Predictive value of electrophysiologic studies during treatment of ventricular tachycardia with the beta-blocking agent nadolol. The Working Group on Arrhythmias of the French Society of Cardiology.

Sixty patients with recurrent inducible sustained ventricular tachycardia were prospectively treated with nadolol (40 or 80 mg/day). Old myocardial infarction was present in 43 patients and dilated cardiomyopathy in 12. In group I (n = 36), nadolol was given alone, whereas in group II (n = 24), previously ineffective treatment with amiodarone was continued in combination with nadolol. Left ventricular ejection fraction was higher in patients in group I (0.40 +/- 0.12) than in group II (0.30 +/- 0.10, p less than 0.01) patients. Electrophysiologic study was repeated after short-term treatment with nadolol, which was continued regardless of the results of this test, according to the scheme of the parallel approach. Recurrence of spontaneous tachycardia or sudden death occurred in 21 patients after 10 +/- 9.2 months; sustained tachycardia was inducible in 19 on nadolol therapy. The remaining 39 patients (of whom 21 had inducible tachycardia while taking the drug) have had no recurrence of tachycardia after 27.8 +/- 9.3 months of follow-up study. Sensitivity, specificity and predictive value of a positive and negative test were 90.5%, 46%, 47.5% and 90%, respectively. The results differ between group I and group II patients, the latter having a high percent of false positive responses. This difference is even more obvious with respect to left ventricular ejection fraction: the predictive value of a positive test was 86% when ejection fraction was greater than 0.40 and 39% when it was less than 0.40.(ABSTRACT TRUNCATED AT 250 WORDS)

Familial incidence of late ventricular potentials and electrocardiographic abnormalities in arrhythmogenic right ventricular dysplasia.

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.

[Drug therapy of ventricular tachycardia]. / Traitement médicamenteux des tachycardies ventriculaires.

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.

[Prevention of recurrent amiodarone-induced hyperthyroidism by iodine-131]. / Prévention des récidives d'hyperthyroïdie a l'amiodarone par l'iode131.

Amioradone-induced hyperthyroidism is a common complication of amiodarone therapy. Although definitive interruption of amiodarone is recommended because of the risks of aggravation of the arrhythmias, some patients may require the reintroduction of amiodarone several months after normalisation of thyroid function. The authors undertook a retrospective study of the effects of preventive treatment of recurrences of amiodarone-induced hyperthyroidism with I131. The indication of amiodarone therapy was recurrent, symptomatic, paroxysmal atrial fibrillation in 13 cases and ventricular tachycardia in 5 cases (M = 14, average age 64 +/- 13 years). The underlying cardiac disease was dilated cardiomyopathy (N = 5), ischaemic heart disease (N = 3), hypertensive heart disease (N = 2), arrhythmogenic right ventricular dysplasia (N = 2) or valvular heart disease (N = 2). Two patients had idiopathic atrial fibrillation. An average dose of 576 +/- 184 MBq of I131 was administered 34 +/- 37 months after an episode of amiodarone-induced hyperthyroidism. Amiodarone was reintroduced in 16 of the 18 patients after a treatment-free period of 98 +/- 262 days. Transient post-radioiodine hyperthyroidism was observed in 3 cases (17%). Sixteen patients (89%) developed hypothyroidism requiring replacement therapy with L-thyroxine. There were no recurrences of amiodarone-induced hyperthyroidism. After 24 +/- 17 months follow-up, the arrhythmias were controlled in 13 of the 16 patients (81%) who underwent the whole treatment sequence. The authors conclude that preventive treatment with I131 is an effective alternative to prevent recurrence of amiodarone-induced hyperthyroidism in patients requiring reintroduction of amiodarone to control their arrhythmias.

[Sinus rhythm and standard deviation in cardiac cycles. Influence of myocardial status and beta-blocker treatment]. / Fréquence sinusale et écart-type des cycles cardiaques. Influence de l'état myocardique et du traitement bêta-bloquant.

