Long-term pacemaker dependency after radiofrequency ablation of the atrioventricular junction

This prospective study was conducted to determine the percentage of patients with long-term pacemaker dependency after successful radiofrequency ablation of the atrioventricular junction. Abrupt inhibition of the pacemaker was performed 13.5 +/- 8.1 months after ablation in 59 patients. A > or =5-second asystole was considered to indicate pacemaker dependency. Pacemaker dependency was present in 18 patients. Absence of escape rhythm immediately after ablation was strongly associated with a higher incidence of long-term pacemaker dependency. The following variables were not associated with pacemaker dependency: age, presence of cardiac disease, presence of preablation bundle branch block, number of radiofrequency applications, a bilateral approach for ablation, and continuation of antiarrhythmic therapy after ablation. We concluded that (1) long-term pacemaker dependency is present in 30.5% of the patients after successful atrioventricular junction radiofrequency ablation and (2) absence of escape rhythm immediately after ablation predicts long-term pacemaker dependency.

[Endocoronary ultrasonography and quantitative coronary angiography. Correlations before and after transluminal coronary angioplasty]

A comparative study of the results of quantitative coronary angiography and endocoronary ultrasonography was performed in 37 patients undergoing percutaneous transluminal coronary angioplasty to determine the correlations between the two methods. The analyses were made before and after angioplasty at the site of stenosis and on a reference segment. A complete study before and after angioplasty using both techniques was only possible in 24 cases. The quantitative ultrasonographic analysis consisted of measurement of two orthogonal diameters, total surface area of the vessel, the endoluminal surface area and surface area of plaque. Transluminal coronary angioplasty acts mainly by forcing the plaque outwards. Ultrasonography showed a decrease in plaque area, from 10.5 +/- 6 mm2 to 9.8 +/- 5.5 mm2 and the total surface area of the vessel increased from 12.8 +/- 0.7 to 15.3 +/- 6.9 mm2 (p < 0.05). This accounted for the gain in main surface area of the stenosed lumen, from 2.28 +/- 1.28 to 5.9 +/- 2.65 mm2 (p < 0.001). The correlations between quantitative coronary angiography and ultrasonography at the site of stenosis were only significant after angioplasty both the vessel diameter (r = 0.67; p < 0.0002) and endoluminal surface area (r = 0.63; p < 0.0001). A correlation was not observed before angioplasty because of the complexity of the plaque and its excentric location. At the reference site, the correlations between ultrasonography and angiography before and after angioplasty were significant but not very close (Spearman coefficient 0.53 and 0.82 respectively, p < 0.001). Therefore, correlations between quantitative data obtained by coronary angiography and ultrasonography are modest in patients undergoing transluminal coronary angioplasty. The ultrasonographic information is more qualitative, enabling a better understanding of the mechanism of the therapeutic procedure and allowing optimal choice of the appropriate tool.

[Angiographic course over 10 years of giant aneurysm of the circumflex artery]

Pathological dilatations of the coronary arteries are not exceptional and are called megadolichoartery, aneurysm or ectasia. Cases of marked arterial dilatation, although much rarer, are regularly reported following their discovery due to the impressive angiographic, echocardiographic or autopsy findings. However, their course, particularly in the long term, remains unclear. The authors report the case of a patient with a very large spindle-shaped aneurysm of the circumflex artery whose course was able to be followed over a period of ten years on three successive angiographic assessments performed for clinical coronary events. This follow-up was dominated by thrombosis of the aneurysm, extension of the aneurysmal disease and severe deterioration of left ventricular function.

[Torsades de pointe with spiramycine and metiquazine therapy. Apropos of a case]

The authors report the case of a 21 year old woman with a congenital long Q7 syndrome who had several syncopal attacks at least one of which was caused by torsades de pointe. This sudden complication was attributed to the simultaneous prescription of Spiramycine and Mequitazine over a 48 hour period. These two drugs are not considered to be predisposing factors for torsades de pointe despite the fact that they belong to two families of drugs which can trigger this type of arrhythmia. The withdrawal of this treatment led to the complete regression of the syncopal episodes with a follow-up of two years and a significant shortening of the initial QTc interval which remained, nevertheless, longer than normal. This case underlines the potential risks of drug associations of these two families of drugs, especially in patients with the congenital long Qt syndrome.

