Proceedings the British Cardiac Society · Proceedingsofthe British Cardiac Society 609...

British Heart Journal, I971, 33, 607-6I6.

Proceedings of the British Cardiac Society

THE FIFTIETH ANNUALGENERAL MEETING of the BritishCardiac Society was held in the ArtsTower, University of Sheffield, onWednesday and Thursday, I4 and I5April I97I. The President, SIR JOHNMcMICHAEL, took the Chair at 9.ooa.m. during Private Business beforehanding over to the Chairman, T. E.GUMPERT.

Private Business

i The Minutes of the Annual GeneralMeeting having been published in theJournal (1971, 33, 142-I5I) were takenas read and confirmed.

2 The Treasurer reported that theincome of the Society was now£i,988.9.9, which was derived from£135s.4.9 in investment interest andCi,853.5.-. in members' subscriptions.By 1972, the full membership of theSociety would be reached, and unless itwas decided to enlarge the Society, theincome would be constant at £I,890per annum.

Expenditure in the last year was£1,307. 10.9., consisting of £279.7.4. onmeetings; £548.4.6. on secretarial assist-ance; £i82.i2.-. on printing and sta-tionery; £i89.6.-. on subscriptions toother societies, International Society ofCardiology, European Society of Cardi-'ology, etc.; £82.i9.II. on sundrygeneral expenses; and £25.4.-. to theSociety's Auditor. The cost of meetingswas £I4.12.8. less than in I969, butsecretarial assistance was up by £47.4.6.,and printing and stationery by £79.I2.-.

Despite the steadily increasing cost ofrunning the Society with its developing?activities, it had been possible to main-tain a steady excess of income over ex-penditure each year, and it was hopedthat this would continue, especially inview of the new investment policy.The Congress Fund had been merged

with the General Fund, and on therecommendation of the Finance Sub-Committee, new investments had beenmade. The Treasurer expressed histhanks to Michael Oliver, Marquis, andEmanuel for their advice. Since theSociety was able to meet its commit-ments from subscriptions without call-ing upon investment income it was feltessential to invest the General Fund in

maximum growth stock to ensure appre-ciating assets of the Society as a buttressagainst inflation. Accordingly, afterseeking Broker's advice, the followingreinvestments were made:

Conversion Stock 197I and I974 wassold, and the proceeds, plus £500 fromthe General Fund, invested in -950 Charifund Units ( £170.2.-. and

1,620 Scotexempt Growth ( £i06.5.-,to a total of £1,758.The donation from the VI World

Congress of CIo,ooo was invested inequities designed for maximum growthalso, as follows -700 de Beers Consolidated Mines (

232p.39o Barclays Bank ( 4I5p.44o Shell Transport& Trading Ordin-

ary ( 333P.6oo Rio Tinto Zinc @ 245sp.

2,750 Witan Investment Trust 25p.Ordinary @ 72jp.

The interest from the investmentswould help to defray increased costs ofrunning the Society in future years,while the principal should afford a soundfinancial backing for the Society. Whenthe financial commitments for next yearhave been evaluated, it should be pos-sible to invest more from the GeneralFund.The capital of the Thomas Lewis

Lecture Fund was reinvested in BassCharrington 81 per cent DebentureStock I987-92, which should yield£107 per annum instead ofthe C60.I7.-.currently. The stock was chosen pri-marily for maximum interest rates inorder to provide an increased sum to paythe biennial lecture fees and expenses.

3 The following resignations on retire-ment were accepted -

Hosford and Pearson.4 Sir John McMichael was re-electedPresident of the Society.

5 Malcolm Towers was elected Trea-surer of the Society on retirement fromthis office of John Goodwin.6 The following two new Members ofCouncil were elected in place of MichaelOliver and Lawson McDonald: Johnsonand Hollman.

Semple was co-opted to the Councilto represent the Scottish members,under Rule 21.

7 Jean Lequime of Brussels and C. K.Friedberg of New York were electedHonorary Members of the Society.

8 Donald Fredrickson of the NationalInstitutes of Health, Bethesda, U.S.A.,and Z. Fejfar of the World HealthOrganization were elected CorrespondingMembers.

9 The following new Ordinary Mem-bers were elected: Allen Keith Brown,Lancaster; Michael James Godman,Edinburgh; John Andrew Kennedy,Glasgow; Dennis Michael Krikler,London; Andrew Ross Lorimer, Glas-gow; Fergus James Macartney, Leeds;Brian Maurer, London; Patricia Mor-ton, Belfast; Rosemary L. Radley-Smith, London; Peter Carew Reynell,Bradford; Owen Conor Ward, Dublin;Alan Kenneth Yates (SM), London;and from Overseas Membership: L. A.G. Davidson.

io Gerald S. Humphreys of Jamaicawas elected to Overseas Membership;Segal and Binnion were elected fromOrdinaryMembership,andthefollowingwere re-elected: Hywel Davies, Fulton,Harries, Parry, Rahimtoola, Resnekov,Seymour, Somers, and Wilson.

II The Secretary reported that therewere 9 vacancies before the total of 300Ordinary Members was reached. Theage composition ofthe Society suggestedthat there would be a considerable num-ber of retirements in the next few years,and it was agreed to make no alterationto the Rules with regard to the totalnumber of members at this time.

I2 The Autumn Meeting of the Soci-ety would be held at the Royal CollegeofPhysicians on4and 5 November I97I.

13 The Annual General Meeting in1972 would be held in Dublin onThursday, 23 March.

14 Goodwin said that the Report ofthe Cardiology Committee of the RoyalCollege of Physicians of London on theCareer Structure in Cardiology had beenpassed by the Comitia of the Collegeand by the Council of the Society andthat copies had been circulated to allmembers. Following this the report had

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6o8 Proceedings of the British Cardiac Society

been sent by the College to the BritishMedical Journal, The Lancet, the De-partment of Health and Social Security,and The Times.

iS Goodwin reported that the RoyalColleges of the United Kingdom andIreland, and the Association of Pro-fessional Heads of Departments ofMedicine and Paediatrics had set up aJoint Committee on Higher MedicalTraining. This Committee would beadvised by Specialist Advisory Com-mittees representing each specialty. TheSpecialist Advisory Committee on Car-diology consisted of Gray and HamishWatson (nominated by the Joint Com-mittee) and Ball, Walter Somerville,Whitaker, and Goodwin (nominated bythe British Cardiac Society). Goodwinhad convened a meeting of the Com-mittee after the Scientific Session onThursday, I5 April, when the trainingrequirements for cardiologists would bediscussed in the light of the recommen-dations of the Cardiology Committee ofthe Royal College of Physicians of Lon-don and the Cardiology Committee ofthe Scottish Colleges. Goodwin saidthat the Society should be kept in touchwith all the Committee's decisions andasked for any views to be expressed tohim as Convenor of the Committee.The President pointed out that it was

important to avoid too rigid criteria foraccreditation or registration of special-ists being laid down so that promisingpeople with an unorthodox approach tocardiology should not be excluded.Melville Arnott said that one of the pur-poses of accreditation might be to antici-pate the needs of the European Econ-omic Council if Britain went into theCommon Market.

