[Fitness for sports of patients with Wolff-Parkinson-White syndrome]. / Aptitude au sport chez les patients porteurs d'un syndrome de Wolff-Parkinson-White.

The fitness of patients with Wolff-Parkinson-White syndrome to indulge in sporting activities is a practical cardiology problem. The major risk is sudden death due to atrial fibrillation deteriorating to ventricular fibrillation. This risk is small or even theoretical, but signing a fitness certificate engages the clinician's responsibility. Non invasive complementary examinations are useful. Echocardiography may detect a heart disease that would preclude any sport. Exercise tests explore the behaviour of the accessory pathway and rarely trigger off arrhythmias. Holter recordings mainly investigate disorders of the atrial rhythm. The decision concerning fitness may be based on clinical symptoms. Exercise-induced tachycardia is a classical contra-indication to competitive sports. In patients whose tachycardia is unrelated to exercise, fitness may be discussed according to the results of exercise tests and of the electrophysiological study. A refractory period which would be considered as rather prolonged at rest does not protect against fast ventricular rate during passage to atrial fibrillation. If pre-excitation disappears during the exercise test in an asymptomatic patient, then competitive sports can be authorized without limitations. If not, only surgical excision or fulguration would provide full protection against a potentially dangerous fibrillation. It is concluded that Wolff-Parkinson-White syndrome contra-indicates competitive sports in most cases. Games played outside competitions remain possible in the absence of symptoms or when arrhythmias are well controlled by medical treatment.

[Phonomechanography of recent myocardial infarct: the jugulogram and carotidogram]. / Phonomécanographie de l'infarctus du myocarde récent: Le jugulogramme, le carotidogramme

The mechanographic tracings of 30 patients with recent myocardial infarction, usually uncomplicated and without mitral incompetence, were compared with those of two control groups. The jugular venogram was unhelpful; full measurements can be made in only 40% of cases, and the scatter of normal values is too great. The carotid arteriogram is usually of the "arterial" type. Transmission time and the duration of the rising phase were both shortened. These findings result from the high level of peripheral resistance. The mean left systolic time was, except for qB2, abnormal, and remained so at the end of the first month. In this series there were neither maximal changes in J3, nor significant improvement from J12 nor J30. The largest increases in PPE and PPE/LVET were found in cases with large infarcts, and the largest reduction of LVET was in a case with left ventricular failure. There was no particular peculiarity corresponding with the site of the necrosis. Alteration in the ratio PPE/LVET is often a lasting measure of depressed left ventricular function. It would be most useful to study this ratio in the long term and to use it as a measure of recovery of function and as a guide to advising the patient on his future life style.

[Study of changes in myocardial contraction and left ventricular diastolic regidity after aortocoronary bypass]. / Etude des modifications de la contractilité myocardique et de la rigidité diastolique ventriculaires gauches après pontage aorto-coronarien

Eighteen patients with coronary insufficiency underwent a left ventricular cineangiography before and an average of four months after aorta-to-coronary bi-pass in order to assess the post-operative changes of myocardial contractility and diastolic rigidity. The contractility indices (VCF: mean speed, and VCF max: maximum shortening speed of the equatorial diameter of the left ventricle (% delta theta) were unmodified in the group (I) of fourteen patients with at least one pervious by-pass. On the contrary, a decreased % delta theta was observed in the group (II) of four patients in whom all the by-passes were occluded. The left ventricular end-diastolic pressure (LVEDP), the end-diastolic volume (LVEDV) and the "normalized" rigidity index (K) were unmodified in both groups after operation. The cardiac rate increased in the post-operative period in the group I (p less than 0.01) and the whole of the 18 patients (p less than 0.001); there was a positive correlation (p less than 0.02) between this variation and that of VCF, VCF max. and % delta theta, the significance of which is discussed. Besides there was a negative correlation between the variations of LVEDV and the VCF, and between the equatorial end diastolic diameter of the left ventricle and VCF, VCF max. and % delta theta, both in the pre-operative and the post-operative periods.

[Embolism in a fragment of the mitral papillary muscle to the left main coronary artery. A rare complication of valve replacement]. / Embolie d'un fragment de pilier mitral dans le tronc coronaire gauche. Une complication rare du remplacement valvulaire.