New insights into the pathophysiology of carotid sinus syndrome

BACKGROUND

The pathophysiology of carotid sinus syndrome remains poorly understood. Currently, two main hypotheses are provided: a lesion at the level of carotid sinus receptors or a central defect at the level of the nuclei of the autonomic nervous system. The objective of our study was to present arguments in favor of one of these two hypotheses.

METHODS AND RESULTS

Test selection was guided by the following hypothesis: a degenerative central or local lesion could be associated with dysfunctions in the structures surrounding or comprising the baroreflex centers or their pathways. To test this hypothesis, brain stem auditory-evoked potentials; somatosensory-evoked potentials; blink reflexes; sympathetic skin responses; and styloglossus, sternocleidomastoid, and superior trapezius muscle electromyography were systematically performed from the right and left sides in 17 patients with carotid sinus syndrome and in 17 sex- and age-matched control subjects. Similar responses were found in the two groups for the "central" tests. Contrasting with this result, the electromyographic analysis of the sternocleidomastoid muscle differed significantly between the groups: 13 (76%) had pathological responses in the carotid sinus syndrome group compared with only 4 (23.5%) in the control group (P < .01). Furthermore, the abnormality was found on the right and left sides in 9 patients (53%) in the study group and in none of the control group (P < .005).

CONCLUSIONS

This study strongly suggests that the neuromuscular structures surrounding the carotid mechanoreceptors are involved in the carotid sinus syndrome; however, the exact mechanism remains speculative.

[Mid-term outcome of escape rhythm after radiofrequency ablation of the atrioventricular junction]

Mid-term outcome of the underlying escape rhythm developed after radiofrequency ablation of the atrio-ventricular junction was studied in 50 consecutive patients (28 women and 22 men with a mean age of 66.2 +/- 9.6 years). The escape rhythm was assessed immediately after ablation and after 13.7 +/- 8 months. At the end of ablation: an escape rhythm was present in 38 patients (76%), with a mean rate of 40.7 +/- 9.7 beats/min and a QRS morphology identical to the preablation QRS morphology in 22 patients (58%). At follow-up: an escape rhythm was present in 37 patients (74%), with a slower mean rate of 36.4 +/- 6.8 beats/min (p < 0.05) and an unchanged QRS morphology in 87.5% of the patients. Patients presenting with an escape rhythm at follow-up were more frequently found to have a postablation escape rhythm (p < 0.01). Escape rhythm presence at follow-up was not influenced by age, presence of a cardiac disease, continuation of an antiarrhythmic treatment after ablation, use of a bilateral approach for ablation or number of radiofrequency applications.

CONCLUSION

after abrupt inhibition of the stimulation, an escape rhythm was present only in 74% of the patients 13.7 +/- 8 months after atrio-ventricular junction radiofrequency ablation. QRS morphology was identical to the preablation morphology in 57% of the patients.

[Mortality and morbidity in the acute phase of myocardial infarction. Comparison of 3 patient cohorts admitted to hospital over 10 years]

The management of acute myocardial infarction has been transformed over the last thirty years by a number of therapeutic innovations. The authors decide to compare the outcomes of three cohorts of unselected patients admitted to hospital at 10 year intervals, to evaluate the impact of these innovations on morbidity and mortality. Six hundred and sixty one patient admitted to the Coronary Care Unit for acute myocardial infarction were included: Group I comprised 223 patients admitted consecutively during the period 1972-1973; Group II comprised 243 patients admitted between 1982-1983 and Group III comprised 195 patients admitted between 1992-1993. The average age was comparable, about 65 years, in the 3 groups, although there were gender differences. Taking into consideration earlier hospital admission, the in-hospital mortality decreased from 25% in Group I to 21.8% in Group II and to 15.4% in Group III (p < 0.05 between the first 2 groups and the third group). This decrease in mortality is even greater in anterior wall infarction and is observed in all ages. Similarly to selected patients in large scale randomised clinical trials, the ordinary "run of the mill" patient has also benefited from therapeutic innovations over the last ten years.

