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The authors report the case of chronic dissection of the aorta presenting with congestive cardiac failure. The diagnosis was made for the first time by transoesophageal echocardiography which showed both the dissection of the aorta and its fistulalisation into the pulmonary artery. Aortography confirmed the diagnosis. The patient underwent surgery which consisted of suture of the fistula and replacement of the ascending aorta with a prosthetic tube. The outcome was favourable after 8 months follow-up.

We report two cases of coronary-to-bronchial artery communication responsible for coronary steal. In both cases the anastomosis originated from the proximal circumflex artery and developed because of bronchiectasis. In both cases closure of the anastomosis was achieved successfully by embolization. To date, the patients remained free from symptoms.

Despite the introduction of new therapeutic techniques such as radiofrequency ablation and the implantable defibrillator, the classical opposition of monomorphic ventricular tachycardia in apparently normal hearts and that arising from documented cardiac disease remains useful. In the first case, treatment is only symptomatic whereas, in the second, lethal progression to sudden death must be prevented. Generally speaking, in chronic post-infarct situations, betablockers are underused although they have been shown beyond doubt to reduce cardiovascular mortality. This is probably explained by the fear of possible haemodynamic decompensation in patients who often have left ventricular dysfunction. Nevertheless, different randomised studies of the use of betablockers in cardiac failure have reported reduced mortality with no serious side effects. The use of beta-blockers is therefore advisable, and possible inpatients with or without sustained ventricular tachycardia and underlying cardiac disease. In cases at high risk of sudden death, amiodarone may be associated. Recent randomised studies (MADIT, AVID), comparing the use of implantable defibrillators with those of antiarrhythmic therapy, have shown better results with the implantable defibrillator. However, in these studies, only about 10% of patients received betablockers in the antiarrhythmic treatment groups. This factor has introduced some doubt as to the real benefit of implantable defibrillators. Therefore, a randomised study comparing the efficacy of betablockers with amiodarone against implantable defibrillators is desirable in order to determine the respective indications of each of these two therapeutic modalities.

Familial forms of arrhythmogenic right ventricular dysplasia (ARVD) have been described. Signal-averaged electrocardiograms (SAECGs) and standard electrocardiograms have been used to detect ARVD. The purpose of this prospective study, for a given family member, was to evaluate the risk of having ARVD or only belonging to an affected family. To address these issues, we assessed the incidence of late ventricular potentials and electrocardiographic (ECG) abnormalities in the families of our patients with ARVD. SAECGs and electrocardiograms were recorded in 101 eligible family members and compared with those recorded in ARVD patients with sustained ventricular tachycardia (13 patients in 12 families), and in 37 control subjects with a normal electrocardiogram. The incidence of late ventricular potentials was significantly higher in family members than in control subjects (16% vs 3%, p <0.05). The incidence of ECG abnormalities was 34% in family members. When the incidence of late ventricular potentials and/or ECG abnormalities were added up, results were 38% abnormal findings in family members. Late ventricular potentials and/or ECG abnormalities were found in members of all 7 families; these abnormalities were initially thought to be sporadic forms, and thereafter were classified as familial forms. Thus, SAECGs and standard ECG recordings in ARVD family members showed 38% abnormal findings, and that all cases of ARVD could be classified as familial forms. The incidence of familial forms of ARVD was greater than was previously believed, which is highly suggestive of a genetic transmission of the disease in our geographic area.

