[Tilt test in the etiological diagnosis of syncope unexplained by electrophysiological study]. / Apport du test d'inclinaison dans le diagnostic étiologique des syncopes inexpliquées après exploration électrophysiologique.

In order to determine the role of tilt testing in the aetiological diagnosis of syncope unexplained by electrophysiological investigation, the authors retrospectively studied the results of this test in 275 patients with a mean age of 64 +/- 16 years. These 275 patients were divided into two groups: group I: 43 patients with a mean age of 50 +/- 19 years presenting with vagal syncopes, group II: 232 patients with unexplained syncope, probably vagal: group IIa (120 patients, mean age: 67 +/- 15 years), sudden syncope: group IIb (112 patients, mean age: 67 +/- 13 years). The electrophysiological investigation was inconclusive in every case. In group II, 50% of tilt tests were positive (19% under basal conditions, 31% after isoproterenol), with 61% of positive tests in group IIa, including 31% on the basal test, and 38% of positive tests in group IIb, including 11% on the basal test. In group I, 84% of tests were positive (33% on the basal test, 51% after isoproterenol), indicating a sensitivity of the test of 84%. In 96 patients with a doubtful electrophysiological investigation, the tilt test was positive in 70% of cases, allowing specific treatment or a pacemaker to be avoided in the majority of cases. 84% of vasovagal syncopes were therefore confirmed by tilt testing; 50% of syncopes unexplained by electrophysiological investigation were demonstrated to be of vasovagal origin. The author emphasize the value of tilt testing in certain discordant situations in which the clinical context is disturbing and/or electrophysiological investigation is not completely reassuring.

[Left syncopal bundle-branch block during tachycardia. A new, syndrome?]. / Bloc de branche gauche syncopal per-tachycardique. Nouveau syndrome?

The authors report four observations: three are essentially clinical cases where sustained rate dependent left bundle branch block can induce syncope, where as there is no syncope when the same supraventricular tachycardia at the same frequency has narrow QRS complexes. The fourth case demonstrates the dramatic decrease of arterial electrophysiological slowly accelerated atrial pacing in a patient investigated for a loss of consciousness of unknown origin. The hemodynamic impairment due to intermittent left bundle branch block has been demonstrated even in patients with normal ventricular function. If there are critical hemodynamic events such as during fast supraventricular rhythms occurrence of a left bundle branch block may determinate a dramatic decrease of arterial pressure with syncope. Syncope of supraventricular tachycardias might be induced not only by very fast rate but also by functional left bundle branch block. It might have some interesting applications in the diagnosis of syncope when coexist electrophysiological data of supraventricular arrhythmia substrate and frequency dependent left bundle branch block.

[Evaluation of electrophysiological properties of asymptomatic Wolff-Parkinson-White syndromes. Comparison with symptomatic Wolff-Parkinson-White syndromes]. / Evaluation des propriétés électrophysiologiques des syndromes de Wolff-Parkinson-White asymptomatiques. Comparaison avec les syndromes de Wolff-Parkinson-White symptomatiques.

The aim of this study was to compare the electrophysiologic properties of asymptomatic Wolff-Parkinson-White (WPW) syndromes with those of symptomatic WPW, and in particular the anterograde refractory period of the accessory tract and atrial vulnerability. This retrospective study involved 171 patients with WPW seen in their surface electrocardiogram, untreated, having undergone standard invasive electrophysiologic investigation. These patients were divided into two groups: group I consisting of 42 asymptomatic patients and group II consisting of 129 asymptomatic patients. 1) The mean anterograde refractory period (mean ARP) did not differ statistically between group I (330 +/- 97 msec) and group II (311 +/- 110 msec). The mean minimum interval between two preexcited complexes during atrial fibrillation (mean RR min) did not differ statistically between group I (313 +/- 80 msec) and II (300 +/- 105 msec). The mean retrograde refractory period (mean RRP) was significantly (p < 0.001) longer in group I (416 +/- 126 msec) than in group II (307 +/- 75 msec). 2) A reciprocal tachycardia was induced in 95% of cases in group II (122 patients) as compared with 9.5% of cases in group I (4 patients), with a very significant (p < 0.001) difference. Atrial fibrillation was induced in 24% of cases in group I (10 patients) and 34% of cases in group II (44 patients), the difference not being significant. 3) The incidence of potentially serious forms did not differ statistically between groups I and II. Nine patients in group I (21.4%) and 49 patients in group II (38%) had rapid anterograde conduction in the accessory tract (ARP or RR < or = 250 msec).(ABSTRACT TRUNCATED AT 250 WORDS)

[Unstable angina with threatening coronary lesions turned down for surgery. Outcome and prognostic factors]. / Les angors instables avec lésions coronariennes menaçantes récusés pour la chirurgie. Devenir et facteurs pronostiques.