[Contribution of doppler echocardiography to the diagnosis of the first attack of acute rheumatic fever]

Since 1944, the Jones criteria for the diagnosis of acute rheumatic fever have been regularly revised to integrate technical and diagnostic innovations. Echographic and Doppler criteria, however, remain unrecognised due to valvular insufficiency in healthy subjects. The aim of this study was to determine the cardiac lesions occurring in acute rheumatic fever and the diagnostic value of Doppler echocardiography. One hundred patients with an average age of 10 years were admitted to hospital because of a first attack of acute rheumatic fever between January 1991 and September 1992. Eighty-six had articular signs, 5 had chorea, but none had cutaneous lesions. Forty-seven murmurs of mitral insufficiency (MI) and eight of aortic insufficiency (AI) were detected; 10 children had signs of cardiac failure. Conduction defects were recorded in 12 cases. Echocardiography showed 7 pericardial effusions; often, the left heart chambers were dilated without alteration of the fractional shortening. The commonest lesions of the mitral valve were thickening of the two leaflets, the reduced mobility of the posterior leaflet, the rigidity of the anterior leaflet and 2 cases of ruptured chordae tendinae. The Doppler mode showed 73 cases of MI, 26 of which were at least moderately severe. These cases of MI were commonly excentric jets behind the posterior leaflet. There were 47 cases of AI, 10 of which were at least moderately severe. If all cases of moderately severe or mild AI and MI are considered as pathological when associated with suggestive morphological valve changes, the number of cases of carditis increased from 50 without the Doppler mode to over 80 with this mode. Doppler echocardiography validated the Jones criteria in 16 children. The authors propose Doppler echocardiography criteria for the validation of carditis.

Frequency of obstructive sleep apnoea syndrome detected by means of a questionnaire in patients with coronary heart disease

As previous studies have suggested an association between obstructive sleep apnea syndrome (OSA) and ischaemic heart disease, the aim of the present study was to evaluate the frequency of clinically relevant OSA in this selected population. From September 1992 to April 1993, 136 patients referred to the Cardiology Unit for suspected angina pectoris were asked to participate in the study. The main inclusion criterion was a stable coronary heart disease, diagnosed by angiography. A sleep questionnaire was administered by a trained physician. Patients who experienced one of the following symptoms: association of body mass index (-weight/height2) above 27.5 and heavy snoring, breathing stops, or daytime hypersomnolence, were selected for a nocturnal oxygen saturation recording. The occurrence of at least one desaturation, defined as a 4% fall from baseline, led to a full night-time polysomnography. One hundred and eight patients (78 males), satisfied the entry criteria. A pulse oximetry was performed in 15, and three patients experienced a significant desaturation. Finally, one patient satisfied the criteria of OSA. The estimated proportion of OSA amounted to 0.92%, in accordance with the prevalence of OSA described in the general population. Clinically relevant OSA does not appear to be more frequent in patients suffering from stable coronary heart disease. Systematic sleep investigations in such patients do not appear to be useful in daily clinical practice.