Background: Nitric oxide (NO) donors, in addition to their vasodilator effect, decrease platelet aggregation and inhibit vascular smooth muscle cell proliferation. These actions could have beneficial effects on restenosis after coronary balloon angioplasty., Methods and Results: In a prospective multicenter, randomized trial, 700 stable coronary patients scheduled for angioplasty received direct NO donors (infusion of linsidomine followed by oral molsidomine) or oral diltiazem. Treatment was started before angioplasty and continued until 12 to 24 hours before follow-up angiography at 6 months. The primary study end point was minimal lumen diameter, assessed by quantitative coronary angiography, 6 months after balloon angioplasty. Clinical variables were well matched in both groups. However, despite intracoronary administration of isosorbide dinitrate, the reference diameter in the NO donor group was significantly greater than in the diltiazem group on the preangioplasty, postangioplasty, and follow-up angiograms. Pretreatment with an NO donor was associated with a modest improvement in the immediate angiographic result compared with pretreatment with diltiazem (minimum luminal diameter, 1.94 versus 1.81 mm; P = .001); this improvement was maintained at the 6-month angiographic follow-up (minimal lumen diameter, 1.54 versus 1.38 mm; P = .007). The extent of late luminal narrowing did not differ significantly between groups (loss index in the NO donor and diltiazam groups, 0.35 +/- 0.78 and 0.46 +/- 0.74, respectively; P = .103). Restenosis, defined as a binary variable (> or = 50% stenosis), occurred less often in the NO donor group (38.0% versus 46.5%; P = .026). Combined major clinical events (death, nonfatal myocardial infarction, and coronary revascularization) were similar in the two groups (32.2% versus 32.4%)., Conclusions: Treatment with linsidomine and molsidomine was associated with a modest improvement in the long-term angiographic result after angioplasty but had no effect on clinical outcome. The improved angiographic result related predominantly to a better immediate procedural result, because late luminal loss did not differ significantly between groups.

Objectives: Evaluate magnetic resonance imaging of the coronary arteries., Methods: The study was conducted in 18 healthy volunteers (mean age 26 years, range 22-32). A superconducting magnet operating at 1.5 Tesla was used with an in-phase matrix surface coil. Images were obtained with 2D acquisition with flow compensation on ultra-rapid echo gradient sequences coupled with the electrocardiogram and segmentation of the Fourier plane. A coronary image was obtained during a 15 to 20 sec apnea. Frontal slices were used to identify cardiac structures before selecting axial slices starting from the origin of the aorta to the coronary ostia. Orthogonal, oblique and radial slices were then obtained starting from the axial slices. Slice thickness was 3 to 5 mm separated by 0.5 mm with a 30 degrees angle and a 320 mm field. Echo times were 5.8 and 10.3 msec with 2 excitations. Heart rate varied from 59 to 85 sec giving 15 to 18 ms repetition and 96 to 144 msec time resolution., Results: The proximal, middle and disatal segments of the right coronary artery were seen in 100% of the subjects, the common left coronary artery in 100%, the proximal anterior interventricular artery in 83% and the proximal circumflex artery in 80%. All the coronary arteries were visualized on at least two slices with different incidences. The proximal measurements were: common trunk 3.75 +/- 0.66 mm; anterior interventricular 3.25 +/- 0.43 mm; circumflex 2.62 +/- 0.48; right coronary 3.37 +/- 0.51., Conclusion: Magnetic resonance angiography provides good visualization of the coronary arteries.

The authors report the case of a 84-year old patient admitted to hospital for pulmonary embolism. The diagnosis was made by ventilation and perfusion pulmonary scintigraphy. Transthoracic echocardiography was performed routinely and showed a thrombus wedged across a patient foramen ovale, confirmed at transoesophageal echocardiography. Spiral thoracic computerised tomography showed thrombus in the two main pulmonary arteries and the inferior vena cava. Thrombolysis or thrombectomy under cardiopulmonary bypass, was thought to carry an excessive risk at that age and with the left-sided position of the thrombus. The alternative was therefore anticoagulation which led to dissolution of the thrombus without recurrence of pulmonary embolism or cerebrovascular accident.

The aim of this study was to analyse the prognostic factors of long term left ventricular function after successful delayed angioplasty of residual coronary stenosis after thrombolysis for myocardial infarction. The left ventricular function of fifty patients, aged 54 +/- 10 years, who underwent intravenous thrombolysis 2.9 +/- 1.3 hours after the onset of myocardial infarction (28 anterior, 22 inferior wall) was assessed by angiography at the 6.1 +/- 1.7th day and 6.1 +/- 2.5 months after successful angioplasty undertaken on the 8.3 +/- 5.2nd day. In cases without reocclusion (n = 44), the ejection fraction and the wall motion of the infarcted region improved significantly from 56.8 +/- 12.2% to 59.5 +/- 15.4% (p < 0.002) and from 8.4 +/- 14.8% to 18.3 +/- 24.3% (p = 0.0001), respectively. These parameters did not change in cases with reocclusion (n = 6). When the dilated artery remained patent, an improvement in motion of the infarcted region was observed in 69.5% of hypokinesis (n = 23), 50% of akinesis (n = 10) and 9.1% of dyskinesis (n = 11) (p < 0.005). The improvement in motion of the infarcted zone was negatively correlated with the delay of thrombolysis (r = 0.36; p < 0.02) and peak CPK levels (r = 0.31; p < 0.04). Over 60% restenosis on digitalised densitometry (n = 11) did not compromise the possibilities of improvement, the evolution of wall motion of the infarcted zone and volumes with respect to cases without restenosis (n = 33).(ABSTRACT TRUNCATED AT 250 WORDS)

