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Transthyretin (TTR) cardiac amyloidosis results from the dissociation of the tetrameric, liver-synthetized transport protein, either because of a mutation (hereditary CA), or spontaneously due to ageing (wild type CA). Monomers self-associate into amyloid fibrils within the myocardium, causing heart failure, arrhythmias and conduction defects. This overlooked disease must be recognized in case of unexplained increased thickness of the myocardium, particularly in subjects of African descent, in patients with heart failure and preserved ejection fraction, and in those with aortic stenosis. Some extra-cardiac symptoms must also be considered as red flags: carpal tunnel syndrome, lumbar canal stenosis, recent deafness, peripheral neuropathy, or dysautonomia. Medical assessment includes an electrocardiogram, biological assessment including troponin, natriuretic peptide and monoclonal protein assay, echocardiography with 2-D strain study, MRI and bone scintigraphy. Once the diagnosis established, cardiologic management must avoid beta-blockers and other rate-slowing drugs, which are deleterious in restrictive cardiomyopathy, and restrain the use of renin-angiotensin system inhibitors, of little use and often poorly tolerated. Congestion must be treated with diuretics. Anticoagulants are often necessary due to the risk of arrhythmias and stroke. Pacemaker or defibrillator implantation should be determined in patients with high risk of sudden death. Until now, etiologic treatments were liver and/or heart transplantation in some rare cases. Tafamidis, a TTR stabilizer has recently been approved, and new therapeutic approaches targeting TTR at the transcriptional level are under investigation., (Copyright © 2020. Published by Elsevier Masson SAS.)

Introduction: Endomyocardial fibrosis with apical obliteration is the best known involvement among heart lesions induced by hypereosinophilia. However, hypereosinophilic heart disease may involve all three heart layers, with a polymorphic clinical and echocardiographic presentation., Methods: Retrospective descriptive study of five patients highlighting the various manifestations of hypereosinophilic heart disease., Results: We report five cases illustrating the variety of hypereosinophilic heart disease and review the pathophysiology of this potentially severe illness: cytotoxicity of eosinophils is mediated by the release of granular proteins that primarily damage the endocardium, leading to thrombosis and embolic complications, then to fibrosis and valvular complications; myocardial involvement may induce a dreadful acute eosinophilic myocarditis; finally, pericardial involvement may cause tamponade., Conclusion: These observations highlight the whole spectrum of the heart manifestations of hypereosinophilia, remind that the vital prognosis may be involved in the acute phase and underline that functional prognosis depends on early detection and treatment to reduce the risk of early thromboembolic and late fibrotic complications.

Low-frequency electromyostimulation (EMS) acts on the skeletal muscle abnormalities that aggravate intolerance to effort in patients with chronic heart failure (CHF). It improves the oxidative capacity of muscles and thus enhances aerobic performance and physical capacity to almost the same degree, as does conventional physical training. No local or hemodynamic intolerance has been reported, even in cases of severe CHF. However, the presence of a pacemaker is one of the relative contra-indications (prior evaluation of tolerance is required), while that of an implanted defibrillator is one of the absolute contra-indications. EMS is an alternative to physical effort training when the latter is impossible due to a high degree of deconditioning or because there is a contra-indication, which may be temporary, due to the risk of acute decompensation and/or rhythm troubles. EMS can also be used in patients waiting for a heart transplant or in CHF patients who are unwilling to engage in physical activities. As EMS is not expensive and easy to set up, its use is likely to develop in the future.

Acute renal failure due to paradoxical embolism is exceptionally reported. A new case gives the opportunity to review mechanisms, diagnosis and therapeutic issues. A 49-year-old woman without medical history is admitted for crural venous thrombosis and acute pulmonary embolism. At day 2, a left flank acute pain with fever, doubling of plasma creatinine, and controlateral recurrence at day 12, leads to diagnosis of acute bilateral renal infarction only at day 20. Paradoxical embolism is then suspected and confirmed by transoesophageal contrast echocardiography, disclosing patent foramen ovale with right-to-left shunt. Nine months later, successful percutaneous closure of patent foramen ovale with Amplatzer PFO occluder 25 mm allows subsequent discontinuation of oral anticoagulation. Diagnostic criteria for paradoxical embolism are present in our case. If this mechanism is often discussed in cryptogenic cerebrovascular stroke of young patients, it is exceptionally reported as responsible for clinical renal disease, particularly acute renal failure (whereas anatomical renal involvement is not unfrequent). The clue is the difficulty to suspect and confirm renal infarction, especially when classical causes of cardiac embolism are lacking. The relevance is the opportunity to save renal tissue in the acute phase, and to close patent foramen ovale (currently most often percutaneously) weeks or months after the acute bout.