A 64-year-old man, who underwent double valve replacement for mitral and aortic incompetence due to infective endocarditis, presented with a coronary embolism of a fragment of mitral papillary muscle in the immediate post-operative period. The diagnosis, suggested by the sudden development of acute myocardial insufficiency during ventricular filling, was confirmed by the absence of clinical or electrical improvement during circulatory assistance and by surgical exploration of the left coronary artery. Complete recovery after embolectomy emphasises the value of the association of circulatory assistance and immediate myocardial revascularisation.

[Phonomecanography in recent myocardial infarction. Ventricular mechanic curve]. / Phonomécanographie de l'infarctus du myocarde récent. la courbe mécanique ventriculaire

Repeated recordings were made of the apexcardiogram throughout the first month after myocardial infarction in 30 patients. The classical timed intervals of the systolic wave are open to some criticism. The systolic waveforms are important. In the majority of transmural anterior infarctions there is a rounded appearance to the beginning of the wave which seems to prolong the electromechanical latency, followed by a late systolic bulge, or a domed waveform. This signifies a non-contractile area, and not neccessarily an ectasia. The early diastolic "peaktrough" appearance, found very frequently wherever the necrosis is situated, is indicative of asynergic contraction of the left ventricle. All of the diastolic phases are altered, probably by increased parietal stiffness: the TRI is lengthened; the "F" wave is flattened (and often absent later on in the condition), its duration is shortened over the anterior positions, and it may contain a shallow dip if there is LVF; the stasis wave is very feeble; the "a" wave is large when the infarct is extensive, or when there is LVF, or when there is longstanding hypertension. Enlargement of the "a" wave is especially indicative of a lowering of the performance of the left ventricle.

[Optimum flow of intravenous trinitrine during the acute stage of myocardial infarct with cardiac insufficiency: its effects on survival]. / Le débit optimal de trinitrine intraveineuse au stade aigu de l'infarctus du myocarde en insuffisance cardiaque. Action sur la survie.

Twenty-one patients were treated during the acute stage of a myocardial infarction for failure of the left or right ventricle. The systematic use of varying rates of flow of intravenous trinitrin (between 0.6 and 4.8 mg/h) was designed to find out for each patient the optimal effect on the cardiac index. The fall in pulmonary capillary pressure, obtained within 10 to 15 minutes, is proportional to the flow rate of trinitrin, and reaches 48% of its original value at a perfusion rate of 4.8 mg/h. The lowering of systemic arterial pressure is also proportional to the flow rate, and reaches 13% at a flow of 4.8 mg/h. The cardiac index and systolic index were significantly improved at flow rates of 1.2 to 2.4 mg/h, and lowered the pulmonary capillary pressure to levels of 17.6 mm of mercury and 15.3 mm of mercury respectively. Trinitrin given intravenously is very well tolerated, but it often become less effective after 24 hours of treatment, which implies that haemodynamic measurements must be made several times a day, and the speed of infusion often increased. The improvement in immediate and late prognosis is discussed relative to the initial values and Weber's index of survival.

[False failure of an aortocoronary bypass. Spasm of an artery revascularized by 2 saphenous vein graft]. / Faux échec du pontage aorto-coronaire. Spasme sur artère revascularisée par greffon veineux saphène.

The cause of recurrent resting angina one year after aorto-coronary bypass is presented. A 65 year old female with effort and resting angina with syncope had an isolated narrowing of the proximal portion of the left anterior descending artery on coronary angiography. Saphenous vein aorto-coronary bypass and cardiac plexectomy were performed on the 18 . 12 . 78, and an excellent result was obtained in the first postoperative year. Nocturnal angina with syncope recurred on the 31 . 12 . 79 and anterior subendo-cardial ischaemic changes were noted on the post critical electrocardiogramme. On control angiography 10 days later, the bypass graft was shown to be patent. A provocative test with methylergometrine showed spasm of the whole of the revascularised artery without any changes in the other vessels. Attacks of spontaneous angina with ST depression on Holter monitoring continued despite treatment with Nifedipine (6 capsules/day). The substitution of Diltiazem (3 capsules/day) prevented further recurrence with a follow-up of three months. The authors conclude that spontaneous angina after aorto-coronary bypass is not synonymous with graft dysfunction, and suggest that the effects of cardiac denervation in vasospastic angina, where Nifedipine and Diltiazem seem to have different modes of action, need further confirmation.

[Unruptured aneurysms of Valsalva sinus of septal origin]. / Anévrysmes du sinus de Valsalva non rompus à développement septal

Aneurysms of Valvsalva sinus unruptured into a cavity, but developing into the membranous and even muscular interventricular septum are exceptional. Two cases illustrating this fact are reported. In one of them, a massive mitral incompetence by elongated chordae tendinae related to the presence of a voluminous intra-septal pouch. Atrio-ventricular and intraventricular conduction disturbances were present in both patients. The interest of supra-valvar angiography which makes it possible to advise operation before the eventual rupture is underlined.