Alternans of the ST segment is a rare phenomenon during coronary angioplasty. The authors report three cases. It is usually observed in left anterior descending arteries without collateral circulation. Alternans is not accompanied by haemodynamic changes and does not initiate malignant ventricular arrhythmias. It is a transient phenomenon. Electrical alternans is thought to be due to changes in the configuration of the transmembrane action potential and modifications of calcium exchanges.

Arterial patency is a good prognostic factor in terms of survival and left ventricular function after myocardial infarction. The aim of this prospective study was to evaluate the benefit of secondary angioplasty of the infarct-related artery in single vessel, left anterior descending disease, on regional and global left ventricular function. Initial coronary angiography was undertaken at the 7th +/- 2 days after the onset of infarction. Arterial patency was assessed by the TIMI criteria and by percentage stenosis on quantitative angiography. Forty consecutive patients (Group I) underwent conventional angioplasty of the left anterior descending artery at the 9th +/- 2 days. Twelve consecutive patients (Group II) did not undergo angioplasty. A repeat coronary angiographic study was performed at 3 months. The results showed no difference between the two groups of patients in base line values. A significant improvement in arterial patency was observed in Group I (TIMI Grades II or III) and in residual stenosis at 3 months (54.7 +/- 13% versus 80.6 +/- 13%, p < 0.05). In addition, a significant improvement in ejection fraction of +4.7% (p < 0.02), of left anterior descending myocardial regional wall motion of +7.6 (p < 0.02) and a reduction of induced left ventricular end systolic volume of -2.2 ml/m2 (p < 0.05) were observed in Group I. Initial segmental hypokinesia or akinesia improved in 67.5% of patients. However, 50% of patients in Group II improved their segmental wall motion abnormalities at 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous coronary artery dissection is rare compared with the high incidence of atheromatous coronary artery disease. Eight new clinical and angiographic cases diagnosed between 1984 and 1990 are reported. The patients were 6 men and 2 women with an average age of 44.1 +/- 10.7 years. The initial presentation is angina in half the cases, and myocardial infarction in the other half. Clinical signs and the results of non-invasive investigations are non-specific. Diagnosis is made by coronary angiography. The dissection is usually observed on a proximal segment of one of the main coronary arteries. In 5 cases, the disease was confined to a single vessel left anterior descending (3) and right coronary arteries (2). One patient had double vessel disease (left anterior descending and left retroventricular arteries); one patient had triple vessel disease (left anterior descending left circumflex and right coronary arteries), and finally, one patient had left main stem disease extending to the left anterior descending and first diagonal arteries. There was no aetiological factor in 5 cases whereas 3 had coronary atherosclerosis. After a period of 25 months all patients are alive. Five have drug therapy and 3 have undergone coronary bypass surgery. Six patients are asymptomatic and 2 have mild angina. One patient's coronary circulation has returned to normal. The extension of the indication of coronary angiography explains the diagnosis of an increasing number of spontaneous coronary artery dissection. The condition is serious but there are more and more long-term survivors as in our series.

