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Background Accessory pathways (APs) with anterograde decremental conduction properties referred to as Mahaim fibers have recently been recognized as originating from the right lateral atrium. Little information is available about their distal insertion. The purpose of this study was to determine the different kinds of APs involved and the characteristics of their distal insertion site. Methods and Results Twenty-one patients (mean age, 28±13 years) with reciprocating tachycardia or atrial fibrillation were studied. Right-sided atrial and/or ventricular endocardial mapping during tachycardia identified different types of APs. (1) Seventeen patients had long APs originating from the right lateral atrium and coursing several centimeters to the right ventricle. In 10 patients, the AP terminated in or close to the right bundle-branch system (atriofascicular AP) and in 7, the AP terminated in the anterior right ventricle (atrioventricular AP). Patients with atriofascicular APs had narrower QRS complexes (133±10 versus 165±26 milliseconds, P =.02) and narrower initial r wave in leads V 2 through V 4 during maximal preexcitation than patients with atrioventricular APs. In addition, they had earlier His-bundle and right bundle-branch retrograde activation, ie, shorter V-His (16±5 versus 37±9 milliseconds, P P Conclusions Different types of APs account for tachycardias previously called Mahaim fibers. Long and short atrioventricular APs are observed in 81% and 19%, respectively. Long APs often have a distal arborization and may have either a fascicular or ventricular insertion. Radiofrequency current is more efficient when applied to the AP bundle or AP proximal insertion rather than to the distal insertion in patients with long APs.

Biventricular resynchronisation is an additional therapeutic option in the management of refractory heart failure, with a functional and haemodynamic benefit as well as an improved morbidity and mortality. However, the rate of non-responsive patients has prompted a re-think about the presumed mechanisms of action for this procedure. This study aims to identify candidates more successfully. Based on five years experience in this centre, our work confirmed a medium and long term clinical benefit with multisite pacing. Nevertheless, there was evidence of a relative discordance between the functional benefit and the haemodynamic impact in terms of ejection fraction achieved with resynchronisation. While QRS narrowing appears to be a predictive factor for a successful procedure, the ECG alone is not sufficient to select 'unsynchronised' candidates. Statistical analysis reveals that before implantation the independent predictive factors to identify non-responsive patients include the presence of a complication of myocardial infarction and a low grade mitral leak. The limits of the ECG suggest a more mechanical than electrical approach to understanding the mechanisms of action for resynchronisation. Its effectiveness in cases of right bundle branch block confirm the hypothesis of left intra-ventricular conduction defects, not apparent on the surface ECG but accessible through new imaging techniques. Based on the hypothesis of delayed movement of the ventricular walls, the principle of resynchronisation aims to restore homogenous contraction. Echocardiography allows observation of electromechanical delay and opens new perspectives in the future for selecting patients for pacing. Ar

Catheter ablation techniques for atrial fibrillation have undergone an extensive evolution, starting with linear lesions in the right, then the left atria before being superseded by ablation of triggers, mainly from the pulmonary veins. We investigate the feasibility and results of combined pulmonary vein and linear ablation utilizing a specific linear lesion connecting the lateral mitral annulus to the left inferior pulmonary vein (left isthmus).115 patients (101 M: 54 +/- 9 years) with paroxysmal atrial fibrillation (7 +/- 5 years) resistant to 4 +/- 1.6 anti-arrhythmic drugs were studied. After electrophysiologically guided disconnection of all four pulmonary veins, the left isthmus line was performed with an irrigated tip catheter. Complete linear block was demonstrated during coronary sinus pacing by local mapping looking for widely separated double potentials and confirmed by differential pacing. Mapping and ablation from within the coronary sinus was performed if an epicardial gap was detected after unsuccessful endocardial radiofrequency delivery.100% of pulmonary veins were successfully disconnected and the left isthmus line was complete with bi-directional block in 88% after a mean of 22 +/- 12 min of endocardial radiofrequency delivery in 44 patients. In 58 patients, additional radiofrequency delivery was required from within the coronary sinus for 5 +/- 5 min. After a follow-up of 6.5 +/- 2.6 months and a mean of 1.4 +/- 0.6 procedures/patient, 79% were in stable sinus rhythm without antiarrhythmic drugs.the left isthmus line is feasible and safe and when performed in addition to pulmonary veins isolation can contribute to an increased success rate.

Congenital isolated atrio-ventricular block (CAVB) is a rare pathology, and its management is still rather poorly described through international literature. Within the service of pediatric cardiology leaded by Pr Choussat and Dr Jimenez (Cardiologic Hospital Haut-Lévêque of Bordeaux), we collected from 1980 to 2003, 30 isolated congenital CAVB, constituting the purpose of this retrospective study. Average follow-up is 14 +/- 8.8 years. None death occurred. CAVB are discovered at an average age of 4.8 years old; 6 cases were diagnosed in utero, half of them were associated with maternal lupus. Twenty patients on 30 were fitted with stimulator at an average age of 8.7 +/- 6.9 years old, due to symptoms or bradycardy. Epicardic fitting in VVI mode represents 65% of first approaches, it is followed by endocavitary way for 81% of cases. Cardiac stimulation does not prevent from dilated cardiomyopathy. Among 30 patients 10 were not fitted with stimulator, half of them presents chronotrop insufficiency during effort. As a conclusion, our patients show a good long-term vital prognosis; although CAVB discovered in utero lead to worse prognosis for children.

