[Intravenous and oral propafenone in the treatment and prevention of paroxysmal atrial fibrillation]

The efficacy of propafenone in the treatment of paroxysmal atrial fibrillation was investigated in 16 patients presenting with frequent and/or poorly tolerated paroxysmal atrial fibrillation despite prophylactic treatment in 13 patients. Prolonged atrial fibrillation (> 10 minutes) was triggered in 16 patients following a standard atrial stimulation protocol. Intravenous injection of propafenone (2 mg/kg over 5 minutes) restored sinus rhythm in 12 patients (75%) within 15 minutes after the end of the injection. In five of the 10 patients in whom this was possible, propafenone prevented the induction of atrial fibrillation in response to programmed stimulation by the same protocol. Oral propafenone (900 mg/24 hours) was indicated in 11 patients. The treatment was discontinued in 1 patient due to severe dizziness. Atrial fibrillation recurred in 4 patients 10 to 91 days after treatment began. With a mean follow-up time of 8 months, 4 patients had been brought under control and 2 had relapsed despite a generally beneficial effect. Three patients suffered side effects which did not make it necessary to stop treatment. This study suggests that intravenous propafenone is effective against persistent atrial fibrillation induced by stimulation. Oral propafenone may be useful for the prevention of attacks of recalcitrant paroxysmal atrial fibrillation.

[Wolff-Parkinson-White syndrome. Value of intravenous flecainide for detecting Kent's pathways with short refractory period]

The aim of this study was to assess the value of a non-invasive test in detecting accessory pathways with short anterograde effective refractory periods (AERP) (less than or equal to 270 ms) in patients with the Wolff-Parkinson-White syndrome. An intravenous injection of Flecainide acetate was administered to 19 consecutive patients referred for electrophysiological investigation of a WPW syndrome with permanent pre-excitation of the surface electrocardiogram. The first 8 patients (Group I) received a dose of 1.5 mg/kg over 5 minutes and the following 11 patients (Group II) were given 2 mg/kg in 5 minutes. In Group I, preexcitation disappeared in 3 patients (37.5%) who all had accessory pathways with AERP greater than 270 ms. It persisted in the other 5 patients (62.5%) of whom 4 had AERP less than or equal to 270 ms and 1 an AERP greater than 270 ms (false negative). In Group II, preexcitation disappeared in 8 patients (72.2%) of whom 4 had AERP greater than 270 ms and 4 had AERP less than 270 ms (false positives). Preexcitation persisted in the 3 other patients (27.3%); the AERP was less than or equal to 270 ms in 2 patients and greater than 270 ms in the other patients. These results suggest that intravenous Flecainide acetate at the dose of 1.5 mg/kg could be useful in differentiating WPW syndromes with long refractory periods (greater than 270 ms) from those with short refractory periods (less than or equal to 270 ms) with a satisfactory sensitivity and specificity, and that further studies on larger numbers of patients are required to confirm this hypothesis.

[Post-traumatic fistula of the left anterior descending coronary artery and left ventricle. Apropos of a new case]

The authors report the case of a 23 year old man who presented with a continuous murmur five years after closed chest trauma. The electrocardiographic and echocardiographic findings indicated previous apical myocardial infarction. The underlying diagnosis was first suggested by continuous wave Doppler which showed systolo-diastolic flow in the septo-apical region directed towards the left ventricle (LV) in diastole. Color Doppler flow studies showed a mosaic pattern opposite a dilated left anterior descending (LAD) artery. These signs of LAD-LV fistula with a single orific were confirmed at coronary arteriography. The patient's previous history was in favour of a traumatic etiology. In the absence of left ventricular failure and myocardial ischaemia by coronary steal, surgery was deferred; Doppler echocardiography would seem to be a good method of following up the fistula and its consequences on left ventricular function. A traumatic left coronary to left ventricular fistula is an extremely rare condition and merits publication. The authors review the literature and describe the physiopathology, diagnosis and therapeutic indications of these fistulae.