At medium term, the results of delayed angioplasty (DA) following intravenous thrombolysis (IVT) in terms of arterial permeability but particularly of left ventricular function (LVF) is still poorly understood and is the subject of this prospective study. Over 18 months, 76 patients underwent DA for the residual stenosis on day 8 +/- 5 with complete and partial success rates of 88.2% and 11.8% respectively. Rapid reocclusion (< 48 hours) was documented in 9.2% of cases. After 6 months, there had been no deaths and no recurrence of infarction but a recurrence of angina in 23.7% of cases. Angiographic monitoring, carried out in 56 cases (73.7%) after 6 +/- 2.4 months identified 21 restenosis (37.5%) and 6 re-occlusions (10.7%). 12 of the restenosis were successfully re-dilated. The effect on LV function was investigated in 50 patients. In the absence of reocclusion, the ejection fraction and the kinetics of the infarcted territory were improved; significant restenosis (> 60% by digital densitometry) did not appear to offset these improvements. In addition to the maintenance of arterial permeability, the possibility of functional recovery appears to be conditioned by the degree of contractile abnormality observed during the initial ventriculography. Despite the absence of restenosis after 6 months, the occurrence on day 6 of akinesia or above all of dyskinesia reduces the chances of contractile improvement with as a corollary more marked LV changes.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

The 4 cases of transmural myocardial infarction by closed chest trauma reported by the authors bring the number of angiographically documented and published cases to 52. This group serves as a basis for a detailed review of coronary and myocardial anatomical lesions and their pathophysiological mechanism is suggested. Long controversial, direct traumatic coronary damage has been confirmed by coronary angiography and is the essential mechanism of transmural infarctions. Myocardial contusion, much commoner, is responsible for non transmural lesions which remain difficult to diagnose. The authors stress the twin value of coronary arteriography: pathophysiological with its medicolegal consequences, and also therapeutic since a revascularisation procedure may be particularly beneficial in situations where thrombolysis is generally contraindicated.

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery--left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.

The aim of this prospective study carried out in picardy (Aisne, Oise and Somme Departments) between October 1st 1985 and September 30th 1986, was to determine the incidence and outcome of recent myocardial infarction (less than 1 month) hospitalised in the region, to assess the time delay before hospital admission, the mode of management, treatment in the acute phase and at discharge, and the attitudes to exercise stress testing and coronary angiography. All public and private hospitals of the 3 departments who admitted patients with acute myocardial infarction accepted to fill out the questionnaire. A total of 1260 infarcts in patients with an average age of 66.7 +/- 12.6 years were collected. Nearly 3 out of 4 patients were male, and the men generally 10 years younger (64 +/- 12.6 years) than the women (73.4 +/- 10 years). The time delay to hospital admission was very long: 16.6 +/- 47.5 hours. Two thirds of patients were transferred by non medicalised transport; 82 per cent of patients were directed to the casualty department which redirected 71 per cent to the cardiology department. Myocardial infarction was inaugural in 46.5 per cent of cases. The incidence of anterior and inferior infarction was almost identical (44 ans 45.5 per cent respectively). Treatment in the acute phase included Heparin (94 per cent), nitrate derivatives (93.7 per cent) and calcium inhibitors (78 per cent). Thrombolytic and betablocker therapy was only prescribed in 8.3 and 23.5 per cent of cases respectively. During the hospital period, average 17 +/- 9 days, the mortality rate was 22.3 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

This Doppler echocardiographic study of patients with a dual chamber pacemaker was undertaken to assess the changes in mitral and aortic flow induced by passing from the double stimulation to the atrial detection mode. Thirteen patients totally dependent on ventricular pacing were examined and mitral and aortic blood flow recorded by pulsed wave Doppler. The chronology of left atrial contraction as assessed by the Doppler mitral A wave was measured with respect to the ventricular stimulation. The A wave was recorded on average 177 ms after the right atrial stimulation artefact. For an average AV delay of 168.8 ms and an identical pacing frequency, the passage from the double stimulation to the atrial detection mode led to left atrial contraction occurring on average 70 ms earlier with respect to ventricular stimulation, reflecting prolongation of the programmed AV delay related to the delay in detection of the sinus atrial wave. This earlier atrial systole shortened the total duration of mitral flow from 363 to 317 ms, decreased the early diastolic mitral flow and increased the atrial end diastolic flow; the stroke volume and cardiac output calculated from the aortic velocity time integral decreased significantly from 73 +/- 11 ml to 67 +/- 10 ml and 5.4 +/- 1.11/mn to 4.9 +/- 1.01/mn respectively. The initial parameters were restored (average 74 +/- 9 ml and 5.5 +/- 1.11/mn respectively) when the AV delay in the atrial detection mode was reduced by a value close to that of the calculated increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Restenosis is the usual mechanism of recurrent myocardial ischaemia in the months following successful percutaneous transluminal coronary angioplasty (PTCA). Control coronary arteriography may occasionally show another cause: the constitution of a new stenosis near the dilated segment or in the left main coronary stem after angioplasty in a branch of this artery. The authors report 4 cases of patients who developed new coronary stenoses within a few weeks of PTCA, interpreted as traumatic complications of the initial procedure due to a lesion of the intima with a secondary fibrotic reaction and luminal narrowing. The guiding catheter was probably responsible for the trauma to the left main coronary stem whereas the tips of either the balloon catheter or the guide wire were thought to have been responsible for the endothelial effraction of the dilated vessels.

