Heart Journal, 20I-209. Proceedings British Cardiac · Paediatric Cardiology presented addi-tional difficulties, but should include 2 years' adult cardiology and 2 years' paediatric

British Heart Journal, I972, 34, 20I-209.

Proceedings of the British Cardiac Society

THE AUTUMN MEETING of theBritish Cardiac Society was held at theRoyal College of Physicians, London,on Thursday and Friday, 4 and 5November 197I. The President, SIRJOHN McMICHAEL, took the Chairat 9.30 a.m. during Private Business. Atthe Scientific Session which followed,the Chair was taken by ALASTAIRHUNTER.

Private BusinessI The President reported with deepregret the deaths of Twort and DorisBaker.2 The Minutes of the Annual GeneralMeeting having been published in theJournal (I97I, 33, 607-6I6) were takenas read and confirmed.

3 The Treasurer reported that theSociety's investments stood at nearly£12,ooo. In line with stock marketprices there had been some recentappreciation in value. He had recentlyreviewed the holdings with the Society'sBroker who was generally satisfied withthe behaviour of the shares and recom-mended no change at this time.

£i,ooo had been taken out of theDeposit Account and invested in 8J%Bass Charrington Debentures for theSinking Fund, bringing this to £I,5OO,with s500 left on deposit, on Broker'sadvice, for easy availability.

Expenses of all kinds were risinginexorably, and though he was exploringways and means of getting work donemore cheaply most increases had to beaccepted. Members' subscriptions justabout covered current expenses; butthe actual position would be knownwhen the books for 197I were closed atthe end of the year.The financial accounts of the VI

World Congress of Cardiology had nowbeen closed and the Society had re-ceived a further kI,967-26. It had beenagreed that £5oo should be given fromthe Society to the Lord AlexanderAppeal Fund of the British HeartFoundation; that £i,ooo should be heldin reserve to assist members with someof their travelling expenses to attend theVII World Congress; and the remainderbe put into the Society's general fund.

4 The Secretary reported that arrange-ments for the Annual General Meeting

in Dublin on 23 March I972 were pro-ceeding satisfactorily.

5 The Secretary reported that arrange-ments had been made to hold the nextAutumn Meeting on 9 and I0 NovemberI972 at the Royal College of Physicians,but the possibility was being exploredof holding the dinner elsewhere.

6 The Secretary reported that theAnnual General Meeting in 1973 wouldbe held on I2 April in Glasgow, im-mediately before the meeting of theAssociation of Physicians.

7 Goodwin reported that the findingsof the Cardiology Committee of theRoyal College of Physicians on CareerStructure in Cardiology had gone to theDepartment of Health, but no officialreaction to the report had been received.

8 Goodwin, as Chairman of theSpecialist Advisory Committee onCardiology of the Joint Committee onHigher Medical Training, reported thatthe Committee had now formulatedprovisional recommendations for train-ing programmes for Groups I and IIcardiological consultant work, and forpaediatric cardiology. It seemed likelythat the Groups II and III outlined inthe Report of the Cardiology Committeeof the Royal College of Physicians onCardiological Staffing and Career Struc-ture could in future be merged. TheSpecialist Advisory Committee hadrecommended 8 years training forGroup I and II and Paediatric Car-diology, which included i year pre-registration jobs, 3 years general medicaltraining, and 4 years (in the case ofGroup I) and 3 years (in the case ofGroup II) in specialist training ina Special Cardiac Medical-SurgicalCentre. The 4th year for Group Ishould include some general medicine.Paediatric Cardiology presented addi-tional difficulties, but should include 2years' adult cardiology and 2 years'paediatric cardiology in addition togeneral paediatrics and neonatal paedi-atric training, probably to be taken inthe 3 years of general professionaltraining.Goodwin emphasized most strongly

the firm recommendation of his Com-

mittee that the utmost flexibility re-garding the training schedules must bemaintained with regard to the order inwhich training should be taken, and thebackground oftrainees. No training pro-gramme should be so rigid that itsrequirements would permit people withunorthodox backgrounds but of specialbrilliance to be excluded.The recommendations had been pre-

sented to the members of Council, whohad added their comments and suggest-ions, and the report had been discussedand agreed provisionally at the meetingof the full Committee for HigherMedical Training in October.

9 Davison and Oram reported on theresults of discussions they had had withDr. Lees of the Department of Healthand Social Security on cardiologicaltechnicians' pay and conditions. Theyfelt that they had had a full opportunityto explain the position and they werehopeful that a sympathetic view wouldbe taken of the need for appropriatesalary scales for cardiological tech-nicians.

10 The Secretary informed the Societythat a memorandum had been receivedfrom Dr. Lees of the Department ofHealth and Social Security with regardto the possibility of interference withthe function of demand pacemakers.Dr. Lees was anxious to establish aregister of demand pacemakers, andmembers were requested to notify Dr.Lees of the name and address of anypatient, and the make and model of thepacemaker being used.

Following the Scientific Meeting onthe Thursday, the Thomas LewisLecture - 'Function of Nerves of theHeart' - was given by Linden.

After the Scientific Meeting on theFriday, the National Heart Hospital St.Cyres Lecture - 'The Skeleton in HeartDisease' - was given by Jefferson.The Society dined together at the

Royal College of Physicians, withMcMichael in the Chair. The guestsincluded Professor J. N. Morris. ThePresident spoke about recent develop-ments including progress in the creationof chairs of cardiology by the BritishHeart Foundation.

