¼ 0.023) and peri-procedure Trop I elevation occurred in significantly lower number of patients treated with Bivalirudin þ Tirofiban (p ¼ 0.029). Conclusions:The combination of Bivalirudin þ Tirofiban was safe and effective as compared to UFH þ Tirofiban in high risk patients undergoing elective PCI.

Objective-To evaluate the healing of balloon induced coronary artery dissection in individuals who have received radiation treatment and to propose a new intravascular ultrasound (IVUS) dissection score to facilitate the comparison of dissection through time. Design-Retrospective study. Setting-Tertiary referral centre. Patients-31 patients with stable angina pectoris, enrolled in the beta energy restenosis trial (BERT-1.5), were included. After excluding those who underwent stent implantation, the evaluable population was 22 patients. Interventions-Balloon angioplasty and intracoronary radiation followed by quantitative coronary angiography (QCA) and IVUS. Repeat QCA and IVUS were performed at six month follow up. Main outcome measures-QCA and IVUS evidence of healing of dissection. Dissection classification for angiography was by the National Heart Lung Blood Institute scale. IVUS proven dissection was defined as partial or complete. The following IVUS defined characteristics of dissection were described in the aVected coronary segments: length, depth, arc circumference, presence of flap, and dissection score. Dissection was defined as healed when all features of dissection had resolved. The calculated dose of radiation received by the dissected area in those with healed versus non-healed dissection was also compared. Results-Angiography (type A = 5, B = 7, C = 4) and IVUS proven (partial = 12, complete = 4) dissections were seen in 16 patients following intervention. At six month follow up, six and eight unhealed dissections were seen by angiography (A = 2, B = 4) and IVUS (partial = 7, complete = 1), respectively. The mean IVUS dissection score was 5.2 (range 3-8) following the procedure, and 4.6 (range 3-7) at follow up. No correlation was found between the dose prescribed in the treated area and the presence of unhealed dissection. No change in anginal status was seen despite the presence of unhealed dissection. Conclusion-radiation appears to alter the normal healing process, resulting in unhealed dissection in certain individuals. In view of the delayed and abnormal healing observed, long term follow up is indicated given the possible late adverse eVects of radiation. Although in this cohort no increase in cardiac events following coronary dissections was seen, larger populations are needed to confirm this phenomenon. Stenting of all coronary dissections may be warranted in patients scheduled for brachytherapy after balloon angioplasty. (Heart 2000;83:332-337)

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