Since proof exists of the individual efficacy of thrombolytics and intravenous beta-blockers in the acute phase of myocardial infarction (MI), it seemed to us logical and interesting to combine them. The aim of this retrospective study was to evaluate the safety and potential benefit of this drug combination for left ventricular function. We compared 40 patients (group I) of mean age 53.9 +/- 8.5 years admitted for MI in the six hours following the onset of symptoms treated by thrombolysis and intravenous beta-blockers (metoprolol or atenolol), with 27 patients (group II) of mean age 57.1 +/- 9.4 years treated within the same time lapse by thrombolysis alone. All patients underwent coronary arteriography and only two in group I were not examined by ventriculography. The two groups were comparable in terms of age, coronary history, localization of MI, clinical status at the outset, and time lapse before administration of the thrombolytic. Only heart rate differed at the outset (lower in group II; p = 0.05). A significant reduction in heart rate of 18% was seen in group I. When administration of the two drugs was simultaneous (less than or equal to 30-min lapse between each drug) this reduction was greater (22%) than when they were given separately (13%). In group II, the drop in heart rate was not significant (63%). In contrast, the decrease in systolic pressure in both groups was significant and comparable (group I: 16.6%; group II: 14.5%) even in the case of simultaneous administration (22%). There was no between-group difference in left ventricular ejection fraction (LVEF).(ABSTRACT TRUNCATED AT 250 WORDS)

The therapeutic effects of the association of propranolol (P) and nifedipine (N) were compared with those of propranolol alone in the treatment of effort angina. Ten patients under 65 years of age with stable effort angina confirmed by stress testing and coronary arteriography were studied. The criterion of selection was inadequate improvement of symptoms with the betablocker alone, prescribed in first intention. The patients were divided into two groups (A and B) at random: --Phase I (2 weeks) : group A : P 80 mg/day + N 30 mg/day, group B : P 80 mg/day + Placebo 3 tablets/day; --Phase II (2 weeks) : group A : P 80 mg/day + Placebo 3 tablets/day, group B : P 80/day. The results of this cross-over trial were assessed blind. The association N + P compared to P alone led to a clinical improvement in 7 out of 10 patients, a clear cut increase in maximal exercise capacity (44%), a reduction in ST depression of 0.8 mm and to the disappearance of effort angina in half the patients. The haemodynamic tolerance of this drug association was good. These statistically significant differences between the P + N and P + placebo treatment periods demonstrate that this drug association is beneficial in patients with effort angina who are inadequately relieved by betablocker therapy alone.

Pulmonary haemodynamics was studied in the course of a calibrated exercise test on an ergometric cycle in 55 patients with chronic obstructive respiratory disease. Three groups of patients could be distinguished: absent pulmonary artery hypertension, both at rest and on exercise (group I), pulmonary artery hypertension on effort only (group II), permanent pulmonary hypertension, both on effort and at rest (group III). If adaptation of the cardiac output to exercise was identical in three groups and appeared to be normal, the relationship between pulmonary artery pressure and flow differed clearly from one group to another. Elements of orientation make it possible to foresee this latent pulmonary artery hypertension on the basis of rest gazometry and simple spirography data. The prognostic and aetiologic significations were discussed.

