This study shows that peripheral venous flow detected by Doppler ultrasound becomes synchronously pulsatile with heart beats as soon as central venous pressure (CVP) is above 7 mm Hg. CVP was above 7 mm Hg in 13 among 46 patients. Clinical signs of right heart failure were detectable in only 7 of these 13 patients (sensitivity 54%), whereas peripheral venous flow was pulsatile in 12 of them (sensitivity 92%). In 4 patients with a normal CVP, peripheral venous flow was also pulsatile; all of them suffered from valvular heart disease with left ventricle ejection fraction below 60% in 3 of them. The detection of a pulsatile peripheral venous blood flow constitutes an early sign of right heart failure, more sensitive than clinical evaluation, and probably even more than CVP.

A 48-year-old male saxophone player underwent successful PTCA to the left circumflex coronary artery (LCx) in 1992. At the time, a small aneurysm was noted before PTCA, just below the target stenosis. The patient stopped smoking and was treated for hypercholesterolemia and high blood pressure. In 1997, he developed recurrent grade II angina, and a bicycle stress test was positive. Repeat catheterization showed a tight restenotic lesion of the LCx proximal to the aneurysm, which had enlarged significantly, as well as a new lesion more distally (Figure 1).Repeat PTCA was done with a 3.0ϫ30-mm balloon through a 10F left Amplatz guiding catheter with a good result (Figure 2). A 20-mm segment of saphenous vein was then harvested from the left leg and sutured onto the external aspect of a 25-mm-long slotted-tube stainless steel stent (Bestent, Medtronic-Instent) with 4 separate 7-0 prolene stitches at each extremity. The stent was crimped onto the previously used balloon and advanced into the LCx to cover both lesions and the aneurysm (Figure 3). The stent and vein were expanded at a maximal pressure of 14 bar, and the final angiographic result was satisfactory, with no residual stenosis and complete sealing off of the aneurysm (Figure 4). The patient had an uneventful in-hospital course and was discharged on ticlopidine and aspirin. Six weeks later, he remained asymptomatic, and the stress test had become negative.

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A diastolic gradient across the mitral valve is generally indicative of mitral valve stenosis. In the present study, echocardiography was used to demonstrate two less common causes of left ventricular inflow obstruction: one patient had a fibromuscular membrane beneath the valve, the other a large vegetation attached to the posterior leaflet of the mitral valve. Echocardiography proved to be the optimal imaging technique in each case.