The efficacy of beta-blockers in preventing sudden death after myocardial infarction would seem to be greater in patients with cardiac failure and proportional to the reduction in heart rate induced by these drugs. In addition, a reduction in heart rate variability measured by the standard deviation from the average cardiac cycle over 24 hours has been reported to be an independent bad prognostic factor after myocardial infarction. This study compares the heart rates and the standard deviations from the mean cardiac cycle over 24 hours in 41 patients divided into 3 groups of comparable age (group I: normal subjects, n = 15; group II: hypertrophic cardiomyopathy without cardiac failure, n = 13; group III: cardiac failure, n = 13) before and after administration of acebutolol (10 mg/kg). The average 24 hour heart rates, the maximum 8-hour diurnal and minimum average 4-hour nocturnal heart rates, day-night ratio and standard deviations from the average 24 hour heart rate and at the hours of maximum and minimum average heart rates were measured by Holter monitoring with an ATREC II system. The 24 hour heart rates were slower in groups II (-18.1 p. 100) and III (-19.1 p. 100) than in group I (-9.5 p. 100), p less than 0.01, the basal heart rates being comparable and the heart rates after acebutolol being significantly lower in groups II and III. The degree of change was comparable during the diurnal and nocturnal periods.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ablation of the slow pathway in reciprocating nodal rhythms by radiofrequency]. / Ablation de la voie lente des rythmes réciproques nodaux par application d'un courant de radiofréquence.

Radiofrequency ablation is a therapeutic alternative to drug therapy in recurrent reciprocating nodal rhythms. Selective ablation of the slow pathway guided by endocavitary recordings has the advantage of being effective at the price of a very low incidence of atrioventricular block. The authors report their experience with this technique. Fifty consecutive patients with recurrent attacks which were syncopal or uncontrolled by medical therapy, underwent selective ablation of the slow pathway. Firstly, they all underwent electrophysiological investigation to confirm the nodal origin of the reciprocating rhythm before proceeding to ablation itself, guided by the search for the slow pathway potentials. After ablation, it was impossible to trigger reciprocating tachycardia. Interruption of the anterograde slow pathway was achieved in 24 patients and of the retrograde pathway in 1 patient : the other 25 patients went on having dual conduction but with a prolongation of the effective refractory period of the slow pathway (268 +/- 46 ms vs 251 +/- 41 ms : p < 0.01). There were no cases of permanent complete atrioventricular block. Interruption of the slow pathway was associated with shortening of the effective refractory period of the rapid pathway (323 +/- 71 ms vs 348 +/- 80 ms : p < 0.01), which was not observed in cases of persistent dual conduction. No recurrence of tachycardia was observed during follow-up (mean period = 19.2 months) : however, control endocavitary studies in 25 asymptomatic patients after 1 to 3 months showed recurrence in 4 cases, which led to immediate further radiofrequency ablation which was successful. The authors conclude that guided selective radiofrequency of the slow intranodal pathway is a remarkably effective and reliable method of treating poorly tolerated or resistant reciprocating nodal tachycardias. Widening of the clinical indications to patients not wishing to undergo long-term antiarrhythmic therapy is now possible.

[Myocardial fibroma. Apropos of a case followed for 11 years]. / Fibromes myocardiques. A propos d'un cas suivi pendant 11 ans.

A case of myocardial fibroma of the left ventricle is described in a young girl. The association of recurrent ventricular tachycardia and radiological deformation of the cardiac silhouette suggested the diagnosis and it was confirmed by myocardial scintigraphy, echocardiography and coronary angiography. At surgery, the tumour was too extensive to be removed. After 11 years follow-up, control of the arrhythmias is satisfactory and there has been no apparent increase in the tumour size. A review of 116 cases in the literature confirms the poor prognosis of myocardial fibroma. The diagnosis was made at autopsy in 60 cases. The 56 remaining patients were operated. Total resection was possible in 37 cases and partial resection in 4 cases. The tumour could not be removed in 15 cases. Overall operative mortality was 35 p. 100 but the prognosis thereafter was good.