Carotid sinus syndrome: acute hemodynamic evaluation of a dual chamber pacing mode

Cardiac pacing is the treatment of choice in patients with carotid sinus syndrome (CSS). Three different pacing modes were tested in 20 patients (16 males, 4 females; mean age 75 +/- 9 years) with documented symptomatic CSS. Three carotid sinus massages (CSM) were performed in each supine patient successively paced in random order in: DDI--the reference pacing mode; DDD--automatic mode conversion (DDD/AMC) allowing automatic switching from AAI to DDD when AV block occurs; DDD/AMC plus atrial acceleration (DDD/AMC+acc); and OOO (CSM without pacing) to determine whether the vasodepressive effect was still present 10 minutes after the preceding CSM. Intraarterial blood pressure was continuously monitored. Results were expressed as the value of the mean systolic BP at T0 + 3 s + 6 s ... T0 + 30 s divided by the value of the mean systolic blood pressure prior to onset of CSM. The drop in arterial blood pressure was more severe in the DDI mode than in DDD/AMC (P < 0.001) and DDD/AMC+acc (P < 0.0001) in 20 patients. In the OOO mode, the drop in arterial blood pressure was most marked and greater than in the DDI mode (P < 0.0001). The average time between start of the CSM and onset of the drop in blood pressure was the same in the three dual chamber modes. We conclude that the DDD/AMC mode significantly improves the vasodepressor response to CSM compared to the DDI mode. There is a current trend favoring DDD/AMC+acc over DDD/AMC.

Efficacy and safety of d-sotalol, a pure class III antiarrhythmic compound, in patients with symptomatic complex ventricular ectopy. Results of a multicenter, randomized, double-blind, placebo-controlled dose-finding study. The d-Sotalol PVC Study Group

BACKGROUND

There is increasing interest in pure class III antiarrhythmic compounds, ie, drugs in which the electrophysiological effect is confined to the propensity for producing an isolated lengthening of action potential duration. d-Sotalol represents the prototype of such pure class III agents. This double-blind, placebo-controlled, randomized dose-finding study evaluated the antiarrhythmic efficacy and safety of d-sotalol in patients with symptomatic chronic ventricular ectopy.

METHODS AND RESULTS

A total of 233 patients presenting with > or = 30 premature ventricular contractions (PVCs) per hour during drug-free Holter monitoring randomly received placebo or d-sotalol at dosages of 50, 100, or 200 mg BID. Drug efficacy was assessed by repeat Holter monitoring at the end of double-blind therapy. There was a dose-dependent increase in QT and QTc duration, indicating class III activity. A dose-related decrease in hourly PVC counts was observed, reaching statistical significance for patients receiving 200 mg d-sotalol BID (311 PVCs/h during baseline compared with 135 PVCs/h during active treatment, P < .05). Analysis of the primary efficacy criterion (ie, > or = 75% reduction in total PVCs/h) revealed a significant treatment effect only for the highest d-sotalol dose, with 8 patients (14%) meeting this criterion. Eighteen patients reported side effects, which led to drug discontinuation in 5. One sudden death and one nonfatal cardiac arrest occurred in patients with dilative cardiomyopathy receiving 200 mg d-sotalol BID. No incidence of torsade de pointes was reported.

CONCLUSIONS

d-Sotalol exerts dose-dependent class III activity in patients with symptomatic ventricular ectopy. Its PVC-suppressing activity is modest and becomes evident predominantly at dosages of 200 mg administered BID. The observation of drug-associated serious adverse arrhythmic events emphasizes the need for individualized careful dose titration, particularly in patients with advanced organic heart disease.

[Patency of left border artery bypass after 1 year; comparison of three techniques]

The one year results of three techniques of bypass grafting of the artery of the left border of the heart were compared in a retrospective study in 120 patients all undergoing left anterior descending bypass grafting with an internal mammary artery. Group I comprised 38 consecutive patients: the left border artery was bypassed with a venous graft. Group II comprised 49 consecutive patients who had the left border artery bypassed by an internal mammary artery in situ. Group III comprised 33 consecutive patients who had the left border artery bypassed by an internal mammary graft issuing from a Y-shaped construction (right internal mammary artery as a free graft reimplanted into the left internal mammary artery). The operative mortality, morbidity and functional results were comparable in the three groups. The rate of angiographic success of the left border artery graft at one year was: 65.7% in group I, 89.5% in group II and 87.8% in group III. The one year patency of internal mammary artery grafting of the artery of the left border was higher than that of venous grafts (p < 0.05).

