[Obstructive cardiomyopathy and stenosing coronary atherosclerosis. Apropos of 5 cases]

Five cases of hypertrophic obstructive cardiomyopathy with coronary artery disease are reported; 2 males and 5 females, aged 27, 49, 64, 67, and 70 years respectively. Four patients had angina, the other being asymptomatic. The diagnosis of hypertrophic obstructive cardiomyopathy was based on the presence of at least 4 of the following 5 signs: an ejectional systolic murmur, an external carotid pulse tracing showing a second endsystolic peak, an echocardiogramme showing both systolic anterior motion of the mitral valve and asymmetrical septal hypertrophy biloculation and/or disaxation of the left ventricular cavity on selective angiography, and a spontaneous or provoked intraventricular pressure gradient of over 30 mm Hg. Coronary angiography showed one or more stenoses of over 70% on at least one of the three main coronary arteries in all patients. Two of the 5 patients underwent coronary artery bypass surgery without myomectomy; the remaining 3 patients were treated medically. All patients have been followed up for periods ranging from 8 months to 6 years (average: 4 years) with a favourable outcome in 4 of them who are currently asymptomatic; the other patient has moderate angina (non-operated, treated with propranolol). The frequency of the association of hypertrophic obstructive cardiomyopathy and coronary artery disease was initially underestimated, but in fact it does not appear to be uncommon. The association would seem to be fortuitous. The long-term prognosis is not known and the management is not codified. It would seem logical to propose simultaneous surgical correction of the two conditions by myomectomy and coronary bypass surgery when anatomically possible, when beta blocker therapy fails, despite a relatively high operative risk, according to the few published cases.

[Starr-Edwards mitral valve prosthesis and secondary clinical deterioration. Hemodynamic study in 14 patients]

The haemodynamic and angiocardiographic data of 19 patients with Starr-Edwards mitral valve prosthesis were analysed to determine the causes of secondary deterioration observed in 14 of them. This was shown to be due to: 1. Surgical complications or progression of pre-existing valvular lesions which were not, or only partially, corrected (3 cases) (adiastole due to pericardial effusion, aortic valve disease and severe tricuspid incompetence); average diastolic pressure gradient CPW-LV 4.7 +/- 1.5 mmHG, the functional valve surface area (FVA) 1.37 +/- 0.2 cm2, LVEDP 17.7 +/- 4 mmHg, LVEDV 57.5 +/- 11 ml/m2, and EF 73.5 +/- 8 p. 100; 2. Deterioration of left ventricular contractility with LVEDP greater than 13 mmHg, LVEDV greater than 100 ml/m2 and EF less than 45 p. 100 (4 cases); CPW-LV gradient 9.8 +/- 4 mmHG, FVSA 1.30 +/- 0.2 cm2, LVEDP 20.5 +/- 8 mmHG, LVEDV 212 +/- 168 ml and EF 38 +/- 21 p. 100; 3. Significant reduction of left ventricular volume (LVEDV 22 ml/m2 1 case); 4. Left atrial thrombosis (1 case); 5. Prosthetic valve dysfunction (5 cases) one paravalvular leak and 4 thromboses. In these 4 cases, the PCW-LV gradient was 15 +/- 5 mmHg, FVSA 0.95 +/- 0.1 cm2 LVEDP 8 +/- 2 mmHg, LVEDV 132.8 +/- 93 ml/m2 and EF 45 +/- 28 p. 100; these results were different to whose found in the other patients and those investigated systematically (PCW-LV gradient 8.2 +/- 3 mmHg, FVSA 1.38 +/- 0.3 cm2, LVEDP 11 +/- 4 mmHg, LVEDV 66.4 +/- 33 ml/m2, EF 53 +/- 13 p. 100). The significant haemodynamic criteria in favour of thrombosis of the prosthesis were: CPW-LV gradient greater than 12 mmHg under basal conditions or after exercise and a FVSA less than 1.1 cm2.