I6 The memorandum on the relationof the British Cardiac Society to boththe European and International Soci-eties of Cardiology, circulated by Coun-cil, was discussed in detail, and Oliverand Watson reported on the activities ofthe International Society of Cardiology.It was agreed that the objectives of theSociety were worth supporting. Dis-quiet was expressed over the inter-national bodies, particularly the lack ofaudited accounts, but it was agreed thatthe British Cardiac Society should con-tinue its membership in an effort to im-prove the arrangements.

17 Davison reported on negotiationshe had had, in conjunction with Oram,with the Society of Cardiological Tech-nicians, regarding the pay and condi-tions of their members. It was reported

that the Unions involved had agreed aninterim pay increase of approximately12 per cent linked with an understand-ing that cardiological technicians' payscales would be related to those ofmedi-cal physics technicians within sixmonths. It was thought desirable topress for special recognition of the needsfor an adequate salary scale for the lesswell-trained cardiographers who wereresponsible for most routine work inhospitals, and also for appropriate pro-vision for an adequate career structureat the upper end of the salary scale forfully-trained technicians in supervisoryposts. Davison reported that he andOram were seeking an interview with theMinister to press for urgent implemen-tation of these requirements prior to thefull application of the ZuckermanReport.

I8 The Secretary reported that mem-bers could take either the British Heartjournal or Cardiovascular Research inthe combined subscription, now £8-50per annum; but notice of any changefrom one journal to the other must begiven before i June each year, as ex-plained in the notice recently circulated.

The Society dined together at Ran-moor House, in the University, theprincipal guest being Professor SirCharles Stuart-Harris, C.B.E. ThePresident, Sir John McMichael, paidtribute to each member of the Organiz-ing Committee of the VI World Con-gress of Cardiology, and a specialpresentation from the Society was madeto Shillingford in recognition of hiswork as Chairmnan of the OrganizingCommittee of the Congress. Gumpertthanked the local organizers.

Addressing a medical meeting:effect on heart rate, electrocardio-gram, plasma catecholamines,free fatty acids, and triglycerides

Walter Somerville, Peter Taggart, andMalcolm Carruthers (both introduced)

Many persons when speaking before anaudience experience a rapid forcefulbeating of the heart - often described as'nerves' by the layman. To investigatethe behaviour of the heart under thesecircumstances, observations have beenmade to find out the effect of addressinga medical meeting on the heart rate,electrocardiogram, plasma catechol-amines, free fatty acids, triglycerides,and cholesterol.

Immediately before speaking, theheart rate increased to I00-12o, reached150-170 while speaking and fell to I20

during question time. Electrocardio-graphic changes consisting of flatteningof T waves and depression of ST werecommonly recorded during the maxi-mum tachycardia, subsiding to the pre-speaking pattern with the subsidenceof the tachycardia.Plasma catecholamines (noradrenaline

and adrenaline) were usually raised atthe end of the address, sometimes todouble the resting level. Noradrenalineaccounted for the greater part of the in-crease. Free fatty acid levels were invari-ably raised immediately after speakingand, in some subjects, immediatelybefore the address. There was a moregradual rise in triglycerides, reaching apeak one hour after speaking. Chol-esterol levels were normal and showedno change throughout.

Failure of high blood free fattyacid concentrations to provokeventricular arrhythmias in experi-mental coronary artery occlusion

L. H. Opie, R. Norris, A. Holland,P. Owen (last three introduced), andM. Thomas

In patients with acute myocardial infarc-tion, the highest blood free fatty acidvalues are associated with the highestincidence of serious arrhythmias. Were-examined the possible toxicity ofhigh plasma free fatty acid concentra-tions in experimental coronary arteryocclusion. The anterior descendingartery or one of its branches was ligatedin 27 open-chested dogs. In i5 dogsligation was followed by administrationof heparin-Intralipid. In 6 experiments,heparin-Intralipid was infused both be-fore and after arterial ligation. In 6experiments, multiple ventricular ecto-pic beats after initial arterial ligationwere provoked by further ligation or byintermittent infusions of adrenaline(about 12 Fg/kg/min); plasma freefatty acid levels were then rapidly raisedand kept high by continued heparin-Intralipid administration. In no casewas it clear that high plasma free fattyacid concentrations (mean: 5ooo ,IEq/l.)provoked or exaggerated ectopic activityeven though the site and size of arterialligation, multiple ligations, and adrena-line infusion were designed to lead toarrhythmias. Of all 27 dogs, ventriculartachycardia or fibrillation occurred inonly 3. Our experiments thereforeargue against the importance of the roleof high plasma FFA concentrations orthe administration of heparin in thegenesis of serious arrhythmias aftercoronary artery occlusion.



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Effect of prolonged exercise onmyocardial metabolism in man

B. W. Lassers, L. Kaijser, M. Wahl-qvist, and L. A. Carlson (last threeintroduced)

Coronary sinus catheterization withmeasurement of arterial-coronary sinusconcentration differences of varioussubstrates and calculation of oxygenextraction ratios was used to study theeffect of 2 hours of supine leg exerciseat an average work load of 500 kp m/minon myocardial metabolism in I5 healthyfasting men. A continuous infusion ofalbumin-bound 3H-palmitate was givento provide a tracer for the plasma freefatty acids. Chemical and isotope meas-urements were made at rest and duringthe final minutes of exercise.

Exercise produced a significant fall inthe average arterial concentration ofglucose, large increases in the concen-trations of lactate, pyruvate, free fattyacid, and free glycerol but no significantchange in plasma triglyceride concen-tration. Coronary sinus oxygen satura-tion fell significantly.

Prolonged exercise produced no sig-nificant change in the myocardial RQ.There was a fall in the oxygen extractionratio for glucose and a rise in that forlactate, with little change in the totalratios for carbohydrate substrates. Theoxygen extraction ratios for plasma tri-glyceride did not change significantly.The free fatty acid oxygen extractionratio calculated from isotopic measure-ments fell significantly. Thus, duringprolonged exercise in the fasting state,the principal plasma energy substrate,as estimated by the oxygen extractionratio, was lipid, though its contributionrelative to plasma carbohydrate fell.Exercise was also accompanied by ahighly significant release of free glycerolinto the coronary sinus suggestinghydrolysis of considerable amounts ofcardiac triglyceride.

Effects of transient occlusion ofcoronary circulation on catechol-amine and electrolyte gradients inhuman atrium

Peter Taggart, J. D. H. Slater, M. E.Carruthers (all introduced by WalterSomerville), and I. K. McMillan

One, two, or three atrial biopsies weretaken from each of a group of 14 patientsundergoing cardiopulmonary bypassoperations with intermittent occlusionof the coronary circulation at varioustimes during the procedure. The biop-

sies have been analysed for noradrena-line, adrenaline, sodium, potassium,chloride, total H20, and extracellularfluid volume.The expected loss of intracellular

potassium (K,) and gain of intracellularsodium (Na,) were found to be linearlyrelated to the length of occlusion. TheNa, gain was less than the K, loss. Theextracellular fluid volume increasedconsiderably with a corresponding de-crease in intracellular fluid. A significantrelation was seen between loss of K,and loss of tissue catecholamines, withrising plasma catecholamine levels.The accumulation of Ko during the

occlusive period, which is not washedaway, together with the net loss of intra-cellular crystalloid, may be responsiblefor the redistribution of water. Such anoedematous state may be reached whenareas of muscle become resistant to re-perfusion for purely mechanical reasons,and a vicious circle is established. Theconsequences in terms of theoreticalmembrane potential and action poten-tial characteristics, arrhythmias, the lowoutput syndrome, and possible simi-larities in ischaemic heart disease arediscussed.