[Can atrial fibrillation be managed without anti-arrhythmia drugs?]

Antiarrhythmic drugs are widely used in atrial fibrillation. The demonstration of severe pro-arrhythmic effects in recent years has led to the reappraisal of their indications in this pathology. Antiarrhythmic agents have three roles: reduction of the fibrillation, maintenance of sinus rhythm and, in case of failure, control of the ventricular response. In the first indication, although intravenous injection of Class Ic antiarrhythmics is effective in 70% of cases, there is an alternative: electrical cardioversion, which is effective in 90% of cases with the transthoracic method when a certain number of technical conditions are respected. The success rate is even better with endocavitary defibrillation. Sinus rhythm is sustained in only 25% of patients at one year with placebo and in 50% of patients with antiarrhythmic therapy. The alternatives in this indication are few at present and consist in right atrial pacing in cases of vagal fibrillation and biatrial pacing for resynchronizing the activation of the two atriae when there is a major interatrial conduction defect. The control of the ventricular response, in cases of permanent atrial fibrillation, is usually reserved to digitalis, betablockers, amiodarone and some calcium antagonists. They are often inadequate and an alternative is radiofrequency catheter ablation of the atrioventricular node, which requires permanent ventricular pacing. In conclusion, there are a few alternatives to antiarrhythmic drug therapy in atrial fibrillation, but they are relatively ineffective in maintaining sinus rhythm.

[Permanent cardiac stimulation after aortic valve replacement: incidence, predictive factors and long-term prognosis]

Between January 1981 and June 1992, 382 patients, operated by the same surgical team, underwent aortic valve replacement for pure severe aortic stenosis. This population was divided into 2 groups according to whether or not surgery was complicated by the development of a conduction defect (atrioventricular and/or intraventricular block), necessitating permanent cardiac pacing. The aim of this study was to analyse not only the incidence and predictive factors but also the long-term prognosis of the paced patients (Group II: 22 patients) in comparison with the control group (Group I: 360 patients). The results showed: the incidence of permanent cardiac pacing after this type of surgery remains low (5.7%); the predictive factors of atrioventricular block requiring permanent pacing were: pre-existing conduction defect (p < 0.02), decreased ejection fraction (p < 0.05), calcification extending to the subaortic interventricular septum (p < 0.0001); the long-term prognosis of the patients was good with 5 and 10 year actuarial survival rates of 95.4% and 68.9% respectively, identical to those of the control group.

[Vasovagal syncope, from diagnosis to treatment]

The concept of vasovagal syncope has changed over the last 10 years. The clinical presentation has changed since the observation of syncopes of vasovagal origin resembling the sudden syncope of the Stokes-Adams syndrome. The physiopathology has been considerably improved but none of the hypotheses proposed is universally accepted. The results of research already performed and of that underway, prompted by these hypotheses, will be determinant for the elucidation of the relations of the cardiovascular and autonomic nervous systems. This revolution is largely due to the introduction of the tilt test in the 1980s as a clinical means of investigation of the autonomic nervous system. Its protocol and results remain to be confirmed but it has already become a reference examination with the same value as Holter monitoring and electrophysiological studies in the evaluation of unexplained syncope after classical investigations. Therapy has improved after these diagnostic improvements and recent physiopathological hypotheses; their number and absence of strictly performed controlled studies are only reflections of this rapidly evolving subject. Only time and randomised trials, with double-blind protocols when possible, will enable effective treatment and a greater precision in the clinical indications.

