Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from British Heart Journal, 1971, 33, I42-I5 I. Proceedings of the British Cardiac Society

THE FORTY-NINTH ANNUAL post. The names receiving the most would be merged with the contingency GENERAL MEETING of the British votes shall be elected in each case at fund. Cardiac Society was held in the Konin- the next Annual General Meeting. In klijk Institut voor de Tropen, Mauri- the event of a draw for any office, the 4 The following resignations were ac- tskade 63, Amsterdam, on Thursday Council shall decide the member to be cepted with regret: Bingham, J. G. M. and Friday, 23 and 24 April I970 as a elected. Hamilton, A. C. Macdonald. joint meeting with the Dutch Society. Rule 25 to be amended as follows: 5 Hamer was elected as Secretary of The President, SIR JOHN Mc- Three Ordinary Members shall be the Society. MICHAEL, took the Chair at 9.oo elected in accordance with Rule I4 a.m. during Private Business before (as amended above) as Secretary, 6 Sowton was elected as Assistant handing over to the Chairman, R. W. D. Assistant Secretary and Treasurer Secretary of the Society. TURNER. respectively. The Secretary shall 7 The following two new Members of hold office for not more than two Council were elected in place of Tubbs years and the Assistant Secretary for Business and A. J. Thomas: Donald Ross and Private not more than two years; the Trea- Byron Evans. i The Minutes of the Annual General surer shall hold office for five years Meeting having been published in the and shall be eligible for re-election. 8 J. H. Wright was elected an Hono- Journal (1970, 32, 55i) were taken as They will all be ex officio Members of rary Member of the Society. read and confirmed. the Council. 9 The following were elected Extra- 2 The following amendments to the The remaining Rules will be amended Ordinary Members of the Society: Rules of the Society were agreed: to omit any mention of Associate Mem- Cookson, Muir, Bruce Perry, and Sir Rule 4 to be amended to: bers, and this will necessitate arranging George Pickering. them in a slightly different order. There shall be a President of the So- 3 The Treasurer reported that there Io The following Corresponding Mem- ciety who shall be elected by the bers were elected: Gotthard Schettler, members from one of the names put was an excess of income over expendi- Heidelberg, and Velva Schrire, Cape forward by the Council. If, however, ture in I969, but that this was smaller http://heart.bmj.com/ any member wishes to submit an than in I968: £58i.17.-. as compared Town. additional name his nomination must with £673. The decrease was due to in- ii In accordance with the amendment be signed by ten members and re- creased cost of meetings, secretarial to the Rules of the Society adopted at ceived by the Council at least six help, and subscriptions to the Inter- this meeting, whereby the category of weeks before the Annual General national Society and European Society Associate Member had been abolished, Meeting. The President shall be elec- of Cardiology. the present Associate Members (with ted for two years and may be eligible At the present rate of financial tur- the exception of Rahimtoola and Sey- for re-election for further periods of over, there would continue to be an ex- mour) were elected Ordinary Members.

one year to a total of five years. He cess of income over expenditure as the Shaper was elected an Ordinary on September 25, 2021 by guest. Protected copyright. shall be ex officio a member of the increase in the number of subscriptions Member from Overseas Membership, a Council. He will represent the So- from new members would counter- and the following new Ordinary Mem- ciety at home and abroad and may balance the increasing costs. But in bers were elected: Peter Fletcher Bin- preside over meetings of the Council three to four years the income would nion, Belfast; Peter Carson, North but not at the Scientific Meetings of equal the expenditure unless the size of Staffordshire; Douglas Anthony Cham- the Society for which a local Chair- the Society was enlarged, or the sub- berlain, London; Bernard Melville man will be elected for each meeting. scription was increased. Council felt Groden, Glasgow; John Reynolds Rules Io and iI to be omitted. that it was essential to form a con- Hampton, Nottingham; Alexander Har- tingency fund to provide a solid financial ley, Manchester; Robin Brian Hed-o Rule 14 to be amended to: backing for the Society, and it was worth-Whitty, London; Marian Ion The Council shall nominate up to ten planned to reinvest the capital to obtain Ionescu (SM), Leeds; Brian Kirby, names from the Ordinary Members better growth of capital, and to invest Edinburgh; John Robert Muir, Lon- of the Society for each of the Offices funds from the deposit account of the don; Eckhardt G. J. Olsen, London;' (President, Secretary, Assistant Se- Society in similar stock. If there were Lionel Hentry Opie, London; Harry A. cretary and Treasurer) and for Coun- funds available from the VI World Con- Rees, Swansea; Philip Slade (SM), cil Members as holders retire, in gress of Cardiology for the Society, Leicester; Michael Webb-Peploe, Lon- accordance with Rules 4 (as amended these would be used to strengthen the don; John Donald Whiteside, Chiches.