[Performance of endorectal echography in tumors of the rectum]

From November 1986 to December 1987, endorectal ultrasound (EUS) has been performed 57 times in a total of 54 patients. In the cancers of the low and mid rectum (n = 34), the extent of the tumoral infiltration was accurately assessed by preoperative EUS in 88% of cases. Sensitivity of tumor spread beyond the rectal wall was 0.96. Classification of lymph nodes was more hazardous. The muscular layer was intact in 5 villous adenomas. The diagnosis was difficult in the case of a huge and massively secreting tumour. In the follow-up of the patients after rectal resection(n = 11) or local excision (n = 3) for cancer, EUS allowed an accurate analysis of the suture line in 12 cases. Three submucosal recurrences were detected. The follow-up showed no recurrence in the other cases with a tumor-free suture line pattern. The literature confirms that EUS is a non invasive, efficient and inexpensive method in the preoperative staging of non stenotic rectal tumors. The problem of accuracy of lymph node staging has not been resolved. The technique shows some promise in detecting local recurrences.

Electrocardiographic characteristics of the escape rhythm in transient complete atrioventricular block induced by transcatheter electrical ablation of the atrioventricular junction

The electrocardiographic characteristics of spontaneous escape rhythm during complete heart block induced by transcatheter ablation of the atrioventricular junction was prospectively studied in 21 patients by periodically interrupting temporary pacing. The data derived from 13 of these 21 patients, in whom conduction recurred after the procedure, were analyzed. An escape rhythm was present in 12 patients 8.2 +/- 5.8 minutes after shock delivery at a cycle length of 1985 +/- 974 ms. The escape QRS had a configuration of right bundle branch block with left axis deviation in 9 patients, of right bundle branch block with normal axis in 1, of left bundle branch block with left axis deviation in 1, and 2 distinct morphologies in the remaining patient. After resumption of conduction, the conducted complexes were identical to the escape complexes in six patients, different only in axis in four patients, and different in morphology in two patients. This suggests that in the majority of patients the escape rhythm seen during transient heart block, induced by transcatheter ablation of the atrioventricular junction, presents a right bundle branch morphology with or without a left axis deviation, and most likely originates from an area above, or close to, the site of the anatomical damage.

[Wolff-Parkinson-White syndrome. Outcome of patients treated with anti-arrhythmia agents from data of electrophysiological examinations]

Seventy-two consecutive patients with electrocardiographic evidence of Wolff-Parkinson-White syndrome underwent electrophysiological study (EPS). Fifty-five of these patients (76 p. 100) had episodes of tachycardia, 11 experienced palpitations or syncopes and 6 were asymptomatic. The decision to prescribe an antiarrhythmic agent was reached on the basis of the patients' symptoms and EPS data. One patient was treated by surgery before the medical treatment was tried; 17 patients were discharged without treatment, 4 were discharged with an episodic and 50 with a preventive antiarrhythmic treatment. Among these 50 patients, 46 (92 p. 100) could be followed up for a mean period of 45.7 +/- 28 months. One died of lung cancer; 43 presented with spontaneous episodes of tachycardia, 4 were able to discontinue treatment at the end of the follow-up period since they had very few symptoms and 2 were lost sight of. Among the 37 patients under antiarrhythmic treatment followed up, 29 (78 p. 100) are well controlled, while 8 (22 p. 100) still present with episodes of tachycardia. A tachycardia-reducing pacemaker was implanted in 5 of these 8 patients. It therefore appears that 78 p. 100 of patients presenting with spontaneous episodes of tachycardia associated with WPW syndrome can be controlled with an antiarrhythmic treatment. This result was obtained after trying at least two types of antiarrhythmic agents in 86 p. 100 of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiomuscular lysosomal glycogenosis in adults without known enzyme deficiency. A cause of familial myocardiopathy and lysosomal glycogen overload with normal acid maltase]

An unusual form of familial myocardiopathy is reported. The disease affected siblings entering adulthood and presented as subclinical skeletal muscle and patent cardiac muscle lesions. Quadriceps muscle biopsy performed in a young man who subsequently died of cardial failure revealed excessive lysosomal glycogen storage, as in type II glycogenosis, but biochemistry showed normal enzymatic activity. In a sister with hypertrophic myocardiopathy only leucocytes were examined; they also showed normal enzymatic activity. Other clinical manifestations of this form of familial myocardiopathy are hypoglycaemia and moderate skeletal muscle involvement. At histology, the image is that of Pompe's disease, but the acid maltase level is normal. The condition seems to be transmitted as an autosomal dominant trait.