Anthropometric measurements in patients with growth hormone deficiency before treatment with human growth hormone

In 74 children (52 males, 22 females) with growth hormone (GH) deficiency (30 cases with isolated GH-deficiency, two of them familial; 4 familial and one isolated case with tendency for formation of antibodies against hGH; 29 with other pituitary hormone defects; 10 craniopharyngiomas), various anthropometric measurements were analyzed before treatment with hGH. In all groups, standing height, sitting height, and subischial leg height were equally retarded, and bihumeral width was more retarded than biiliac width; the head was relatively large; fat tissue was increased with subscapular skinfolds being greater than triceps skinfolds, indicating relative obestiy of the trunk; muscle and/or bone mass was reduced. In isolated GH-deficiency, head shape was slightly scaphoid; in combined defects, it was round, and in craniopharyngioma cases, it was brachycephalic. It is concluded that antrhopometric measurements may help in differentiating the type of GH-deficiency.

[Study of the effects on coronary circulation and myocardial metabolism of a single intravenous dose of dihydralazine in 10 cases of primary myocardiopathy]

The effects of a single intravenous injection of dihydralazine (0.1 mg/kg) on coronary blood flow and myocardial metabolism were studied in 10 patients with primary congestive cardiomyopathy. Cardiac output and coronary blood flow increased significantly (p < 0,001 and p < 0,05); myocardial oxygen consumption, cardiac work and the coronary arteriovenous difference in lactates did not change significantly. However, the effects of dihydralazine are variable; coronary blood flow decreased in 2 patients; myocardial oxygen consumption increased in 3 patients; the coronary arteriovenous difference of lactate concentration fell or inversed in 5 patients. This data suggests that dihydralazine may have an undesirable effect on myocardial metabolism in some cases of congestive cardiomyopathy. Further long term studies are indicated to define the role of this drug in cardiac therapeutics.

[Hemodynamic and angiographic aspects of endomyocardial fibrosis. Apropos of 19 cases]

19 cases of endomyocardial fibrosis were studied. Angiocardiography localises the site of fibrosis and seems to be the best diagnostic method. All cases in this series had left ventricular involvement which resulted in changes of the silhouette (square, polylobulated or deformed like the shape of a heart on a playing card) and of the ventricular contour (smooth, lacunar or "doubled"). Ten patients had mitral incompetence. The ejection fraction was normal in 8 patients but significantly reduced in the series as a whole (EF = 0,56, p less than 0,05). 15 patients had right ventricular involvement. Apart from the smooth contour of the anterior wall, the only abnormality in the mild cases, the most suggestive feature was an amputation of the ventricular apex, giving rise to a ventricular appearance of a narrow, akinetic (apart from the infundibular region) tube. The catheter data demonstrated the haemodynamic changes due to the fibrosis. A constrictive syndrome was observed in all the severe poorly tolerated cases. This was not apparent under basal conditions in milder cases. The value of pharmacodynamic testing and endomyocardial biopsy in cases where the diagnosis is uncertain should be stressed. The results of resection of the fibrosis and valvular replacement in severe cases depend to a large extent on the degree of myocardial involvement.

[Effects of intravenous trinitrin infusion on systemic and coronary circulations during atrial electric stimulation]

Intravenous infusion of trinitrin (0.38 +/- 0.25 mg/hour) during rapid atrial pacing reduced pulmonary capillary pressures, cardiac output, coronary blood flow and myocardial oxygen consumption. At these dosages trinitrin allows patients with ischaemic heart disease to undergo atrial pacing in the best conditions by maintaining the pulmonary capillary and systemic arterial pressures and myocardial lactate production within limits close to the basal values. The beneficial effects last during the recovery period after the termination of pacing and of the intravenous infusion.

[Late thrombosis of mitral valve prosthesis in 27 cases]

Twenty seven cases of late thrombosis of ball and floating or tilting disc prostheses were studied. All patients were on anticoagulant therapy which appeared to be well adapted in 33% patients. Signs suggestive of thrombosis were inconsistant and the diagnosis was made on the association of severl of the following features: -- systemic embolism (44%); -- radiographic signs of left ventricular failure (51%); -- absence of opening click, variable A2 -- opening click intervals, apparition or aggravation of a systolic regurgitant murmur or a distolic murmur suggestive of obstruction on the phonocardiogramme; -- delayed opening of the mobile component or the presence of abnormal echos between the ball and anterior cage echo on the echocardiogramme; -- a gradient of over 12 mmHg across the prosthesis. An isolated episode of systemic embolism when the rest of the work-up is negative may be managed by the addition of a platelet antiaggregant and reinforcement of the anticoagulant therapy; further investigaton is advisable in the face of progressive symptoms. Fibrinolytic treatment and/or surgery is justified when systemic emboli recur or if the work-up is positive.