- above), 21 (previously 22) and 24 (as contingency fund. The Congress Fund, ter; Magdi H. Yacoub (SM), London. amended below). In the normal which had been used to help with course of events the Assistant Secre- members' expenses at the V World I2 The following Overseas Members tary shall succeed the Secretary. Congress of Cardiology in I966 would were elected from Associate Member-; These names shall be sent out to all also be available for the VI World Con- ship: Rahimtoola and Seymour, and Ordinary Members who shall vote by gress. After this, the Congress Fund the following were re-elected: David- Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from Proceedings of the British Cardiac Society I43

son, Hywel Davies, Fulton, Harries, present, this proposal would be tried of 50-i86 mm. Hg were found and Parry, Resnekov, Somers, and Wilson. out for the Annual General Meeting in angiocardiographic studies were avail- 1971. able. Mild aortic regurgitation was pre- 13 Shillingford, Chairman of the The Dutch and British Societies sent in 8. Though symptoms noted Organizing Committee, reported that dined together under the Chairmanship before operation in 7 disappeared in 6, the arrangements for the VI World of Dr. Erkelens. The President thanked clinical assessment was difficult as the Congress of Cardiology to be held in our Dutch hosts for excellent arrange- physical signs were unchanged in I0, London in September I970 were mov- ments and emphasized the intercon- and the electrocardiogram improved in ing ahead according to plan. Registra- nexions of Dutch and British medicine only 7. tions were coming in satisfactorily, and and the continuing influence of Ein- Postoperative haemodynamic and an- it looked as though there would be thoven. giocardiographic studies were carried 4-5000 delegates including wives. out in 8 and showed reduction or aboli- 14 It was confirmed that there would tion of the gradient in the area of the be no Autumn Meeting of the Society in Natural history of Ebstein's resected membrane. Small subaortic I970. anomaly of the tricuspid valve in gradients usually below the site of the childhood and adolescence original obstruction of 5-15 mm. Hg 15 The Annual General Meeting in were found in 4, and 20-60 mm. Hg in 1971 would be a two-day meeting in Hamish Watson 4, rising in 3 with isoprenaline. In 4 Sheffield on Wednesday and Thursday, patients without electrocardiographic April 14 and I5; this would in part Interest in Ebstein's anomaly of the improvement the left ventricle was as compensate for the lack of an Autumn tricuspid valve has been quickened by thick or thicker than before operation Meeting in 1970, but was not meant to the successful replacement of severely and showed some features seen in establish a precedent for a two-day damaged valves. Patients with Eb- obstructive cardiomyopathy, though the spring meeting. stein's anomaly, however, are noto- membrane had been well removed. Fac- riously bad operative risks, and the tors present before operation in those I6 Career Structure in Cardiology nature of the malformation itself makes with and without this disappointing The President reported that a question- its surgical treatment not only difficult postoperative course were compared. It ary had been sent to members of the but hazardous. Because of this and was concluded that in a number of British Cardiac Society by the Cardio- because the insertion of a prosthesis - it- patients the disease is not a simple prob- logy Committee of the Royal College of self with a doubtful prognosis - into a lem of a well-defined obstruction and Physicians asking for details of the growing child seems advisable under its removal, but that there may be a establishment, of the promotion to only the direst of circumstances, an congenital abnormality of the whole left consultant grade, and of emigration, of attempt has been made by the Associa- ventricular outflow tract. Senior Registrars in Cardiology. The tion of European Paediatric Cardiolo- results of this questionary had come in gists to determine the natural history of http://heart.bmj.com/ and had been discussed by the Cardio- Ebstein's anomaly in childhood and Beta adrenergic blockade with logy Committee. As a result ofthese dis- adolescence. practolol