[Coronary artery ectasia. Apropos of a case treated surgically in 2 stages]. / Ectasies des artères coronaires. A propos d'un cas opéré à deux reprises.

The authors report a new case of coronary artery aneurysms in a 35 year old man who presented with a rudimentary myocardial infarct. Coronary angiography showed a localized aneurysm of the left anterior descending and left circumflex arteries, and a diffuse dilatation of the right coronary artery. The underlying cause was certainly atheroma because a severe stenosis was observed on the right coronary artery in association with the aneurysm. Five years later aorto-right coronary bypass surgery, when anticoagulant therapy was withdrawn, a second rudimentary infarct occurred due to intra aneurysmal thrombosis on the left circumflex artery. The aneurysmal and atheromatous disease had progressed, justifying a double bypass on the left anterior descending and circumflex arteries with exclusion of the two aneurysms. The patient was reviewed 14 months and 8 years after the first attack of spontaneous angina with good results. This and other reported cases underline the good postoperative prognosis and the necessity for a life-long anticoagulant therapy.

[Determination of the optimal atrioventricular timing by impedance plethysmography in patients with cardiac pacing; correlations with left ventricular filling]. / Détermination du délai auriculo-ventriculaire optimal par pléthysmographie d'impédance chez des patients stimulés; corrélations avec le flux de remplissage ventriculaire gauche.

The stroke volume (SV) was measured by the change in the impedance in thirteen patients with dual chamber pacemakers at different atrioventricular delay (AVD) intervals: 31 to 219 ms or 75 to 220 ms. The mitral inflow was also recorded by Doppler echocardiography at each AVD with measurement of the duration of mitral flow (MFD) and the velocity time integral (VTI). All thirteen patients were studied in the DDD mode; in addition, 5 patients were studied in the atrial sensing ventricular stimulation VDD mode. The SV measurement by impedance plethysmography was reproducible with an average variability of 3.5%: the optimal AVD was determined by this method in 11 patients with DDD and 4 patients with VDD pacing: in 3 patients (2 in DDD and 1 in VDD mode) 2 optimal AVD were obtained. The optimal AVD was 123 +/- 31 ms (63 to 156 ms) in DDD mode and 91 +/- 17 ms (63 to 110 ms) in VDD mode. The analysis of left ventricular filling showed that changes in AVD led to similar changes in mitral VTI. The MFD increased as the AVD was shortened to a constant value at the optimal AVD. In all patients, the optimal AVD was obtained when the MFD became maximal and constant. Measurement of MFD is a simple and rapid means of assessing optimal AVD at rest in patients with dual chamber pacing systems.

[Right accessory pathways with slow and decremential anterograde conduction. Electrophysiological changes during ablation of the proximal atrial poles]. / Les voies accessoires droites à conduction antérograde lente et décrémentielle. Observations électrophysiologiques lors de leur ablation centrée sur l'insertion proximale atriale.