Surface mapping of the RS-T seg-ment in acute myocardial infarc-tion and effect of beta-blockade

D. S. Reid, L. J. Pelides (bothintroduced), M. Thomas, andJ. P. Shillingford

Electrocardiograms were recorded from72 standard points on the surface of thechest of patients with acute myocardialinfarction. These records allowed theconstruction of surface maps of thedeviation of the RS-T segment from theisoelectric line. Such surface maps weredrawn at regular intervals during thecourse of the patient's acute illness andduring convalescence. With the aid ofthese two-dimensional maps, the naturalhistory ofthe evolution of the RS-T seg-ment in acute myocardial infarction wasdescribed more completely than thestandard electrocardiogram allows. Dif-ferent patterns of evolution were foundand in some instances an ischaemic areawas identified when the standard elec-trocardiogram was normal. The effectson the RS-T segment of the beta-blocking drug practolol were studied.After an intravenous injection of I0-20mg practolol, the area and the maximumheight of the RS-T segment elevationwere reduced. We conclude that practo-lol interferes with the ST segment eleva-tion associated with acute myocardial

infarction in man. Therefore possibletherapeutic benefit to the ischaemicmyocardium should be considered.

Beta-blockade in experimentalmyocardial ischaemia: metabolicand electrocardiographic effects

M. Thomas, R. Norris (introduced),L. Opie, G. Shulman and P. Owen(both introduced)

The effects of beta-blocking drugs onelectrocardiographic and metabolicchanges in acutely ischaemic myocar-dium were investigated in greyhounddogs. Plasma potassium, inorganic phos-phate, glucose, free fatty acids, andblood lactate and pyruvate were meas-ured in arterial, coronary sinus, andlocal coronary venous blood before andafter coronary artery ligation. Theeffects of beta-blocking drugs on themetabolic parameters were comparedwith the effects on ST segment eleva-tion shown by epicardial electrocardio-gram leads over the ischaemic area.

In other experiments, blood flowthrough the anterior descending coron-ary artery and the great coronary veinwas measured with electromagneticflow meters before and during constric-tion of the anterior descending coronaryartery. Arteriovenous differences forlactate and haemoglobin oxygen satura-tion could therefore be used to quanti-tate lactate output and oxygen utiliza-tion by the ischaemic myocardium.

Propranolol, practolol, and other beta-blocking drugs were shown to limit epi-cardial ST segment elevation. However,discharge of potassium, inorganic phos-phate, and lactate from the ischaemicarea into local coronary venous bloodindicated severe myocardial metabolicdamage. The data therefore questionthe use of epicardial ST segment eleva-tion as sole index of the severity ofischaemic damage in these circum-stances.

Clinical significance of minorabnormalities of ST segment andT wave

David Short

Abnormalities of the ST segment or Twave, too slight to be included in theMinnesota Code, are frequently en-countered in patients with suspectedcoronary disease. Thus, there were 272such cases among IooO electrocardio-grams recorded in the course of an



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electrocardiogram reporting service forfamily doctors in Aberdeen. Such ab-normalities are widely considered to beof little significance. To test this im-pression, the case records of 250 pa-tients with similar electrocardiograms,examined personally by the author, wereanalysed. They were selected fromapproximately 3000 patients with sus-pected cardiovascular disease, seeninitially either at outpatient or domicil-iary consultation. i58 (63%) were foundto have convincing evidence of coronaryheart disease, either acute or chronic (ina number of cases this diagnosis was notestablished for days or weeks after theelectrocardiogram showing the minorabnormality); 44 (I7'5%) had left ven-tricular hypertrophy; 32 (13%) hadmiscellaneous conditions such as acutebenign myocarditis or paroxysmal tachy-cardia; and in i6 (6j5%) the diagnosiswas uncertain.Minor abnormalities of the ST seg-

ment and T wave must, therefore, beregarded as strong evidence of heartdisease.

Dermatoglyphs in congenital heartdisease

T. J7. David (introduced byD. W. Barritt)

A previous study of finger and palmprints (dermatoglyphs) in patients withcongenital heart disease has shown thatcertain fingerprint patterns are associ-ated with familial cases of congenitalheart disease (David, I969). A furtherstudy has resulted in the finding of anassociation between a rare specific mid-line palmar dermatoglyphic abnormal-ity, a double proximal axial triradius(DPAT), and two congenital malforma-tions of midline structures, ventricularseptal defect and Meckel's diverticulum.

No. of No. %patients with patients

DPAT withDPA T

Ventricular septaldefect 63 8 12-7

Atrial septal defect 6o I I-7Other congenital

heart disease 2Io 0 0Meckel's diverti-culum 23 3 13.0

Other congenitalmalformations 52 0 0

Controls 1059 5 0 47

None of the patients with ventricularseptal defect were known to have aMeckel's diverticulum. A DPAT wasfound to be associated only with ventri-cular septal defect and Meckel's diver-ticulum, and the only common factor

to these malformations is that they in-volve midline structures (cardiac sep-tum and small intestine). It is thoughtthat this finding may give a clue to thenature of the embryonic disturbance inthese two defects.

ReferenceDavid, T. J. (I969). Fingerprints in con-

genital heart disease. Bristol Medico-Chirurgical_Journal, 84, I67.

Presentation and natural historyof Eisenmenger syndrome

Katherine A. Hallidie-Smith,R. Tortoledo (introduced), andJ. F. Goodwin

Forty patients diagnosed as having theEisenmenger syndrome have been in-vestigated at Hammersmith Hospitalover the past I3 years, the diagnosticcriteria being based on those of Wood(1958). The anatomical diagnoses wereventricular septal defect (24), atrial sep-tal defect (6), persistent ductus arterio-sus (7), truncus arteriosus (2), and totalanomalous pulmonary venous drainage(i). The earliest age of confident diag-nosis of Eisenmenger syndrome was 3years (ventricular septal defect) and theoldest 44 years (atrial septal defect).The characteristic presentation of

patients with ventricular septal defectwas with symptoms of a high pulmonaryblood flow in infancy with a relativelynormal early childhood. Those with per-sistent ductus arteriosus became shortof breath in early life while those withatrial septal defect presented in adultlife with arrhythmias, headaches, syn-cope, chest pain, and haemoptysis,which were common to all groups.The patients were relatively unre-

stricted by their symptoms until shortlybefore death and were able to undertakea wide range of occupations. Two hadlive babies with one maternal death.I0 patients have died at a mean age of37 years. Persistent ductus arteriosuscarried the worst prognosis, 6 of the 7patients having died; and ventricularseptal defect the best, accounting foronly i death in 24 patients.