[Complex ventricular extrasystole. Value of technics of programmed electric stimulation]

The incidence and significance of ventricular arrhythmia induced by programmed electrical stimulation in subjects with complex ventricular ectopy were studied in 46 consecutive subjects: 34 with heart disease, 12 with an apparently normal heart. The procedure consisted of delivering on one spontaneous and 2 imposed rhythms one, two, then three extrastimuli. Significant arrhythmia with more than 6 ventricular complexes was induced in 17 patients (37%), including 6 (13%) with sustained ventricular tachycardia and 11 with unsustained ventricular tachycardia. Induction of ventricular arrhythmia was observed in 12 of the 14 patients with a history of myocardial infarction. At the end of a mean follow-up period of 12 +/- 4 months, there were 2 sudden deaths, and 3 patients had clinically sustained ventricular tachycardia. Clinical ventricular tachycardia occurred in the group of 17 patients inducible during programmed electrical stimulation. The patients who died suddenly belonged to the group of 29 patients without induced ventricular arrhythmia. This study shows a high proportion of significant stimulation-induced arrhythmia in patients who had suffered from myocardial infarction more than 3 months previously and who had complex ventricular ectopy. Owing to the good condition of this group of patients after a mean follow-up of 12 months, we were unable to determine the influence of stimulation-induced arrhythmia on mortality. However, it must be noted that spontaneous sustained tachycardia occurred in the group of patients with significant induced ventricular arrhythmia.

Electrophysiologic properties of falipamil (AQA-39)--a new bradycardiac agent

Falipamil hydrochloride (AQA 39) is a new antiarrhythmic agent structurally related to verapamil. We evaluated the electrophysiologic properties of intravenous falipamil (1.5 mg kg-1 within 20 minutes) in 12 patients. The spontaneous cycle length was significantly (P less than 0.001) prolonged (+79 +/- 59 ms). Atrioventricular conduction was significantly (P less than 0.001) shorter due to AH interval shortening (-17 +/- 14 ms), most probably related to an anticholinergic effect. Similarly, the anterograde Wenckebach point occurred at a significantly (P less than 0.06) higher rate after falipamil (+10 +/- 7 beats min-1). No statistically significant effect was noted on the refractory periods of the AV node, although there was a trend to shortening. The refractoriness of the right atrium and ventricle was significantly prolonged. It is concluded that falipamil is a bradycardiac agent with electrophysiologic properties quite different from those of verapamil and similar to those of class IA antiarrhythmic agents.

[Evaluation of the prognosis of mitral valve prolapse]

It is not easy to evaluate the prognosis of mitral valve prolapse. First of all, a positive diagnosis is difficult: the clinical insufficiencies are ill-compensated by sonocardiography as it is less reliable than expected; the very existence of the "mitral valve prolapse" described by Barlow is being challenged. Secondly, the most severe complications of mitral prolapse are rare, with respect to its frequency. Some complications are currently well defined. Thus, severe mitral insufficiency, leading to valve replacement, affects elderly men more than young women, although the pathological lesions correspond to the same disease. Endocarditis is rare and only occurs when there is an audible murmur. Rhythm disorders are varied, with however, frequent junction tachycardias and a marked influence of catecholamines, which may explain the clinical effectiveness of beta-blockers. Unfortunately, severe complications are not as well known. Thus, the risk of sudden death and cerebral vascular accident cannot be figured out from large statistical studies. Only studies of some so called "risk" sub-groups, should allow a better knowledge of these two complications and a more effective prevention.