[Spontaneous and isolated dissection of the coronary arteries, apropos of 8 cases with favourable outcome]

Spontaneous coronary artery dissection is rare compared with the high incidence of atheromatous coronary artery disease. Eight new clinical and angiographic cases diagnosed between 1984 and 1990 are reported. The patients were 6 men and 2 women with an average age of 44.1 +/- 10.7 years. The initial presentation is angina in half the cases, and myocardial infarction in the other half. Clinical signs and the results of non-invasive investigations are non-specific. Diagnosis is made by coronary angiography. The dissection is usually observed on a proximal segment of one of the main coronary arteries. In 5 cases, the disease was confined to a single vessel left anterior descending (3) and right coronary arteries (2). One patient had double vessel disease (left anterior descending and left retroventricular arteries); one patient had triple vessel disease (left anterior descending left circumflex and right coronary arteries), and finally, one patient had left main stem disease extending to the left anterior descending and first diagonal arteries. There was no aetiological factor in 5 cases whereas 3 had coronary atherosclerosis. After a period of 25 months all patients are alive. Five have drug therapy and 3 have undergone coronary bypass surgery. Six patients are asymptomatic and 2 have mild angina. One patient's coronary circulation has returned to normal. The extension of the indication of coronary angiography explains the diagnosis of an increasing number of spontaneous coronary artery dissection. The condition is serious but there are more and more long-term survivors as in our series.

[Dilated cardiomyopathies in severe cardiac failure in chronic alcoholics: clinical course after complete withdrawal]

We have prospectively evaluated 6 patients admitted for a severe heart failure in alcoholic patients with dilated cardiomyopathy. We concluded that complete abstinence results in a short-term clinical improvement, associated to a significant increase in left ejection fraction.

[Rupture and extravascular migration of a vena cava filter. Apropos of a case]

The authors report the case of a 68 year old woman who underwent implantation of a Greenfield vena caval filter for recurrent pulmonary embolism. Migration of the filter out of the vena cava into the perivenal fat was discovered two years later during another embolic episode. One of the spokes of the filter had migrated into the iliac fossa. This case illustrates two possible complications of caval filters: rupture and migration. The increasing number of cases reported in the literature indicates the necessity of keeping a register of the complications encountered with different models to avoid the most dangerous ones.

[Patency of the artery responsible for myocardial infarction: role on ventricular function and long-term outcome]

Out of 3,171 consecutive patients referred for coronary angiography, 240 were selected on the following criteria: recent primary myocardial infarction, single vessel coronary disease, no angioplasty or coronary surgery after the angiography which was performed 20 to 90 days after the onset of myocardial infarction. The patients were divided into 2 groups according to whether the artery responsible for infarction was patent (Group I: 115 patients) or not (Group II: 125 patients). The left ventricular ejection fraction was significantly higher in Group I (58 +/- 10.8%) than in Group II (53.7 +/- 11.3%) and end systolic and end diastolic left ventricular volumes were greater in Group II (51.8 +/- 22 ml/m2 and 88 +/- 22 ml/m2 respectively). Long-term follow-up (56 +/- 25 months in Group I and 61 +/- 26 months in Group II) was possible in 112 patients in Group I and 123 patients in Group II. Of the 7 patients who died in group II, 4 deaths were of cardiac origin; in addition, 2 cases of sustained ventricular tachycardia were observed in this group. None of the 6 deaths observed in Group I was of cardiac origin and there were no cases of ventricular tachycardia (p = 0.05). The functional status was identical in the two groups at the end of the study. These results suggest that the patency of the coronary artery responsible for myocardial infarction at a distance from the acute event is associated with better left ventricular function and a better long term prognosis.

Atrial natriuretic factor release during exercise in patients successively paced in DDD and rate matched ventricular pacing

Dual chamber pacemakers were implanted in nine patients with permanent second or third degree AV block (eight had complete retrograde block). Two identical exercise tests were performed after at least 1 month after implantation. During the first test (T1) the pacemaker was programmed to the DDD mode and heart rates were recorded every 15 to 30 seconds during exercise and 30 minutes after exercise. Following 30 minutes of rest, the implanted pacemaker was programmed to the VVT mode and driven by an external pacemaker via a skin electrode. The second exercise test (T2) was then performed and the rate of the external pacemaker was progressively changed to reproduce exactly the rate observed during T1 at the same exercise stress. Atrial natriuretic factor (ANF) levels were determined at rest, at regular intervals during exercise, and 30 minutes after exercise. ANF levels and release were statistically higher during rate matched ventricular, than DDD pacing. It is concluded that preservation of AV synchrony reduces ANF release induced by heart rate acceleration during exercise.