The aim of this study based on a series of 200 patients, was to define the outcome and the prognostic factors of patients presenting with unstable angina, according to Bertolazi's criteria [3] and at least one stenosis greater than 80% on a proximal segment of a main coronary trunc, and to determine which factors should eventually be taken into consideration in the discussion of surgical indications. 70 out of 200 patients (35%) were turned down for direct revascularisation surgery because of an ejection fraction less than 0,35 and/or a poor arterial run off. Coronary arteriography showed 30% patients with a menacing stenosis (greater than 80%) on all three vessels, 36% on two vessels and 22% on a single vessel. The distribution and the extent of the lesions was about the same as in the operated patients. 20% patients had an ejection fraction less than 0,35, 24% between 0,34 and 0,50, and 56% greater than 0,50. At patient, the follow up period ranges from 22 to 66 months (average 32 months). In this group, the hospital mortality was 2,9%, the secondary cardiac deaths 16% and the global mortality 19% compared to 12,6% for the operated patients in the same period. The incidence of secondary non-fatal infarction was low (9%). 52% of survivors have persistent angina, 39% severe (Class II or III). Two prognostic factors were detected from this study: the type of angina: the intermediary syndrome had a bad prognosis, 38,5% mortality compared to 13% for aggravated chronic angina; and the ventriculography: patients with ejection fractions less than 0,35 had 64% mortality compared to 7,3% for those with ejection fractions greater than 0,40. The number of menacing lesions, the extent of the lesions of the artery involved did not affect the prognosis when severe abnormalities of left ventricular function were absent.

[Outcome of myocardial infarctions complicated by heart conduction disorders in the acute phase]. / Devenir des infarctus du myocarde compliqués en phase aiguë de troubles de la conduction.

Of 945 patients hospitalised for myocardial infarction between January 1st 1972 and December 31st 1975, 40 with anterior myocardial infarction (Group I-A) and 53 with posterior myocardial infarction (Group II-A) were complicated by atrioventricular and/or intraventricular arrhythmias. The average follow up period is now of 48 months (range 24 to 78 months). Their outcome was compared to two control groups of 50 anterior myocardial infarctions (Group I-B) and 50 posterior myocardial infarctions (Group II-B) uncomplicated by arrhythmias in the acute phase. The immediate (10%) and secondary (30%) mortality was identical in the two groups II-A and II-B with posterior wall necrosis. The immediate (32%) and secondary (40%) mortality in Group I-A was much higher than in Group I-B (22% and 28% respectively). Sudden death was the most frequent form of demise in all groups (I-A, II-A, II-B) except Group I-B in which heart failure predominated. Death occured earlier in Group I-A than in the control Group II-B. These results pose the problem of the indication of prophylactic permanent pacing to decrease the incidence of sudden death.

[Continuous ambulatory electrocardiographic recordings using the Holter system in the late phase of hospitalization for recent myocardial infarct. Value and limitations studied in a series of 100 patients]. / Enregistrements électrocardiographiques continus en ambulatoire par système Holter en phase tardive d'hospitalisation pour infarctus du myocarde récent. Intérêt et limite à propos d'une série de 100 patients.

Repeated continuous ambulatory electrocardiography by Holter monitoring was performed after early mobilisation post-myocardial infarction in 100 patients, without ventricular extrasystoles on classical ECG. Frequent ventricular arrhythmias were recorded in 58 p. 100 cases, unrelated to the localisation of the infarct. The observation of ventricular arrhythmias in the Coronary Care Unit (CCU) was not related to the occurrence of VEs during Holter monitoring. On the other hand, VEs were less frequent (38 p. 100 compared to 68 p. 100) in patients taking amiodarone or betablockers on transfer from the CCU. The reduced activity of patients during Holter monitoring minimises the frequency of arrhythmias, and 10 p. 100 patients were observed to have VEs only after exercise tolerance testing. These VEs seem to be a bad prognostic factor; the 9 patients who died in this series all presented VEs on ambulatory monitoring (7) or during exercise tolerance testing (2). However the number of patients with triple vessel disease was greater in the group with VEs on ambulatory monitoring (57 p. 100 compared with 13 p. 100). It is difficult to assess the precise role of the VEs amongst the other risk factors of sudden death. This is not a randomised study, but it would appear that long=term amiodarone or betablockers therapy may influence the medium-term prognosis.

[Primary and idiopathic hyperaldosteronism. Course 1 year after operation. Apropos of 28 cases]. / Hyperaldostéronisme primaire et idiopathique. Etude de l'évolution un an après l'intervention. A propos de 28 observations

The course of mean arterial pressure was compared in two series concerning 18 primary or tumoral hyperaldosteronism and 8 idiopathic ones. Identification of the nature of the hyperaldosteronism should not yet motivate a decision on principle, surgical in case of tumor, medical in an idiopathic case. In the latter case cooperation and tolerance of medical treatment, severity of hypertension also come into consideration. A positive spirolactone test, a hypertension course of less than six years were in our experience a good indication of successful surgery, as opposed to a normal unilateral renal biopsy. In case of operation, the removal protocol should adapt to the peroperative findings; 80% adrenalectomy is the most common procedure, except in the case of isolated adenoma of more than 10 mm diameter.