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202 Proceedings of the British Cardiac Society

Nitrous oxide analgesia in acutemyocardial infarction

F. Kerr, D. J. Ewing, J. B. Irving(all introduced), and B. J. Kirby

Many drugs used for pain relief in myo-cardial infarction have circulatoryeffects. An agent that relieves pain with-out major haemodynamic effect wouldbe advantageous. In IS patients withacute myocardial infarction we studiedthe analgesic and cardiorespiratory pro-perties of a 50 per cent nitrous oxide 50per cent oxygen mixture (Entonox,B.O.C.). During a control period thepatients breathed air via an air forcemask connected to a demand valve.With a three-way tap, transfer to Ento-nox, breathed through a similar assem-bly, was accomplished without thepatient's knowledge. In 5 patients thecardiac index was measured with indo-cyanine green and intra-arterial pres-sures recorded at 5-minute intervals.After a 20-minute control period Enton-ox was administered for 30 minutes:mean heart rate fell 5/minute, meanarterial pressure remained constant, car-diac index fell 0o4 I./min per m2n, andsystemic vascular resistance rose 334dynes sec cm-5/m2. Blood gases in 6patients showed a rise in arterial Po2 of35 mmHg during Entonox administra-tion, returning to the control level onwithdrawal. Complete pain relief wasdemonstrated in all patients with nosignificant side-effects. We concludethat Entonox is a safe and effectiveanalgesic in acute myocardial infarction.

A study of the incidence of venousthrombosis following myocardialinfarction

B. J. Maurer and R. Wray (introduced)

Using the 125I-fibrinogen isotope tech-nique, ioO patients with acute myocar-dial infarction have been studied todefine the incidence of venous thrombo-sis complicating this illness. None of thepatients was given anticoagulants rou-tinely, but in IO patients anticoagulantswere employed at an early stage in theillness for reasons other than the treat-ment of venous thrombosis. Of the gopatients who were not given anticoagu-lants, 34 (37%) developed a calf veinthrombosis. None of the IO patientsgiven anticoagulants developed throm-bosis. In IO ofthe 34 patients the throm-bus was bilateral. In all, the thrombusbegan in the calf. In 7 limbs the throm-bus extended to involve the veins of thethigh and the femoral vein. In one

patient the thrombus extended to thepopliteal vein. When such extension wasnoted these patients were given anti-coagulants. Over 50 per cent of thethrombi were found in the first 72hours. No patient in this series sus-tained a major pulmonary embolus. Theincidence found in these patients is verysimilar to that recorded in patients whohave recently undergone surgery.

Atrial gallop in diagnosis of earlycoronary heart disease

P. G. F. Nixon and H. J. N. Bethell(introduced)

The clinical diagnosis of early coronaryheart disease traditionally depends uponthe history and the electrocardiogram,little of importance being expected orobtained from the examination of theheart sounds and pulsations.The purpose of this communication

is to report findings from a series of I59cases of coronary heart disease withoutevidence of myocardial infarction, hy-pertension, or valvar disease.One hundred and eleven patients had

classical angina pectoris and the restingelectrocardiogram was abnormal in 21(i8%). In the remaining 48 patients,the diagnosis of coronary heart diseasewas made from abnormalities of theelectrocardiogram at rest or after exer-cise. The resting electrocardiogram wasabnormal in 24 (50%).

In io8 of the patients, the heartsounds and pulsations were recorded bylow frequency phonocardiography andapex cardiography, with the patient inthe left lateral or semilateral position.The tracings were examined for fourthheart sounds and enlargement of theatrial components ('A' waves) of theapex cardiogram. In the 7I patients inthe classical angina group, the tracingswere abnormal in 65 per cent, and theresting electrocardiogram abnormal in17 per cent.

It is concluded that physical examina-tion in the left lateral position, by reveal-ing palpable and audible atrial galloprhythm, may be more useful than theresting electrocardiogram in detectingearly coronary heart disease.

Significance of atrial sound inacute myocardial infarction

E. D. Bennett, C. R. Smithen (bothintroduced), and E. Sowton

The incidence and significance of theatrial sound was assessed in 20 patients

with acute myocardial infarction. Highfrequency phonocardiograms were re-corded from the left atrial border andapex on several occasions in all patients.Pulmonary artery pressures were mea-sured with a flow guided catheter.Simultaneous electrocardiograms werealso obtained.

Atrial sounds were present in allcases. The interval between the P waveof the electrocardiogram and the initialdeflexion of the atrial sound of thephonocardiogram (PG interval) wasmeasured. The ratio of PG interval tothe PR interval of the electrocardio-gram progressively increased from 8iper cent on the first day to 89-3 per centon the fourth day, demonstrating thatwith resolution of the infarction, theatrial sound moved towards the firstheart sound. Those patients with a com-plicated clinical course had a signifi-cantly smaller PG/PR ratio than thosepatients whose course was entirelyuncomplicated.There was a significant correlation

between this ratio and the pulmonaryartery diastolic pressure, suggestingthat those patients with the greatestdegree of left ventricular dysfunctionhad the shortest PG intervals (r=o052,y=37-I 4x, P < OcOOI).

It is concluded that in acute myocar-dial infarction an atrial sound is univer-sally present and that the PG intervalreflects alterations in the clinical andhaemodynamic state of the patient.

Lowering of blood cholesterol bydietary recommendations inmiddle-aged men

A. G. Shaper, Jean W. Marr,J. A. Heady, and J. N. Morris (lastthree all introduced)

Male civil servants aged 40-49 years,who had previously participated in aquestionnaire on leisure activity, tookpart in a further study designed to assesswhether a significant reduction inblood cholesterol level could be achievedin a free-living population by simpledietary recommendations. The studyinvolved 5 visits over a 6-month periodand included physical examinations,electrocardiography, detailed dietarystudies, biochemical measurements (in-cluding blood cholesterol, triglycerides,uric acid, glucose, fatty acid patterns),and studies of the blood fibrinolyticactivity. Two groups of men were givendietary advice and two groups remainedas the controls.The control groups showed an in-

crease in blood cholesterol level over the



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winter months of the study. The groupsgiven dietary advice showed a fall inblood cholesterol level on reassessmentat 6 weeks and maintained this loweredlevel at 4 months. Body weight increasedin the control group and fell in the diet-ary group, but within the diet group,there was no significant relation betweenthe amount of weight change and theamount of cholesterol change in indi-vidual subjects. The control group wasthen provided with the dietary recom-mendations and all subjects will be re-examined at I2 months from the startof the study.

