Response of normal and abnormal sinus node to right ventricular stimulation.

Right ventricular pacing at progressively increasing rates was performed in 25 patients with complete ventriculoatrial block, before and after autonomic blockade with intravenous propranolol and atropine. At the end of each ventricular pacing stage a right intraatrial electrogram and electrocardiographic leads were simultaneously recorded. The relation between right ventricular pacing and atrial rates was studied from the recordings obtained at each pacing stage in both group I, 8 patients with sick sinus syndrome, and group II, 17 patients with normal sinus function. Right ventricular pacing was associated with an increment in atrial rate that ws significantly smaller (probability [p] less than 0.001) in patients in group I (mean +/- standard error of the mean 8 +/- 6 beats/min) than in group II (mean 25 +/- 10 beats/min). The maximal atrial rate reached during right ventricular pacing exceeded 80 beats/min in all patients in group II but remained less than 74 beats/min in patients in group I. Because autonomic blockade did not significantly influence the preceding results, it is concluded that a mechanical effect on the sinus node may explain this phenomenon.

Constrictive perivenous mesh prosthesis for preservation of vein integrity. Experimental results and application for coronary bypass grafting.

Saphenous veins undergo dramatic morphologic changes when used as coronary bypass grafts, and careful preparation of the graft alone is inadequate in preventing these changes. In this study, the use of a constrictive mesh for vein graft was evaluated. Fourteen sheep were subjected to a 5 cm resection of the carotid artery. Six sheep (Group A) received a jugular vein interposition graft, and the other eight sheep (Group B) received a jugular vein graft on which the constrictive mesh had been applied. The diameter of grafts in Group A was 14 +/- 1 mm compared with 7 +/- 0.5 mm for Group B (p = 0.05). The animals were put to death 4 months later. Scanning electron microscopy showed a disruption of the endothelial lining in Group A and a normal endothelium in Group B. Microscopy showed a statistical difference between Groups A and B regarding regularity and thickness of the intimal hyperplasia. Group B showed a moderate and regular intimal thickening and increased vasa vasorum. This indicates that distention and subsequent damage of the vein graft may be minimized by use of a constrictive mesh. Saphenous grafts surrounded by this constrictive mesh were inserted in four patients. Vein diameters were, respectively, 5, 4.3, 3.5, and 3.5 mm before meshing. After insertion in the mesh, vein diameters were 4.3, 3.5, 2.8, and 2.5 mm, respectively. Angiography performed 2 months later showed patent grafts of regular caliber.

Tricuspid valve myxoma: a rare indication for tricuspid valve repair.

Excision of a myxoma involving the tricuspid valve often necessitates tricuspid valve replacement or a less than optimal margin of resection. We report a successful tricuspid valve repair after en bloc resection of a myxoma involving the septal leaflet of the tricuspid valve.

Right ventricular function in healed myocardial infarction in man. A cineangiographic assessment.

To evaluate the frequency of right ventricular dysfunction following recovery from myocardial infarction (MI) and the relationship of segmental right ventricular (RV) wall motion abnormalities to left ventricular (LV) function or location of coronary arterial stenosis, biplane right and left ventricular cineangiograms were obtained in 100 consecutive patients (4 +/- 3 months post MI). Thirty (group A) had anterior MI and significant stenosis or obstruction of left anterior descending artery (LAD). The remaining 70 patients had inferior MI. They were divided into three groups according to the site of the main coronary stenosis or obstruction and corresponding LV akinesia: right coronary artery (RCA) proximal to the acute marginal artery (RMA), (group B: 32 patients), RCA distal to the RMA (group C: 18 patients), left circumflex artery (LCF), (group D: 18 patients). RV and LV end-diastolic volume index (EDV), end-systolic volume index (ESV), stroke volume (SV) and ejection fraction (EF) have been determined. RV segmental wall motion was assessed in RAO and LAO projection by determining the percentage of systolic shortening (+ delta R) along 11 hemiaxes. Mean axial shortening (delta R) of the RV inferior and free walls were considered. When compared with that in 10 normal subjects, RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV) were increased and RV ejection fraction (RVEF) was lower in patients with anterior or inferior MI. Inferior delta R exhibited comparable sequential changes in the three groups of inferior MI and similar LVEF alteration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Patent foramen ovale: an anatomical study. Apropos of 500 consecutive autopsies]. / Le foramen ovale perméable: étude anatomique. A propos de 500 autopsies consécutives.