Right sided accessory pathways with slow and decremential anterograde conduction differ from the anatomical substrates of the nodo-ventricular connections described by Mahaim. The connection may also be atrio-ventricular or atrio-fascicular. The authors report a series of 6 patients (2 men, average age 31 +/- 9 years) with antidromic reciprocating tachycardia implicating accessory pathways with decremential conduction (wide QRS complexes with left bundle branch block) the radiofrequency ablation of which was centered on the proximal atrial pole. The increment of pre-excitation was 75 +/- 18 ms. No nodo-ventricular or nodo-fascicular connections were observed. One patient had an atrio-ventricular connection, the mapping and ablation (5 applications) of which were performed on the annulus, as if it were a bundle of Kent. Five patients had a nodo-fascicular connection which was masked during sinus rhythm. The localisation of the proximal atrial insertion on the tricuspid annulus was initially estimated by studying the superior junction of the circuit and by endocavitary stimulation, and then by recording the M potential (activation of the accessory pathway). This was recorded in 4 patients, either at a specific point on the annulus (lateral or postero-lateral) which was the target of ablation (3 patients, 5 +/- 3 applications) or over a wider region (2 cm) at which ablation failed (1 patient: 13 applications). The site of the increment was determined in 2 patients and was proximal to the M potential. The M potential could not be recorded on the annulus in one patient. In 2 patients, the M potential was also recorded along the side of the pathway on the antero-lateral wall of the right ventricle of the tricuspid valve at its distal pole. In 2 patients, ablation was centered on the distal pole in second intention, near to the terminal part of the right bundle where it was localised in one of the two (18 applications). Finally, ablation was obtained in 5 out of 6 patients. They remain asymptomatic after 12 +/- 7 months follow-up. These cases show that accessory pathways with slow decremential conduction usually behave like a complete conduction pathway with an accessory laterally situated atrioventricular node on the tricuspid, an accessory bundle and a distal insertion which are all accessible to ablation.

[Ectopic atrial tachycardia complicating a congenital left atrial aneurysm: value of an electro-anatomical mapping system]. / Tachycardie atriale ectopique compliquant un anévrysme congénital de l'auricule gauche: apport d'un système de cartographie électro-anatomique.

The authors report the case of a patient with a congenital left atrial aneurysm complicated by ectopic atrial tachycardia treated successfully by surgery. Transoesophageal echocardiography and magnetic resonance imaging provided accurate measurements of the aneurysm and its anatomical relationships. Three-dimensional electro-anatomical mapping with the CARTO, system (Biosense) confirmed the shape and dimensions of the aneurysm. The system showed the electrically mute zones and the ectopic focus situated just beyond the aneurysmal neck. Surgical ablation confirmed the morphological and functional data of the imaging techniques and the patient was definitely cured.

[Free-wall rupture during the acute phase of myocardial infarction. Apropos of 2 cases surgically treated with success]. / Rupture pariétale à la phase aiguë de l'infarctus du myocarde. A propos de 2 cas opérés avec succès.

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.

[Value of beta blockers in the treatment of recurrent ventricular tachycardia in cardiac insufficiency]. / Intérêt des bêtabloquants dans le traitement des tachycardies ventriculaires récidivantes chez l'insuffisant cardiaque.

Beta-blockers were used to treat 20 patients (mean age 55 +/- 12 years) presenting with severe ventricular arrhythmia on chronic heart failure (NYHA stages II to IV; mean ejection fraction 29.7 +/- 7.8%) due to coronary disease (18 cases) or to cardiomyopathy (2 cases). Ventricular tachycardia sustained (7.6 +/- 6.3 attacks/patient) in 19 patients, unsustained in 18, monomorphous in 8 and polymorphous in 12, had been present for 12.4 +/- 18 months. In all but one hitherto untreated patient, the condition had failed to respond to amiodarone combined with a type Ia (19 patients) and type Ic (16 patients) antiarrhythmic drug. Short-term results were: 17 successes, 2 failures and 1 death due to cardiogenic shock. Fifteen patients were followed up for 14 +/- 6.7 months. Thirteen of them benefited from smaller doses of a formerly ineffective treatment; there was one failure, and one patient in whom the attacks of tachycardia, but not the numerous and polymorphous extrasystoles, were controlled by the beta-blockers suddenly died at night. The actuarial mortality rate was 11.4% as against an expected figure of 30% in such a high risk group. Although no significant changes in ejection fraction were observed, heart failure became worse in 8 patients, but it was compensated by diuretics and/or vasodilators. The effects of beta-blockers in resistant ventricular arrhythmia on heart failure suggest that an adrenergic factor is involved in the mechanism of arrhythmia. Provided treatment is progressive and its haemodynamic consequences carefully monitored, beta-blockade is well tolerated. Its effectiveness on severe arrhythmia and on mortality rate seems to confirm that it prevents sudden death by an anti-arrhythmic mechanism.