Changes in skinfold thickness, bloodpressure, and fibrinolytic activity werealso observed over the initial 6 monthsof the study. Relations between diet andthese measurements will be discussedwith reference to the possible signifi-cance of this study to the primary pre-vention of coronary heart disease.

Supervised physical training aftermyocardial infarction

C. M. Morgans (introduced byD. W. Barritt)

Supervised physical training in menaged 35 to 65 recently recovered frommyocardial infarction is being studied.Twenty-three men form the exercisegroup and 22 are controls. The exercis-ing patients trained three times weeklyfor three months in a hospital gym-nasium. The control group receivedroutine aftercare.

Parameters measured before and ifpossible after three months includeheart rate, pulmonary artery pressure,and venous oxygen saturation, mea-sured at rest and during supine exerciseon a bicycle ergometer, using a floatcatheter.One patient in each group has died.A significant (P <oos) fall in resting

and exercising heart rates occurred inthe exercise group. A smaller insignifi-cant fall occurred in the controls.The investigation consisted of mea-

surements during a 20-minute periodof cycling at IOO, 200, 300, and 400kpm/min. Inthosepatients inthe exercisegroup who were unable to complete thecycling period because of angina pec-toris or 2 mm ST segment depression,there was an improvement in exercisetolerance after the training period. Theimprovement correlated with lowerexercising heart rates.

Resting diastolic pulmonary arterypressures were raised in one-third of thepatients and exercising diastolic pul-monary artery pressures were raised in

two-thirds. There were no significantchanges at the second investigation.Mixed venous oxygen saturations werealso unchanged.A self-rating depression scale has

been used to assess possible changes inmood.A short film showing the exercises

used in training is available.

Initial experiences of routineautomated electrocardiographicinterpretation

P. W. Macfarlane (introduced) andT. D. V. Lawrie

In a previous communication to theBritish Cardiac Society a technique forelectrocardiographic interpretation bycomputer was described and resultsdiscussed. The present communicationreports the initial experiences of intro-ducing the method into a large generalteaching hospital for routine purposes.During the first six months of opera-

tion, 3,455 3-lead electrocardiogramswere interpreted by a computer sitedwithin the hospital. The number re-corded monthly was increased graduallyand in the sixth month was 725, repre-senting almost 40 per cent of the totalhospital requirement.

In parallel with this introduction, aseries of lectures was given to medicalstaff to explain the diagnostic principlesof 3-lead electrocardiography. Thisfacilitated acceptance and minimizedcriticism of the computer interpreta-tions.

Significantly erroneous interpreta-tions totalled under 4 per cent, while afurther 4-5 per cent of computer reportshad minor discrepancies. These resultshave led to further modifications towave recognition techniques and cri-teria, together with insistence on highertechnical standards of electrocardiogra-phic recording.The conclusion reached is that the

method will prove acceptable for routinepurposes in any centre where there isadequate scientific support. Technicallysatisfactory electrocardiograms input tothe computer will produce satisfactoryinterpretations as output.

Computer storage of catheteriza-tion data - preliminary report ofa co-operative study

J. P. Blackburn (introduced),D. C. Deuchar, P. R. Fleming,G. A. H. Miller, and D. G. Morgan(introduced)

Data from I60oo cardiac catheterizationsperformed at 3 separate hospitals fromI January 1970, to 30 June 1971, havebeen stored using a digital computer. Aspecially designed form is used on whichcan be recorded not only the numericaldata derived from the procedure butalso, by means of a coding system, adescription of the technique of catheter-ization, the chambers and vessels en-tered and details of angiocardiography.In addition it is possible to record theeffect of interventions such as the ad-ministration of drugs. The diagnosticcoding permits not only a statement ofthe diagnosis but also allows the expres-sion of clinical doubt about the natureand severity of the lesion.

Print-outs are sent to the participatinghospitals weekly; a copy of the originalform is retained for reference until theprint-out is available.Programmes have been written to per-

mit a wide range of data retrieval andanalysis, and some results of suchanalyses will be presented. The projectis a first step towards constructing acomprehensive system of data retrievalrelating to hospital cardiological prac-tice, while the co-operative nature ofthe project increases the pool of dataavailable for analysis.

Cardiovascular data analysis on asmall digital computer

C. J. Mills (introduced) andI. T. Gabe

The general problem of analysing dataduring cardiovascular investigation hasbecome greater in recent years with theincrease in the number of variables re-corded and with the necessity to mea-sure records in a more detailed way. Tofacilitate such analysis, a small digitalcomputer - a PDP-I2 - has been pro-grammed to process left ventricularpressure together with pressure andvelocity records from the aorta. Dataare accepted in analogue form eitherdirectly from the patient or from a taperecorder. It is converted to digital formand stored on one of two magnetic tapeunits. After calibration, subsequent pro-cessing includes, (i) a system for averag-ing records over a predetermined num-ber of beats to produce estimates of andstatistics on systolic, diastolic, mean,and maximum rates of change of pres-sure and velocity; (2) beat-to-beat cal-culation of similar sets of variables; and(3) calculation of harmonic content ofaortic pressure and velocity wave formsand the computation of vascularimpedance.



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Intracellular action potential inhypertrophic obstructive cardio-myopathy

D. 7. Coltart and S. J. Meldrum(both introduced by John Hamer)

Some skeletal muscular dystrophies areknown to be associated with cardio-myopathy, and Meerschwam and Hoots-mans (197I) have reported abnormalelectromyographic potentials in theskeletal muscles of patients with hyper-trophic obstructive cardiomyopathy. Inview of these findings we have studiedthe intracellular action potential inspecimens of myocardium removed atoperation in 2 patients with hypertro-phic obstructive cardiomyopathy, usingthe microelectrode technique, and com-pared the findings with action potentialsin tissue from other hypertrophiedhearts.