This analysis suggests that the Eisen-menger syndrome is not present atbirth, develops later, and that the prog-nosis, though severe, permits survival inreasonable health to near middle age inmany.

ReferenceWood, P. (1958). The Eisenmenger syn-

drome; or pulmonary hypertension withreversed central shunt. British MedicalJournal, 2, 70I.

Auscultatory and phonocardiogra-phic findings in Ebstein's anomaly:correlation of first heart soundwith ultrasonic records of tricuspidvalve movement

Thomas L. Crews, Ronald B. Pridie,Ramsey Benham (all introduced), andAubrey Leatham

Heart sounds and murmurs have beenanalysed by multichannel phonocardio-graphy in io patients with Ebstein'sdisease.Remarkably wide splitting of the first

sound was heard and recorded in everycase and attributed to electrical andmechanical delay of the tricuspid com-ponent of the first sound. Wide splittingof the second sound in 4 patients wasattributed to delay of the pulmonarycomponent from right bundle-branchblock; in the remaining 6 patients P2could not be recorded presumably be-cause of low pulmonary artery pressure.A high frequency diastolic sound washeard and recorded from the lower leftsternal edge in 5 patients and attributedto opening of the tricuspid valve. Ven-tricular filling sounds, pansystolic andatrial systolic murmurs were present inmost cases.

Ultrasonic echograms were made in 6of the I0 patients and it was possible torecord from both the mitral and tricus-pid valves in each case. Simultaneousrecords of valve movements, the phono-cardiogram, and electrocardiogram wereobtained in 3 subjects. In every case tri-cuspid closure was much later than mit-ral and coincided exactly with the de-layed component ofthe first heart sound.Thus abnormally wide splitting of the

first sound proved to be the most con-stant auscultatory sign of Ebstein'sdisease and was shown to coincide ex-actly with greatly delayed closure of thetricuspid valve as displayed by ultra-sonics.

Palliative treatment of transposi-tion of great arteries

Michael Tynan (introduced byR. E. Bonham Carter)

Eighty infants with transposition of thegreat arteries had balloon atrial septos-tomy: 50 were under i month of age.There were no incidental cardiac in-juries. The hospital mortality rate of 24per cent (I9 deaths) and the late mor-tality rate of 20 per cent (I6 deaths)include deaths following additionalpalliative operations for associated car-diovascular lesions. Calculated survival



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rates were 75 per cent at 6 months ofage and 49 per cent at 21 years of age.Arterial oxygen saturation: preopera-tively 2 populations were identified withmean values of 35 and 45 per cent re-spectively; immediately after balloonatrial septostomy only one populationwas identified, with a mean value of 65per cent (75 cases, SD 14). Late investi-gation in 57 cases revealed a fall in themean arterial oxygen saturation from 65to 59 per cent (SD io). This differencewas significant, P < 002.These results will be compared to the

results of surgical septostomy showingthat balloon atrial septostomy provideda short-term advantage in survival, butthe long-term results were similar forboth forms of treatment. It is suggestedthat the best prospect for survival intransposition of the great arteries isgiven when balloon atrial septostomy isfollowed by early total correction.

Results of 'inflow correction' fortransposition of great arteriesEoin Aberdeen (introduced), R. E.Bonham Carter, G. R. Graham,7. F. N. Taylor, M. J. Tynan, andD. J. Waterston (last three introduced)The results of inflow correction fortransposition of the great arteries in II2consecutive patients were presented.The increased operative risk when thislesion is accompanied by ventricularseptal defect, pulmonary stenosis, or bybanding of the pulmonary artery wasdemonstrated.The immediate and possible long-

term problems after inflow correctionwere viewed in the light of observa-tions made in the postoperative period.

Blood velocity measurements inaortic regurgitation using heatedthin film and ultrasonic techniquesD. S. Tunstall Pedoe (introduced byP. Sleight)Direct measurement of the regurgitantfraction of left ventricular output inaortic regurgitation is possible only atthe time of valve surgery using cuffelectromagnetic flow meters or byspecialized angiographic techniques.

Early attempts to measure the amountof reverse flow velocity using velocitycatheters in the ascending aorta in 7patients were unsuccessful because ofthe turbulent eddies in the flow and lackof knowledge of the velocity profilesclose to the valve.A transcutaneous directional Doppler

Ultrasound Flowmeter with a stableflow zero (SOPHIA I35) has been usedto measure blood velocities in the most

central accessible artery, the subclavian.A characteristic velocity trace showingexcessive reverse flow has been foundin all ofmore than 25 patients with aorticregurgitation so far examined, and thegrading of the severity of the regurgita-tion from the Doppler record has corre-lated well with radiographic assessmenteven in the presence of mitral valvedisease.

Serial records can be obtained, andthough the technique displays the bloodflow velocity rather than the volumetricflow, these preliminary results suggestthat this non-invasive technique may bea valuable method of assessing the de-gree of aortic regurgitation.

Replacement of aortic valve withunsupported fascia lata: report ontechnique and results in 43 cases

D. N. Ross, A. K. Yates and J. E. C.Wright (both introduced)The prosthetic valves in current usehave certain disadvantages. For thisreason it has been the policy of theauthors to pursue a research and de-velopment programme for valve replace-ment with biological tissue.The good long-term results achieved

by Ake Senning led to the use of fascialata as a cusp substitute. However, theresults proved disappointing when usedmounted on a rigid frame. The presentvalve was designed to be inserted in theaortic position easily and reliably, butwithout the disadvantage of a metalsupport.

Research by A. K. Yates involving de-tailed anatomical measurements of theaortic root and cusps in the human heartestablished that there was a significantcorrelation between the aortic rootdiameter, aortic sinus diameter, andmean commissure height.As a result of this, two designs of un-

supported fascial valves have been usedand both will be described. During thepast year 43 aortic valves have beenreplaced using this technique.The majority of cases were reinvesti-

gated by cardiac catheterization andangiocardiography after operation.

Comparison of clinical and haemo-dynamic results of mitral valvereplacement with fascia lata graftsand Starr-Edwards prosthesis

S. H. Taylor, M. Galvin, P. A. Majid,J. B. Stoker (last three introduced),R. J. Linden, W. Whitaker, D. R.Smith, M. I. Ionescu, D. A. Watson(introduced), and G. H. Wooler

A randomized trial of the results of mit-ral valve replacement with two types ofprosthesis was designed. After pre-operative haemodynamic investigation,patients with isolated mitral valve dis-ease unsuitable for valvotomy were re-ferred by random selection to one oftwosurgical teams, one of whom practisedframe-supported fascia lata and theother cage-ball prosthesis replacementof the mitral valve. All patients werereviewed six months after operation andthe first nine patients in each groupwithout evidence of regurgitationthrough or around the artificial valvewere restudied.