A patent foramen ovale (PFO) was looked for in 500 consecutive adult autopsy studies (265 men, 235 women) in which death was due to acquired cardiovascular pathology (mainly coronary artery disease); this condition was demonstrated in 73 cases (42 men, 31 women); 14.6%. A PFO forms a short inter-atrial communication (average length 5 mm) directed anteriorly and slightly superiorly, opening in the right atrium anteriorly at the junction of the fosse ovale-limbus and in the left atrium under membranous fold concave anteriorly, which represents the anterior expansion of the valve of the fosse ovale. The average surface area of the PFO is 0.5 cm2 (range 0.2 to 1.5 cm2). The underlying cardiac pathologies, age, sex, had no relation to the frequency of PFO. Of the different analysable anatomical features, weight of the heart, atrial size, tricuspid regurgitation, texture of the fosse ovale (thickness over 1mm, or thin, transparent membrane), dimensions of the Eustachian valve, had no influence on the frequency of PFO. No thromboses were observed incarcerated in, in contact with or adherent to the right atrial surface of the PFO. Three of the 73 patients with PFO had, shortly before death, experienced an embolic cerebrovascular accident: in all 3 cases there was a thrombus in the left heart chambers.

[Carotid sinus hypersensitivity. Median-term development as a function of treatment and symptoms]. / Hypersensibilité sino-carotidienne. Evolution à moyen terme en fonction du traitement et des symptômes.

The aim of this study was to assess the incidence and natural history of carotid sinus hypersensitivity (CSH) with respect to treatment and symptoms. Between May 1976 and December 1981, 714 patients underwent carotid sinus massage (CSM) during electrophysiological investigation (271 for syncope, 163 for dizziness); 79 had a pathological response (sinus arrest for over 3 s or two successive pauses of over 2 s each). Twenty five of these patients were excluded from the study group; 23 had the sick sinus syndrome or an associated AV block, and two were lost to follow-up. The remaining 54 patients were divided into two groups: Group I, comprising 33 patients who were given no treatment, and Group II, comprising 21 patients who were treated by permanent pacing. The patients in Group I were followed up for an average of 29 +/- 16 months and those in Group II for 25 +/- 22 months. Nine of the 18 patients in Group I, hospitalised for syncope, but none of the 5 patients admitted for dizziness alone, relapsed during follow-up. Only 1 patient without syncope or dizziness at the time of investigation reported having had a syncope during follow-up. The actuarial graph of absence of syncope fell regularly in Group I (58 p. 100 at 5 years), 4 patients in Group I were then given demand pacemakers and there was no further recurrence of syncope (follow-up: 34 +/- 15 months). Only 1 patient, admitted for dizziness, out of the 21 patients in Group II (13 syncopes, 8 cases of dizziness) continued to complain of the symptoms for which he had been paced.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rheumatic involvement of the tricuspid valve. Anatomical types and possibilities of dilatation]. / Les atteintes rhumatismales de la valve tricuspide. Etude des types anatomiques et des possibilités de dilatation.

In 194 cases of rheumatic cardiac valve diseases (41 men, 153 women), macroscopic examination singled out 21 lesions of the tricuspid valve (11 p. 100). These lesions were found exclusively in women and were always associated with a mitral valve disease (18 cases) or a mitral and aortic valve disease (3 cases). The fairly uncommon tricuspid valve lesions were of two different types, the incidence of which did not seem to be influenced by age. There were 7 cases of moderately tight (n = 5) or tight (n = 2) stenosis (TS) and 14 cases of tricuspid valve disease (TD), where a moderately tight stenosis coexisted with a varying degree of regurgitation (TR). In subjects with pure TS the three commissures were regularly fused by fibrosis, whereas the only lesion of the tricuspid leaflets was thickening of their free border. In TD the commissural fusions were less extensive, but the fibrous thickening was retractile and invaded the entire leaflet. The other anatomical data (perimeter of the tricuspid annulus, condition of the right cardiac cavities, heart weight, etc.) were approximately the same in both types. On anatomical specimens, percutaneous dilatation seemed possible only in pure TS; TD did not lend itself to this of treatment. In most cases two-dimensional echocardiography combined with doppler ultrasound can provide an accurate evaluation of the lesions from which can be deduced roughly the possibilities of percutaneous valvuloplasty limited to pure TS.