Repolarization was greatly prolongedin the tissue and the rate of depolariza-tion was reduced. There were alsocharacteristic abnormalities in the effec-tive refractory period and the contrac-tile response. The usual 'quinidine-like' effect of propranolol on the actionpotential could be demonstrated.The findings of an abnormal myo-

cardial and skeletal muscle potential inpatients with hypertrophic obstructivecardiomyopathy support the view thatthis condition might be a generalizedmuscular dystrophy with early majorcardiac manifestations.

ReferenceMeerschwam, I. S., and Hootsmans, W. J.

M. (I97i). An electromyographic studyin hypertrophic obstructive cardiomyo-pathy. In Ciba Foundation Study GroupNo. 37: Hypertrophic Obstructive Car-diomyopathy, p. 55. Ed. by G. E. W.Wolstenholme and M. O'Connor.Churchill, London.

Spectrum of pre-excitation and itselucidation by His bundle electro-graphy

Dennis Krikler, Charles Smithen(introduced), and Edgar Sowton

We review 4 patients with different as-pects of the pre-excitation syndrome,studied by His bundle electrography.Two had type A Wolff-Parkinson-White conduction, both with recurrentparoxysmal tachycardia. In one, ven-tricular extrasystoles appeared to be im-portant in the production of thearrhythmias; tachycardia could not beinitiated by right heart stimulation, but

surprisingly we could do this in theother case with type A conduction.Though Case 3 had type B WPW con-duction, we were unable to initiate anarrhythmia nor did he suffer fromparoxysmal tachycardia. In Cases i and2, His bundle electrography showedonly mild pre-excitation during sinusrhythm, though in one the degree variedspontaneously: pacing caused the His-Vinterval to decrease sharply to zero asthe major part of depolarization oc-curred via the presumed bypass. InCase 3, with conspicuous pre-excitationin sinus rhythm, a similar responseoccurred on pacing. The fourth patienthad the syndrome of a short PR andnormal QRS interval, with a short P-Hisinterval on the electrogram; he suffersfrom paroxysmal atrial flutter.The possible mechanisms for the

different modes of conduction seen inpre-excitation were presented, withspecial reference to the occurrence ofarrhythmias and their control.

Effects of glucagon on myocardialcontractility and cardiac output

John Hamer, Derek Gibson, andJohn Coltart (introduced)

Intravenous glucagon has been recom-mended as an inotropic agent in themanagement of low cardiac outputstates.We have investigated the effect of 2

or 3 mg glucagon intravenously at car-diac catheterization in 3 patients withserious aortic stenosis, using thermo-dilution curves to measure left ventricu-lar volume. There was a striking rise incardiac output (from 4.4 to 6-3 I./min),due to moderate increases in heart rate(from 8I tO go per min) and strokevolume. There was a considerable in-crease in end-diastolic volume, butmean circumferential shortening rate,an index of contractility, was unchangedor fell. Left ventricular systolic pres-sures rose slightly and there was a con-siderable increase in wall force, possiblydue to the Starling effect in the largerleft ventricle.The maintenance of the shortening

velocity in the presence of an increase inwall force may be an indication of someinotropic effect, but there is no evidenceof an increase in contractility whichcould produce the observed rise in car-diac output. It seems likely that a risein splanchnic blood flow is produced,and that the cardiac changes are largelysecondary to the increase in venousreturn. The therapeutic value of this re-sponse in cardiac disease is questionable.

Alpha-adrenergic blockade intreatment of heart failure

S. H. Taylor, P. A. Majid, andB. Sharma (the last two introduced)

The adrenergic alpha-receptor blockingdrug, phentolamine, was administeredto I2 patients with severe progressiveleft ventricular failure due to ischaemicheart disease. The rationale for the useof this drug in this circumstance wasbased on two considerations; that thereflex increase in systemic resistancethat accompanies the onset of pumpingfailure may further aggravate the leftventricular failure by increasing thepressure-work load on the ventricle;that in heart failure the redistribution ofthe blood volume towards the heart andlungs may further increase left ventricu-lar dilatation. The drug was adminis-tered intravenously in a dose of I-2mg/min sufficient to lower the systemicarterial blood pressure by 20-30 mmHg.This resulted in an immediate relief ofsymptoms simultaneously with a sub-stantial reduction in the left ventricularend-diastolic and pulmonary arterymean pressures, and a significant in-crease in stroke volume and cardiacoutput. These changes were maintainedthroughout the three-hour period ofinfusion. Patients who were able toexercise also had a significant improve-ment in symptoms, an increase in thecardiac output, and a decrease in theleft ventricular end-diastolic pressureresponse to exercise. Chest x-raysshowed a conspicuous clearing of pul-monary oedema and reduction in heartsize after the drug. The benefits of thistreatment are probably predominantlydue to the effects of the drug in loweringthe systemic vascular resistance thusreducing the cardiac pressure-work loadand volume. However, the drug mayalso directly support the metabolism ofthe failing heart by release of the sup-pression of insulin secretion, and itsbronchodilator action may also con-tribute to the relief of symptoms inpatients with cardiac asthma. Thisapproach to the treatment of severeheart failure may usefully complementconventional treatment with digitalisand diuretics and may be of particularvalue in situations were digitalis iscontraindicated.

Beat-to-beat analysis of leftventricular pressure-volumerelations in atrial fibrillation inman

D. G. Gibson



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Using an echocardiographic methodduring diagnostic cardiac catheteriza-tion, simultaneous records of left ven-tricular dimensions and left ventricularand aortic pressures were made forperiods of up to 50 consecutive cardiaccycles in patients with atrial fibrillation.From these data, end-diastolic, end-systolic, and stroke volumes were deter-mined and correlated with intraven-tricular pressure, allowing the diastolicdistensibility of the left ventricle to bedescribed, and pressure-volume loopsto be constructed for single cardiaccycles. Left ventricular wall tension,derived from cavity diameter and sys-tolic pressure, and mean circumferen-tial fibre shortening rate, derived fromstroke volume, cavity diameter, andejection time, were determined on abeat-to-beat basis, and were shown tocorrelate with previous pulse intervals.The relation between left ventriculartension-time, an index of myocardialoxygen consumption, and external car-diac work was also shown to be depen-dent on diastolic filling time and strokevolume. These methods can thus beused to examine the interrelations be-tween various aspects of left ventricularfunction in a single patient, as well asgiving a more complete description ofcardiac performance in the presence ofatrial fibrillation on a beat-to-beat basis.