The possibility of curing patients suffering from paroxysmal atrial fibrillation using a radiofrequency ablation treatment is a major change in the management of this arrhythmia. Pulmonary vein disconnection is efficient and safe after a learning curve of the operator. This pulmonary vein isolation is the first and mandatory step allowing disappearance of atrial fibrillation in 70% of the patients. Modification in fibrillatory substrate using linear lesions increases the rate success to 75% in chronic atrial fibrillation and to 82% in paroxysmal atrial fibrillation. The radiofrequency ablation of atrial fibrillation should be considered as a surgical treatment without an open heart, isolating structures and cutting tissues are technical improvements (new radiofrequency catheters) will probably facilitate in the future. Some comparative studies with medical treatment are currently evaluating their efficacy, safety and respective cost and they may lead to a considerable increase in the number of patients who could benefit from these curative treatments.

In this study, 9 cases of tachycardia-induced cardiomyopathy have been reported, with a 7-year follow-up period. The patient population consisted of 5 males and 4 females with a mean age of 41 +/- 18 years (range: 10-70 years). It was difficult to determine the onset of the arrhythmia, due to its frequently asymptomatic course until such time as cardiac insufficiency became apparent (this was the case in 7 patients, while 2 subjects had palpitations). Four cases of AV intranodal reentry tachycardia (3 with an accessory pathway), 2 cases of atrial fibrillation, 1 case of auricular flutter, 1 case of atrial tachycardia and 1 case of ventricular tachycardia were observed. Disappearance of the symptomatology following restoration of sinus rhythm was accompanied by echocardiographically-determined normalization of systolic function on average 5 +/- 4 months post-arrhythmia (range: 1-12 months). Left-ventricular end-diastolic volumes decreased from 60 +/- 5 mm to 51 +/- 4 mm (P0.01), and end-systolic volumes from 50 +/- 7 mm to 35 +/- 4 mm (P0.001), while the left ventricular shortening fraction increased from 17 +/- 5% to 33 +/- 4% (P0.0001). In the differential diagnosis for primary dilated cardiomyopathy, tachycardia-induced cardiomyopathy appears very similar to the former, and only an adequate period of follow-up after the restoration of sinus rhythm can confirm the diagnosis.

We report the observation of a female 45 year old patient presenting with a post-surgery complex congenital cardiopathy, associated with serious ventricular rhythm disorders necessitating the placement of an implantable defibrillator. The palliative surgery performed (cavo-pulmonary Glenn anastomosis) does not allow the usual access to the right ventricle via the superior vena cava. The different possibilities for defibrillator implantation are discussed. These include associating a surgical approach to introduce the bipolar probe with subcutaneous tunnelling to connect the probe to the box.

Atrial fibrillation, the most common of all sustained cardiac arrhythmias can be cured by Surgical atriotomies or linear RF catheter ablation. We have investigated the role of focal RF ablation in paroxysmal atrial fibrillation.sixteen patients with focal atrial fibrillation (extrasystoles, atrial tachycardia and atrial fibrillation due to the same focus firing irregularly at different rates) and 45 with common AF initiated by extrasystolic foci were included. The ablation site was determined on the basis of earliest bipolar activity relative to a stable atrial electrogram reference or to the P wave onset during atrial fibrillation initiation.All the patients with focal atrial fibrillation were treated with a mean of 5 +/- 4 RF applications delivered on a right atrial site (n = 4) or on a pulmonary venous site (n = 13), (one patient had 2 foci). Sixty nine foci (located in the pulmonary veins in 94%) were identified in the 45 patients with common atrial fibrillation initiated by extrasystoles. They were ablated with a mean of 4.5 +/- 2 RF applications. Using a mean follow up of 8 +/- 6 months, 28/45 (62%) were cured without antiarrhythmic drugs.Pulmonary veins play an important role in paroxysmal atrial fibrillation. They are the most frequent source of focal atrial fibrillation and of initiating foci amenable to RF ablation.

The aim of this study was to assess the long-term performance of a new dual chamber rate responsive pacing system based on the dynamic measurement of the peak endocardial acceleration (PEA) index of cardiac contractility. Seventy patients who participated in the Multicenter European Clinical Evaluation were studied 1 year after implantation by continuously recording the PEA and the heart rate (HR) during exercise stress testing and during 24 hours of usual activities. A complete examination of standard parameters was also performed to assess the pacing/sensing lead characteristics. Statistical comparisons were performed with the data recorded with the same protocol at 1 month after implant for each patient. A linear correlation coefficient was calculated between PEA and sinus rate when the patient showed predominant atrial tracked rhythm. There were no significant differences between PEA values measured at 1 month and 1 year (PEA = 0.41 +/- 0.26 g vs 0.45 +/- 0.29 g at rest and PEA = 1.63 +/- 0.77 g vs 1.72 +/- 0.83 g during peak exercise). The correlation coefficient remained stable (0.67 +/- 0.15 vs 0.65 +/- 0.14 during daily life and 0.74 +/- 0.14 vs 0.77 +/- 0.11 during exercise). The PEA signal detected by the sensor was reliable and stable. No long-term complications or adverse effects were observed, and the lead performance was comparable to that of a standard lead.

