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.

Aortoseptal approach for optimal resection of diffuse subvalvular aortic stenosis.

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.

[Asymptomatic recurrence of a left auricular myxoma. Apropos of a case]. / Récidive asymptomatique de myxome auriculaire gauche. A propos d'un cas.

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.

[Artefacts during continuous electrocardiography by the Holter method]. / Les artéfacts au cours de l'enregistrement électrocardiographique continu par la méthode de Holter.

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.

[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.

[Effort electrocardiogram in woman]. / L'électrocardiogramme d'effort chez la femme

On the basis of 150 results on patients who underwent an ECG at submaximal exercise, selective coronary arteriography and cine-arteriography, this study has established that: -- certain elecerographic criteria of coronary insufficiency which have a high predictive value in males (a "near ischeamic" appearance, an J depression at or above 4 mm) are not applicable to the female; -- where an ECG tracing which is abnormal at rest becomes normal on exercise, then in both males and females there is a healthy coronary tree; -- the incidence of false-positives is 22.9%, which is 4 times that found in males; -- propranolol (60 mg orally) returns these pseudo-ischaemic changes in the resting and exercise ECG to normal and affords a simple method of identifying the false positives.

[Comparative diagnostic value of the isoproterenol test and the exercise test in detection of coronary insufficiency]. / Valeur diagnostique comparée du test à l'isoprotérénol et de l'épreuve d'effort dans le dépistage de l'insuffisance coronarienne

It appears that a constant-speed infusion of isoproterinol is as reliable and sensitive a method of detecting coronary insufficiency as the exercise test. It is indicated when: - the exercise test is impossible or not submaximal; - there is disagreement between the clinical findings, which are suggestive, and ergometry, which is negative; - there is pure angina of effort arising spontaneously.

[Left ventricular function with effort in the coronary patient. Study of the correlations with the data on echocardiography, effort ECG, and the teleheart. 2]. / La fonction ventriculaire gauche à l'effort chex le coronarien. Etude des corrélations avec les données de léchocardiographie, de l'E.C.G. d'effort et du télécoeur. 2.partie.

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.

[Iatrogenic coronary stenosis after angioplasty]. / Sténoses coronaires iatrogènes après angioplastie.

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.

[Tricuspid insufficiency and right traumatic ventricular aneurysm. Apropos of a case]. / Insuffisance tricuspidienne et anévrysme ventriculaire droit traumatique. A propos d'un cas.

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.

[Pulmonary embolism and thrombus trapped in a patent foramen ovale. Cure by heparin therapy]. / Embolie pulmonaire et thrombus enclavé dans un foramen ovale perméable. Guérison sous héparinothérapie.

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.

[Hyperventilation test in coronary disease: a comparison with a bicycle ergometer exercise test. Report of 100 cases]. / L'épreuve d'hyperventilation en pathologie coronarienne : confrontation avec l'épreuve d'effort sur cycloergomètre. A propos de 100 observations.

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.

[Changes in left ventricular function with effort in the coronary patient. l]. / L'altération de la fonction ventriculaire gauche à l'effort chez le coronarien.

The altered haemodynamics of the coronary patient have been investigated in 30 patients both at rest and under conditions of maximal effort as carried out on the bicycle ergometer under the usual conditions for an exercise electrocardiogram. Patients with angina of effort but no previous infarction have normal left ventricular function at rest; under the ischaemia induced by exercise there is acute dysfunction of the left ventricle as witnessed by a reduction in maximal cardiac output, a raised end-diastolic pressure, and changes in compliance which are more marked than those in contractility. Patients with a healed infarct but without sequelae have a rigid left ventricle, but it is not failing; they show normal changes in dP/dt max and in the indices of left ventricular work, but a pathological form of negative peak of dP/dt, of end-diastolic pressure, and of deltaP/deltaV (which reflects myocardial compliance). Patients who have had an infarction with sequelae such as angina or attacks of left ventricular failure have filling pressures which are already elevated at rest, and cardiac failure, which becomes evident on exercise.

[Severe pulmonary embolism and recurrent thrombophlebitis caused by hereditary antithrombin III deficiency]. / Embolie pulmonaire sévère et thrombophlébite récidivante en rapport avec un déficit héréditaire en antithrombine III.

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.

[Long-term prevention of the recurrence of auricular fibrillation using cibenzoline. Multicenter study apropos of 89 case reports]. / Prévention au long cours des récidives de fibrillation auriculaire par la cibenzoline. Etude multicentrique à propos de 89 observations.

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.

[Coronary angioplasty and electric alternans of the ST segment]. / Angioplastie coronaire et alternance électrique du segment ST.

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.

[Effects of post-infarct physical training on physical fitness and cardio-circulatory adaptation to effort]. / Les effets de l'entrainement physique post-infarctus sur l'aptitude physique et l'adaptation cardio-circulatoire à l'effort

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%.

[Value of the exercise test in the functional evaluation of non-coronary cardiac patients]. / Intérêt de l'épreuve d'effort dans l'évaluation fonctionnelle des cardiaques non coronariens

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.

[Value of hemodynamic exploration under exercise in chronic bronchitis]. / Intérêt de l'exploration hémodynamique d'effort chez les bronchiteux chroniques

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.

[Left ventricular function and secondary angioplasty after anterior infarction in simple coronary vessel disease]. / Fonction ventriculaire gauche et angioplastie secondaire après un infarctus antérieur chez le monotronculaire.

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)