All patients claimed improvement inexercise capacity after both types ofvalve replacement. There were no con-sistent changes in radiological heart size,or in the electrocardiogram.Haemodynamic studies showed no

statistically significant change in heartrate, stroke volume, or cardiac outputeither at rest or during exercise aftervalve replacement with either prosthesis.After fascia lata graft replacement therewas a significant reduction in the pul-monary arterial and wedge pressuresand pulmonary vascular resistance bothat rest and during exercise, though allthree variables remained high duringexertion. After replacement of the mit-ral valve with cage-ball Starr-Edwardsprosthesis, there was a reduction in bothpulmonary pressures in 6 of the 9patients at rest and during exercise,particularly in those in whom the pres-sures were highest, but the mean chan-ges in the group as a whole were notstatistically significant.

It is concluded that while both typesof valve appear to offer a considerablesymptomatic benefit the full-flow typeof valve affords the best haemodynamicresult. However, even these valves offeronly partial haemodynamic remission inthat the stroke volume and cardiac out-put are still impaired and pulmonarypressures remain considerably raisedafter operation, particularly during exer-cise. Evidence is presented which sug-gests that continued obstruction at themitral orifice probably plays an impor-tant role in the continued haemo-dynamic impairment after fascia latareplacement.

Pulmonary autograft for aorticvalve disease; late haemodynamicresultsG. Gregory Sachs (introduced),Jane Somerville, Richard Emanuel,Lawson McDonald, and Donald RossThe first 43 survivors who had pulmon-ary autograft replacement for severe



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aortic valve disease between July I967and October I969 have been studied I4tO 43 months later. In all, the removedpulmonary valve was replaced by astored aortic or pulmonary homograft.

Patients were aged 13-56 years andwere not placed on long-term anti-coagulants nor was there evidence ofsystemic or pulmonary emboli. 36 ofthe 43 were symptomatic before opera-tion and 29 have maintained improve-ment; 5 were unchanged and 2 deterior-ated due to gross aortic regurgitation;one of these has died and the other hadreoperation.Of the 43, 27 have been studied by

right and left heart catheterization. Sys-tolic gradients across the aortic valve(autograft) were rare and when presentwere not above I0 mmHg. Resting sys-tolic gradients across the right ventricu-lar outflow tract (homograft) werepresent in 14, varying from 5-25 mmHgin 12, and from 40-60 mmHg in 2.Mild angiographic pulmonary (homo-

graft) regurgitation was common butwas severe in only 2. Angiographicaortic (autograft) regurgitation was tri-vial in I4, moderate in 9, and severe in 4.There was no late onset of importantaortic regurgitation and in those whowere shown to have this, it was usuallypresent early in the postoperativeperiod. Pulmonary autograft valve func-tion appeared to be well maintained overa 3-year period.

Development of autonomic neuralresponses in human heart

D. J. Coltart, B. A. Spilker, and S. J.Meldrum (all introduced by J. Hamer)

Human foetal myocardium seems asuitable tissue for electrophysiologicalstudies, since it provides normal myo-cardium which should show a specifichuman response. To date, study of thehuman cardiac action potential has beenrestricted to records obtained in situduring cardiac surgery with flexiblemicroelectrodes, and in vitro using smallpieces of excised atrium or ventricle.These studies are limited since the heartis often hypothermic for operativereasons and usually damaged by rheu-matic fever or other diseases.We have studied the electrophysio-

logical responses of I7 hearts excisedfrom human foetuses of between I2 to22 weeks gestation using a microelec-trode technique. Inotropic dose-response relationships were determinedto cholinergic and adrenergic agents.The action potential of the foetal

myocardium shows widespread pace-

maker activity which is found only inthe sinuatrial node and Purkinje tissueof the adult heart. The inotropic re-sponse to carbamyl choline developsbefore any electrophysiological eventappears. The foetal tissue is less sensi-tive than the adult myocardium in itscontractile response to both cholinergicand adrenergic agents. A gradual ma-turation of the contractile response tonervous stimulation in the foetal myo-cardium is evident as gestation pro-gresses.

Measurements of sinus impulseconduction from electrogram ofbundle of His

S. Bekheit, J. G. Murtagh, P. Morton(all introduced), and E. Fletcher

A catheter technique for recordingbundle of His activity using an electrodecatheter introduced percutaneously intothe femoral vein is described.The results of measurements of sinus

impulse conduction in 20 patients fromthe bundle of His electrogram will bepresented. They illustrate that the PRinterval of the surface electrocardio-gram represents the delay in transmis-sion of the sinus impulse in the atrium,AV node, and between the bundle ofHis and the ventricles. Slight variationin the PR interval of the standard elec-trocardiogram occurred, but the con-duction time from the bundle of His tothe onset of ventricular septal activation(HV interval) remained constant.

It is concluded that in normal sinusconduction changes in the PR intervalalways take place above the bundle ofHis. The technique of obtaining thebundle of His electrogram is simple andreliable. It should be of practical valuein defining the mechanism of conduc-tion disturbances above and below thebundle of His and provide a basis forthe introduction of new nomenclatureof deflections due to electrical activityin the conducting tissues.

Analysis of heart block andarrhythmias by bundle of Hiselectrograms

Charles Smithen (introduced) andEdgar Sowton

Bipolar electrograms of cardiac activityin the bundle of His have been recordedin a series of patients with normal atrio-ventricular conduction, in patients withcomplete heart block and in patients

with rapid supraventricular tachycar-dias.Measurements were made of the fol-

lowing intervals: P-His interval repre-senting atrial and AV nodal conduction;His-Q interval representing the intra-ventricular conduction time and His-Sinterval representing the total intra-ventricular conduction.

Increasing prolongation of the P-Hisinterval was produced by atrial pacingin ten patients, the mean P-His intervalincreasing from I53 msec at go beats/min to I98 msec at I20 beats/min(P < ooi). This represents proximalblock since there was no change in theHis-S interval.

In patients with complete heart blockthe P-His interval was normal, signify-ing that the block was intraventricularand not in the AV node. A normal P-Hisinterval with a prolonged His-Q intervalwas found with right bundle-branchblock and left anterior hemiblock, indi-cating delayed conduction down the leftposterior bundle only.The technique was used to differen-

tiate re-entry tachycardia in a patientwith antegrade but no retrograde con-duction through the His bundle, froman ectopic atrial tachycardia with nor-mal conduction through the bundle ofHis as found in other patients. The useof His bundle recordings provides aneffective method of differentiating dys-rhythmias including aberrant conduc-tion and ventricular ectopic beats.

Expectation of life of pacemakerwith note on discovery of mechan-ism of battery failure

J. G. Davies (introduced by AubreyLeatham)

The most important function of a pace-maker follow-up clinic is to estimateunit power and hence to predict thetime for the unit to be changed. Pre-mature failures have been investigatedin great detail to decide whether theyare random, or follow a uniform pat-tern, and units which are removed, butstill have useful life, are allowed to con-tinue functioning in a warm humidenvironment (water bath at 370C).Over the past 30 months Devices

Fixed Rate TF units have provedreliable, and the figures are given.There have been instances, however,

of loss of power, though not of pacing,sufficient to require replacement of theunit. The cause has been found to befailure of a single battery cell and it hasnot been confined to Devices units. It



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was found that tension stresses in theencapsulating medium had led to separa-tion of the battery top plate and theformation of a secondary cell withreversed polarity reducing the voltagefrom 5 to 3-5 volts. Construction of thebatteries has now been altered.