Reversion of ventricular tachy-cardia by pacemaker stimulation

M. A. Bennett (introduced) andB. L. Pentecost

Transvenous cardiac pacing has beenused with success in the prevention ofrecurrent drug-resistant ventriculartachyarrhythmias. Despite pacing, how-ever, ventricular tachycardia and fibril-lation may recur. With the pacingcatheter situated in the right ventricle,the reversion of ventricular tachycardiato sinus rhythm was achieved by pacing,in seven patients after acute myocardialinfarction. The technique involvedpacing at a rate in excess of the existingtachycardia until ventricular capturewas achieved. Cessation of pacing aftera few seconds was usually followed bysinus rhythm. Because ventriculartachyarrhythmias were recurrent in thepresence of sinus rhythm, the ventricu-lar capture rate was sometimes slowedto the point when ventricular prematurebeats first appeared. The heart was thenpaced slightly in excess of this criticalrate. The technique of reversion seemsa useful extension to the employmentof transvenous pacing in the prevention

of recurrent ventricular tachyarrhyth-mias.

Familial atrial cardiomyopathywith heart block

R. E. Nagle, B. Smith, andD. 0. Williams (last two introduced)

We have studied a cardiomyopathyaffecting 3 out of 5 sibs, characterizedby first degree heart block and ectopicsupraventricular rhythms progressingover some years to persistent atrialstandstill, with complete loss of responseto direct atrial stimulation. At least 2children of one of the patients appearto be similarly affected.We have found only 4 previously

reported cases of this arrhythmia, 3 ofwhom occurred in a family with amyloiddisease. Post-mortem examination of amember of the family showed no evi-dence of this condition.

Systemic arterial supply to lungsin pulmonary atresia and itsrelation to pulmonary arterydevelopment

Keith Jefferson, Simon Rees, andJane Somerville

The pattern of systemic arterial supplyto the lungs and its relation to pulmon-ary artery development has been studiedangiographically in 30 patients with pul-monary atresia and ventricular septaldefect. Necropsy findings were availablein 3 of the patients. The findings revealthat the systemic arteries fall into twogroups. In one group the arteries weresmall, multiple, tortuous, and uncount-able in number, with widespread sitesoforigin from the aorta and its branches,and in patients with this type of arterialsupply the central pulmonary arterieswere invariably present. Full develop-ment of the central pulmonary arterieswas also present when the ductus waspatent.

In the other group, the systemicarteries were much larger, less tortuousand countable, varying from one to fivein number. With one exception theyarose from the descending aorta belowthe isthmus and entered the lungs viathe hilum to become continuous withthe hilar pulmonary arteries, at whichpoint there was usually a stenosed seg-ment.

Patients with larger arteries as thesole source of supply to the lungs hadabsent or incompletely formed centralpulmonary arteries.

The findings are discussed in relationto the implications for surgical treat-ment and to accepted concepts of pul-monary circulation development.

Significance of continuousmurmurs in cyanotic congenitalheart disease

Fergus Macartney, Philip Deverall(introduced), and Olive Scott

Six patients (age 3-25 years) with ven-tricular septal defect and 'pulmonaryatresia' were studied in whom the entirepulmonary blood supply was from large'bronchial' arteries arising distal to theascending aorta, and not from a per-sistent ductus arteriosus (PDA). All hadcontinuous murmurs. Selective 'bron-chial' arteriography showed detailedanatomy. To evaluate the likely resultof surgical anastomosis of a right ven-tricular conduit to a suitable point in abronchial artery, pulmonary resistance(Rp) was measured as the total resistanceto flow distal to that point, as deter-mined by bronchial artery catheteriza-tion and the Fick technique.Of 12 'bronchial' arteries catheter-

ized, only one had significant orificialstenosis. Rp in the 5 patients withoutsuch stenosis was 2I-65 units m2 (mean40), breathing room air. Breathing IOOper cent oxygen produced a rise in pul-monary flow in 4 patients, but Rp re-mained severely raised (I4-39 units M2;mean 34) implying inoperability by theabove technique.By contrast, 2 patients whose entire

pulmonary flow traversed a persistentductus arteriosus, had severe ductalstenosis, but lacked the usual continu-ous murmur probably because of in-adequate ductal flow.We conclude that a continuous mur-

mur is an unreliable guide to anatomyor pulmonary resistance in such patients.

Twelve years follow-up aftersurgical correction of Fallot'stetralogy in childhood

Riaz Haider, P. Finnegan, S. Sanchos-Fomos (all introduced), L. D. Abrams,S. P. Singh, and C. G. Parsons

Eight patients have been reassessedapproximately I2 years after one-stagecorrection of Fallot's tetralogy. It hasbeen shown that right atrial mean pres-sure, right ventricular systolic and end-diastolic pressures, pulmonary arterypressure, and pulmonary vascular re-sistance were all essentially normal at



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rest and during exercise. Arterial oxy-gen saturation was within the normalrange. The systolic pressure gradientacross the right ventricular outflowtract was less than 20 numHg at rest inall patients. The right ventricular/sys-temic ratio ranged from 14 to 42 percent. The response of cardiac output toexercise, and the relation between oxy-gen consumption and cardiac outputwere normal. No patient had a shunt atventricular level.By the methods employed we were

unable to show any significant abnor-mality of cardiac function at rest orduring exertion. There was no detect-able difference in the cardiac functionof patients with a competent pulmonaryvalve and those with incompetenceassociated with a prosthetic patch in theright ventricular outflow tract and/orpulmonary artery.

It is concluded that in these 8 patientscardiac function is normal 12 years aftertotal correction of Fallot's tetralogy andthat the prognosis appears to be goodeven when there is residual pulmonaryincompetence.