[Electro-mechanical dissociation concomitant with myocardial reperfusion in the acute phase of myocardial infarction]

An unusual case of transient electro-mechanical dissociation concomitant with myocardial reperfusion is reported. The patient had myocardial infarction caused by occlusion of the middle anterior interventricular artery relieved by injection of urokinase and plasminogen in situ. The dissociation could be documented by simultaneous ECG recording on 3 leads and direct intravascular recording of femoral arterial pressure, the patency of that artery, and its maintenance, being demonstrated by angiography. This clinical case can be added to the list of events which occur during reperfusion of the myocardium after prolonged ischaemia. Its mechanisms, so far, are purely conjectural.

Remote occurrence of high degree heart block following failure of transcatheter AV junctional ablation: incidence and clinical significance

We report on two patients out of a series of 22 who underwent transcatheter ablation of the atrioventricular (AV) junction. The procedure failed to induce permanent complete heart block in 15 patients, 12 of whom were in sinus rhythm with 1:1 AV conduction before hospital discharge. Of the 12 patients, two (16.6%) were found to be in high degree heart block, one month later. We discuss the mechanism of late occurrence of high degree heart block and we emphasize the need for systematic implantation of permanent ventricular or dual chamber pacemakers, despite failure of transcatheter ablation of the AV junction.

[Percutaneous aortic valvuloplasty by trans-septal approach]

Aortic valvuloplasty has recently been introduced in the treatment of some cases of aortic stenosis. In the case reported here, the aortic orifice was so difficult to traverse by the retrograde route that the obstacle was approached by trans-septal catheterization. The aortic area, initially estimated at 0.25 cm2, increased to 0.82 cm2 at the end of the examination. However, additional dilatation by the retrograde route was necessary, using a catheter 25 mm in diameter.

[Intravenous sotalol in the acute treatment of supraventricular tachycardias]

The effects of intravenous sotalol (0.5 mg/kg in 6 minutes) were studied in 23 patients with supraventricular tachycardia (ventricular rate greater than 120 bpm) after failure of placebo (isotonic dextrose). Thirteen patients had atrial flutter or fibrillation and 10 a junctional tachycardia of recent onset. Sinus rhythm was restored in 4 of the patients with atrial flutter or fibrillation and the ventricular rate was slowed significantly in 3 patients (less than 100 bpm). In 3 other patients the ventricular rate decreased (31 to 35 p. 100) but remained above 100 bpm. Sinus rhythm was restored in 3 of the 10 patients with a junctional tachycardia five to twelve minutes after beginning the injection. A slight slowing of the heart rate (13 to 27 p. 100) was observed in the other 7 patients but the frequency remained over 100 bpm. Overall, a satisfactory result was obtained in 10 patients (43 p. 100) including 7 cases in which sinus rhythm was restored. Sotalol was well tolerated in 21 patients; one patient complained of cold in the legs and one patient developed asymptomatic bradycardia (46 bpm). This study shows that intravenous sotalol may be useful in the emergency treatment of supraventricular tachycardia.

[Sinus dysfunction associated with catecholaminergic ventricular tachycardia. Therapeutic implications]

The presence of resting sinus bradycardia (less than or equal to 45 bpm) with junctional escapes in an 8 year old child with catecholamine induced ventricular tachycardia, raised the problem of an underlying sinus node dysfunction. This was an important consideration bearing in mind the potential risk of the high dose betablocker therapy aggravating the sinus bradycardia. Electrophysiological studies showed pathological sinus node recovery times. Betablocker therapy did not aggravate the bradycardia, even after 6 months' treatment. A review of the literature showed the association of sinus bradycardia and catecholamine-induced ventricular tachycardia to be relatively common (39 p. 100). However, no mention was found of aggravation of this sinus bradycardia by betablocker therapy.