Introduction: Heart failure with conserved systolic function is frequent and attributed to the diastolic dysfunction. The diagnosis of diastolic heart failure requires the association of clinical signs of heart failure, a conserved left ventricular systolic function and a diastolic dysfunction., Objective: To determine the proportion of cases of isolated diastolic heart failure among patients hospitalized for acute pulmonary edema., Methods: The left ventricular ejection fraction (LVEF), the diastolic function and levels of NT-proBNP have been assessed at admission of 145 patients hospitalized for acute pulmonary edema., Results: 49% of patients included were older than 80 years (mean age 78.6 + 0.9 years). Among the 83 patients with conserved LVEF, 25% had an ischemic heart disease, 24% a severe valvular disease, 22% an atrial fibrillation, 5% a severe bradycardia, 2% a severe hypertrophic obstructive cardiomyopathy. Only 15 patients presented an isolated diastolic heart failure. The level of NT-proBNP was correlated to LVEF but was not able to identify those with isolated diastolic heart failure in the group with "conserved systolic function"., Conclusion: Among patients hospitalized for acute pulmonary edema, the prevalence of heart failure with conserved systolic function is high, but only 10% of them presented an isolated diastolic heart failure. The NT-proBNP levels do not permit to identify them.

The case history reported concerns a female patient aged 42 years for whom the clinical picture was that of a blue phlebitis (phlegmatia caerulea dolens), associated with a state of shock evoking a severe pulmonary embolus. The absence of echocardiographic dilatation of the right cavities, and the appearance of a left iliac fossa mass, steered the diagnosis towards internal haemorrhage. Emergency laparotomy allowed diagnosis and treatment of a so-called spontaneous rupture of the left iliac vein, a rare condition for which 20 cases have been reported in the literature. Re-operation performed 24 hours afterwards for the absence of venous return allowed the discovery of Cockett's syndrome with ascending thrombosis, requiring cross-venous bypass associated with the creation of an arterio-venous fistula in order to maintain permeability. One year afterwards the appearance of signs of cardiac insufficiency led to the closure of this fistula.

A number of psychotropic drugs, including tricyclic antidepressants, phenothiazine and lithium, have a well demonstrated risk of cardiotoxicity. Each individual therapeutic class has potentially deleterious effects on electrophysiology and myocardial function. The authors report a case showing how serious side effects may result from the association of these different classes in the presence of a coexistent heart disease, even when the underlying disease is mild.

Most often revealed thanks to chest pain, acute aortic dissection must be suspected and diagnosed without losing anytime, because of their evolutive risks and their specific treatment in a specialised unit. Once the early management is over, survivers must be closely followed, specially for their blood pressure to be kept normal, and to screen for secondary complications that would require surgery. Owing to the improvement of early management and follow up, facilitated by the new non-invasive imaging techniques of the aorta, the severe prognosis of this disease has significantly improved.

A 47 year old man had a massive anterior myocardial infarction with cardiogenic shock with a left parasternal murmur. Coronary angiography showed occlusion of the left anterior descending artery for which angioplasty resulted in failure. There was antero-lateral-apical akinesia and a ventricular septal defect (VSD) with a left-right shunt (Qp/Qs = 1.54). Persistence and aggravation of haemodynamic instability led to intra-aortic balloon pumping with inotropic pharmacological support followed by biventricular assistance with a MEDOS device. Under transoesophageal echocardiographic monitoring, the outcome was marked over 7 days by the progressive increase in the shunt volume of the VSD, a decrease of drainage and injection flow, progressive increase in spontaneous contrast echos followed by the presence of fibrin in the cardiac chambers and canulae, the presence of thrombus in the external ventricles, blockage of the right external valve which only opened after increasing the degree of anticoagulation, and, finally, cardiac tamponade which required drainage before the patient's state improved. On the 8th day, the patient being stable with a normal neurological status, the availability of a donor heart led to the decision to transplant, which was carried out without complications. This case poses the problem of cardiac assist devices and their daily monitoring, and then that of cardiac transplantation in this indication.