[Hemodynamic effects of hydralazine in the cardiac insufficiency of non-obstructive myocardiopathy]

The haemodynamic effects of a single dose of between 0.15 and 0.25 mg/kg hydralazine were studied during cardiac catheterisation of 9 patients with primary congestive cardiomyopathy and heart failure. The systemic arterial resistances decreased (--1 370 +/- 400 dynes/s.cm-5/m2, p less than 0.05); the reduction of pulmonary arterial resistances was less marked (--420 +/- 400 dynes/s.cm-5/m2, p less than 0.05). Intraaortic pressure was reduced (--16 +/- 12 mmHg, p less than 0.02) as was average pulmonary arterial (--4.2 +/- 4,2 mmHg, p less than 0.05) and left ventricular end diastolic pressures (--4.2 +/- 3.0 mmHg, p less than 0,02). Systolic index increased in all cases (+13 +/- 5 ml/syst/m2, p less than 0.001). Heart rate was unchanged. This was due to the improvement of left ventricular function by the reduced impedence. These results confirm the place of hydralazine in the treatment of certain forms of heart failure.

[Study of hemodynamic effects of the methoxamine in 8 cases of obstructive cardiomyopathy with mitral valve insufficiency]

The haemodynamic effects of intravenous Methoxamine were studied in 8 patients with hypertrophic obstructive cardiomyopathy (HOCM) with mitral incompetence (group I) and 8 patients with mitral incompetence due to valvular, subvalvular or other causes (group II). In both groups the left ventricular end-diastolic pressure rose significantly without any great change in the end diastolic surface area: the ventricular distensibility is reduced in both cases. The mean capillary pressure, the V wave/mean capillary pressure ratio, and the degree of regurgitation of the two groups changed in opposite ways : in mitral incompetence due to varying causes (group II) the regurgitation increased, but in mitral incompetence due to HOCM (group I), it decreased. The left ventricular intracavitary gradient in HOCM tended to disappear under the effect of Methoxamine as the systolic aortic pressure approached the basal values recorded in the apical area.

[Action of a sodium lactate perfusion on the hemodynamic effects of beta-blockaders]

In 15 dogs who had been given propranolol and 5 humans who had been given Pindolol, an infusion of sodium lactate produced: 1) an increased in blood lactate levels and pH; 2) an increase in the cardiac index; 3) a state in which an infusion of isoproterenol (inactive on its own) could act as it would have done had the betaadrenergic receptors not been blocked. A perfusion of lactic acid which was sufficient to cause the variations in pH and blood lactate levels that are seen with exercise had no action on the heart rate nor on the cardiac index of 10 dogs treated with propranolol and could not re-establish the betastimulating properties of isoproterenol. Finally, alkalosis produced by an infusion of THAM in 13 dogs or sodium bicarbonate in 2 humans, changed neither the cardiac index nor the heart rate, nor the response to isoproterenol after a betaadrenergic blockade. Infusion of sodium lactate associated with isoproterenol could be used to combat the depressent effects of betablockers in patients with cardiac disorders.

[Long-term results of aortocoronary bypass. 2 Angiographic aspects]

Follow-up arteriograms carried out between one and six years (mean follow-up period two years) in 80 cases of aorto-coronary bypass graft procedures showed a good correlation between the quality of the clinical results obtained -- as detailed in the first part of this article -- and a larger proportion of patent grafts: 82% of 130 grafts had remained patent, and 94% of patients have all or some of their grafts patent. Late occlusion of the grafts is rare, and does not appear to be influenced by abnormalities of the graft found at early follow-up, these abnormalities being fairly stable. These follow-up have especially shown the good correlation between the quality of the clinical results and the functional status of the coronary network in the long term, a function not only of the permeability of the grafts which have been carried out, but also of the complete or incomplete correction of the lesions of the three coronary trunks. Such a complete procedure which was carried out or could have been carried out in only 30% of the total patients, was then successful in 94% undergoing it. The clinical results should therefore lead us to carry out operations which remove the lesions as completely as possible.