Endocavitary catheter ablation by radiofrequency energy applied on the slow pathway is an effective method of treatment of nodal reentrant tachycardias. The aim of this report was to determine the criteria predictive of success during radiofrequency ablation of the slow pathway guided by the presence of slow potentials. Thirty-five patients (21 women, 14 men, mean age 44 +/- 14 years) with frequent attacks of junctional tachycardia were studied. After confirmation of the diagnosis by electrophysiological investigation, radiofrequency energy was delivered at a site characterised by the presence of slow potentials between the atrial (A) and ventricular (V) potentials. The criteria investigated at each site were: before application: A/V ratio; amplitude of A and V: maximum A/minimum A ratio; amplitude and duration of the A potential; during ablation: radiological stability of the catheter position and occurrence of a junctional rhythm. All 35 patients had successful procedures with no inducible tachycardia at the end of the procedure. The slow pathway was destroyed in 20 cases (57%) with no complication of atrioventricular block. The duration of the A potential was longer in the successful cases (56 +/- 16 vs 48 +/- 14 ms; p = 0.04). The appearance of junctional rhythm and catheter stability during the procedure were predictive of success (79% vs 48%; p = 0.02; 74% vs 43%; p = 0.01). The authors concluded that an ablation site with a long duration A potential and a slow potential is a good target. In addition, ablation should be started when the catheter is radiologically stable and should not be interrupted in the absence of a junctional rhythm.

Survival after His bundle ablation for supraventricular arrhythmias was analysed over 10 years (May 1982 to December 1992) in 312 consecutive patients (5 were lost to follow-up): 54 died (17.3%), 13 of sudden death (24%). The survival rates were 94.5% at 1 year (n = 256), 80.1% at 5 years (n = 88), 72.8% at 8 years (n = 20) and 51% at 10 years (n = 4); patients without apparent heart disease had a better prognosis. This series serves as a reference for other techniques of His bundle ablation.

The object of this study was to assess the efficacy and risks of radiofrequency ablation of common atrial flutter and to determine the optimal site of ablation in a large population of patients. Three different methods were used to determine the site of ablation: the first was anatomical and electrophysiological whilst the two others were based essentially on anatomical landmarks for localising the critical zone of the reentry circuit. Recent studies report that radiofrequency ablation is effective in interrupting and preventing recurrences of common atrial flutter both by using anatomical and electrophysiological methods. Nevertheless, a larger series of patients was necessary to establish the efficacy and to determine the optimal site of ablation. A series of 110 consecutive patients with common atrial flutter resistant to antiarrhythmic drugs was studied. The site of ablation of the first 50 patients was determined using both anatomical landmarks and electrophysiological parameters. The anatomical zones were: zone 1, between the septal leaflet of the tricuspid valve and the orifice of the inferior vena cava; zone 2, between the septal leaflet of the tricuspid valve and the ostium of the coronary sinus, and zone 3: between the orifice of the inferior vena cava and the ostium of the coronary sinus. The electrophysiological criterion was an endocavitary auriculogramme occurring during the plateau phase preceding the F wave of the flutter.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective study of 192 patients centered on the outcome of supraventricular arrhythmias after catheter ablation of the atrioventricular junction provided some useful information concerning the choice of pacing mode in these patients. With the exception of atrioventricular bloc after ablation of the rapid nodal pathway where simple DDD pacing is adequate, rate adaptive pacing would seem to be essential. The VVIR mode should be the mode of choice in atrial flutter, permanent atrial fibrillation, poorly controlled atrial fibrillation and paroxysmal atrial fibrillation of elderly subjects (over 70 years) and/or of male sex, and/or complicating advanced cardiac disease (valvular, ischaemic or primary). The DDDR mode (with an algorithm to prevent endless loop tachycardia) is the mode of choice in sinus node dysfunction and/or in young patients (under 60), and/or females and/or in idiopathic arrhythmias and/or when retrograde VA conduction persists. When the pacemaker is replaced, the indication should be reviewed with respect to the outcome of the arrhythmia, which underlines the value of accurate implanted Holter systems.

The incidence of sudden death in the Wolff-Parkinson-White (WPW) syndrome is not well documented and probably underestimated. This retrospective study concerned 28 consecutive patients presenting with ventricular fibrillation either spontaneously (20) or during electrophysiological investigation (8) but whose characteristics allowed them to be assimilated into a single group. Their clinical and electrophysiological characteristics were compared with those of 60 consecutive patients with the WPW syndrome who had documented atrial fibrillation (and even reciprocating tachycardia) but never ventricular fibrillation. There were no significant differences between the two groups with respect to the following clinical parameters: sex, duration of symptoms, the type of tachycardia previously recorded, history of syncope and presence of underlying cardiac disease. With respect to the electrophysiological data, there were no differences in the point of anterograde block, the effective anterograde refractory period of the accessory pathway, the effective and functional refractory periods of the right atrium and atrial vulnerability. On the other hand, a significant difference was observed in the age of patients with ventricular fibrillation (29 +/- 13 years vs 36 +/- 12 years; p0.02), the prevalence of multiple accessory pathways (25% vs 7%; p0.04) with a dominant localisation in the postero-septal region (75% vs 47%, p0.026), preexcitation during exercise stress testing and under antiarrhythmic therapy (95% vs 68%, p0.037). The most discriminating parameter was the shorter RR interval during atrial fibrillation (172 +/- 23 ms vs 230 +/- 50 ms, p0.008). Multivariate analysis only showed one independent predictive factor: the minimum preexcited RR interval.(ABSTRACT TRUNCATED AT 250 WORDS)