A case of asymptomatic recurrence, in a 23-year old female patient, of a left atrial myxoma surgically removed 7 years previously is reported. The initial tumour, revealed by lipothymias and progressive heart failure, had been diagnosed by TM-mode echocardiography. The myxoma had been entirely removed, together with part of the atrial septum around its pedicle. The recurrent tumour was discovered by chance during routine control echocardiography. Post-surgical recurrent cardiac myxomas are uncommon (5% of the cases), and they predominate in the left atrium, like the initial tumours. They develop more rapidly and may recur several times in succession, becoming increasingly aggressive and multiple, though most of them remain benign. They are thought to result from the proliferation of myxomatous cells in clusters disseminated within the cardiac walls. Echocardiography is the key to the diagnosis; it is also used for post-surgical follow-up.

This study was undertaken to assess the diagnostic and prognostic value of ST depression equal to or more than 3 mm during exercise stress testing (EST). Out of 4050 EST performed over an 8 year period, 128 patients (3,2%) had this degree of ST depression. These changes were observed in leads V4 V6 in 92% of cases. Coronary angiography was performed in 56 patients: all had significant coronary artery disease (greater than 50% stenoses) with 50% three vessel, 30% two vessel and only 20% single vessel disease; all patients had at least one severe stenosis (greater than 75%) of a main coronary artery. The predictive value of EST was therefore 100% in the 56 patients undergoing coronary angiography. Angina or ventricular extrasystoles during EST or greater than 5 mm ST depression were predictive of multiple vessel disease. The following correlations were observed between EST and the extent of coronary artery disease: maximal heart rate and systolic pressure were lower, ischemic changes appeared sooner (less than 2 min) and lasted longer during the recovery phase (greater than 7 min) in patients with multiple vessel disease. The 5 year prognosis was studied in 58 patients; it was poor (death or infarction) in 31 cases (53%). The following factors were associated with a poor prognosis: low maximal heart rate and systolic blood pressure, early ischemic changes and frequent ventricular extrasystoles on EST; on the other hand, the development of anginal pain during EST was not of significant prognostic value in this series. ST depression greater than 3 mm on EST is rare.(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to evaluate the long-term efficacy of cibenzoline in preventing recurrence of atrial fibrillation compared to a reference drug: quinidine arabo-galactane sulfate (QAGS). The two products were administered orally in a double blind multicentre trial to two different groups of patients (96 patients in all) in whom atrial fibrillation had been previously converted to sinus rhythm after having been present for at least 15 days and less than 18 months. The patients were either given four 65 mg gelules of cibenzoline (group I) or four 206 mg gelules of Longacor (group II) and were reviewed systematically after 3 days of treatment, in order to retain only those who had not relapsed during the first 72 hours (89 patients: 42 in group I; 47 in group II). As Holter monitoring was not available in all centres, follow-up was assessed by conventional ECG during clinical examination after 2 weeks, 6 weeks, 3 months and 6 months. The results seem to indicate that cibenzoline was more effective at the 6th month (20% recurrence rate in group I compared to 43.2% in group II). This difference was significant especially at the end of the 2nd week of treatment (p less than 0.04); the number of recurrences did not differ significantly between the two groups thereafter. In general the clinical tolerance was good. Biochemical tests showed a greater increase in serum transaminases (SGOT) in the cibenzoline than in the QAGS group but this difference did not attain statistical significance. We conclude that at 6 months cibenzoline is more effective than QAGS in preventing recurrent atrial fibrillation.

72 cardiac patients underwent an exercise test on the bicycle ergometer, with direct measurement of the oxygen consumption (VO2). These results are compared with those of 55 healthy subjects undergoing the same test. The amount of handicap varied with the nature of the cardiac lesion, being 39% for the mitral and cardiomyopathy groups, 31% for those with both mitral and aortic valve disease, 27% for the aortic valve group, and 25% for those with congenital abnormalities. The linear relationship between Watts and VO2 was reproduced both in the healthy and cardiac subjects, which allows us to calculate the value of VO2 under conditions of load for more than 3 minutes during a standardized exercise test.