Glucose disappearance in infants of diabetic mothers. I. Relationship to maternal glucose tolerance and insulin production

Glucose disappearance and insulin response were determined in mother--infant pairs of normal, gestational diabetic and diabetic pregnancies following an intravenous glucose load. Mothers were studied in the third trimester of pregnancy and at least 6 wk postpartum. Significant differences were present in glucose disappearance and insulin response in both gestational diabetic and diabetic mothers during pregnancy compared with the control group. Infants were studied within 4 h of birth while fasting, and glucose and insulin levels followed through the first 3 days of life. Neonatal hypoglycemia did not occur and glucose disappearance (KT) was not different among the three groups. There was no correlation between maternal glucose tolerance or insulin production and that of their infants. The only distinguishing factor among the infants was higher insulin production in infants of diabetic mothers during the 60-min intravenous glucose tolerance test which persisted up to 4 h following the infusion. It is concluded that factors other than the degree of maternal glucose tolerance are responsible for the development of neonatal hypoglycemia in infants of diabetic mothers, most notably control of maternal diabetes, the amount of glucose infused immediately before delivery and neonatal glucose production.

[Lesions of the right branch of the bundle of His. Clinical, electrocardiographic and histologic study of 33 cases]

The topography and severity of lesions of the right branch of the bundle of His have been studied as a function of the electrocardiographie changes and the associated heart disorder in 33 cases with more than 50% of the fibres destroyed. It appears that lesions of the right branch of the bundle of His, while severe and diffuse in cases of chronic complete right branch block, were severe but localised in 5 of the 6 cases with a stable incomplete right block. Total, subtotal or partial destruction of the right branch of the bundle of His was associated with lesions of the A-V node and/or the main truck of the bundle of His in the five cases with a complete atrio-ventricular block. The lesions of the right bundle branch involved the superior, middle and inferior portions in the case of aortic valve lesions, the middle portion in mitral valve disease, and the inferior portion in those with myocardial infarction. Ventricular hypertrophy seems to play an important in deciding whether the axis of the QRS, complex is left or right.

[Spontaneous development of obstructive myocardiopathies]

49 cases of obstructive cardiomyopathy (37 of the sporadic type, 12 of the familial type), confirmed by phonomechanocardiographic, haemodynamic and/or angiographic investigation and followed up for more than 5 years (mean 7.5 years) without surgical intervention, form the basis of a study on the natural history of this condition. There were 19 deaths (39%), of which 7 were of the familial type (58%) and 12 of the sporadic type (32%). The actuarial survival curves, which were commenced at the time or the first clinical symptom or the date of the first hospitalisation, show that approximately one patient in two dies at or about the age of 40. In 6 cases, death occurred in patients who were greatly improved by medical treatment to the extent of remaining symptomfree up to the time of death. No factors could be found in the initial investigation (phonomechanocardiographic electrocardiographic, radiographic, haemodynamic and angiographic examination (phonomechanocardiographic, electrocardiographic, between the patients still alive and those who had died; each paramater studies had mean values which overlapped in the two groups. Only the age at which the first clinical feature appeared separated the two groups: those patients who died had their first symptom or sign of disordered function at a much younger average age (15.9 years) than the survivors (25 years). This study has confirmed the very serious nature of obstructive cardiomyopathy, especially the familial types, and those with a low age of onset. It emphasises the extreme difficulty in arriving at a prognosis in this condition.

[Hemodynamic diagnosis of tricuspid insufficiency]

An analysis and comparison has been made of the value in the diagnosis and assessment of the degree of tricuspid incompetence of the following: the pressure curves of the right side of the heart, intracardiac phonocardiography and the venous dilution curves of ascorbic acid. The study was carried out on 49 patients, and a comparison made with selective right ventricular cineangiography, which was chosen arbitarily as a baseline. The information from the pressure curves and from intracardiac phonocardiography often contains errors of ommission or commission, but that from the venous dilution curves of ascorbic acid came out as the most reliable; these curves do tend to overestimate the degree of regurgitation, but they still allow us to reserve selective cineangiography, which is quantitatively a more precise method, for those cases in which the curves indicate a particularly severe degree of tricuspid incompetence.

The nuclear dehydrogenation of steroids by intestinal bacteria

We have postulated that bacteria able to dehydrogenate the bile-acid nucleus are important in the aetiology of cancer of the colon. In this paper we report on screening for the ability to carry out two such reactions. The relevant enzymes are produced by a high proportion of strains of Clostridium paraputrificum, C. tertium and C. indolis, and by small numbers of strains in other clostridial species, but not by organisms of the other genera tested. Strains able to dehydrogenate the bile-acid nucleus represent a high proportion of the lecithinase-negative clostridia isolated from faeces of people living in Britain but a low proportion of those from people living in Uganda or Hong Kong.