[Combination of celiprolol and amiodarone in the treatment of recurrent ventricular tachycardia]. / L'association du céliprolol à l'amiodarone dans le traitement des tachycardies ventriculaires récidivantes.

The combination of beta-blockers and amiodarone has been shown to be affective in the treatment of refractory chronic ventricular tachycardia. However, the possible induction of excessive sinus bradycardia can constitute a limitation to the use of this treatment. Celiprolol is a cardioselective beta-blocker with a partial beta-2 agonist activity and an alpha-2 blocking activity, with a minimal depressant effect on heart rate. It therefore seemed useful to evaluate this drug in combination with amiodarone in patients with chronic ventricular tachycardia refractory to amiodarone alone. Twelve men with age of 57 +/- 16 years (9 with a history of myocardial infarction) received 200 mg of celiprolol per day associated with an average of 2 grams of amiodarone per week. Failure of oral amiodarone alone was confirmed by "reloading" (1,200 mg per day for 4 days) in 11 patients. The mean left ventricular ejection fraction was 36 +/- 19%, and was < or = 30% in 5 patients. Three patients were classified as stage 3-4 of the NYHA functional classification. Episodes of tachycardia were paroxysmal in 10 patients and diurnal in 10 cases. The effects of treatment were evaluated by clinical examination, continuous electrocardiographic monitoring, stress test and endocavitary electrophysiological investigation. No patient developed cardiac decompensation or collapse during beta-blocker treatment. In one case, the dose of celiprolol had to be decreased to 100 mg per day because of hypotension. No proarrhythmic effect was observed. The sinus rate remained unchanged after addition of celiprolol to amiodarone (57 +/- 3 bpm before versus 56 +/- 4 bpm after). On the stress test, the exercise capacity was maintained and no tachyarrhythmia was induced. Right ventricular refractory periods were not modified by celiprolol (mean effective period 289 +/- 20 ms before versus 294 +/- 20 ms after). Following a hospital stay of 17 +/- 7 days, the beta-blocker was discontinued in 5 patients because of persistence of permanent tachycardia in 1 case, and because of inducibility of a tachycardia with the same frequency as before treatment in the other 4 cases. No sudden death or haemodynamically unstable recurrence of ventricular tachycardia were observed during follow-up over a period of 38 +/- 24 months (range: 2-55) of the 7 patients in whom treatment was considered to be effective. Only one patient presented a temporary and reversible deterioration of heart failure. The absence of excessive bradycardia was also observed during follow-up. In one patient, celiprolol was replaced by another antiarrhythmic due to the recrudescence of inducibility to programmed stimulation. Three patients developed a spontaneous recurrence of sustained monomorphie ventricular tachycardia, which was well tolerated. In conclusion, these results suggest that celiprolol in combination with amiodarone in the treatment of refractory chronic ventricular tachycardia is a valuable therapeutic option because of its good inotropic and particularly chronotropic safety. However, the efficacy of treatment must be evaluated by a stress test and by endocavitary electrophysiological investigation including programmed ventricular stimulation in every case.

[Electrophysiological evaluation of ventricular tachycardia]. / Exploration électrophysiologique des tachycardies ventriculaires.

The ability to induce and terminate ventricular tachycardia reproducibly by programmed stimulation has led to the development of electrophysiological investigations for the management of patients suffering from spontaneous arrhythmias. The investigation consists in introducing several multipolar catheter electrodes under local anaesthesia which are then positioned in contact with the endocardium in several regions of the heart. There is no consensus as to an ideal stimulation protocol for these patients but the basic principle is the introduction of one or several ventricular extrasystoles every 8 beats in sinus rhythm or during a controlled ventricular paced rhythm. At present, the major indication is rarely diagnostic in the presence of wide QRS complex tachycardias difficult to analyse by electrocardiography. On the other hand, electrophysiological investigations are highly recommended in cases of unexplained syncope in patients with documented or suspected heart disease, in symptomatic patients with intraventricular conduction defects in whom ventricular arrhythmias are suspected as the cause of symptoms or after cardiac arrest without transmural infarction or, for many teams, after the 48th hour of transmural infarction. Electrophysiological investigations are also justified in patients in whom surgical or catheter ablation of an arrhythmogenic focus is planned because of resistance to antiarrhythmic drug therapy. Evaluation of the efficacy of antiarrhythmic drugs by repeated investigations is common in the United States but is not so widely accepted in Europe.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastroesophageal reflux during++ sleep in obese patients]. / Reflux gastro-oesophagien pendant le sommeil chez l'obèse.

Evidence of relationship between gastrooesophageal reflux (GER) and obstructive apneas in some near-miss children, led us to investigate its possibility in adults. Our purpose was to look for 1) sleep stages of GER occurrence, and 2) the possible chronological link between sleep apneas and GER. Eight obese patients were investigated. Esophageal pHmetry was carried out on two consecutive nights. On the second night, sleep polygraphy was performed including EEG, EOG, EMG, nasal and buccal flows, thoracic and abdominal motions. Esophageal pHmetry was analyzed between the onset of sleep and the definite waking. Fifteen GER episodes occurred in 4 of the 8 patients. Fourteen of them occurred during wakefulness or transient arousals. Only 1 occurred during REM sleep. Four hundred forty five apneas were recorded in 7 patients. None of the obstructive apneas, or mixed apneas followed or preceded a GER. In 1 patient, 2 central apneas succeeded to GER during REM sleep. We conclude that 1) GER, as in healthy subjects, occurs essentially during wakefulness or transient arousals; 2) in these patients, we did not establish a causal relationship between GER and obstructive apneas nor between apneas and GER.