[Tight calcified aortic valve stenosis in adults aged from 50 to 69. Anatomical study of 50 cases]. / Les sténoses aortiques orificielles serrées et calcifiées de l'adulte de 50 à 69 ans. Etude anatomique de 50 observations.

The results of anatomical examination in fifty patients aged from 50 to 69 years presenting with calcified and tight aortic stenosis are reported. The calcifications were located mostly on the aortic side of the valves, and the aortic orifice area was less than 1 cm2. The macroscopic features of the aortic valve system fell into three categories: bicuspid valve in 28 patients (21 men, 7 women), trivalve orifice with commissural adhesion (calcified in every case) in 21 patients (18 men, 3 women), and trivalve orifice without commissural adhesion in 1 patient (a 68-year old man). Male predominance was obvious (40/50; 80 p. cent). From an analysis of the various anatomical data recorded three differences emerged: the aortic annulus was wider in cases with bicuspid valve (P less than 0.01); the calcifications did not involve the free border of the valves in cases with bicuspid valve or trivalve orifice without commissural adhesion, but they involved this free border in 1 out of 2 cases with trivalve orifice and commissural adhesion; the aortic stenosis was minimal to moderate in all cases with trivalve orifice and commissural adhesion. In patients of that age group, the main cause of stenosis was bicuspid valve which seemed to be congenital in all cases. Dilatation with the finger through the left ventricle - which cannot by any means be assimilated to inflation of a balloon passed into the aortic orifice - resulted in significant opening of the aortic orifice by compression and/or disruption of the calcareous formations in patients with bicuspid valve.(ABSTRACT TRUNCATED AT 250 WORDS)

[Narrow and calcified aortic valve stenosis in subjects in their 8th and 9th decades. An anatomic study of 64 cases]. / Les sténoses aortiques orificielles serrées et calcifiées des sujets des 8e et 9e décennies. Etude anatomique de 64 observations.

Anatomical data obtained from 64 patients aged from 70 to 86 years with calcified and tight aortic orifice stenosis (functional area less than 1 cm2) were divided into three types according to the macroscopic appearance of the aortic valve: (1) tricuspid valve without commissural fusion: 44 cases (18 men, 26 women, mean age 76 years); (2) tricuspid valve with commissural fusion: 12 cases (8 men, 4 women, mean age 72 years); (3) calcified congenital bicuspid valve: 8 cases (6 men, 2 women, mean age 73 years). Thus, the distribution of patients by sex became the same starting from the eighth decade of life. Calcified aortic orifice stenosis (CAOS) of degenerative origin was the most common lesion (69 p. 100), with a strong female predominance. There were several differences between degenerative CAOS and bicuspid valve stenosis on the one hand and aortic orifice stenosis with commissural fusion on the other hand. In the first group, calcification did not involve the free edge of the aortic cusps, large calcifications of the mitral ring were extremely frequent, and there was little or no aortic regurgitation. Moreover, the aortic ring clearly was wider in cases with bicuspid valve. In patients with degenerative CAOS and bicuspid valve, attempts at digital dilatation by the left ventricular route succeeded in most cases in obtaining a fairly important widening of the aortic orifice by compression and/or disruption of the valvular calcium deposits, without causing significant regurgitation of injuring the valve; the cusps recovered some mobility.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tricuspid insufficiency in posterior infarction caused by occlusion of the right coronary artery. Anatomical study]. / L'insuffisance tricuspidienne dans les infarctus postérieurs par occlusion de l'artère coronaire droite. Etude anatomique.