[Delayed filling of the anterior interventricular artery. Apropos of 9 cases]

Selective coronary angiography has shown that typical angina pectoris may occur in the absence of atheromatous coronary stenosis. Other causes of these attacks of pain have been found: coronary spasm, small vessel disease, abnormal dissociation of haemoglobin or metabolic disturbances of the myocardial cell. Of all the patients undergoing coronary angiography in 1984 at the Centre Cantini, 9 had no classical coronary lesions but delayed filling of the left anterior descending artery. This syndrome was described for the first time in 1972 by Tambe as the "slow flow velocity syndrome". The aim of this study was to analyse the clinical, ECG and haemodynamic profiles of those patients. Five of them also underwent stress Thallium myocardial scintigraphy. An ergometrine provocation test was performed afterwards under ECG control. Delayed filling was appreciated by comparison with the other vessels and also by measuring the filling time which was two or three times longer than in a control series of 9 patients with angina and normal coronary arteries. The difference was statistically significant. These findings were only observed in strictly normal coronary vessels; they were reproducible and unaffected by the administration of nitrate derivatives. In our series all 9 patients were men with an average age of 51.4 years. One patient was asymptomatic and had a history suggestive of myocardial infarction, and 4 others had typical angina of effort: all had abnormal exercise stress tests. The other 3 patients had spontaneous atypical chest pain, normal resting ECG and a negative exercise stress test (impossible in one case). The five stress Thallium scintigraphies showed myocardial perfusion defects.(ABSTRACT TRUNCATED AT 250 WORDS)

A new method for evaluating the effect of antiarrhythmic drugs on atrioventricular nodal conduction

Electrophysiological variables were studied in 19 patients before and after one of three commonly used antiarrhythmic agents. The pacing rate at which alternating Wenckebach periods appeared in eight patients was significantly reduced by intravenous digoxin (0.01 mg/kg body weight). The atrioventricular nodal conduction time (A-H interval) and Wenckebach point were not significantly altered by digoxin. Intravenous propranolol (0.1 mg/kg body weight) in four patients did not affect the A-H interval, but it reduced the pacing rates at which the Wenckebach point and alternating Wenckebach periods occurred. Intravenous disopyramide (2 mg/kg body weight) significantly increased the pacing rate required to produce alternating Wenckebach periods but did not significantly alter the other indicators of atrioventricular conduction in seven patients. It is concluded that the pacing rate required to produce alternating Wenckebach periodicity may be a useful and sensitive variable in the evaluation of the effect of antiarrhythmic agents on atrioventricular nodal conduction.

[Treatment of recurrent ventricular tachycardias using oral propafenone]

The effect of oral propafenone on prevention of pacing-induced ventricular tachycardia (VT) was studied in 11 patients. All patients experienced documented sustained VT refractory to 4.1 +/- 2 antiarrhythmic agents per patient including amiodarone in 8. Programmed electrical stimulation was performed before and 48-72 hours after oral propafenone (900 mg/day) 2-3 hours after the last dose. Two patients developed spontaneous incessant VT before the scheduled date of the study on propafenone, and were classified as aggravation. Propafenone prevented pacing-induced VT in 2 patients (successful results). In 3 additional patients the results were partial, as non-sustained VT was induced on propafenone whereas sustained VT could be provoked during the control study. In the remaining 4 patients, oral propafenone failed to prevent pacing-induced VT. Tachycardia cycle length increased in 3 (C = 284 +/- 129 P = 450 +/- 202 ms) and was shorter in 1 aggravation. The 5 patients with successful or partial results (45.4 p. cent), underwent long-term therapy with a mean follow up of 5.6 +/- 4 months. Recurrence of VT occurred in 2. The remaining 3 are well controlled. This study demonstrates that propafenone is able to prevent pacing-induced VT in a limited number of patients. Stimulation techniques are useful in order to detect patients with potential pro-arrhythmic effect.