The aim of this study was to identify the long-term haemodynamic changes of the transplanted heart. Between 1987 and 1997, 136 patients required cardiac transplantation at Dijon hospital. During follow-up, 76 patients aged 51.2 +/- 9.46 years underwent catheter studies (12 women, 15.8%; and 64 men, 84.2%). Right and left heart catheterisation was performed at 3 months, 1, 2, 3 and 5 years after transplantation. Right heart catheterisation included measurement of mean pulmonary artery and pulmonary capillary pressures and pulmonary arteriolar resistances. During left heart catheterisation, cardiac output, mean aortic pressure, the ejection fraction, the dp/dt max of the left ventricular wall, systemic arterial resistances and left ventricular end diastolic pressures were measured. At each catheter study, the indexed myocardial mass, indexed end systolic and end diastolic left ventricular volumes, the mass/volume ratio, the residual serum cyclosporine concentrations and the serum creatinine were analysed. In addition, an endomyocardial biopsy was also performed. Initially raised, the mean pulmonary artery and pulmonary capillary pressures decrease from the 3rd month to the 2nd year. From the 3rd year onwards, they readjust to the upper limits of normal. The pulmonary artery resistances underwent the same changes. The left heart parameters remained constant over the period of follow-up but with a heart rate, mean aortic pressure and left ventricular end diastolic pressure higher than normal. The indexed myocardial mass was increased at all periods. The indexed left ventricular end systolic and diastolic volumes decreased with a M/V ratio which increased. Cyclosporine concentrations decreased whereas serum creatinine increased. The frequency of severe rejection and of coronary atherosclerosis was low. Significant correlations were observed between different parameters at different periods. In the long-term, the function of the transplanted heart is not normal in the strict sense of the term. The apparent normality is obtained by anti-hypertensive treatment. The transplanted heart adapts to the increase in cyclosporine-induced afterload by permanent myocardial hypertrophy, and increased diastolic pressure probably relates to diastolic dysfunction without noticeable intracardiac fibrosis.

The use of 6F catheters has been validated for coronary angiography. The use of small-caliber catheters is a more recent development. The aim of this study was to assess the feasibility, the cost and complications of coronary angiography using the femoral approach with 4F catheters. The authors undertook a randomized prospective study of 4F Care Infiniti catheters (N = 100) and 6F Spertorque Plus catheters (N = 100) in hospitalised patients. Criteria of non-inclusion were valvular pathology, acute myocardial infarction, aorto-coronary bypass or aorto-femoral bypass procedures. No statistical difference was observed between the two groups with respect to feasibility, to duration of the procedure, or of irradiation or to cost. The quality of the angiograms was good except in one patient in the 4F group; 4 patients in the 6F group required a 4F catheter to complete their examination. Left ventricular catheterisation was more difficult with 4F catheters (p = 0.016). Use of 4F catheters was associated with injection of significantly less contrast (p = 0.00007), reduced the duration of compression (p < 10(-6)) and its complications (p = 0.004). The authors conclude that 4F catheters are safe and well tolerated. They are associated with less patient morbidity, without any loss in quality of the angiogrammes. Other studies in valvular heart disease and after coronary bypass surgery should lead to the generalisation of their use in all coronary patients.