Experience with inductivelycoupled pacemaker betweenFebruary 1960 and February I970

D. 0. Williams (introduced byL. D. Abrams)

Since February I96o more than 300patients with complete heart block orother arrhythmias have been treatedwith the inductively coupled pace-maker. This communication presentscertain aspects of the treatment of 260patients by this method during the firstten years. The advantages of rate con-trol and immunity of the apparatus fromoutside electrical interference are dis-cussed. Figures are presented to showthe relative freedom from repeatedoperations which this method allows.The mortality, with special reference

to the difference between those patientswith stable complete heart block andother arrhythmias, is described.

Conversion of atrial flutter ortachycardia to atrial fibrillationby rapid atrial stimulation

D. A. Chamberlain, D. J. Coltart, andH. A. Ead (last two introduced)

Rapid atrial stimulation has been usedin 8 patients in an attempt to convertatrial flutter or atrial tachycardia toatrial fibrillation. A bipolar electrodewas introduced to high right atrium in6 patients; in the remaining 2 patientswho developed arrhythmias after cardiacoperations, pacing wires had beensutured to an atrium at operation. Apacemaker capable of delivering 6ooimpulses/min at up to 20 mA was usedin 6 patients. Electrograms showedatrial 'capture' by stimuli delivered ata frequency greater than the spontane-ous rate. Speeding or slowing the pace-maker resulted in atrial fibrillation in 4instances. In 2 patients a stimulatorproviding 3000 impulses/min at io mAproduced atrial fibrillation. Thus therhythm was successfully changed in 6of 8 cases, and in 4 ofthese sinus rhythmsupervened spontaneously within 3 days.Ventricular rate is usually more easilycontrolled in atrial fibrillation than influtter or atrial tachycardia, and in some

circumstances fibrillation is more stablethan sinus rhythm. Rapid atrial stimula-tion should, therefore, be considered forthe treatment of refractory or recurrentsupraventricular arrhythmias.

Symptomless myocarditis andmyalgia in viral and Mycoplasmapneumoniae infections

David Lewes and DavidJ7. Rainford(introduced)

Of 17 patients with proved viral (influ-enza A, Echo 9 and 30) or Mycoplasmapneunoniae infections, 6 showed electro-cardiographic evidence of symptomlessmyocarditis which was invariably associ-ated with myalgia. Myalgia is an impor-tant symptom presaging myocarditisand is an indication for an early electro-cardiogram in all suspected viral infec-tions, even in the absence of cardiacsymptoms or signs. M. pneumnonae myo-carditis is reported for the first time.Cardiographic signs, chiefly over theright ventricle, persisting for 2 tO I4days and occasionally for months, mayclosely mimic coronary artery disease orseptal cardiac infarction. Correct elec-trocardiographic interpretation is essen-tial if unwarranted cardiac invalidism isto be avoided, particularly in thosepatients with an indefinite history ofinfection and in those with protractedabnormalities in the electrocardiogram.

Mobile coronary care service withnon-medical staffing

Gerard Gearty, Noel Hickey (intro-duced), and Risteard Mulcahy

This communication reports the experi-ence of a mobile coronary service oper-ating in Dublin for the past 3 years.Two ambulances are available to servicefive metropolitan hospitals on a rotabasis. The ambulances are staffed bycrews who are specially trained incardiorespiratory resuscitation and ex-ternal defibrillation. No doctor or nursetravels with the ambulance.

This communication records the ex-perience of specially trained lay per-sonnel in achieving successful resuscita-tion. Among the first 2500 subjects car-ried by the mobile service, 80 per centsuffered from acute coronary heartdisease, left ventricular failure, or life-threatening arrhythmias. Nineteen casesof primary ventricular fibrillation weresuccessfully resuscitated by the ambu-lance crew.

It is suggested that trained non-medical ambulance personnel can suc-

cessfully deal with cardiac arrest in aprehospital mobile coronary care sys-tem.

Details of organization and of thefirst 3 years' results are presented.

'Fascicular' block in acute myo-cardial infarction

M. J. Godman, B. Alpert (both intro-duced), and D. G. Julian

The intraventricular conduction systemcan be considered as functioning viathree fascicles - the right bundle-branchand the two main subdivisions of theleft bundle. The concepts of 'fascicularblock' and 'hemiblock' have been usedin this study to analyse and documentthe features of296 cases ofintraventricu-lar conduction disturbances in acutemyocardial infarction. The electrocar-diographic features of hemiblock anddifferent degrees of fascicular block arereviewed as well as the frequency of thedifferent patterns.

Interruption of conduction in onefascicle was the first abnormality notedin 214 patients, of whom I25 had leftanterior hemiblock and 54 left posteriorhemiblock; 34 patients from this groupsubsequently developed electrocardio-graphic features of bifascicular blockand I9 patients trifascicular block.Of i6i patients with unifascicular

block, 8 developed complete heartblock but were not noted to develop bi-fascicular or trifascicular block. Ninety-five patients were observed to have bi-fascicular block, either as their firstconduction abnormality orafter unifasci-cular block; 25 in this group developedcomplete heart block. A further 40patients had features of trifascicularblock as their first conduction abnor-mality, or after unifascicular or bi-fascicular block and of these 23 pro-gressed to complete heart block.The variation in the course of these

different conduction disorders and inparticular the relative frequency of pro-gression to complete heart block isemphasized.

Changes in QRS complex afteraortic valve replacement

W. R. Ginks and F. Follath (bothintroduced by J. F. Goodwin)

The electrocardiograms of 50 patientsafter isolated aortic valve replacementwere examined. Two main types ofpost-operative QRS changes were found.



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In the first instance, 13 patients de-veloped intraventricular conduction de-fects. Of these trifascicular block wasfound in 2 patients; the first developedcomplete heart block during operationwhich later changed to left bundle-branch block and then to left anteriorhemiblock; the second patient had leftbundle-branch block before operationwhich changed to right bundle-branchblock with left anterior hemiblock aftervalve replacement. Bifascicular blockdeveloped in a further 2 patients: nor-mal intraventricular conduction chang-ing to right bundle-branch block withleft anterior hemiblock in one and nor-mal intraventricular conduction chang-ing to left bundle-branch block in theother. However, left anterior hemiblockoccurring as an isolated lesion was themost frequent finding.The other prominent abnormality of

the QRS complex after operation wasthe appearance of abnormal Q wavessuggesting inferior wall infarction in 8patients and anterior wall infarction inone.

Intraventricular conduction defectswere interpreted as evidence of involve-ment of the conducting system duringremoval of the abnormal valve whereasuneven myocardial blood flow duringcoronary perfusion was thought to beresponsible for the appearance ofabnormal Q waves.With the exception of the patient

with transient complete heart block andthe patient with anterior wall infarction,no haemodynamic complications wereobserved and the postoperative coursewas not different from those withoutelectrocardiographic changes.