[Oral and intravenous bepridil in the treatment of recurrent sustained ventricular tachycardias. Electropharmacological study]

The antiarrhythmic properties of bepridil on ventricular tachycardia (VT) termination and prevention were studied in 16 patients using programmed electrical stimulation techniques. All patients were admitted for documented sustained VT resistant to 3.5 +/- 2.4 antiarrhythmic agents. Intravenous bepridil (2 mg/kg) successfully terminated 4 out of 8 and prevented 3 out of 8 patients with hemodynamically well tolerated sustained VT. Oral bepridil (800 mg day 500-600 mg the following days) prevented successfully pacing-induced VT in 7 patients (43.7 p. cent) and a partial result was obtained in additional 3 (18.7 p. cent). In 6 patients bepridil failed to prevent pacing-induced VT including 2 patients with a shorter cycle length on bepridil (classified as aggravation). Tachycardia cycle length lengthened in the remaining 4 a mean of 11 +/- 12 p. cent. One of the 7 patients with a good result presented on bepridil evidence of sinus node dysfunction. The remaining 6 underwent long-term therapy (600 mg/24 h). During a mean follow up of 19 +/- 4 months, 4 patients are well controlled, 1 presented a side-effect (paralytic ileus) and 1 a recurrence. This study emphasizes the antiarrhythmic properties of bepridil at the ventricular level and provides evidence of its usefulness in patients with recurrent sustained VT.

[Treatment of recurrent ventricular tachycardia with hydroquinidine. Evaluation of its efficacy with electrophysiological technics]

Electrophysiological investigations were used to test the efficacy of dihydroquinidine chlorhydrate (600 or 1 200 mg/day) in a prospective study of 18 patients with recurrent ventricular tachycardia documented by electrocardiography. These patients did not respond to an average of 3.1 +/- antiarrhythmic drugs, including amiodarone in 12 patients. Hydroquinidine was well tolerated in 17 patients but had to be withdrawn in 1 patient because of hypotension. The effect of hydroquinidine on ventricular tachycardia induced by programmed pacing was evaluated after a 48 to 72 hours treatment, 3 to 5 hours after the last dose. After hydroquinidine it was not possible to induce ventricular tachycardia in 10 patients (58.8%). In the other 7 patients, it was possible to induce a ventricular tachycardia under treatment. In one case, hydroquinidine aggravated the arrhythmia as the induced tachycardia had a shorter cycle. In the other patients, hydroquinidine lengthened the tachycardia cycle by an average of 94 +/- 79 ms. The right ventricular refractory period increased cycle by 44 +/- 23 ms. Long-term hydroquinidine was prescribed for 7 patients, twice in association with amiodarone. Relapse was observed in 2 patients, 1 and 5 months after the onset of treatment. Five patients were well controlled by the treatment. The results of this study demonstrate the efficacy of hydroquinidine for the prevention of tachycardia induced by stimulation and underline its value in the treatment of sustained, recurrent ventricular tachycardia. This study illustrates the illustrates the importance of electrophysiological techniques for the identification of patients likely to benefit from a given antiarrhythmic treatment.

[Supraventricular tachycardia induced by effort and by catecholamines]

The role played by catecholamines in the initiation of certain forms of ventricular tachycardia is now recognised. On the other hand, a similar predominant or exclusive mechanism has not been demonstrated in supraventricular tachycardia. We observed a rate case of reproducible attacks of junctional tachycardia on effort in a 45 year old man. This patient had experienced attacks of tachycardia on effort for a number of years, stopping about 10 minutes after the end of effort. An exercise stress test performed for an anginal attack, induced a narrow complex tachycardia at 270/min at the first minute of the recovery period which terminated spontaneously 18 minutes later after a brief episode of atrial fibrillation. During a second exercise stress test, an episode of tachycardia at 250/min was recorded at the second minute of recovery, lasting 11 minutes. Investigations showed a retrograde concealed septal bundle of Kent activated retrogradely during reciprocating tachycardia. A similar form of tachycardia was induced by an injection of isoproterenol. The adrenergic mechanism of the arrhythmia led to the prescription of a beta-blocker (propranolol 120 mg/day), which effectively prevented clinical tachycardia and the forms of tachycardia induced by ergometric tests 15 days and 3 months after the initiation of treatment.