Objectives: Analyze ten years experience with heart transplantation at the Dijon University Hospital and determine which parameters control mid and long term outcome., Patients and Methods: One hundred thirty six heart transplantations were performed over a 10 year period (1987-1997) in 118 men and 18 women aged 51-87 years. Heart transplantation was indicated on the basis of the following criteria: ejection fraction *20%, pulmonary arteriole resistance < 6 Wood units, peak oxygen uptake < 14 l/kg/min. The Shumway or anatomic technique was used. The triple immunosuppressive protocol combined corticosteroids, azathioprine and cyclosporin. The same team conducted the post-transplantation follow-up with regular programmed consultations in addition to those requested by the general practitioner, the cardiologist or the patient. Follow-up was oriented according to the clinical situation (blood chemistry, cell counts, cyclosporinemia, search for infection, echocardiography, endomyocardial biopsy, coronarography)., Results: Five patients (3.6%) died when still on the waiting list. Absolute emergency transplantation was performed for patients (28.1%) including 8 (5.9%) after circulatory assist. Hospital mortality was 11.7% and late mortality was 16.1%. Actuarial survival was 78% at 1 year, 71% at 5 years and 69% at 10 years. Among the survivors, 94% were taking two, three or even four drugs for hypertension. Cyclosporin levels decreased and creatinine levels increased. Episodes of rejection were minimal: 86.57% of the biopsies were * grade 1 and 4.45% * grade 2. Cytomegalovirus infection was documented and treated in 7.55% of the cases. Incidence of graft coronary artery disease was 3.4% at 1 year, 6.5% at 2 years and 7.9% at 3 years., Conclusion: Our follow-up structure where the same small team conducts regular examinations together with our approach to heart transplantation appears to be the main factor leading to the quality results obtained in this series.

The aim of this study was to collect different problems seen in long-term evolution of patients who had anatomical cardiac transplantation and to compare with those seen in patients with standard transplantation. During the mean follow-up of 36 months, we analysed different data of 60 patients mean aged 51, who underwent anatomical cardiac transplantation. Six patients (10%) died within the 30 days after surgery. No patient needed the use of permanent pacemaker. Echocardiographic examination found normal atrial shape. One month after surgery, echocardiography described 16 tricuspid regurgitations (22.66%) and 8 mitral regurgitations (13.33%), 1 year later, there was respectively 13.33 and 6.66% tricuspid and mitral regurgitation. We had 8 late deaths: 1 sudden death, 2 chronic rejections, 1 pancreatitis and 4 cancers. The survival analysis pointed out 84% at 1 year, 80 at 2 years, 78 at 3 years and 73 at 5 years. Six months after surgery, 80% of patients were treated for high blood pressure; 85% had serum creatinine level equal or superior to 13 mg/L, with mean serum ciclosporin at 130 ng/mL. At the 3rd month, 6 endomyocardial biopsies were equal or superior to grade 2 rejection (International Society for Heart Transplantation). Between the 3rd and 12th month, 3 endomyocardial biopsies were equal or superior to grade 2 rejection, and the same between the 12th and 24th month. The infections rate was 0.8 episode per patient. Long term follow-up of anatomical cardiac transplantation faces the same problems as in standard cardiac transplantation. It is better to perform anatomical cardiac transplantation because of its early postsurgical advantages. Long term care is the same as in standard cardiac transplantation.

The usual causes of pulmonary edema are left ventricular dysfunction, mitral valve disease or left atrial myxoma. Obstruction to pulmonary venous drainage is a rare and unrecognised diagnosis which should be considered when the usual investigations are unproductive. The authors report four cases in which transesophageal echocardiography showed pulmonary edema to be due to compression of one or more pulmonary veins by a mediastinal mass (2 cases), by the false lumen of dissection of the aorta (1 case) and postoperative stenosis of the pulmonary veins (1 case). These cases underline the diagnostic value of this technique which rapidly provides diagnostic information with privileged visualisation of the pulmonary veins and abnormalities of acceleration of blood velocities in the Doppler mode due to obstruction.

Objectives: Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment., Methods: A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data., Results: Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture., Conclusion: Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.