[Carotid sinus hypersensitivity associated with a treated otorhinolaryngologic cancer. Study of 103 patients]

The incidence and characteristics of carotid sinus hypersensitivity were investigated in a homogeneous population of patients undergoing radiotherapy and surgery for ear, nose and throat (E.N.T.) cancers. Among the 103 patients who were thus treated but had none of the risk factors usually correlated with the disease investigated, 30 percent showed evidence of mainly vasodepressive (87 percent) carotid hypersensitivity when subjected to carotid sinus massage accompanied by electrocardiography and intra-arterial blood pressure measurement. The large number of positive responses, as well as the good reproductibility of this provocation test and its concordance with the site of local treatment suggest that surgery contributes to the genesis of the abnormality. Owing to the considerable variations in the type of response obtained, carotid sinus hypersensitivity should systematically and repeatedly be searched for in cases of syncope in patients treated for E.N.T. cancer.

[Evaluation of beta-adrenergic blockader therapy in vasovagal syncope reproduced by head-up tilt test]

Increased sympathetic tone is one physiopathological mechanism of vasovagal syncope. In this case, betablocker therapy is logical. The reports in the literature suggest that the head-up tilt test can reliably reproduce vasovagal syncope. Ten patients (4 men and 6 women, mean age 59 +/- 18 years) who suffered from recurrent vasovagal syncopes (2 to 10 attacks in 6 patients and more than 10 in the other 4) with a positive initial head-up tilt test (syncope or severe dizziness with marked hypotension after a maximum of 40 minutes at 60 degrees) were treated with atenolol (200 mg daily in 7 cases and 100 mg daily in the other 3). A second head-up tilt test was performed 15 +/- 6 days later under betablocker therapy; this test was negative in 7 and remained positive in 3 cases. Irrespective of the result, the 10 patients followed the same therapy at the same dosage. After 9 +/- 5 months, 3 patients had another syncopal attack; 2 stopped taking their medication and the third patient continued the betablocker because there was a marked reduction in the frequency of his attacks. There were no further syncopal episodes during follow-up of the other 7 patients. The medium-term efficacy could not be predicted from the results of the second head-up tilt test. The following conclusions may be drawn from this study: The head-up tilt test becomes negative in 70% of cases after introducing betablocker therapy, assuming a 100% reproductivity. This treatment is effective in over half the patients at medium term and should be considered in patients with recurrent vasovagal syncope.

[Sequential revascularization of anterior myocardium using the internal mammary artery. A year-long clinical and angiographic follow-up]

One hundred and twenty-one consecutive patients (104 men, 17 women; mean age 56 +/- 7.8 years) underwent sequential mammary artery grafting for anterior (left anterior descending or diagonal arteries) wall revascularisation. There was one death (0.8%) and five myocardial infarctions (4.2%) including two anterior infarcts during the first 30 postoperative days. All survivors were reviewed at one year. Of these 120 patients, 77 (64%) accepted control coronary angiography on average 456 +/- 143 days after surgery. One internal mammary artery anastomosed to 2 diagonal arteries was occluded. All the other latero-lateral anastomoses were patent. There was, however, one 60% stenosis. Three termino-lateral anastomoses on the left anterior descending artery were occluded and 2 others stenosed (40% and 60% luminal narrowing, respectively). Four internal mammary arteries were narrowed 2 because of stenosis and 2 because of the small calibre of the receiving artery. The patency rate considering the total number of anastomoses was therefore 96.8%. These results show that sequential internal mammary artery grafting for myocardial revascularisation does not increase the number of perioperative complications and is associated with a low rate of occlusion on the left anterior descending artery at one year. This surgical technique may therefore be used routinely.