Tricuspid incompetence associated with a right ventricular aneurysm wa discovered after a non-penetrating thoracic injury. The severity of the tricuspid lesion was confirmed by phonomechanography, catheterisation and angiography. The mechanism was demonstrated by two-dimensional echocardiography: the right ventricular aneurysm was located in the right ventricular outflow tract. As the hemodynamic tolerance was good, surgery was not performed. A review of the literature found 41 other reports of traumatic tricuspid incompetence, and 4 cases of right ventricular aneurysm, only one of which was associated with tricuspid regurgitation. The points of interest of ths case: the rarity of the association, the good hemodynamic tolerance and the value of two-dimensional echocardiography for the diagnosis of ruptured chordae in the absence of surgical observations.

Severe pulmonary embolism with thrombosis of the inferior vena cava was observed in a 16 year old girl with no risk factors and treated successfully by fibrinolytic therapy. Secondarily, despite heparino-therapy, upper limb venous thrombosis occurred. Investigation of the clotting factors in the patient and her family revealed a hereditary deficit of antithrombin III. The features of the haemotological diagnosis of this rare condition and the therapeutic implications are discussed.

The large frequency of arrhythmias and conduction disorders in the course of Steinert's myotonic dystrophy is well known; most of the time, the muscle disease is already known when the heart disease is discovered. The authors report three cases of young subjects (2, 31 and 35 years) in whom an atrial flutter without obvious etiology preceded by several years (14, 2.5 and 2 years) the diagnosis of muscular disease. On this occasion, the characteristics of the heart involvement in Steinert's disease are reminded: large frequency of atrial and also ventricular rhythm disorders, distalic conduction disorders. Our cases emphasize the importance of diagnosing Steinert's disease by clinical examination, electromyography and neuro-muscular biopsy in front of a rhythm disorder--especially atrial flutter--or an interventricular conduction disorders occurring, without obvious etiology, in a young subject.

Modern two-dimensional imaging is of such quality that echocardiography is now capable of detecting intrapericardial formations. Three morphological types of abnormal intrapericardial echoes have been described: round masses, mattresses and linear echoes. These have been observed in effusions of various origin and seem to be lacking in aetiological specificity. In order to determine more precisely the echocardiographic signs of pericardial metastases, the authors have analyzed 7 cases of intrapericardial masses visualized in a series of 10 patients with metastatic pericardial effusion and examined in two-dimensional mode. These were echogenic and dense masses implanted on the pericardium and subject to cyclic movements linked with those of that membrane. Morphologically, they fell into two categories: round and sessile masses (6 cases) 8 to 23 mm high and 22 to 48 mm wide at their implantation; they were found mostly opposite the cardiac apex (4 cases) and/or in the lateral wall of the right ventricle (3 cases), oval formations (2 cases) which were 70 mm long and 17 mm wide in one case and 50 mm long and 15 mm wide in the other. One patient had two masses of different shapes. A review of the literature showed that these two echocardiographic images corresponded to two macroscopic types of pericardial invasion: either tumoral nodules or infiltration plaques betraying a diffuse invasion of the pericardium. All masses observed by the authors were located on the visceral leaflet of the pericardium. This predominantly epicardial location might be due to the visceral leaflet being selectively invaded by retrograde lymphatic embolization from the mediastinal lymph nodes.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of conventional operative resection of diffuse subaortic stenosis (tunnel subaortic stenosis and diffuse idiopathic hypertrophic subaortic stenosis) have been less than satisfactory. A new approach using the concept of aortoventriculoplasty was designed to allow adequate surgical resection of a diffuse subvalvular aortic stenosis. The aorta, the right ventricle, and the septum are incised in the same way as during aortoventriculoplasty , with the aortic anulus being divided carefully across the commissure between the left and right aortic cusps. The septotomy is extended beyond the limits of the stenosis, and fibrous and/or muscular tissue is removed from each edge of the septal incision. After adequate widening of the subvalvular area, the various incisions are closed and the aortic valve is reconstructed. This aortoseptal approach was studied experimentally in the dog and then carried out on two patients, both of whom had excellent hemodynamic and functional results. The aortoseptal approach may be the procedure of choice in the treatment of diffuse stenoses limited to the subvalvular area, whereas other procedures ( aortoventriculoplasty , and apico-aortic valved conduit) should be used when the valvular and/or supravalvular levels are involved.