[Cardioversion by internal electric shock of permanent atrial fibrillation]

A new technique for cardioversion of chronic atrial fibrillation was used in 17 patients whose arrhythmia had resisted all attempts at electrical and pharmacologycal cardioversion. Atrial fibrillation was badly tolerated by all patients despite digitalis administered alone (8 patients) or combined with amiodarone (9 patients). Twelve patients had left atrial dilatation at echocardiography. The 200, 300 or 400 joule electrical shock was delivered between the proximal pole of a quadripolar catheter (cathode) and a back plate (anode). The catheter was positioned at the His bundle recording site then withdrawn into the right atrium. The internal shock restored sinus rhythm in 15 patients (88 p. 100). Transient atrioventricular block (3-315 sec) was observed in 8 patients. Eleven patients were discharged in sinus rhythm. In 4 patients, the atrial fibrillation recurred on day 8 and after 2, 4 and 9 months. A second shock was attempted in two patients and succeeded in one. After a mean follow-up period of 14.8 +/- 8 months (range 2 to 25 months), 8 of the 11 patients successfully cardioverted (72 p. 100) or of the attempted reductions (47 p. 100) were in sinus rhythm. The remaining 9 patients were treated with antiarrhythmic drugs (n = 5) or by his bundle catheter ablation (n = 4). High energy internal shock therefore seems to be an interesting treatment in patients with permanent atrial fibrillation after failure of external electric shock. It enabled 13 of the 17 patients in this series to avoid His bundle catheter ablation indicated by the quasi-impossibility to control the atrial rate and associated symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Atrioventricular block, a complication of radiotherapy of the mediastinum]

Cardiac complications of mediastinal irradiation usually concern the pericardium, the ventricular myocardium and the coronary arteries. We report the case of a 42-year old woman who experienced a syncopal atrioventricular (AV) block 12 years after irradiation of a mediastinal Hodgkin's lymphoma. Electrophysiological recordings showed infranodal conduction disturbances. A review of the literature yielded only 12 cases of syncopal radiation-induced AV block. This case highlights the risk of syncopal AV blocks occurring a long time after mediastinal irradiation and leading to severe damage of the His bundle and its branches. The presence, as in our patient, of an associated right ventricular outflow tract stenosis confirms the importance and severity of radiation-induced cardiac lesions.

[Anatomopathological criteria of progression in chronic idiopathic colitis]

Idiopathic inflammatory colitis are diseases of remissions and exacerbations of various severity. The criteria of activity are based on a conjunction of clinical, radiologic, endoscopic and anatomopathological data. From the macroscopical point of view, they are different in ulcerative colitis and Crohn's disease. Ulcerative colitis is characterized by a diffuse and uniform mucosal inflammation; any biopsy outside an ulcerative area can be used to evaluate the inflammatory components which are in the acute phase (chronic active phase): oedema, vascular congestion and an inflammatory infiltrate composed of a mixture of lymphocytes, plasma cells and polymorphs with partial destruction of the glands (crypt abscesses). In the revolving phase, the inflammation regresses; the crypts are distorted, the crypt abscesses gradually disappear. In ulcerative colitis in remission, the inflammation vanishes but there is loss of parallelism and branching of the crypts. In Crohn's disease, the inflammation is often discontinuous and focal; biopsies must be taken from multiple sites. It is not rare to see a coincidence of lesions at different stages of activity. The criteria of activity are less reliable than in ulcerative colitis. Acute lesions present with oedema and infiltration of the lamina propria by polymorphs, neutrophils as well as eosinophils. Granulomas probably represent a particular reactional status. There features and number do not very significatively in the course of the disease.

The single-chain form of tissue-type plasminogen activator has catalytic activity: studies with a mutant enzyme that lacks the cleavage site