Late results of fascia latareconstruction of the rightventricular outlet

Fergus J. Macartney, Olive Scott,and Marian I. Ionescu

Twenty previously reported patientswho have survived reconstruction ofthe right ventricular outlet with a fascialata composite graft have been followedfor up to I9 months. All are symp-tomatically improved, with a normalexercise tolerance, requiring no medica-tion. All have pulmonary ejectionsystolic murmurs and three have mur-murs of pulmonary incompetence. Thecardiothoracic ratio on x-ray has re-mained unchanged from before opera-tion in each case.

However, postoperative cardiaccatheterization in 8 patients (6 to i6months after operation) has revealed,in each case, a systolic pressure gradientbetween the right ventricle and pul-monary artery, resulting in a right ven-tricular systolic pressure of 40-I12mmHg. The gradient across the valvegraft varied from 5-70 mm, while thegradient between graft tube and pul-monary artery was o-40 mm. Selectiveright ventricular angiocardiography hasshown satisfactory motion of the fascialvalve cusps in 3 patients, but in 2 thecusps could not be visualized and in 3there was considerable narrowing of the

fascial conduit at the valve site. Pulmon-ary arteriography in one patient re-vealed mild pulmonary incompetence.The value of fascia lata reconstruction

of the right ventricular outlet appears tobe limited by the high incidence of post-operative pulmonary stenosis.

Influence ofextracellular potassiumconcentration on ouabain effects inhuman cultured cells

D. McCall, J. V. Lamb (bothintroduced), and T. D. V. Lawrie

Experiments have been carried out todetermine the effects of prolongedouabain treatment on the ionic contentsof a strain of cultured cells derivedinitially from human right atrium(Girardi et al., I958). Preliminary ex-periments showed that sensitivity tocardiac glycosides was similar to otherhuman tissues. Treatment of the cellswith low concentrations of ouabain, in-cluding those concentrations that wouldbe encountered in clinical practice, forvarying intervals of time from 8 hoursto 5 days, was carried out. The intra-cellular Na rose, and intracellular Kfell, to new steady levels, and these newlevels were linearly related to the con-centration of ouabain used.Reducing the extracellular K con-

centration increased the changes in theionic contents of the cells brought aboutby the low concentrations of glycoside,whereas in the presence of increasedextracellular K concentration the oua-bain had a less obvious effect. Both ofthese effects were significant (P <oooi).At each concentration of K however,the 24-hour ionic levels remained linear-ly related to ouabain concentration.

In a further series of experiments thecells were exposed to tritiated ouabain,in concentrations identical to those usedin the preceding experiments, for 24hours. The amount of glycoside boundat the end of this time was dependent onthe concentration of ouabain used andinversely related to the extracellular Kconcentration.

It is concluded that extracellular Kinfluences the effect of the glycoside bymodifying the amount of the glycosidebound to the cell membrane.

ReferenceGirardi, A. J., Warren, J., Goldman, C.,

and JefEries, B. (1958). Growth and CFantigenicity of measles virus in cellsderiving from human heart. Proceedingsof the Society for Experimental Biologyand Medicine, 98, i8.

Changes in serum and urinarymagnesium levels in patientsundergoing open heart surgery

M. P. Holden (introduced),M. I. Ionescu, and G. H. Wooler

Magnesium is quantitatively the fourthmost important cation in the body aftersodium, potassium, and calcium, par-ticularly in myocardial function. Thereis increasing evidence that divalentcations are essential controlling factorsin the transfer of monovalent ions acrosscellular membranes. For these reasons,we investigated possible changes inserum and urinary magnesium levels inpatients undergoing open-heart pro-cedures.

Fifty patients were studied and a con-trol group of 33 patients undergoinggeneral thoracic operations was investi-gated at the same time.Some patients with mitral disease, in

congestive heart failure and receivingdiuretics, had low serum magnesiumlevels before operation.The serum magnesium levels in all

patients fell during perfusion and re-mained low for the first 3 postoperativedays. The levels in the serum were nor-mal by the time of discharge from hos-pital 2 to 3 weeks later. There was adecreased amount of magnesium in theurine during the first 3 postoperativedays.The biological importance of mag-

nesium and its role in myocardial func-tion was reviewed and the value of mag-nesium therapy discussed. The clinicaleffects of giving magnesium to thesepatients and those undergoing cardio-version was discussed.

'Jet lesion' in aortic valveendocarditis

L. Gonzalez-Lavin (introduced),Jane Somerville, and Donald N. Ross

During the course of infective endo-carditis the aortic valve is frequentlyaffected and becomes regurgitant. Theresulting jet of blood disseminates theinfecting bacteria in a retrograde fashionthat may impinge on the mitral valvewith variable destructive effects andaggravate the already compromised leftventricular function.From June I963 to December I970,

292 patients were operated upon at theNational Heart Hospital for aortic re-gurgitation; in 94 ofthem the regurgita-tion was a result of bacterial endocar-ditis. Of these 94 patients, I9 werefound to have secondary infective in-



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volvement of the mitral valve. This 'jetlesion' may be present in the form ofpitting, ulcerations, vegetations, or per-forations, or in a combination of thesemanifestations and possibly with associ-ated rupture of chordae tendinae. Itspresence has been consistently in theanterior cusp of the mitral valve. Themitral valve lesion can often be correctedwith a conservative procedure, as in I4of the I9 presented patients.An awareness of the frequent co-

existing 'jet lesion' phenomenon inaortic valve endocarditis is essential assurgical attention to both valves is im-perative to achieve a good haemo-dynamic result.

Development of a pump and itsuse in prolonged left ventricularbypass

C. R. W. Gray (introduced) andC. E. Drew

During the past 5 years a ventriculartype pump has been developed, whichis unique in that the ventricle, valves,and cannulae are formed from a singlesilicone rubber moulding. The surfacepresented to blood is smooth, makinganticoagulation unnecessary.The drive system is hydraulic so that

in the event of rupture of a siliconepart, blood can only mix with normalsaline. The control system is pneumaticand permits independent variation ofsystolic and diastolic duration and strokevolume.