Junctional tachycardias may be related to intranodal reentry or to the existence of an accessory pathway. All are suitable for radical treatment by radiofrequency current applied either in the perinodal region or at the tricuspid or mitral atrioventricular rings respectively. 176 patients with intranodal reentry were treated by preferential modification of the rapid (8) or slow (167) anterograde pathway of the reentry circuit, with a 99% success rate (1 failure) and without significant complications, in particular atrioventricular block in the case of ablation of the slow pathway. 362 patients with one or more accessory pathways, patent or latent, were treated using the same type of energy. The ablation site was determined on the basis of indirect criteria and/or recording of the specific activity of the accessory pathway. The success rate here was 98%, once again without significant complications with the exception of those inherent to catheterisation procedures. Treatment duration time was 41 +/- 38 min in the treatment of intranodal reentry and 58 +/- 49 when one or more accessory pathways were responsible. X-ray exposure times were 14 +/- 14 min and 23 +/- 21 min respectively. Such results would justify the expectation of widened indications of the method.

The aim is the analysis of the P wave on the signal averaged ECG in 31 pts: 12 control pts (6 M, 6 W, 40 +/- 10 y) 12 HTA (9 M, 3 W, 60 +/- 7 y), 7 pts (5 M, 2W, 48 +/- 7 y) with sustained paroxystic atrial fibrillation (AF) without organic heart disease, without antiarrhythmic drugs. We measured the filtered P wave duration (Ad), the integral of Ad, the root mean square voltage of Ad for the last 10, 20, 30, 40, 60 msec and the duration of P wave on the ECG in lead II (P II) and the echocardiographic dimensions of the atria (LAd). HTA Ad (132 +/- 12 msec)* etcontrol Ad (116 +/- 10 msec) HTA LAd (38 +/- 3 mm) etcontrol LAd (31 +/- 0.7 mm) HTA PII (120 +/- 1.5 mm)* etcontrol PII (88 +/- 10 mm). The difference between HTA Ad (132 +/- 12 msec) and AF Ad (129 +/- 7 msec) is not significant. The linear regression tests don't show correlation between P II and Ad and between LAd and Ad in HTA group. There is a correlation between Ad and LAF in AF group (r = 0.83, p 0.02). HTA RMS 2o (2.2 + 0.6 microV), control RMS 2o (3.9 + 1.8 V) but HTA RMS 2o and AF RMS 2o (2.4 +/- 0.6 microV) are not significantly different and are not correlated with LAd and PII. A long duration of P filtered P wave and a low RMS 2o observed in HTA group and AF group would be a criteria of atrial vulnerability. p0.05.

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

The objective of this study was to assess the electrophysiological properties of intravenous bisoprolol in patients with and without coronary artery disease (CAD) by programmed stimulation. Sixteen inpatients subjected to an electrophysiological investigation because of dizziness or palpitations were given 10 mg of intravenous bisoprolol after basal measurement and were checked again 15 and 45 min after infusion. Eight patients with CAD (seven males and one female; mean age of 60+/-4 years) and eight patients without CAD (five males and three females; mean age of 59+/-4 years) were investigated after washout of prior antiarrhythmic drugs. For coronary patients, the CAD was documented by a history of myocardial infarction or by a confirmatory coronary arteriography. Main outcome measures were parameters of invasive electrophysiological exploration, with measurement of conduction intervals at rest and during pacing and of refractory periods by means of extrastimulus technique. No significant difference was noted at baseline between the two groups except for CSNRT. After infusion of 10 mg of bisoprolol, with the exception of CSNRT (increased in the group without CAD), no significant differences were noted on comparison between coronary and noncoronary patients. Bisoprolol significantly increased the sinus cycle length, SACT, and FRP of the atria. Regarding atrioventricular nodal conduction, bisoprolol significantly increased the AH 100, ERP, and FRP and significantly decreased the Wenckebach point. In the right ventricle, bisoprolol moderately, but significantly, decreased the corrected QT and induced a small, temporary, significant increase in ERP. Bisoprolol appears to be a very potent beta-blocker that is well tolerated at an intravenous dose of 10 mg. Its depressant effects concern mainly the atrial function and the nodal conduction, without significant differences between the two groups of patients. The decrease in QTc may be a favorable aspect regarding its electrophysiologic tolerance especially in the acute phase of myocardial infarction.