Continuous ECG by the Holter method provides valuable information on the electrical activity of the heart but the interpretation of the playback may be made difficult by the presence of artefacts. The principal artefacts which may mimic arrhythmias or blocks, disturb QRS detection or deform the ventricular depolarisation are described. The majority are caused by incomplete preparation of the patient or the electrodes, but others may arise from a mechanical or electrical fault. Artefacts interfere with the automatic analysis of the tape, which is one reason for knowing the limitations of these systems of automatic analysis, and therefore control visual reinterpretation is necessary in cases where there is the slightest doubt. The presence of these artefacts is a limitation of the Holter method, the practice of which demands a certain amount of experience to avoid incorrect diagnoses which could lead to inappropriate or injustified therapy.

The authors report the case of a 38 year old sportsman who received a football in the centre of his chest during a football match. Over the following minutes, he experienced a mid-thoracic pain which corresponded to the development of a myocardial infarction which was secondarily complicated by left ventricular failure. Ventriculography revealed a large apical aneurysm and coronary angiography revealed thrombosis of the anterior interventricular artery. Based on this case, the authors discuss the mechanism of cardiac trauma and the type of coronary lesions.

Correlations were established, for 30 coronary patients, between the haemodynamic findings and those adduced from non-invasive techniques - electrocardiography, both at rest and on exercise, telethorax, and echocardiography. Left ventricular function in the coronary patient can be assessed, even before catheterisation, by means of: 1. The clinical findings: angina of effort, an uncomplicated infarct, and an infarct with sequelae each has its own peculiar haemodynamic pattern at rest and on exercise; 2. The ECG finding of an extensive anterior infarct implies a haemodynamic picture vastly different from that with a limited posterior infarction; 3. The appearance of an ischaemic shift in the ST segment on exercise implies an acute malfunctioning of the left ventricle; 4. On the echocardiogram, an end-diastolic volume greater than 150 ml/m2, an ejection fraction less than 0.50 and VCF greater than 0.8 c/s are always accompanied by disturbances in the haemodynamics. By contrast, the cardio-thoracic ratio, except in post-infarct cases complicated by left ventricular failure, gives no predictive indication of cardiac function. These various examinations should therefore be applied to the coronary patient as an index of cardiac function.

A hundred cases have been studied and divided into three categories:--60 normal subjects;--30 coronary subjects with a positive exercise test;--10 subjects with defective nervous control of the circulation; using the exercise test, we studied the effects of hyperventilation on repolarisation of the ventricle. In the normal subjects there was no ischaemic depression of the ST segment, but there were minor changes in repolarisation which affected the T wave in 73% of subjects and were essentially posterior in distribution. In the coronary subjects, we found three with ischaemic depression of the ST segment and one with ST elevation of 2.5 mm (6.7% of the coronary subjects). This last finding is evidence against the commonly held hypothesis that reproduction of ST depression by hyperventilation during the exercise test indicates a false positive test. In the patients with defective nervous control of the circulation, 9 had an ischaemic type of ST depression, either as a new feature or as a more severe one compared with that found at rest. The mechanism by which these depressions are produced has not been totally explained:--in the cases with defective nervous control of the circulation, it appears that latent increased sympathetic activity is increased by the hyperventilation;--in the coronary subjects, it may be caused by true ischaemia or by an associated defect in nervous control of the circulation.

In fifteen patients recovering from a myocardial infarction dating of at least three months, examined at rest or during a submaximal exercise, various circulatory (cardiac rate, blood pressure, cardiac output...) and ventricular parameters (oxygen consumption, ventilation per minute) both before and after a program of physical training for a period of six to eight weeks. The benefit of readaptation was judged on the increased work capacity (VO2max increase of 24.6%) and the improvement of cardio-circulatory adaptation during a submaximal exercise: reduction of the cardiac rate by 11%, of Katz's index by 12.6%, of the cardiac output by 5.8% and of the left ventricular work by 8.8%. This cardiac thrift at the origin of the increase of physical aptitude is essentially due to a better peripheral circulation adaptation to exercise, as indicated by the increased oxygen arterio-ventout difference by 11.4%.