[Myocardial infarct due to diffuse arteriopathy of the coronary trunk in a 13-year-old child]. / Infarctus du myocarde par artériopathie coronarienne tronculaire diffuse chez un enfant de 13 ans

A case of antero-septal myocardial infarction in a child of 13, presenting as syncopal attacks, is reported. Selective coronary angiography showed severe diffuse lesions of the anterior descending artery and the right coronary artery. Clinical progress was satisfactory over an 18 month follow-up period. The only biochemical abnormality was a raised serum uric acid, the significance of which is discussed.

[Aortopulmonary fistula with interventricular defect and pulmonary valve stenosis in a 15-year-old girl. Surgical correction]. / Fistule aorto-pulmonaire avec communication interventriculaire et rétrécissement orificiel pulmonaire chez une jeune fille de 15 ans. Correction chirurgicale

A young girl of 15 with an aorto-pulmonary fistula was treated surgically, with a successful outcome. The clinical diagnosis could only be established at right-sided catheterisation, and especially at retrograde per-arterial aortography. The small size of the fistula explains the low level of the pulmonary arterial hypertension, and the way in which the condition was well-tolerated for some time. The association of this lesion with ventricular septal defect and pulmonary stenosis is extremely rare.

[Diastolic compliance and indices of contractibility in aortic insufficiency]. / Complicance diastolique et indices de contractilité dans l'insuffisance aortique

A cine-angiographic study was carried out in eleven patients with major aortic incompetence, in two of whom there was an associated aortic stenosis. The ventricular end-diastolic volume is always greatly increased, disproportionately to the modest increase in end-diastolic pressure. The pressure-volume relationship during filling is therefore altered, and makes it possible for a normal end-diastolic compliance (dV/dP) TD to be preserved. The indices of contractility are markedly altered, despite the recent appearance of signs of poor tolerance. These findings argue in favour of a full haemodynamic investigation and of early corrective surgery.

[Coronary angiography in the preoperative exploration of non-ischemic acquired valve diseases]. / La coronarographie dans l'exploration pr-opératoire des valvulopathies acquises non ischémiques.

One hundred and fifty-nine patients with aortic valve disease (86 cases), mitral valve disease (58 cases) or mitral and aortic disease (15 cases) underwent a pre-operative haemodynamic study, including coronary arteriography either as a routine (age greater than 50 years) or because of chest pains. Coronary arteriography is easy to do during left heart catheterisation and nowadays carries minimal risk. In the cases of chest pains, it showed stenotic lesions of the coronary vessels in 22% of patients with aortic valve disease and in 35% of those with mitral disease. In the absence of angina, coronary arteriography showed no evidence of coronary artery disease in the cases of mitral regurgitation and of aortic valve disease. In contrast, it showed stenotic lesions in three cases of mitral stenosis. In the whole of the series, coronary artery disease proved a contra-indication to surgery in three cases, and was an indication for aorta-coronary by-pass grafting, in addition to valve surgery, in seven other cases. In the absence of angina, coronary arteriography has only a slight influence on the decision to operate. It does however give additional security, which justifies its routine use in patients over 50 years of age, particularly those with mitral valve disease.

[Comparison of 24 hours ambulatory electrocardiography and endocavitary recording in the diagnosis of heart rate disorders]. / Confrontation de l'enregistrement continu ambulatoire de l'électrocardiogramme des 24 heures et des explorations endocavitaires dans le diagnostic des troubles du rythme cardiaque.

Ninety symptomatic patients aged between 16 and 90 years were investigated by ambulatory continuous 24 hour electrocardiography. 75 of these patients underwent endocavitary exploration of atrioventricular conduction and sinus node function within 48 hour of ambulatory electrocardiography. Symptoms occurred during the recording in 30% patients, enabling the mechanism of the malaise to be determined. Every time that abnormalities in the zone surrounding the Tawara node were demonstrated by endocavitary recordings, the 24 hour electrocardiogramme showed the symptoms to be due to other causes than complete heart block. In 70% patients no symptoms were experienced but 58% of them had cardiac arrhythmias and particularly sinus node dysfunction (24 out of 37 patients) on the 24 hour electrocardiogramme. Comparing the results of these two methods of investigation, continuous electrocardiography appears to be a better technique for the diagnosis of sinus node dysfunction but endocavitary study of sinus node function would seem more suited to determine its severity. Endocavitary recordings seem more reliable in the investigation of paroxysmal atrioventricular blocks. These results demonstrate the complementary nature of these two methods in determining the causes of syncope and dizziness.