The electrophysiological properties of of 0,6 mg/Kg SOTALOL administered intravenously were studied in 15 subjects aged between 32 and 81 years. The following parameters were recorded: sinus rate (SR), corrected sinus node recovery time (SNRT), sinoatrial conduction time (SACT), PA interval, right atrial effective refractory period (ERP), right atrial functional refractory period (FRP), AH interval at rest, at 100 bpm, Luciani-Wenckebach point (LWP), AV node ERP and FRP, HV interval, His-Purkinje ERP, right ventricular ERP, corrected QT interval. At this dosage, intravenous SOTALOL displays two types of behaviour: --That common to the betablocker drugs: slowing SR by 16%, increasing the AV nodal conduction, increasing the AH interval at rest (5%), at 100 bpm (23%), increasing AV nodal ERP (26%) and FRP (20%), decreasing the LWP (18%). --Other properties: increasing intraatrial PA interval (3%), increasing right atrial ERP (II%), FRP (I7%), increasing right ventricular ERP (8%), increasing His-Purkinje ERP (when measurable) (about 6%), no change in corrected QT interval. At this dosage, SOTALOL exhibits electrophysiological behaviour similar to drugs in Class III (Touboul): those with a "wide electrophysiological spectrum".

A comparison of the haemodynamic and electrocardiographic data was carried out in 180 coronary patients. All underwent catheterisation and coronary angiography for angina. They were divided into three main groups: 53 patients with coronary atheroma without significant stenosis; 43 patients with at least one coronary stenosis greater than 50%; 84 patients had myocardial infarction with ECG changes of transmural necrosis and coronary thrombosis (or greater than 80% stenosis). Parameters of left ventricular function (LVF), especially ejection fraction (EF), systolic work (LVESW), end diastolic pressure (LVEDP), end diastolic volume (LVEDV), myocardial mass calculated from angiography (LMV) and volumic compliance were analysed in all cases. Each patient had at least 5 ECG recordings analysed by a HP 6 calculator which determined the values of the principal numeric ECG parameters and the means of the 5 recordings. Particular attention was given to the sum of the R waves in the 12 leads (sigma R mV) and Macruz's index (duration of P/PR - P in Lead II). A satisfactory correlation was found overall between sigma R and EF (r = 0,45, p less than 0,001). sigma R was the only ECG variable related to LVF in patients without infarction. In this group of 96 patients, sigma R correlated with LVEDV (r = 0,46, p less than 0,001) with LVM (r = 0,46, p less than 0,001), with LVESW (r = 0,52, p less than 0,001). There was a discordance between angiographically measured LVM and the mass of electrically active myocardium in patients with infarction. sigma R was independent of LVM, LVEDV, and LVESW.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical data and presenting signs of 17 cases of atrial myxoma (14 left atrial, 3 right atrial myxomas) were analysed. The aim of the study was to assess changes in the presenting features since the introduction of non-invasive methods of cardiovascular investigation. Two groups of patients were identified according to whether the tumour has been diagnosed before (Group A) or after (Group B) the advent of echocardiography. The diagnosis of cardiac tumour, especially myxoma, has become easier with echocardiography and radio-isotope techniques. The presentation of myxoma, recognised earlier, has changed; the features of advanced valvular disease with resistant heart failure are no longer seen. Variable, atypical clinical signs are now encountered (syncope, pyrexia of uknknown origin, transient ischaemic attacks). The average delay between the first sign and diagnosis was 30 +/- 32 months in Group A, compared to 4,6 +/- 6,5 months in Group B (p0, 005). Of the 7 patients in Group B, three had normal cardiac auscultation, and normal ECG, and four had normal ESRs. The diagnosis of myxoma should be considered at the least doubt and an echocardiographic examination, preferably with 2-dimensional echo should be requested. It not only allows positive diagnosis but also orientates the patient to surgery without further investigation.

251 untreated patients with mild to moderate hypertension were included in a multicenter study aimed 1) to detect arrhythmias (24-H Holter recording) and 2) to assess the efficacy of sotalol on blood pressure and possible arrhythmias. Patients with coronary heart disease or previously documented arrhythmias were excluded. Atrial arrhythmias such as premature beats, fibrillation, flutter and paroxysmal atrial tachycardia were detected in 16% of patients. Monomorphic ventricular premature contractions (VPCs) (Lown I and II) were detected in 41% of patients and polymorphic VPCs or duplets/triplets (Lown III and IV) in 14%. A correlation seems to exist between the level of hypertensive cardiopathy, judged on electrocardiographic data (Tarazi classification), age of patients and severity of arrhythmias. Sotalol was administered during 2 months at a mean dose of 160 mg per day. The treatment was effective on blood pressure and arrhythmias (82% improvement of severe VPCs) and the drug was well tolerated. It was difficult to conclude if these good results are due to the betablocking properties or specific class II antiarrhythmic effects of sotalol or to the combined activity.

Hypertensive heart disease has been studied by means of the maximal exercise test, mechanographic techniques and echocardiography. The patients have been divided into three groups according to their electrocardiogram and the size of their heart as measured radiologically: I: normal ECG, normal size; II: ECG shows left atrial hypertrophy, heart of normal size; III: ECG shows left ventricular hypertrophy, heart is dilated. The total work on exercise decreases from group I to group III. The parameters of the pumping action (PEP/TEVG, VCF, FE) were identical in all three groups and were normal. The relationship A/H on the apexogram and the left ventricular mass/volume relationship on the echocardiogram increased from group I to group III. One possible interpretation of these findings suggests an alteration in diastolic compliance of the left ventricle in the early stages of hypertensive heart disease. The response to beta-blockers as measured on the echocardiogram also argue in favour of this theory.