A multicentre study was undertaken to determine the diagnostic value of transoesophageal echocardiography (TOE) in tumours of the heart and pericardium. Forty-five cases were recensed: 24 myxomas, 1 fibroma, 1 hydatid cyst, 2 lymphomas, 3 sarcomas, 1 pleuropericardial cyst, 1 branchogenic cyst and 12 cardiac metastases. The diagnosis was made in all 45 cases by TOE but only in 35 cases by conventional transthoracic echocardiography which failed to recognise 2 myxomas, 1 hydatid cyst, 1 sarcoma, 2 paracardiac cysts and 4 cardiac metastases. The site of the tumour was identified 45 times by TOE compared with only 12 times by transthoracic echocardiography. However, the anatomical investigation of mediastinal tumours requires complementary computerised tomography. Moreover, TOE, like all other imaging techniques, is unable to predict the benign or malignant nature of the tumour, 1 leiomyosarcoma having been confused with a myxoma.

The authors report the results of a multicenter study which recensed 59 cases (46 men, 13 women, average age 59.8 +/- 14 years) of valve ring abscesses defined by echocardiographic criteria alone (20 cases) or by echocardiographic and/or operative criteria (39 cases). The site of abscess was aortic (53 cases), mitral (5 cases) and tricuspid (1 case). The abscess complicated a prosthetic valve in 34 cases, occurred with a non-pathological valve in 11 cases or a pathological valve in 14 cases. Taking the 39 operated patients as a reference, the diagnostic sensitivity of transthoracic echocardiography was 25% and that of transoesophageal echocardiography: 88%. Bacterial vegetations were diagnosed with a sensitivity of 55% for transthoracic and 88% for transoesophageal echocardiography. The mediocre results of transthoracic echocardiography make transoesophageal echocardiography mandatory when there is a clinical suspicion of abscess: transoesophageal echocardiography should be systematic in prosthetic valve endocarditis and widely employed in native aortic valve endocarditis. The clinical outcome of these cases was: 39 cases were operated: global mortality of 23%, and 18 cases were treated medically, surgery having been declined for various reasons: old age (2 patients), operative risk (1 patient), patient refusal (4 patients), general condition considered to be too good to justify surgery (11 cases, including 6 sterilised abscesses diagnosed some time after the acute infectious phase). The outcome of these 18 patients, who form the biggest non-operated series of valve ring abscesses to date, was studied in detail: 4 died (18% mortality), 1 was operated secondarily for progressive valve dehiscence and 13 had a favourable outcome with an average follow-up period of 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the case of a 33-year-old patient with dermatopolymyositis, admitted to hospital for acute cystic pericarditis with fever and deterioration of the general state. The aetiological diagnosis was obtained by analysis of the pericardial fluid after surgical drainage, revealing purulent Staphylococcus aureus pericarditis. This case emphasises that, despite the marked rarity of pericardial effusion in the course of dermatopolymyositis, due to the steroid sensitivity of this disease, the possibility of septic contamination should be considered in the presence of persistent pericarditis in the context of this disease.

Lipomatous hypertrophy of the inter-atrial septum is characterised by fatty accumulation in the inter-atrial septum. Long unrecognised, it has been discovered anew by virtue of the use of transesophageal echocardiography. The authors report three cases, including one presenting as acute ischemia of the right lower limb. After studying the contribution of imaging techniques to its diagnosis, the authors consider the principal differential diagnoses of this condition.

The authors report the case of a patient who had undergone tricuspid valve replacement with a bioprosthesis in 1985 after infectious endocarditis complicated by paradoxical embolism. The appearance of signs of right heart failure eight years later led to the diagnosis of stenotic degeneration of the bioprosthesis. Inoue balloon valvuloplasty was performed with no complications leading to significant improvement in the patient's condition.

Malignant primary cardio-pericardial tumours are rare and difficult to diagnose because of the diversity of their clinical expression. The authors report a case of pericardial angiosarcoma and review the literature, underlining the value of new non-invasive imaging techniques in the diagnosis and surgical approach to obtaining histological confirmation. Magnetic resonance imaging is a valuable tool in this context as it allows scanning of the tumoral extension in all spatial planes and the visualisation of the haemorrhagic signs of malignancy the pericardial effusion related to this pathology.