Assessment of ventricular damagefollowing after myocardialinfarction

Robert Nagle

2I8 consecutive patients with provedmyocardial infarction were studiedduring the first few days of their illnessin order to record signs of severe cardiacdamage and cardiac aneurysm. 153 ofthem attended a follow-up clinic whenthey were re-examined and a goodcorrelation was found between thepresence of such signs at the two differ-ent stages of the disease.

Patients with severe cardiac damagewho had disabling symptoms were fur-ther investigated by cardiac catheteriza-tion and ventriculography. A film showsthe different kinds of abnormal musclefunction observed and these are related

to physical signs, symptoms, and thepossibilities of surgical treatment.The studies suggest that it is possible

to identify, at an early stage in the ill-ness, those patients who are liable tosuffer from muscle damage later on, butthey show that ventriculography isessential for an accurate assessment ofthe extent of the damage.

Measurement of left ventricularvolumes in man by echocardio-graphy - comparison with biplaneangiographs

D. G. Gibson

In order to assess the place of echo-cardiography in measuring left ventricu-lar dimensions in man, a direct com-parison has been made between valuesobtained in this way and those derivedfrom biplane Elema angiograms in 50patients undergoing diagnostic cardiaccatheterization. The internal dimensionof the left ventricle was measured fromthe posterior surface of the interven-tricular septum to the posterior wall ofthe left ventricle, with the transducer atthe left sternal edge in the 4th inter-space. There was close correlation be-tween the left ventricular volume deter-mined angiographically by the methodof Arvidsson and the cube ofthe internaldimension (r=o-9i, P <o-ooi), and alsobetween values of ejection fraction ob-tained by the two methods (r=o-82,P <o-ooi). The specificity and sensi-tivity of the method in assessing leftventricular volume has been comparedwith thermodilution in a similar groupof patients, left ventricular angiogramsbeing the reference standard in both.It appears that echocardiography is asatisfactory method of measuring leftventricular volumes and ejection frac-tion in man.

Heart rate response to certainphysiological manoeuvres:proposed measure of degree ofbeta-receptor blockade

J. D. Fitzgerald (introduced),D. J. Rowlands, G. Howitt, andE. T. L. Davies (introduced)

Since available beta-adrenergic blockingagents are competitive antagonists, it isimportant to be able to test whethersufficient drug has been given to blockendogenous catecholamines. For clinicaluse the test should be simple, non-invasive and reproducible.

The heart rate increases associatedwith the following manoeuvres wereinvestigated: (I) assuming an uprightposition, (2) sustained hand grip, (3>mild exercise, (4) maximal exercise,(5) voluntary hyperventilation, (6) Val-salva's manoeuvre, (7) taking glyceryltrinitrate. Six normal subjects werestudied: the electrocardiogram wasmonitored continuously, sustained handgrip, voluntary hyperventilation, andValsalva's manoeuvre were carried outsitting, exercise was performed on acycle ergometer. Trinitrin (o 5 mg) wastaken standing. Four control responseswere obtained to each manoeuvre; themanoeuvres were repeated during treat-ment with propranolol at two dose levels(6o and 240 mg daily). In every casemeasurements were taken before andafter atropine (2-5 mg i.v.).

Sympathetic stimulation was a majorfactor in the tachycardia associated with(i) taking trinitrin, (ii) standing, (iii)Valsalva's manoeuvre. The trinitrintachycardia was due only to increases insympathetic activity since the incrementwas unaffected by atropinization. Thisreflex may be used to determine thedegree of beta-adrenergic blockade.

Effects of propranolol, oxprenolol,and practolol on denervated dogheart

J. D. Harry, C. T. Kappagoda (bothintroduced), R. J. Linden, andH. M. Snow (introduced)

It has been reported that some beta-adrenoreceptor blocking agents depressthe heart by an action other than beta-receptor blockade. In the denervateddog heart we have determined the effectofpropranolol, oxprenolol, and practololon the relation between the chronotropicand inotropic effects induced by iso-prenaline.

In 5 dogs in the presence ofproprano-lol (o-o4-o.8 mg/kg) for a heart rate ofi8o beats/min induced by isoprenaline,dP/dt max measured 820o mmHg/secand in its absence 9800 mmHg/sec.For oxprenolol (0o04-0o32 mg/kg) in 4dogs at a heart rate of i8o beats/min,dP/dt max measured 6300 mmHg/seccompared with 8ooo in its absence. In4 dogs in the presence of practolol(o04-2.o mg/kg), at a heart rate of I8obeats/min dP/dt max measured 8200mmHg/sec compared with gooo in itsabsence. Thus each of these beta-blocking drugs had qualitatively thesame action. Further there was no evi-dence of an action of these drugs otherthan beta-blockade.



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An explanation of the results may bethat adrenergic receptors in the sinu-atrial node behave differently from thosein cardiac muscle.

Assessment of beta-adrenergicblocking and non-specific proper-ties of propranolol

D. J. Coltart (introduced by J. Hamer)

Racemic propranolol possesses bothbeta-adrenergic blocking and non-specific properties. Beta-adrenergicblockade can be shown by competitiveinhibition of the effects of isoprenalineinfusion or sympathetic stimulation onheart rate and force of contraction.Non-specific effects of propranolol arenot due to competitive inhibition ofcatecholamines and are demonstratedeither as local anaesthetic activity, myo-cardial depression, or electrophysio-logically by a reduction in rate of de-polarization. The latter has providedthe most sensitive measurement in vitroof non-specific activity. The concentra-tion of propranolol needed to demon-strate both beta-adrenergic blocking andnon-specific properties has been assessedin man.The concentration of racemic pro-

pranolol producing a significant reduc-tion in rate of depolarization has beendemonstrated by a microelectrode tech-nique on the isolated human myocardialcell. This concentration (I0 ,ug/ml) ismuch greater than the plasma proprano-lol level associated with complete sup-pression of the tachycardia induced bystrenuous exercise (ioo ng/ml) and withtherapeutic suppression of ventricularectopic beats.These findings suggest that the non-

specific properties of propranolol are oflittle clinical significance.

Role of peripheral vascular system'in control of cardiac output,demonstrated by use of selectivebeta-adrenergic stimulating andblocking agents

D. G. Gibson and J. Hamer

,With the development of selective beta-adrenergic blocking and stimulatingdrugs, it has become possible to distin-guish cardiac and peripheral vascularcomponents of the overall haemo-dynamic response to beta-adrenergicblockade in intact man. Intravenouspractolol, which has little peripheral

action, causes a significant reduction inheart rate, little change in cardiac out-put, and a significant increase in strokevolume, with no change or a reductionin left ventricular end-diastolic pressureand depression of left ventricular con-tractile state. Intravenous salbutamol,which has little cardiac effect, is associ-ated with an increase in cardiac outputin the absence ofpositive inotropic effect.These results show that, under the con-ditions of study, it is not heart rate orthe inotropic state of the left ventriclethat determines the cardiac output. Thechanges in output found in these studiesare probably due to variations in venousreturn mediated by changes in peri-pheral vascular tone. Changes in cardiacoutput due to non-selective drugs suchas propranolol or isoprenaline are there-fore likely to be due to their peripheralrather than to their cardiac effects.