in hypertrophic obstruc- cussions, a report on the general situa- A preliminary survey of some 450 tive cardiomyopathy tion, including proposals for improve- cases collected from 29 countries con- ment in staffing, training, and career firms the impression that though some M. Webb-Peploe, R. S. Croxson structure in cardiology, had been pre- babies with severe lesions may not sur- (introduced), and Celia Oakley pared and would be discussed by the vive infancy, most cases do remarkably College Committee next month. well after a somewhat slow start. Few Beta adrenergic blockade with propra- develop severe symptoms or die during nolol has been used extensively in the a I7 The following meetings were an- childhood. Surgical treatment, on the investigation and treatment of patients on September 25, 2021 by guest. Protected copyright. nounced: other hand, carries a high mortality and with hypertrophic obstructive cardio- (a) European Association of Paedia- most of those who did not survive it myopathy, though its mode of action tric Cardiologists, May 6 to 9 I970, would probably have come to no great remains unclear. We report here the Warsaw. harm had they been left alone for a few preliminary results on 5 patients who (b) Conference of Polish Society of more years. have been studied at cardiac catheteriza- Internal Medicine and of the Polish The high natural mortality among tion using a new cardio-selective beta Cardiological Society, May IS and i6, babies suggests that, as with other blocking agent, practolol. Haemo- 11970, Warsaw. severe lesions, this is the area where dynamic measurements were made at (c) The 2nd Czechoslovak Congress greater and more intensive effort is rest, after straight leg-raising exercise, of Internal Medicine with International required to save lives. during atrial pacing, and after in- Participation, I5 to i8 September 1970, travenous isoprenaline injection. The Bratislava. measurements were repeated after 20- of intravenous (d) International Cardiac Surgery Fate of fixed membranous 40 ml. practolol by Conference, Melbourne, 27 tO 29 May subaortic stenosis after resection injection. I971. Changes at rest were slight; however, Jane Somerville, and Julio Montoyo after exercise practolol reduced heart I8 It had been suggested that abs- (introduced) rate by I0 per cent, left ventricular and tracts of papers should be circulated in diastolic pressures (LVEDP) by 33 per advance of meetings, and though there The course of I2 patients, aged 8 to 32 cent, while effective stroke work in- were a number of difficulties - includ- years, was studied I tO S years after open creased by I2 per cent. The tachycardia ing the submission of abstracts by resection of a subaortic membranous induced by isoprenaline was reduced by members considerably earlier than at stenosis. Preoperative gradients at rest i I per cent and LVEDP by 24 per cent. Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from 144 Proceedings of the British Cardiac Society

There was only a slight fall in LVEDP The glucose-insulin regimen lowered shown to be due to stimulation of on increasing heart rate by atrial pacing the plasma potassium in the acute baroreceptors and chemoreceptors res- from 6o to 130 beats a minute in 2 hypokalaemic experiments from a nor- pectively. The superficial veins showed patients and the LVEDP was not signi- mal resting level of 4-0 mEq/l. to 2-4 only a constrictor response which, ficantly altered by practolol on repeated mEq/l., and the tissue 3H-digoxin con- since it persisted after vagotomy and pacing at similar heart rates in these centrations were 206 in the left ventricle, carotid sinus nerve section, was not due patients, showing that the reduction in 29I in the right ventricle, 6I in the to stimulation of baro- or chemorecep- LVEDP after practolol was not due to a atria, and 349 in skeletal muscle. tors, nor of receptors in the heart and rate effect. Outflow tract gradients were These experiments show that acute lungs. little influenced by practolol. reduction of plasma potassium in- These results after exercise suggested creases the uptake of digoxin by myo- improved cardiac efficiency after prac- cardial and skeletal muscle. These Effect of cardiopulmonary bypass tolol, allowing the same cardiac work to results were used to support a hypo- on plasma digoxin levels be achieved at a lower LVEDP, and thesis for the uptake of digoxin by that this action is not primarily rate special myocardial receptors and the D. J. Coltart, D. A. Chamberlain, dependent. Since a rise in LVEDP on hypothesis was extended to explain the T. W. Smith, and J. L. Mercer (all effort commonly causes dyspnoea and relation between potassium, digoxin, introduced by John Hamer) may induce atrial fibrillation, any and