["Slowing" right bundle-branch block in reciprocating tachycardia from a latent right lateral Kent bundle]

The authors report the case of a 56 year old man with paroxysmal reciprocating tachycardia. The participation of a right lateral Kent bundle, latent in sinus rhythm and with retrograde atrioventricular conduction during tachycardia was proved by : 1) the slowing of the tachycardia rhythm and lengthening of the ventriculo-atrial conduction time by 50 ms during right bundle branch block ; 2) atrial mapping during tachycardia showing right lateral atrial pre excitation ; 3) the spontaneous termination of some attacks after a blocked Hisian depolarisation. Analysis of the mechanisms of spontaneous termination of tachycardia showed a block in the accessory pathway in 80% of cases, leading to the successful use of Amiodarone. The particular electrophysiological mechanism of functional bundle branch block makes it the most reliable positive diagnostic criterion in reciprocating tachycardia. A review of previously reported series shows participation of right lateral and septal accessory pathways to be uncommon during reciprocating tachycardia. Functional bundle branch block does not necessarily lengthen the ventriculo-atrial interval with septal accessory pathways. Left lateral Kent bundles are much more common. These points are analysed together with the mechanism of functional bundle branch block in the discussion.

[Clinical, haemodynamic and biochemical effects of angiotensin-converting enzyme inhibition in chronic refractory cardiac failure (author's transl)]

Twenty patients with chronic congestive heart failure resistant to conventional treatment with digitalis, diuretics and vasodilators received captopril, an oral inhibitor of the angiotensin-converting enzyme, in daily doses of 200 mg and were followed up for 2 months or more. At 2 months, there was a significant reduction in functional symptoms (NYHA classification), bodyweight and left ventricular filling pressure, with an equally significant rise in cardiac output and sodium urinary excretion. There was no fall in systemic blood pressure, nor tachycardia. These effects were sustained in 8 patients followed up for 6 months. They seem to indicate that captopril is both effective and well tolerated in chronic congestive heart failure.

[Surgical revascularization of infarcted myocardial areas. Its effects on left ventricular function]

The results of twelve patients undergoing revascularisation procedures of infarcted myocardial territory alone were analysed quantitatively by planimetry in the right anterior oblique projection. Patients operated in the acute phase of myocardial infarction (2 cases) were distinguished from those with preinfarction syndromes (8 patients) and those with postinfarction angina (2 patients). Two posterior wall and ten anterior wall revascularisations were carried out by single bypass grafts (8) and double bypass grafts (2) with no operative deaths. The results were assessed 2 months to two years after operation (average: 6 months). Twelve of the fourteen bypass grafts were patent. Only one of the twelve operated patients, an anterior wall revascularisation, was considered a complete surgical failure: global left ventricular function and segmental wall movement progressively deteriorated with reduced contractility and velocity of fibre shortening. Improved contraction of both anterior and posterior walls was observed in the other 11 patients. The ejection fraction of the 9 patients with anterior wall revascularisation rose significantly from 47,1 +/- 10,5% to 56,3 +/- 3,5% and a similar rise was observed in systolic index (29,0 +/- 12,0 to 36,8 +/- 11,0 ml/syst./m2); the average akinetic end diastolic perimeter fell by 17%; segmental wall analysis of mean radial shortening and mean amplitude of excursion on the hemiaxes was improved, especially in the antero apical region: the corrected rates of mean excursion and average systolic work indices (33,2 +/- 15 to 41 +/- 13 gm/syst./m2) also increased. Surgical revascularisation of infarcted zones, made possible by new methods of cardioplagia and reliable circulatory assistance, may lead to improvement in global and segmental left ventricular function with minimal risk to the patient: this is thought to be due to an active mechanism and not to the passive process of scarring. Although a reserved attitude should be adopted in the acute phase of myocardial infarction, preinfarction syndromes and unstable postinfarction angina could well benefit from surgical management.

Echocardiographic diagnosis of mobile left ventricular tumour

Echocardiography detected a mobile left ventricular tumour. The tracing showed a cluster of echoes in the left ventricular outflow tract corresponding to the location of the tumour as confirmed by cineangiograms. At operation, a thrombus was discovered, attached to a chorda tendineae.

His bundle block and concealed His bundle premature depolarization

His bundle electrocardiograms were recorded from a patient with previously unexplained PR prolongations or shortenings suggestive of both type I and II second degree AV block. The conduction disturbances were due to the association of concealed His bundle depolarizations (H') not propagated to atria or ventricles with first degree AV block in the His bundle. These data strongly suggest that frequent spontaneous His bundle depolarizations are another manifestation of a disease process involving the His bundle, a kind of "Sick--His bundle syndrome".

[Stenosis of the trunk of the left coronary artery. Contribution of coronary arteriography and hemodynamic correlations. Apropos of 34 cases]

From a study of 34 cases, the authors have tried to define the characteristic features of this very specialised type of coronary artery disease. From the clinical standpoint, if the common combination of uncontrolled angina and a past history of myocardial infarction are taken as representative, the basal ECG can in no way differentiate the diagnosis; on the other hand tests on the bicycle ergometer appear to have a good indicative value. Coronary arteriography shows the sharply isolated character of the stenosis of the trunk which is part of the picture of diffuse coronary disease, and the frequency (2 cases out of 3) of total coronary occlusion. The haemodynamic findings are even more variable and unpredictable, and bear no relationship to the degree of trunk stenosis, to the index of the lesion, and to the number of occlusions. However, joint analysis of the index of the lesion and of the degree to which the coronary circulation is compensated or de-compensated allows a better interpretation of the haemodynamic picture.

[Are stenoses of the common trunk of the left coronary artery at the root of unstable angina?]

In a series of 200 cases of unstable angina who have had coronary arteriography carried out, a stenosis of more than 60% of the trunk of the left coronary artery was noted in 40 cases (20%). This sinister site of arteriosclerosis may be suspected in patients presenting with long-standing angina (mean for the group 44 months), an angina which has recently become worse, one which is not responding rapidly to rest and beta-blockers, and in particular one where there has been a previous infarction (50% of cases). Coronary arteriography shows that the lesions were more diffuse and more severe in the group with stenosis of the main trunk. Surgical prognosis becomes worse (31% mortality) because of the risk of vascular complications. Treatment by large doses of Propranolol improves the classically gloomy prognosis of these patients when treated medically.