Thirty-one autopsy cases of patients (20 men, 11 women) who died within 5 days of the onset of primary posterior wall myocardial infarction due to occlusion of the right coronary artery (RCA) were divided into two groups: Group A (19 cases) with associated right ventricular infarction and Group B 812 cases) without right ventricular extension of the infarct. The causes of death were practically identical in the two groups except for cardiac rupture which was always septal and more common in Group A. In Group A, the complete occlusion of the RCA was always proximal to (18 cases) or at the site of origin (1 case) of the right marginal artery. Twelve cases (63 p. 100) of tricuspid regurgitation were detected in Group A but there were no such cases in Group B. Tricuspid regurgitation was associated with a significantly poorer short term prognosis. It was not related to a greater degree of dilatation of the tricuspid ring but to more severe septal and right ventricular infarction causing prolapse of the septal and posterior septal leaflets into the right atrium. A second group of autopsy cases comprised 40 patients dying in the long term (1 to 14 years later) after primary posterior wall infarction. In 15 cases (Group A) the post-mortem study showed chronic right ventricular infarction, an extension of a chronic left ventricular infarct. These findings were absent in the other 25 cases (Group B). The mean survival times (Group A : 6.1 years, Group B : 5.9 years) were comparable.(ABSTRACT TRUNCATED AT 250 WORDS)

[Calcifications of the trunk of the left coronary artery in coronary disease. Anatomical study]. / Les calcifications du tronc de l'artère coronaire gauche dans la maladie coronarienne. Etude anatomique.

Calcification of the left main coronary artery (LCA) was found, with an equal sex distribution, in 30 out of 145 patients (21%) at autopsy. A series comprising 68 males and 77 females in whom death resulted from myocardial infarction (111 cases) or ischaemic heart disease (34 cases). The condition is rare before the sixth decade but becomes more frequent after the seventh decade of life. The incidence was the same in lethal anterior and posterior infarction (15% and 16% respectively). It was more common in ischaemic heart disease (38%, p less than 0,005). Significant narrowing of the LCA was found in 26 cases (87%) but this was only less than 70% in 11 cases. When the total number of LCA stenoses (calcified and non calcified: 39 cases) was considered, only two thirds had associated calcification. This was, therefore, only a moderately sensitive index of LCA stenosis. Calcification, nearly always circumferential, was usually situated on the second portion of the LCA. Its division was involved in all cases, the calcification extending to the initial segments of the left anterior descending artery (LAD) and left circumflex artery (CX). Calcification of the LCA was always associated with calcification of the LAD, 78% of which had stenotic lesions. Calcification of the CX and right coronary arteries was practically constant, the average percentages of occlusion being 72% and 68% respectively. On anatomical criteria, myocardial revascularisation surgery could only have been proposed in about 20% cases, and this would only rarely have been total. It is concluded that calcification of the LCA usually corresponds at least anatomically, to severe, diffuse multivessel coronary artery disease.

[Coronary disease in homozygous twins. Respective roles of heredity and environment]. / Coronaropathie chez les jumeaux homozygotes. Rôles respectifs de l'hérédité et de l'environnement.

Two 44 year old female homozygote twins presented with cardiac ischaemia due to coronary atheroma, at 39 years of age and 43 years of age, respectively. The coronary risk factors (hypertension, cigarette smoking, hypercholesterolaemia, obesity, oral contraception) were comparable in both cases. Although presenting at different times, the electrocardiographic changes were in the same territory and coronary angiography showed a similar anatomical and lesional distribution. The literature is reviewed with respect to these cases to try to determine the respective roles of heredity and the environment in the initiation and progression of coronary atheroma.

[Recurrent supraventricular tachycardia. The efficacy of a radio frequency system inserted into the coronary sinus]. / Tachycardie supra-ventriculaire subintrante. Efficacité système radio-fréquence avec sonde dans le sinus coronaire.

The case is reported of a man of 66 with attacks of recurrent supraventricular tachycardia (SVT) which failed to respond to the standard medical treatment and which, because of their frequency, led to mental disturbances. The electrophysiological features of SVT are discussed, and the possibilities of recording potentials from the SA node. A definitive pacemaker was placed in the coronary sinus, and linked to a simple stimulator working at radio frequency (and activated by the patient himself); this led to an almost immediate reduction in the attacks of SVT.