[Disorders of sino-atrial and auriculo-ventricular conduction in Steinert's disease. Apropos of one case]. / Troubles de la conduction sino-auriculaire et auriculo-ventriculaire dans la maladie de Steinert. A propos d'un cas

The authors report a case of Steinert's disease with disordered sino-atrial and atrio-ventricular conduction. The presence of sudden syncopal attacks and the absence of a cardiomyopathy (excluded by right- and leftsided haemodynamic studies and coronary arteriography) indicated the insertion of a definitive intra-cavitary pacemaker, especially as the life expectancy of this 54 year old patient did not seem to have been significantly reduced by his disease.

[Enhancement of the effect of captopril in the 1st 48 hours of treating refractory heart failure. A comparison with intravenous trinitrine]. / Amélioration de l'effet du captopril au cours des 48 premières heures de traitement de l'insuffisance cardiaque réfractaire. Comparaison avec la trinitrine intraveineuse.

The favourable haemodynamic effects of vasodilator drugs in refractory cardiac failure sometimes alter rapidly after the initial dose. This tachyphylactic phenomenon was looked for during captopril therapy in 14 patients with chronic cardiac failure resistant to digitalo-diuretic therapy and conventional vasodilator drugs. The average age of the patients was 64,4 +/- 3,8 years. Eleven patients had signs of congestive cardiac failure while the remaining three patients had only left ventricular failure. Four patients were classified as Stage III and the other ten Stage IV of the NYHA classification. Right heart catheter studies were performed with a Swan Ganz catheter and systemic pressures were measured by femoral artery catheterisation. Right and left pressures and cardiac output were measured under basal conditions, and 1 and 5 hours after a single dose of captopril (early and late periods). Captopril was given in between meals in 3 to 6 daily doses; in 10 of the 14 cases the dose was 50 mg 6 hourly. The haemodynamic parameters were recorded again during the early and late periods after the dose of captopril 24 and 48 hours after starting therapy. Captopril is a mixed vasodilator and is effective from the first hour of administration. It preferentially lowered pulmonary capillary pressure (PCP) from 29,6 +/- 0,92 mmHg to 21,4 +/- 1,04 mmHg (delta PCP: -27,7%, p less than 0,01). Mean systemic blood pressure (MBP) fell less from 92,4 +/- 3,51 mmHg to 76,6 +/- 3,4 mmHg (delta MBP: -17%, p less than 0,01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognosis of ischemic mitral valve insufficiency]. / Pronostic de l'insuffisance mitrale ischémique.

Seventy-nine patients with ischemic mitral regurgitation were followed up for a period of 20 +/- 8 months. The risk of death increased with age and cardiac failure at the time of inclusion. The risk of cardiac events increased with these factors and also with raised serum creatinine and decreased echocardiographic fractional shortening. The global 2 year survival was 72.8% and survival without a further cardiac event was 48.7%. Surgery and angioplasty increased global survival and freedom from cardiac events of patients with severe regurgitation (74.9% and 68.8% versus 59.4% and 46.1% for medical therapy alone). The functional improvement was also greater in patients undergoing surgery or angioplasty (80% of patients in NYHA Stage I versus 53.8% in the medical group). Angioplasty was only performed in cases of paroxysmal mitral regurgitation by reversible papillary muscle ischemia. Surgery (coronary bypass usually associated with mitral valve replacement) was associated with better results than medical therapy alone in permanent mitral regurgitation by papillary muscle dysfunction or rupture. Despite a high immediate mortality, this option should be considered rapidly in cases of severe ischemic mitral regurgitation with pulmonary oedema.

[Can patients with severe left ventricular dysfunction be treated by coronary artery bypass surgery?]. / Peut-on ponter les coronariens ayant une dysfonction ventriculaire gauche sévère?