Thirty-five experiments have beenperformed on calves. Bypass from leftatrium to aorta was attempted for 24hours. The bypass was then discon-tinued and the animal allowed to sur-vive. Monitoring of blood pressures,blood gases, haematological and bio-

t chemical parameters was performedthroughout bypass. Postmortem histo-logical studies were carried out.

Short cine loops illustrating the modeof action of the pump and its operationduring bypass were shown.A brief reference to the clinical appli-

cation of the pump was given.

Clinical and haemodynamicresults of mitral valve replacementwith Starr-Edwards prosthesis

5T. S. Wright (introduced,E. Wyn Jones, C. S. McKendrick,N. Coulshed, and E. J. Epstein

Clinical and haemodynamic data havebeen analysed on I00 patients who

formed a consecutive series undergoingmitral valve replacement with Starr-Edwards prostheses, models 6I20 (Silas-tic ball) and 6300 (Stellite ball, clothcovered cage). The preoperative find-ings have been correlated with surgicalmortality.

Postoperative catheter studies havebeen carried out on 33 of the 76 sur-vivors. The subjective results, good inabout one-third of cases, have beencompared with the objective clinical,radiological, and haemodynamic find-ings, with often a surprising lack ofpositive correlation.

Obstruction and leakage have beenimportant causes of late failure, and atotal of 8 repeat operations have beencarried out on 6 patients for these rea-sons. Myocardial failure, persistent pul-monary hypertension, and persistenttricuspid regurgitation have all con-tributed to the production of dis-appointing late results, and an attempthas been made to relate these to thepreoperative findings.An appraisal has been made of the

quality of life attained for the survivorsof this operation.

Mitral valve repair: results at 5and Io years

R. _5. Donnelly (introduced),D. R. Smith, M. I. Ionescu, andG. H. Wooler

Results are presented from 46 patientssurviving open conservative surgery formitral valve disease between I957 andI966. At the present time 36 patientshave been traced and reviewed. All 36patients underwent surgery 5 years ormore ago, and I4 of these underwentsurgery I0 years or more ago.

In order to give the results morerelevance to present-day practice, thecases have been divided into those inwhom annuloplasty would be indicatedtoday, i.e. with either a dilated annulusalone or a dilated annulus with minimalcusp and chordal involvement, andthose with what would now be con-sidered poor indications for repair, i.e.with significant cusp and chordaldisease.At 5 years 22 out of 24 patients and at

I0 years 5 out of 6 patients with goodindications for repair were in class I orII of the N.Y.H.A. functional classifica-tion. These results contrasted conspicu-ously with those in which attempts weremade to repair valves with significantcusp disease though a small number ofthese patients have survived withoutfurther operation for I2 and 13 years.

Radiological, electrocardiographic,phonocardiographic, and haemodyna-mic data are presented together with theclinical results.

Mitral valve replacement usingfresh 'unstented' semilunar valvehomografts

Magdi Yacoub, Malcolm Towers, andWalter Somerville

Unstented fresh semilunar valve homo-grafts were used to replace the mitralvalve in i6o patients ranging in agebetween 9 and 70 years. The aorticvalve was replaced at the same time in42 patients and the tricuspid valve in 5patients. The total hospital mortalitywas 8 per cent; there were 2 deaths inthe last 73 single mitral replacements.The indication for operation was severemitral valve disease, unsuitable for mit-ral valvotomy or repair.We believe that mounting semilunar

valve homografts on rigid stents inter-feres with their function. The tech-nique used in this series avoids the useof a rigid prosthesis in the normallymobile mitral ring, preserves the sinusesof Valsalva of the homograft, preventsany protrusion into the ventricularcavity or outflow tract, and excludes allprosthetic material from the circulation.The longest follow-up has been 27

months. There were 6 late deaths un-related to homograft function. Mor-bidity comprised transient haemolyticanaemia (i), and fungus endocarditis(2) requiring re-replacement. Threepatients have residual pulmonary ormyocardial disease. The remainingpatients are improved. Haemodynamicfindings (22 patients) in general supportthe favourable clinical result. Anti-coagulants were not used. There was nothromboembolism or evidence of homo-graft degeneration diring the period offollow-up.

Late results of replacement ofaortic valve in aortic wall disease

A. M. Rowshanzamir, M. P. Singh(both introduced), and H. H. Bentall

Aneurysm ofthe ascending aorta, associ-ated with aortic valve regurgitation, hasbeen treated by replacement of theascending aorta by a graft with trans-plantation of the coronary arteries intothe graft, and simultaneous replacementof the aortic valve in ii patients.Nine patients had Marfan's disease,

one had yaws, and one had syphilis.



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Nine patients are alive and well, eightback at work and one convalescing.The first case in which this new tech-

nique was used was reported in I968,and the follow-up of these patients isdescribed.

Diagnosis of organic tricuspidvalve disease

P. J. Molloy and J. Cleland(introduced)

Thirty-five patients who had tricuspidvalve replacement have been studied.All save one were in the course of mul-tiple valve replacement. Preoperativediagnosis was made in a few cases earlyin the series but became more accuratelater. Principal diagnostic points were,enlargement of the right atrium in theabsence of pulmonary hypertension orfrank congestive failure, the presence ofa raised jugular venous pressure in theabsence of significant left ventricularfailure, and catheter evidence of a tri-cuspid valve gradient. The difficultiesin diagnosis arise in the presence of pul-monary hypertension beyond 50 numHg,atrial fibrillation, and congestive failure.A case is made for operative inspectionas well as digital palpation during opera-tion. All patients who had the valvereplaced had organic disease confirmedhistologically suggesting that organicdisease is commoner than appreciated,and a more aggressive approach to treat-ment is indicated.