Propafenone, an anti-arrhythmic medication recently introduced in class lc, was tested in a multicentric open study including 3,687 patients (mean age: 60 years), presenting a supra ventricular (n = 2,146, 59 p. cent), nodal (n = 351, 10 p. cent) or ventricular (n = 1,613, 44 p. cent) arrhythmia, in order to study its efficacy and tolerance. After exclusion of the patients on whom there was a contra-indications to the use of anti-arrhythmic drugs, Propafenone was administered orally, on a long-term basis, at the usual dose of 600-900 mg per 24 hours. The efficacy and tolerance were evaluated according to the usual clinical and paraclinical criteria (EKG, Holter) on the 15th day, then every month during the treatment period. The efficacy of the treatment was evaluated as very good in 54 p. cent of the cases, good in 25 p. cent of the cases, average in 8 p. cent of the patients and non-existent or non significant for 13 p. cent of the patients. Electrocardiographic alterations under Propafenone are already described: CF, PR, QRS. A cardiac undesirable side effect occurred 102 times, most often a sinus bradycardia type (n = 26), atrio-ventricular conduction disorders (n = 22) or intraventricular conduction disorders (n = 26), disorders of cardiac decompensation (n = 10) or arrhythmogenic effect (n = 18). Other side effects are gastro-intestinal in nature (taste alterations, nausea, vomiting, gastralgia) for 23 p. cent of the patients treated, neuro-sensorial in origin (dizziness, visual disorders, tremors) for 13 p. cent of the patients or of another nature for 5 p. cent of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The new anti-arrhythmic agent flecainide was compared in a single-blind cross-over study to arabogalactane quinidine sulfate in the treatment of stable chronic extrasystole, using a fixed twice-daily dose protocol. Results were assessed by the Holter method. 12 patients (7 men and 5 women) with an average age of 56.5 were selected on the basis of stable and essentially ventricular extrasystole (VES) in 11 cases, and essentially atrial extrasystole (AES) in the remaining case. All patients however had some VES and 6 had some AES, and 5 patients had bursts of VES. The protocol provided for four sequences lasting one week each: one fixed, for selection, and the other three random, flecainide (375 mg), quinidine (660 mg), or placebo (2 doses). Data on each were recorded for Holter analysis. Statistical comparison of results was performed by studying variances on an equilibrated block. Comparison between the selection and placebo sequences showed the stability of the arrhythmia whatever its type. Against ectopic complexes as a whole, only flecainide had significant activity (p less than 0.01). Against AES, both compounds were active (p less than 0.05), quinidine more than flecainide (-73%/63%: a non-significant difference). Only flecainide was active against VES (-88.5%). Quinidine did not significantly reduce VES (-56%).(ABSTRACT TRUNCATED AT 250 WORDS)

Fulguration of the bundle of His consists is interrupting or markedly slow-down the atrio-ventricular conduction, in order to suppress or markedly decrease the symptoms related to refractory atrial arrhythmias. With a consecutive series of 128 cases, it is possible to specify the main indications and present a simplified technique, using Josephson's catheter. At 3 months, the results are as follows: 3rd degree atrio-ventricular block in 80 p. cent of the cases, 1st degree atrio-ventricular block in 10 p. cent, with failure in 10 p. cent of the cases. The immediate complications are rare and benign. Late complications are essentially related to the type of cardiac stimulation offered to the patient. The ventricular stimulation with dependent frequency (particularly on ventilation), enables most patients to return to a normal activity.

The diagnosis of atrial myxoma, the most common cardiac tumour, has been greatly facilitated by the introduction of echocardiography. The principal echocardiographic features and the diagnostic pitfalls encountered in a personal series of 7 atrial myxomas (5 left and 2 right) studied by M mode and 2-dimensional echocardiography are reported. In M mode, left atrial myxoma is a relatively easy diagnosis when the tumour prolapses into the mitral orifice. On standard mitro-aortic scanning, it is recorded behind the anterior mitral leaflet as a mass of abnormal echos appearing shortly after mitral valve opening. The diagnosis is much more difficult or even impossible in nonprolapsing tumours. Right atrial myxomas, prolapsing into the tricuspid orifice, do not usually pose any diagnotic problems. 2-dimensional echocardiography shows its superiority in the early diagnosis of small, localised, relatively immobile and non-prolapsing tumours. The parasternal (long axis and transverse views), the apical (4 and 2 chamber views) and subxiphoid positions were the most useful incidences and the tumour was visualised as a more or less circumscribed mass of echos. In all cases, 2-dimensional echo provided information on the size, mobility, insertion and the length of the pedicle of the tumour. Atrial myxoma is being recognised more easily and more often nowadays by echocardiography, the diagnostic method of choice, and 2-dimensional studies should be preferred.

The authors report another case of successful endocavitary electrocautery in a young woman with Wolff-Parkinson-White syndrome. The pre-excitation was controlled by the administration of two 250 joule electrical shocks applied to the atrial origin of the right anterior bundle. The clinical and laboratory tolerance were satisfactory. Although these results are encouraging, other studies are required in order to define the indications and protocols of electrocautery of accessory pathways.