[Behçet's disease and cardiovascular pathology]

Behçet's syndrome appears in different localisations. Some of them were at the source of the initial description of the disease and are therefore well known. However, cardiovascular localisations were discovered later on and are worthy of detail. They may enable retrospective diagnosis and are an evolutive turning point in this still mysterious disease.

[Large right intracardiac thrombus cause of recurrent pulmonary embolism. Apropos of a case of favourable course]

Echocardiography may be used in patients presenting with pulmonary embolism to visualise the right heart. The authors report the case of a patient who had recurrent pulmonary embolism. Echocardiography demonstrated a large, mobile thrombus moving freely through the tricuspid valve. There were many cardiac and general contraindications to surgery and fibrinolytic therapy in this particular case. Nevertheless, the mass had totally disappeared on control echocardiography after anticoagulant therapy with heparin. There were no further embolic symptoms. The only change was observed on pulmonary scintigraphy. The patient was discharged a few weeks later on oral anticoagulant therapy. In comparison with previously published results, the outcome of this case was surprisingly good; surgery, which was impossible in our case, would seem to be the treatment of choice.

[Coronary occlusion immediately following a successful coronary angioplasty. Treatment by repeat angioplasty]

The authors report the case of a 52 year old patient with a significant stenosis of the medial portion of the left anterior descending artery (LAD) with excellent left ventricular function. Transluminal coronary angioplasty (TCA) was indicated following a positive exercise stress test. This was initially performed successfully. Fifteen minutes after the end of the procedure, a total obstruction occurred at the site of dilatation immediately eliciting significant precordial chest pain and massive elevation of the ST segment. Isosorbide dinitrate (ISDN) at a dose of 2 mg was injected into the artery 3 times without success as was an attempt to pass through the obstruction with a guide wire. Another TCA was then attempted without administration of the thrombolytic agent. The dilating catheter passed easily by the obstruction permitting several dilatations which restored rapid coronary artery flow, relieved completely the chest pain, and normalized electrocardiographic abnormalities. This procedure represents a new therapeutic approach to obstruction, an often unpredictable and serious complication of coronary angioplasty in the absence of collateral circulation, thereby preventing the development of a myocardial infarction and an emergency aortocoronary bypass operation.

[Ventricular arrhythmia following repair of Fallot's tetralogy. Apropos of 59 cases]

Fifty-nine patients operated for Fallot's tetralogy were reviewed over 3 years after surgery. The average age at surgery was 7.4 years (range 6 months to 37 years). The review included ECG, chest X-ray, echocardiography, exercise stress testing and Holter monitoring, completed by cardiac catheterisation in 10 cases and electrophysiological investigation in 4 cases. Forty-eight of the 59 patients (81.3 p. 100) had no signs of ventricular arrhythmia or only benign ventricular extrasystoles (Group I). Four patients (6.8 p. 100) had severe ventricular arrhythmias (Group II). Seven patients (11.9 p. 100) had one or more episodes of ventricular tachycardia (VT) (Group III) and, in 3 of these patients, VT was recorded during Holter monitoring or exercise stress testing. One patient in Group III died after reoperation, but there were no cases of sudden death in this series. The high risk patients Groups II and III) were operated late (after 5 years), had bi- or trifascicular block (7 out of 11 cases), ventricular extrasystoles on resting ECGs (9 out of 11 cases), cardiomegaly (6 out of 7 cases in Group III), echocardiographic dilatation of the infundibulum (6 out of the 8 patients undergoing echocardiography in Groups II and III). They had significant residual malformation but without right ventricular hypertension (as judged mainly by immediate postoperative data). Ventricular arrhythmias occurred over 6 years after surgery. However, none of the patients operated before 2 years of age had ventricular arrhythmias or VT with a mean follow-up period of 7.5 years, perhaps because LV function was protected.(ABSTRACT TRUNCATED AT 250 WORDS)