[Echocardiographic aspects of pericardial metastases. Apropos of 7 cases]. / Aspects échocardiographiques des métastases péricardiques. A propos de 7 observations.

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)

[Asymptomatic and transitory electrocardiographic changes in the 24 hours following coronary transluminal angioplasty]. / Modifications électrocardiographiques asymptomatiques et transitoires dans les 24 heures suivant une angioplastie transluminale coronaire.

Fifty patients underwent a 24-hour Holter system recording immediately after successful coronary angioplasty. Only those patients who had been "successfully" dilated and who, during the following 2 days, had remained totally symptomless and without changes in standard ECG were selected. Arrhythmias occurred in 18 patients: 12 had supraventricular arrhythmia, including 3 prolonged attacks of tachyarrhythmia due to atrial fibrillation; 6 had ventricular arrhythmia, with numerous extrasystoles in 5 cases and bursts of ventricular tachycardia in 1 case. Changes in ventricular repolarization were recorded as: (1) isolated T-wave modification (11 patients), and (2) ST-segment depression (11 patients) reaching or exceeding 2 mn in 5 cases and lasting from 4 to 33 minutes. These silent and transient electrical abnormalities were observed mostly during the 12 hours which followed transluminal angioplasty, and particularly after dilatation of the right coronary artery. The physiopathological mechanisms of these changes are uncertain, but their occurrence has no influence on mid-term results, i.e. the follow-up coronary arteriography at 6 months.

[Dissection of the aorta complicated by aorto-pulmonary fistula]. / Dissection aortique compliquée de fistule aorto-pulmonaire.

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.

[EPIM. Survey of myocardial infarction in Picardie]. / EPIM. Enquête sur l'infarctus du myocarde en Picardie.

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)

[Doppler echocardiographic study of mitral and aortic flow at various rates and atrioventricular intervals in patients with dual chamber pacemakers]. / Etude par doppler des flux mitral et aortique à fréquences et délais auriculo-ventriculaires différents chez des patients ayant un stimulateur double-chambre.

The aim of this study was to measure the changes in mitral and aortic blood flow induced by rate changes and different atrioventricular intervals in dual chamber pacemaker patients. Ten totally pacemaker dependant patients were studied under basal conditions, in double atrial and ventricular stimulation mode, by pulsed Doppler recordings of mitral and aortic flow, at three different pacing rates (80, 100 and 120/mn) and with three different atrioventricular intervals at each rate (short, 90 or 115 ms; medium, 165 or 190 ms; and long, 240 ms). The increase in pacing rate and prolongation of the atrioventricular interval significantly shortened the duration of mitral flow. Increasing the pacing rate induced a significant fall in stroke volume measured from the aortic flow. The optimal atrioventricular interval tended to shorten when the pacing rate was increased; a long atrioventricular interval had a deleterious effect on stroke volume compared with medium and short atrioventricular intervals; however, the difference between the short and medium atrioventricular intervals was not statistically significant even at 120 mn. These observations emphasise the hemodynamic advantages of shortening of the atrioventricular interval of dual chamber pacemakers when the pacing rate increases.

[Hepatocellular carcinoma invading the right atrium: clinical, echographic and angiographic study]. / Carcinome hépatocellulaire envahissant l'oreillette droite: étude clinique, échographique et angiographique.

The authors report the case of a 54 year old woman suffering from hepatocellular carcinoma with tumor growth into right hepatic vein, inferior vena cava and right atrium. On cardiac examination, a pansystolic bruit and a diastolic rumble were audible at the tricuspid focus. Diagnosis was confirmed by inferior vena cavography and two-dimensional echocardiography, which demonstrated a large mobile mass in the right atrium moving to and fro through the tricuspid valve. This case report emphasizes the value of routine cardiac examination during the course of hepatocellular carcinoma.