Fourteen patients with permanent electrocardiographical features of the Wolff-Parkison-White syndrome in sinus rhythm referred for electrophysiological investigation also underwent maximal exercise tolerance tests. The working hypothesis was that in patients with the Wolff-Parkinson-White syndrome with accessory pathways of longer effective refractory periods than the normal pathway (group I) the delta wave should disappear on exercise, whilst in patients with accessory pathways with shorter refractory periods than the normal pathway (group II) the delta wave should persist. Of the 9 patients in group I,the delta wave regressed in 8 and persisted in 1 patient; of the 5 patients in group II, the delta wave persisted in 4 of them. Three patients had attacks of tachycardia during or just after the exercise tolerance test. These results suggest that the exercise tolerance test may help in the identification of patients with accessory pathways with long refractory periods, less susceptible to rapid ventricular rhythms should atrial fibrillation occur, and therefore with better prognoses.

Twenty-two hypertensive patients with normal coronary arteriograms underwent a complete study of left ventricular performance. The patients were classified into three groups according to the findings on X-ray and ECG investigation: group I--ECG normal, X-ray normal (6 cases); group II--ECG showed left atrial hypertrophy, X-ray normal (7 cases); group III-ECG showed left ventricular hypertrophy, X-ray showed cardiac dilatation (9 cases). The results of this study were as follows:--cardiac ouptut was lowered in groups II and III;--end-diastolic volume was lowered in group II and raised in group III;--LVEDP was raised in groups II and III;--V max and VEC max were lower in groups II and III than in group I;--left ventricular compliance was diminished in groups I and II. Myocardial rigidity of the left ventricle was similar in the three groups. Hypertensive heart disease is therefore characterised by early changes in compliance of the left ventricle. These are associated with geometrical changes in the ventricle: disturbance of the volume/mass ratio of the left ventricle. These findings have therapeutic implications for the importance of beta-blockers.

Measurement of the blood volume in cases of essential hypertension has shown a negative correlation with increase in blood pressure. We have been able to distinguish a group of moderate hypertensives who are hypervolemic, and whose systemic effect is more marked than in the moderate hypovolemic type. Such cases respond poorly to single drug therapy with beta blockers, but well to diuretics. The authors propose a general treatment scheme for essential hypertension: single therapy (beta blockers or diuretics) in mild cases of hypertension; single therapy by diuretics in the moderate types with the increased volume; single therapy by beta blockers in the moderate types with low volume, multiple treatment with the drugs together in cases of severe hypertension.

Ninety patients admitted to a neurology unit for cerebral ischaemic accident without evidence of embolism from the heart were examined by ambulatory electrocardiographic monitoring (AEM) and by echocardiography assessable in 76 cases. On the basis of a standard cardiac evaluation (SCE) including physical examination, chest radiography and electrocardiography, the patients were divided into 3 groups: 42 with normal SCE (group I), 19 with isolated arterial hypertension (group II) and 36 with patent cardiac disease (group III). Significant abnormalities were detected by AEM in 10.5% of group I patients, 18.5% of group II patients and 33% of group III patients. A structural cardiopathy was discovered at echocardiography in 33%, 62% and 91% respectively of patients in these 3 groups. The greatest number of mitral valve prolapses (7/9 cases) was found in group I. The main echocardiographic abnormality detected in group II was dilatation of the left cardiac cavities: atrium more than 38 mm in 8 cases, ventricle more than 50 mm in 3 cases. Comparisons between the two explorations showed that arrhythmias were often associated with dilatation of the left cardiac cavities (39%) and much less frequently with mitral valve prolapse (11%) and myocardial hypertrophy (16%). Our results suggest that when examinations cannot be routinely performed in hospital patients with a cerebral ischaemic accident echocardiography should be reserved to patients with heart disease or hypertension, and AEM to those with heart disease or hypertension and with dilatation of the left cardiac cavities.

A population of 236 patients with dilated cardiomyopathy (DCM) was studied and followed up for an average of 38.8 +/- 27 months. The most common atrial arrhythmia was atrial fibrillation (AF) which was observed in 27 p. 100 of cases. Patients with AF (n = 43) and without it (n = 193) at the time of diagnosis were compared: the subjects with AF were older (p = 0.036), had a higher left ventricular ejection fraction and lower end diastolic pressures (p = 0.022). AF was associated with mitral valve prolapse (p = 0.007) and with signs of adiastole (p = 0.0015); the most significantly correlated variable was echocardiographic dilatation of the left atrium (p = 0.0012). AF was the presenting symptom of DCM in 13 cases (5.5 p. 100); in 10 cases (4 p. 100) it was the main clinical and therapeutic problem, realizing an arrhythmic form of DCM. Electrical conversion was successful in 7 out of 11 patients with a 2 year follow-up: 3 patients remained in sinus rhythm for over 6 years and have no clinical symptoms, posing the problem of the dominant if not exclusive underlying role of AF in these cases of DCM. An example illustrated by several echocardiographic examinations is presented. Embolic complications were observed in a quarter of the cases with AF and this arrhythmia was present in half the patients with embolic phenomena. However, the prognosis in the groups with and without AF was not significantly different.