Cardiac involvement in dermatopolymyositis is common but rarely symptomatic. Cardiac failure as the presentation is very rare. No correlation exists between the severity of muscular involvement and cardiac involvement. Myocarditis is not uncommon and must be borne in mind if CK MB are above 3% of total CK. It is always associated with electrocardiographic abnormalities. Corticosteroids remain first line treatment. They generally lead to regression of cardiac problems which are usually of secondary importance. If cardiac involvement is severe, the spectacular action of venoglobulins should lead to their use being envisaged from the outset, combined with corticosteroids.

Digitalis was discovered over two centuries ago and has been in everyday use for 100 years: however nowadays it is not considered to be the almost exclusive treatment of heart failure as it used to be with diuretic therapy. In the last decade, our understanding of the physiopathology of heart failure and the body's mechanisms of adaptation have improved and this has lead to the use of new molecules and a different approach to the problem of left ventricular failure. The classical contra-indications and precautions of use of digitalis have been studied in detail. The use of digitalis is contested especially in patients in sinus rhythm or with ischemic heart disease and it is used less often in adult cardiac emergencies. The competition between digitalis and vasodilator therapy is now very apparent in some situations; however, the choice between these two groups of drugs (as treatment of first intention or in association) has to be carefully considered in each individual case. The future of digitalis therapy lies without doubt in pediatric cardiology where it remains irreplaceable.

Three cases of symptomatic right-to-left interatrial shunt through a patent foramen ovale were detected in the course of a case of paradoxical embolism related to a massive pulmonary embolism, a case of refractory hypoxemia after cardiopulmonary bypass and a case of refractory hypoxemia in a patient with tricuspid endocarditis. According to anatomic studies, the incidence of patent foramen ovale is 25-30% in healthy people. In that case any pathological event generating an increase in the right atrial pressure higher than the left atrial pressure may induce a right-to-left shunt with systemic arterial desaturation and possible paradoxical embolization. The reported cases emphasize the advantage of ultrasonic examinations (contrast sonocardiography, pulsated or coloured Doppler) to show the right-to-left atrial shunt. The demonstration of this acquired shunt requires appropriate measures in order to reverse the atrial gradient. Sometimes a specific therapy is required such as caval filter insertion in case of pulmonary embolization or surgical closure of foramen ovale in some patients.

The authors report the case of a tricuspid endocarditis secondary to Streptococcus bovis with important regurgitation and severe hypoxemia secondary to a right-left atrial shunt through a patent foramen ovale, requiring a surgical treatment which included the replacement of the tricuspid valve and closure of the dehiscence in the inter-atrial septum. The presence of a patent foramen ovale in the course of a tricuspid endocarditis has been exceptionally reported. This diagnosis deserves to be evoked in case of an unexplained hypoxic condition or a systemic embolism complicating a tricuspid endocarditis. The report emphasizes the advantage of ultrasonic examinations (contrast sonocardiography, pulsated Doppler) in order to demonstrate this right-left atrial shunt in addition to the data collected about the tricuspid valve.

The effectiveness and safety of transoesophageal atrial pacing in the treatment of atrial flutter and tachycardia have been well demonstrated. The purpose of this study was to determine the factors that could influence the results of this method at the end of the procedure. Seventy-seven transoesophageal atrial pacings were performed in 62 unselected consecutive patients with either flutter or atrial tachycardia. The following parameters could be evaluated in 55 patients: date of onset of the arrhythmia, echocardiographic diameter of the left atrium, maximum amplitude of oesophageal atrial potentials, voltage and frequency of stimuli in the last stage of pacing. Our results can be summarized as follows: In both flutter and atrial tachycardia taken globally, conversion to sinus rhythm was obtained in 37 p. 100 of the cases, and conversion to atrial fibrillation in 46.7 p. 100 of the cases. The failure rate was 19.4 p. 100; all failures were due to lack of atrial capture during pacing. The main factor or transoesophageal atrial capture is voltage. Patients must be able to tolerate the voltage needed for capture. In the case of flutter, when capture was achieved a normal-sized left atrium and a high maximum amplitude of oesophageal atrial potentials were factors indicating that conversion to sinus rhythm could be expected. This, however, did not apply to atrial tachycardia. -- Whatever the type of tachyarrhythmia, the more recent its onset the easier its reduction.

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