Effect of cardioselective beta-adrenergic blockade in patientswith abnormal left ventricularfunction

J. Graber, P. K. Khanna, M. J. Raphael(all introduced), R. E. Steiner, andM. M. Webb-Peploe

The relation between left ventricularend-diastolic pressure (LVEDP), leftventricular end-diastolic volume (LVE-DV), and left ventricular stroke workindex (LVSWI) have been establishedat cardiac catheterization before andafter intravenous administration of thecardioselective beta-blocking agent prac-tolol (I.C.I. 50172) in doses of o03 mg/kgbody weight. LVEDV was measured by(i) simultaneous indocyanine green dyedilution and thermodilution curves re-corded from left femoral artery andaortic root respectively following di-astolic injection of a mixture of greendye and cold saline into the left ven-tricle; and (2) single-plane cineangeo-grams carried out in the right anterioroblique position. LVSWI was calculatedfrom stroke index (indocyanine greendye dilution in IS patients and Fick'smethod in 6 patients), and planimetricintegration of the left ventricular pres-sure pulse during the ejection phase.To date 2I patients have been

studied: 5 patients with normal leftventricular fimction, 4 patients withcongestive cardiomyopathy, 6 patientswith hypertrophic cardiomyopathy, and6 patients with coronary artery disease.In 2 patients with impaired LV functiondue to severe coronary artery diseasepractolol caused a considerable furtherreduction in LVSWI, but in the remain-

ing patients the drug had little effect onLVSWI. In the patients with normalventricular function, and in those withcongestive cardiomyopathy and coron-ary artery disease, practolol caused anincrease in LVEDV with either nochange or a rise in LVEDP. In the 6patients with hypertrophic obstructivecardiomyopathy, practolol caused eitherno change or an increase in LVEDVwith a fall in LVEDP in 5 and no changein LVEDP in the sixth.These data suggest: (i) That in

hypertrophic obstructive cardiomyopa-thy but not in other forms of heartdisease, antagonism of the cardiac beta-receptors causes an increase in LVdiastolic distensibility and (2) that cau-tion should be exercised in the adminis-tration of practolol to patients with im-paired LV function due to severecoronary artery disease.

Comparison of pulmonary arterydiastolic and left ventricular end-diastolic pressures in patients withischaemic heart disease

R. Balcon, E. D. Bennett (introduced),and G. E. Sowton

The use of bedside flow-guided cathe-terization techniques in patients withacute myocardial infarction has promp-ted many workers to investigate therelation between pulmonary artery di-astolic and left ventricular end-diastolicpressures. A good correlation has notalways been found but patients havefallen into a number of differentaetiological groups and the point takenfor measurement has also varied. Thiscommunication reports the results in agroup of I5 patients with ischaemicheart disease. Measurements were madeat the pre 'a' point when experimentalstudies have shown there is little or noflow between the pulmonary artery andthe left ventricle and thus pressure atthe two sites is equal. An 'a' wave couldbe seen in all records and in 14 of theIS patients one was found in the pul-monary artery trace. The pulmonaryartery diastolic pressure ranged from0 tO 31 mmHg and the left ventricularend-diastolic from o-3o mmHg. Thecorrelation coefficient for 300 compari-sons (20 in each patient) was o095. Thegreatest pressure difference was 5 mm-Hg, and this occurred in only 2-5 percent of comparisons. The difference was2 mmHg or less in 8o per cent. It isconcluded that pulmonary artery di-astolic pressure correlates well with leftventricular end-diastolic over a widepressure range in patients with ischae-mic heart disease.



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Comparison of pulmonary wedgepressure measured by the flowdirected Swan-Ganz catheter withleft atrial pressure

G. A. Batson, K. P. Chandrasekhar,Y. Payas, and D. F. Rickards (allintroduced by D. Verel)

Wedge pulmonary capillary pressurerecorded by the Swan-Ganz catheterhas been compared with left atrial pres-sure measured by simultaneous trans-septal puncture. Difficulties encoun-tered with the technique have includedoccasional failure to enter the superiorvena cava. The quality of wedge tracingobtained is dependent upon the degreeof inflation of the balloon. Good agree-ment between the two techniques isusual. The use of the Swan-Ganzcatheter in the outpatient assessment ofmitral valvotomy is described.

Dietary pulmonary hypertensionD. HeathIn a minority of cases the cause of pul-monary hypertension is obscure. Thissmall group consists of classical primarypulmonary hypertension and pulmonaryveno-occlusive disease. In recent yearsit has been shown that pulmonaryhypertension may be produced in ratsby dietary means.The substances incriminated in this

respect so far have all been pyrrolizidine

alkaloids. Monocrotaline, contained inthe leguminous plant Crotalaria specta-bilis, induces in rats pulmonary hyper-tension, hypertensive pulmonary vascu-lar disease, and complex changes in thelung parenchyma. So does fulvine,which is contained in the plant Crota-laria fulva which gives rise to veno-occlusive disease of the liver in man inthe West Indies. The pyrrolizidine alka-loids of the ragwort plant, Seneciojacoboea, which is on sale in Liverpoolin 'Health Stores' will also produce corpulmonale and pulmonary vasculardisease in rats.A recent epidemic of primary pul-

monary hypertension in Germany,Switzerland, and Austria has beenascribed to the ingestion of the slim-ming drug Aminorex fumarate ('Meno-cil'). So far we have been unable toproduce cor pulmonale or hypertensivepulmonary vascular disease with thisdrug in rats, dogs, or monkeys.

Comparison of streptokinase andheparin in treatment of isolatedacute massive pulmonaryembolism

G. A. H. Miller, G. C. Sutton,I. H. Kerr (introduced), R. V. Gibson,and M. Honey

In 23 patients massive pulmonary em-bolism was proven by arteriography. In

all, embolism occurred between 2 and48 hours previously. No patient hadpre-existing cardiorespiratory disease.IS patients were treated with strepto-kinase and 8 with heparin infused intothe pulmonary artery. Both groups werecomparable in terms of factors (e.g. age,duration of embolism, history of circu-latory arrest or syncope, history of pre-monitory emboli and probable age ofthrombus) which might influence prog-nosis or resolution rate. Haemodynamicand arteriographic findings did notdiffer significantly in the two groups.After a 72-hour treatment period repeatcatheterization and arteriography per-mitted objective assessment of responseto therapy. After treatment patientstreated with streptokinase had signifi-cantly lower values for pulmonaryartery systolic pressure, total pulmonaryresistance, and angiographic severitythan did those treated with heparin.Patients treated with streptokinaseshowed significant improvement in allhaemodynamic variables measured; inheparin-treated patients significant im-provement was limited to arterial oxygensaturation and right ventricular end-diastolic pressure. No patient died, buttreatment had to be changed because ofclinical deterioration in two heparin-treated patients. Complications of strep-tokinase therapy were limited to bleed-ing from cut-down or operation sites.



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