62 of 100 cases of acute pericarditis observed over 15 years were so-called acute benign pericarditis. 20 of these patients (30%) had multiple relapses. Relapse could not be predicted. The interval between the initial affection and first relapse was usually more than one month (18/20). Each relapse was accompanied by pain, fever, ST-T changes, slight cardiomegaly and acceleration of the ESR. Corticotherapy appeared to be responsible for relapse in 13 cases. In 6 cases the eradication of a deep septic focus prevented further relapses. In two cases the duration of anti-inflammatory therapy was thought to have been insufficient. Antibiotic therapy did not seem to be a provocative factor. Relapses may be numerous (10 to 12) and prolonged (24-36 months) especially in the corticodependant forms in which steroids should be tailed off gradually according to a strict protocol.

Two new cases of ventricular tachycardia (VT) in the infant are reported, and reviewed in the light of the 23 case histories found in the literature. The diagnosis rests upon eliminating a pre-excitation syndrome, which is so common in this age group. The VTs found in infants are rapid, irregular, and take many different forms. They often necessitate urgent treatment with electric shocks. Preventive treatment consists of a combination of procainamide and beta-blockers in relatively large doses. The search for an aetiological agent should include a haemodynamic and angiocardiographic study of all the chambers of the heart to exclude cardiomyopathy, tumours, papyraceous right ventricle and congenital heart defects. Where no cause can be demonstrated, preventive treatment should be given, with regular electrical testing and other follow-up investigations. An attempt to reduce the drug dosage should be made every 6 months, in hospital. In cases which prove resistant despite adequate treatment, it seems justifiable to carry out a pericardial exploration with the aim of diathermising the ectopic focus; this approach is suggested because of the poor natural history of this type of case.

The antiarrhythmic efficiency of quinidine arabogalactan-sulphate (QAGS) and disopyramide were determined in 38 patients showing chronic, stable frequency premature ventricular beats (PVB). The study which was carried out in 4 medical Centers, used a longitudinal cross-over design. After a baseline evaluation which consisted of two 24 hours electrocardiograms, the patients were randomised to one of the two drugs during a period of 6 or 7 days. The drug sequence were followed by a placebo sequence. A 24 hours electrocardiogram was performed at the end of each sequence. The daily doses were equivalent to 660 mg of quinidine base for QAGS and 600 mg for disopyramide. Among the 38 patients who entered in the study, 32 went through each sequence of the test. The average number of PVB was significantly reduced by QAGS and disopyramide (p less than 0.0001). With QAGS 18 patients had more than 65 p. 100 reduction of PVB and 12 of them more than 80 p. 100. With disopyramide, 14 patients had more than 65 p. 100 reduction of PVB and 12 of them more than 80 p. 100. There was no statistical difference in the overall efficiency of the two drugs. Three patients died, one from myocardial reinfarction, one from ventricular fibrillation; in one other case, the cause of the death remained undetermined. QAGS was better tolerated than disopyramide; adverse effects occurred in 6 patients with QAGS and in 10 with disopyramide. The responsibility of disopyramide in the occurrence of two severe ventricular arrhythmia may be questioned.

Nine patients aged 47 to 74 years underwent endocavitary destruction of the bundle of His because of paroxysmal arrhythmias resistant to medical therapy. Four patients had paroxysmal atrial fibrillation, 2 had paroxysmal atrial flutter, 1 had reentrant atrial tachycardia, 1 had paroxysmal atrial tachycardia and 1 had an intranodal reentrant tachycardia. One patient had already undergone "surgical ablation" of the His bundle without success. A tripolar or bipolar catheter was introduced via the femoral vein and the His potential localised by bipolar and then unipolar recordings. The lead with the greatest His potential was connected to an external defibrillator and the other pole connected to a metal plaque positioned under the patient's left shoulder. An electrical shock of 200 to 400 joules was administered, in some cases repeatedly. Eight of the 9 patients developed complete atrioventricular block after the shock. This was only temporary in 3 cases, necessitating another shock in 2 cases; the procedure was not repeated in the 3rd case. After 30 minutes of persistent AV block a pacemaker was implanted; 7 of these 8 patients had VVI and I patient (intranodal reentry) DDD pacing. The follow-up period ranges from 1 to 18 months. None of the patients have had symptoms of paroxysmal arrhythmia; in the long-term, there was one initial failure. Of the other 8 cases, 4 remain in complete AV block, 2 have 2nd degree and 21st degree AV block. Three patients have associated antiarrhythmic therapy with quinidine or verapamil. No side effects were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Various studies have established the increase of sudden death in hypertensive patients with left ventricular hypertrophy (LVH). In order to specify its most important factors, an electrophysiological study consisting of Holter recording (HR) and programmed ventricular stimulation (PVS), was performed in 24 patients with hypertension: 12 with LVH and 12 without LVH, on ultrasonography. In all patients, coronary angiography was normal. The results are the following: 1) LVH increases the ventricular vulnerability, this arrhythmogenic substrate and its stability are explored by PVS; 2) HR and PVS are not correlated, therefore HR does not explore the arrhythmogenic substrate of LVH, but rather the potential triggering factors of severe rhythm disorders; 3) it has not been possible to evaluate the role of the autonomous nervous system in this study; 4) finally, a significant correlation was found between the degree of anatomical hypertrophy of the LV and the duration of the interval AH.