Forty three men and 3 women, with an average age of 59 years (13 to 78 years) underwent aorto-coronary bypass surgery despite severe left ventricular dysfunction (ejection fraction < 35%); 96% of the patients had previous infarction; 60% (N = 28) had unstable angina, 52% (N = 24) had had pulmonary oedema or an episode of congestive cardiac failure. The average ejection fraction was 29 +/- 4%, range 17 to 35%. Thirteen patients had ventricular aneurysms, 4 had grade 3 or 4 mitral regurgitation. The coronary lesions were usually multivessel left main coronary (6), triple vessel disease (27), double vessel disease (12), single vessel disease (1). The average number of bypass grafts per patient was 2.3. The average aorting clamping time was 63 minutes (range 26 to 133 minutes). There were 4 mitral valve replacements, 4 resections of ventricular aneurysms and 1 double procedure (aneurysmectomy and valve replacement). The operative mortality was 2.1% (1 death). During an average follow-up period of 27 months (range 3 to 90 months), there were: 2 recurrent infarctions, 13 episodes of cardiac failure and 8 cardiac deaths (cardiac failure: 5, sudden death: 2, recurrent infarction: 1). Two patients underwent cardiac transplantation. The regression of angina (90% of operated patients were asymptomatic) and the low operative risk, justify aortocoronary bypass surgery despite left ventricular dysfunction in patients with severe symptoms (unstable angina, chronic, invalidating angina). The medium-term results indicate a high risk of cardiac failure which is partially responsible for the secondary mortality rate of 17% at 2 years.

[Study of coronary perfusion by radioisotopes]. / Etude de la perfusion coronarienne par les radio-isotopes.

The study of coronary blood flow by radio isotpopes may determine the casual relationship between coronary artery narrowing and myocardial ischemia. Total coronary flow is measured without cardiac catheterisation by double counter technique using 84 Rb and by radionuclide angiography using 42 K and 113m in fixed on siderophilin. This is an easier method, which is very reproductible and which may be sensitised by atrial pacing. The measurement of regional coronary flow gives a better estimation of the physiological effects of coronary artery disease. Two indicators are used; radioactive gases (113 Xe and more recently 81 m Kr) and microspheres tracers. Selective coronary injection of biodegradable microspheres labelled with 99m Tc and 113m In may be used to assess the hyperemic reaction in the coronary arteriolar territory to the triiodide contrast media used in coronary angiography, and to estimate the reserve coronary blood flow. The transmural perfusion may be studied in animal experiments with non-biodegradable microspheres. Tomographic techniques should allow quantification of myocardial perfusion in man.

[Constrictive pericarditis and rheumatoid arthritis]. / Péricardite constrictive et polyarthrite rhumatoïde.

Pericarditis is the commonest cardiac manifestation of rhumatoid arthritis. It is often clinically latent but it may evolve to constriction or less often to tamponade. The case presented is of a 60 year-old woman with a 5 year history of seropositive nodular rhumatoid arthritis in whom bilateral pleural effusions and constrictive pericarditis were observed after sudden termination of corticotherapy. She was treated successfully by pericardectomy. This complication is far from being exceptional (55 cases already reported). It justifies a systematic search for pericarditis in rhumatoid arthritis, especially by echocardiography.

[Clinical and developmental aspects of 1-vessel right coronary atheroma. Therapeutic consequences]. / Aspects cliniques et évolutifs de l'athérome monotronculaire de la coronaire droite. Conséquences thérapeutiques.

This study analysed the clinical profile, prognosis and consequences on left ventricular function of isolated obstructive atherosclerosis of the right coronary artery in order to establish the indications of percutaneous angioplasty. The inclusion criteria were at least one stenotic lesion greater than 75 p. 100 of a dominant or equilibrated right coronary artery and exclusion of stenosis of the other coronary vessels. A questionnaire was sent to the treating physician and to the patient to establish the actuarial survival (Cutler and Ederer's method). The average period of follow-up was 56 months (range 12 to 70 months). Seventy one patients (average age 53 years) were selected from a series of 2,675 consecutive coronary angiograms performed between 1979 and 1984 (2.7 p. 100). The incidence of previous infarction was 60 p. 100; this was located on the inferior wall in 75 p. 100, inferobasal wall in 12 p. 100 and infero-latero-basal wall in 13 p. 100. Bypass surgery was performed in 7 cases and percutaneous angioplasty in 2 cases. Sixty-two cases were managed medically. Analysis of the 71 angiographic films of the series showed in retrospect an indication for percutaneous angioplasty in 29 patients (42 p. 100 of the series). The 5 year mortality rate was 5.6 p. 100. Death was sudden in the 4 cases observed, including one on the 28th day after bypass surgery complicated by perioperative infarction.(ABSTRACT TRUNCATED AT 250 WORDS)