Tissue-type plasminogen activator (t-PA), the serine protease responsible for catalyzing the production of plasmin from plasminogen at the site of blood clots, is synthesized as a single-chain polypeptide precursor. Proteolytic cleavage at the C-terminal side of Arg275 generates a two-chain form of the enzyme whose subunits are held together by a single disulfide bond. We have measured the activities of both forms of the wild-type enzyme, as well as that of a mutant enzyme (Arg275----Gly), created by oligonucleotide-directed mutagenesis, that cannot be cleaved into a two-chain form. Both types of single-chain t-PAs are enzymatically active and exhibit identical Vmax and Km values when assayed with synthetic peptide substrates, indicating that the single amino acid change had no effect on the amidolytic activity of the enzyme. However, cleavage of wild-type t-PA into the two-chain form results in increased activity both on a peptide substrate and on the natural substrates Lys- and Glu-plasminogen in the absence or presence of stimulation by soluble fibrin. The enhanced activity is due to a 3-5-fold increase in the Vmax of the cleaved enzyme, rather than to any change in the Km values for the various substrates. During incubation with plasminogen, the single-chain form of wild-type t-PA is converted to the two-chain form by plasmin generated during the reaction. This conversion, from the less active form of the enzyme, results in a reaction that displays biphasic kinetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Asymptomatic form of left pulmonary artery sling

Eight patients with left pulmonary artery sling, which were asymptomatic at the time of the last consultation, are described: 2 adults and 1 child with no history of symptoms, 3 children with mild forms of airways obstruction and 2 patients with typical severe symptoms of airways obstruction in infancy. The mean follow-up of these 8 patients was 10 years (range 4 to 23), and in 1986, all were in good health and free of respiratory symptoms. The long-term prognosis is usually good.

Tissue plasminogen activator: from molecular biology to myocardial infarction

The recent development of recombinant tissue plasminogen activator as a therapeutic agent during acute myocardial infarction is one of the most lucid examples of the potential impact of recombinant DNA technology in clinical medicine. This remarkable achievement would not have been possible without several key discoveries in molecular biology and clinical cardiology and exemplifies the synergistic relationship between basic and clinical research. This article chronicles this journey from molecular biology to myocardial infarction.

Functional analysis of the role of the A + T-rich region and upstream flanking sequences in simian virus 40 DNA replication

One boundary of the minimal origin of replication of simian virus 40 DNA lies within the A + T-rich region. Deletion of only a few bases into the adenine-thymine (AT) stretch results in a DNA template which is defective for replication both in vivo and in vitro (B. Stillman, R. D. Gerard, R. A. Guggenheimer, and Y. Gluzman, EMBO J. 4:2933-2939, 1985). In the present study, such deletion mutations have been reconstructed into a simian virus 40 genome containing an intact early promoter-enhancer region. The resulting mutants synthesized wild-type levels of T antigen, but were defective for replication and would not form plaques on CV-1 monkey cells. Replication-competent phenotypic revertants were selected after transfection of large quantities of the replication-defective viral DNAs into CV-1 cells. DNA sequence analysis showed that most of these revertants contained insertions or point mutations which partially regenerate the length of the AT stretch. These genotypic alterations were shown to be responsible for the revertant phenotype by replication analysis in vivo of subcloned revertant origin fragments. In general, our results emphasize the importance of the AT region to simian virus 40 origin function. However, one revertant retained the altered AT region but deleted six nucleotides upstream. Experiments using this mutant indicate that the 21-base-pair repeats identified as part of the early transcriptional promoter may compensate for defects in simian virus 40 DNA replication in vivo caused by mutations in the A + T-rich region when positioned at an appropriate distance from the core origin.

Alternate ventriculo-atrial Wenckebach conduction during ventricular tachycardia

Although pacing-induced ventriculo-atrial (VA) Wenckebach conduction has been previously described, the occurrence of this phenomenon during ventricular tachycardia has received little attention. The latter is defined as 2:1 VA block in which the conducted beats show progressive lengthening of VA conduction until the sequence is terminated by two or three blocked ventricular beats. This phenomenon was observed in a 16-year-old boy who underwent electrophysiologic study for ventricular tachycardia as a late complication of surgical correction of tetralogy of Fallot. During pacing-induced ventricular tachycardia with a morphology similar to that of the spontaneous tachycardia, 8:4 alternating VA block was observed. This sequence suggested that the AV node was the site of block, the 2:1 block being located at the upper level, and the VA Wenckebach block at the lower level. Alternate VA Wenckebach conduction appears as a possible cause of variation in atrial depolarization intervals during ventricular tachycardias with short cycle lengths.