Assessment of presence andseverity of ischaemic heart diseaseby measurement of changesinduced by atrial pacing in lactateconcentration in blood fromcoronary sinus

Brian Livesley, Patricia F. Catley (bothintroduced), and Samuel Oram

Under aerobic conditions the myocar-dium utilizes lactate as a substrate. Inpatients with ischaemic heart diseasewhen anaerobic metabolism developsthe lactate concentration of blood in thecoronary sinus exceeds that of thearterial supply. Under these conditionsthe changes in the lactate concentrationcan be small. An accurate enzymaticmethod for estimating lactate nowallows these small changes to be mea-sured. In patients with ischaemic heartdisease atrial pacing can induce acutemyocardial ischaemia. Three groups of

patients have been studied: with ischae-mic heart disease proved, with it sus-pected on clinical grounds alone, andnormal controls.From study of 30 patients our results

indicate that measurement of the chan-ges induced by atrial pacing in the lac-tate concentration of blood from thecoronary sinus provides a reliable semi-quantitative method of assessing theseverity of ischaemic heart disease anddetecting its presence when results ofless sophisticated methods are equivocal.

Venous grafts in treatment ofcoronary heart disease: I. Pre-operative and operative findings

Richard Sutton, Lorenzo Gonzalez-Lavin (both introduced), KeithJefferson, Lawson McDonald, MichaelPetch (introduced), and Donald Ross

Sixty patients with coronary heartdisease were treated by coronary venousgrafts, at the National Heart and Guy'sHospitals up to June I97I. There were53 men and 7 women, aged 37 tO 7Iyears of age, with an average of 50 years.Patients were studied before operationand are now being studied postopera-tively by clinical examination, chestradiography, electrocardiography, sub-maximal exercise tests, atrial pacing,lipid analysis, coronary arteriography,and left ventricular angiography. Theindications for operations were anginapectoris that was resistant to medicaltreatment in 45 patients, cardiac failurein IO, a resistant ventricular dysrhyth-mia in one, and associated 'cardiogenicshock' in 4. The last two indications ledto emergency procedures.

Single vein bypass was performed in25 patients, double vein bypass in 33and the other 2 patients had a triple veinbypass. Twenty-three patients had addi-tional procedures: 8 underwent resec-tion of left ventricular aneurysms, 5had plication or excision of akineticareas, and 7 had surgical correction ofvalvar disease. In 3 an acquired ven-tricular septal defect was closed. Thehospital mortality in those patients whowere treated for resistant angina pec-toris and cardiac failure was 5-5 percent; 3 of the 5 patients, who hademergency operations, died.The place of venous bypass grafts in

the management of coronary heartdisease will be discussed in relation tothe above findings, and in conjunctionwith the postoperative findings on thesepatients.

Venous grafts in treatment ofcoronary heart disease: H. Post-operative findings

Charles Smithen (introduced), EdgarSowton, John Dow, and Donald Ross

Ten patients who had venous bypassoperations for severe angina pectoriswere reinvestigated from 3 to 6 monthsafter operation. In 9 patients there wassignificant clinical improvement and 8were totally free from pain despite ex-tensive physical exertion. All thesepatients had at least one graft patentand functioning well, with good distalrun-off: the last had no clinical improve-ment and both grafts were blocked.Nine patients had no angina pectoris

or ST segment depression during maxi-mal exercise; the last was the patientwith no functioning graft. The meantotal work performed during the exer-cise test increased by i86 per cent froma mean of 137I kpm before operation toa mean of 3786 kpm after (P <o0o5), andthe mean heart rate, at limiting effort,increased by 38 per cent from I13/minbefore operation to I56/min after(P <o0os).

In 7 patients studied by atrial pacingbefore operation angina pectoris andST segment depression averaging I 7mm occurred at a mean heart rate ofI3o/min. After operation no anginapectoris or ST segment depression wasinduced in 6 of the patients.The resting left ventricular end-

diastolic pressure after operation did notincrease with atrial pacing in 9 patientsbut was raised in 3.

Resection of left ventricularaneurysm

B. N. Pickering, John Graber (bothintroduced by John Goodwin),H. H. Bentall, W. P. Cleland, D. Ross,M. Yacoub, and A. K. Yates

Resection was carried out in 48 patientswith left ventricular ischaemic aneu-rysm. There were 6 hospital deaths.The follow-up of the first 26 patients inthe series was submitted to actuarialanalysis which showed an 88 per centsurvival rate at i year after resection anda 71 per cent survival rate 5 years afterresection.

Detailed study of 23 patients fromHammersmith Hospital showed thatthe usual indication for operation wassevere disability from persistent left 'ventricular failure (in 22 out of 23patients). Intractable angina (in 8 pa-tients), repetitive dysrhythmia (in 5



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patients), and systemic embolization (in3 patients) provided additional indica-tions for resection.Aneurysm of the left ventricle or a

large akinetic area can gravely depresstotal left ventricular function. Resectionof the non-contractile area with reduc-tion in cavity size is followed by a mostgratifying fall in the raised left ventricu-lar end-diastolic pressure with sub-sequent relief of failure and angina.The diagnosis of aneurysm was con-

firmed by angiocardiography but clini-cal suspicion ofaneurysm was alerted bythe finding of an abnormal apex impulse(io patients), gallop rhythm (in all 23patients), a suggestive bulge on chestradiography (12 patients), and prema-ture mitral valve closure on the echo-cardiogram (5 out of 7 patients).

It is now policy to carry out selectivecoronary arteriography as part of thepreoperative investigation, and in the 13patients in whom this information was

available the anterior descending branchof the left coronary was diseased in all,but in addition the circumflex was in-volved in 6 patients and the right coron-ary artery in another 6 patients.

Close study of the severe haemo-dynamic derangement was made in IOpatients. This has confirmed the valueof surgical treatment in selected casesand should be combined with aorto-coronary vein bypass grafting to adjacentterritories when indicated.



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Documents

Heart Journal, 20I-209. Proceedings British Cardiac · Paediatric Cardiology presented addi-tional difficulties, but should include 2 years' adult cardiology and 2 years' paediatric