[Paroxysmal junctional tachycardia with simultaneous supra-nodal and infra-nodal 2/1 block]. / Tachycardie jonctionelle paroxystique avec bloc 2/1 simultané supra et infra-nodal.

It is rare to find 2:1 second degree block in paroxysmal junctional tachycardia. In the case described, atrial stimulation at 200/mn during supra-ventricular tachycardia triggered off simultaneous atrio-ventricular and ventriculo-atrial block. This unusual occurrence was very useful because it localised the re-entry circuit to the junctional region by excluding possible accessory pathways.

[Fatal cardiac insufficiency in the course of an initial acute myocardial infarct. Anatomical-clinical data]. / Insuffisance cardiaque mortelle au cours de l'infarctus myocardique aigu inaugural. Données anatomo-cliniques.

In a series of 51 clinico-pathological examinations on patients who died during the first 15 days after the onset of clinical symptoms of their first and only transmural myocardial infarction (anterior: 29 cases; posterior: 22 cases) the causes of death were divided into: heart failure -- 26 cases (53 p. 100); rupture of the heart -- 22 cases (43 p. 100); disorders of ventricular rhythm -- 2 cases (4 p. 100). The anatomical basis of fatal cardiac failure is twofold: either a very extensive area of necrosed muscle, of poor quality of the mass of muscle not involved in the infarction. In the anterior infarctions (16 cases, representing 55 p. 100 of deaths in this group) the first factor was foremost, the mean extent of necrosed muscle constituting 42 p. 100 of the total left and septal ventricular mass; stenotic coronary lesions, which were commonly found on the anterior descending artery, were confined to this artery alone in 10 cases 62 (p. 100). In posterior infarctions (11 cases, representing 50 p. 100 of deaths in this group), the mass of muscle destroyed was less (mean 36 p. 100), but the stenotic coronary lesions were diffuse, involving the three main trunks in 9 cases, which also explains the poor quality of the muscle not involved by necrosis. Thus there is a clear difference between anterior and posterior infarctions followed by deaths from cardiac failure: in the first group, the remaining muscular mass is quantitatively insufficient to maintain the haemodynamics, while in the second it is qualitatively insufficient, because of poor blood supply, to maintain an adequate cardiac output.

[Coronary arterial thrombosis and transmural myocardial infarct. Cause or consequence?]. / Thrombose artérielle coronaire et infarctus myocardique transmural. Cause ou conséquence?

Macroscopical examination at postmortem of 64 patients who died of their first transmural myocardial infarction (32 with anterior infarctions, 28 with posterior and 4 with lateral), during the first 30 days after the onset of symptoms, has shown that in 59 cases (92.2 p. 100) there was a totally occlusive thrombosis in the coronary artery. In all cases these thromboses were sited on the major coronary arterial trunk to zone of muscle which was destroyed, and on top of an ulcerated atheromatous plaque. The age of the thrombosis and the infarction were identical. There was no relationship between the presence (59 cases) or the absence (5 cases) of coronary arterial thrombosis with the age, sex, survival time or extent of the infarction. These postmortem findings are strongly suggestive of a fairly constant cause and effect relationship between coronary arterial thrombosis and acute transmural myocardial infarction.

[Acute posterior myocardial infarction involving the right ventricle. Anatomical study]. / Infarctus myocardique postérieur aigu : la participation ventriculaire droite. Etude anatomique.

Thirty patients who died in the acute phase of an inaugural posterior myocardial infarction were classified in two groups: group A, 14 cases, and group B, 16 cases without extension to the right ventricle. The autopsy examination showed the following differences. In group A: 1. The right coronary artery (RCA) gave off the posterior descending artery in all cases; 2. The RCA had diffuse atheromatous change in 10 cases (p less than 0,05); 3. Total occlusion of the RCA by thrombosis was constant (p less than 0,01) and was always proximal to or near the origin of the right marginal artery (p less than 0,001); 4. Postero-septal extension was constant and nearly always transmural (p less than 0,001).

[Mitral insufficiency, excluding ruptured papillary muscles, in the acute phase of posterior primary infarction. Anatomical study]. / L'insuffisance mitrale, rupture de piliers exceptée, à la phase aiguë d'un primo-infarctus postérieur. Etude anatomique.