Bepridil for recurrent sustained ventricular tachycardias: assessment using electrophysiologic testing

Bepridil was found to possess electrophysiologic properties common to class I and IV antiarrhythmic agents. Intravenous and oral bepridil were evaluated using serial electrophysiologic studies in a selected group of 9 patients with recurrent sustained ventricular tachycardia (VT) unresponsive to usual therapy, including amiodarone therapy in 15 patients. Intravenous bepridil treatment terminated sustained, well tolerated, pacing-induced VT in 3 of 6 patients and prevented the initiation of VT in 2 of these and in a patient in whom the drug failed to restore sinus rhythm. Oral bepridil was administered at a loading dose of 800 mg on day 1, and 500 to 600 mg the following days, and programmed electrical stimulation was repeated 2 to 6 days after initial study. Oral bepridil therapy prevented VT initiation in 6 patients (66%). The tachycardia cycle length was prolonged (30 to 105 ms) in 2 patients in whom VT remained inducible. In 1 patient the tachycardia cycle length significantly shortened after bepridil and prompt cardioversion was required. Five of the 6 patients with successful results underwent long-term oral treatment with bepridil. VT recurred in 1 patient during the hospitalization period and an adverse effect (paralytic ileus) in another patient required drug discontinuation. Three patients remain symptom-free over a follow-up of 4 to 13 months. These data suggest that bepridil may be useful in patients with recurrent, sustained VT.

Bidirectional tachycardia. Mechanism derived from intracardiac recordings and programmed electrical stimulation

His bundle recordings and programmed electrical stimulation were performed in a 70-year-old woman with bidirectional tachycardia; the recordings demonstrated the infra-Hissian origin of the tachycardia. Occurrence of the His deflection slightly after the onset of ventricular depOlarization suggested that the origin of the tachycardia was located near the His bundle bifurcation. Recording of three atrial sites during tachycardia allowed the study of retrograde atrial activation. Two sets of fairly constant and alternating VA intervals were recorded. This fact is consistent with two ventricular circuits used alternatively. The tachycardia could also be interrupted with a single atrial or ventricular premature beat. It is postulated that the tachycardia is due to macroreentry involving the two fascicles of the left branch. This study suggests that reentry may be a possible mechanism in some cases of bidirectional tachycardia.

Long-term results of permanent atrioventricular sequential demand pacing

Pervenous atrioventricular sequential demand pacemakers (AVSDPs) were implanted in 18 patients using an atrial electrode positioned in the right atrial appendage and a ventricular electrode positioned at the apex of the right ventricle. The indications included 13 patients with the sick sinus syndrome (72%), five of whom had the tachycardia-bradycardia syndrome, three with paroxysmal supraventricular tachycardia, one with cardiomyopathy and one with carotid sinus syncope. The follow-up ranged from 6 to 38 months, with a mean of 19.4 months (a total of 350 pacing months). Seventeen patients (94%) are asymptomatic. One patient had persistent episodes of paroxysmal supraventricular tachycardia. In the remaining patients with tachyarrhythmia, pacing alone (three patients) or in combination with antiarrhythmic drugs (four patients) controlled the tachyarrhythmia. There was one displacement of the atrial electrode (5.5%). Extrusion of the pacer occurred in three patients. It is concluded from this experience that AV sequential pacing is an effective technique and may be useful in patients with sick sinus syndrome, in patients with tachyarrhythmia and/or patients with poor myocardial function. However, continued research is needed to prolong battery life and to reduce the size of the pacemaker.

[Coronary insufficiency in the female: possible effect of menopause]

A population of 239 women suffering from chronic coronary disease was divided into two groups according to whether or not they had sustained a myocardial infarction. For the 226 post-menopausal women, the type of menopause (natural or artificial) and their age at its onset were determined, together with the age of onset of the infarction or angina, and possible correlations with other risk factors in atherosclerosis. Whilst the average age at the time of artificial menopause was markedly less than that of natural menopause, the age of onset of coronary complications was comparable regardless of the type of menopause, this applying to both groups. Contrary to a classically accepted opinion, early menopause would not appear to favourise the premature development of atherosclerotic coronary problems, and, in addition, would not appear to affect other coronary "risk factors".