Mitral regurgitation (MR) was demonstrated by water testing valve closure in 23 out 46 cases of patients dying in the 8 days following primary posterior wall infarction due to occlusion of the right coronary or left circumflex arteries (normal valves and chordae; no chronic fibrosis of the papillary muscle). MR was less common with right coronary artery occlusion (14 out of 32; 44%) than with left circumflex occlusion (9 out of 14; 64%). Two anatomical conditions seem to be necessary (all cases but one) for MR to occur: ischaemic necrosis of all or nearly all of the posterior papillary muscle and its base of implantation on the posterior wall. These valvular leaks are usually mild (papillary muscle rupture was excluded) and do not seem to play a major role in the haemodynamic deterioration of these patients, the majority of whom die of irreducible cardiac failure caused by extensive myocardial destruction. The mechanism of the majority of these MR was systolic eversion of the posterior part of the posterior leaflet in the left atrium (6 cases) of the posterior juxtacommissural part of both leaflets (13 cases), of the posterior part of the anterior leaflet (3 cases). Ischaemic destruction of the posterior papillary muscular system and its base of mural implantation (anatomical criteria that we retained) correlated with the occluded artery.

[Comparison of 2 groups of patients hospitalized at 10 years' interval for recent myocardial infarction]. / Comparaison de deux groupes de patients hospitalisés à 10 ans d'intervalle pour un infarctus du myocarde récent.

The aim of this study was to compare two groups of patients admitted consecutively to the Coronary Care Unit in 1972-73 (223 cases) and in 1982-83 (243 cases) for recent myocardial infarction, and followed up for at least 15 days, to try and appreciate the influence of changes in treatment which had taken place during this interval on outcome and mortality. The two groups were comparable with regards to age, sex, time of admission with respect to onset of symptoms, previous vascular disease, and principal coronary risk factors. The clinical presentation of myocardial infarction and its common complications (cardiac failure, arrhythmias) were unchanged at 10 years' interval. The only statistically significant but unexplained difference was the lower proportion of posterior infarctions in 1982-1983 compared to 1972-1973. This decrease was partly due to the increased detection of rudimentary infarcts by more specific enzyme methods. The decrease in the proportion of posterior infarcts probably also explained the lower numbers of atrioventricular blocks. Other differences between the two groups were not statistically significant (slight increase in age, fewer women, lower incidence of cardiac failure). The mortality rate was exactly the same at 20.6%, and the causes of death were identical. The results support those of other rare studies of the same subject showing the lack of effect of recent therapeutic innovations on the majority of patients with myocardial infarction.

[Effects of oral sotalol on the conduction of accessory atrioventricular pathways]. / Effets du sotalol per os sur la conduction des voies accessoires auriculo-ventriculaires.

The effects of oral Sotalol were assessed by electrophysiological investigations in 6 patients with ventricular preexcitation (Wolff-Parkinson-White syndrome) and a short anterograde refractory period (less than or equal to 280 ms) of the accessory pathway. After 27 to 80 days (mean 41 +/- 19 days) of oral Sotalol (160 mg daily in 5 patients, 320 mg daily in 1 patient). The effective anterograde refractory period of the accessory pathway increased from 268 +/- 13 ms to 318 +/- 33 ms (less than 0.05); the shortest QR interval with appearances of preexcitation increased either during rapid atrial pacing (272 +/- 19 ms to 374 +/- 74 ms: p less than 0.05) or during induced atrial fibrillation (258 +/- 61 to 335 +/- 56 ms: p less than 0.01). The effective refractory period could only be measured in 4 cases during Sotalol therapy and increased by 10 ms, 130 ms and by at least 220 and 300 ms. During the repeat electrophysiological investigation the plasma concentrations of Sotalol ranged from 0.33 to 2.3 g/ml. These results show that oral Sotalol significantly increases the effective refractory periods of accessory pathways even when they are short under basal conditions. This product could therefore be effective in preventing the rapid ventricular response to atrial fibrillation in patients with the WPW syndrome and also in the prevention of reciprocating tachycardias.