myocardial cell metabolism. therapy that prevents this increase will The effect of cardiopulmonary bypass be beneficial. on plasma concentrations of digoxin Direct and reflex actions of has been assessed in patients undergoing cardiac glycosides on peripheral cardiac surgery. The urinary excretion Myocardial and skeletal muscle circulation of the dog of digoxin during the operative period uptake of 3H-digoxin in acute and the losses in the oxygenator have hypokalaemia M. Webb-Peploe, E. Ambrosioni also been measured. The measurements and J. T. Shepherd (both introduced were made by radioimmunoassay which P. F. Binnion, and L. M. Morgan by J. F. Goodwin) provides a specific method with satis- (introduced by Evan Fletcher) factory accuracy in the therapeutic The direct effects of acetylstrophan- range. Cardiac glycosides influence sodium and thidin and digoxin on the resistance Relatively small losses occurred dur- potassium movement in red cells and vessels and superficial veins of the hind ing the operative period (mean O13 there is a complex relation between limb were examined in dogs anaesthe- Plasma concentrations these agents and ion tized with mg.). fell initi- movements, par- thiopentone and chloralose. ally, largely as a result of dilution of the ticularly those of potassium. A similar The reflex responses of these vessels volume the and situation occurs with cardiac and skele- and of the splenic capsule and veins to plasma by pump prime transfusion. The concentrations rose http://heart.bmj.com/ tal muscle, where digoxin inhibits the injection of both drugs into the by right again after operation as a new equi- transport of potassium across the atrium in therapeutic doses were also librium was established between muscle cell membrane. It has been recorded. plasma shown and tissue stores. In 8 patients the mean previously that acute hyper- In the right iliac artery perfused at a concentrations were kalaemia inhibits the uptake of tritiated constant plasma I-9 ng./ml. flow, changes in perfusion before operation and 17 ng.fml. after- digoxin by the myocardial muscle cells, pressure were a measure of changes in wards. Plasma and these experiments were carried hind limb resistance. In the left lateral potassium concentra- out to see what tions may fall over the operative period, influence acute hypo- saphenous vein perfused at constant and cause increased kalaemia would have on myocardial flow, changes in driving pressure sensitivity to car-

(i.e. on September 25, 2021 by guest. Protected copyright. digoxin diac glycosides. Digoxin should be uptake. the difference between perfusion and administered after Seventeen anaesthetized dogs were femoral vein pressures) reflected chan- cautiously bypass to divided patients who have been adequately into two groups. In the first ges in superficial venomotor tone. After before group, I0 dogs were given an injection temporary total arrest of the splenic digitalized operation. of 3H-digoxin (o-8 ,uCi) intravenously, circulation, changes in splenic venous and one hour later their tissues were re- pressure were an index of reflex changes I moved for analysis. In a second group of in smooth muscle tension in splenic Assessment of left heart function 7 anaesthetized dogs glucose and insulin capsule and veins. after myocardial infarction were infused for one hour before the Acetylstrophanthidin and digoxin in- P. G. F. Nixon, and D. F. intravenous 3H-digoxin was given and jected in graded doses into iliac artery J. Taylor this infusion was continued for the next and saphenous vein perfusates after (introduced) 6o minutes and then the animals' tissues acute bilateral lumbar sympathectomy Recordings of left ventricular pulsa- were removed. Plasma and myocardial caused an increase in arterial resistance tions and sounds have been shown to potassium was measured using conven- but no change in venous tone. The give a useful indication of diastolic t tional flame photometry, and the tissue cardiac glycosides had therefore a direct events in the left ventricle in valvular 3H-digoxin concentration was measured constrictor effect on arteriolar but not and primary myocardial disease. This 3 using liquid scintillation counting. on venous smooth muscle. paper presents the findings in 5I cases In the control animals the plasma Right atrial injection of acetylstro- of acute myocardial infarction where potassium level was 4-o mEq/l. and the phanthidin caused reflex dilatation of such recordings were taken within three digoxin concentration (in mg. x ic-6 hind limb resistance vessels and of days of the event and thereafter at per g. wet weight) was I29 in the left splenic capacity elements followed by weekly intervals. ventricle, I02 in the right ventricle, 83 reflex constriction. The initial dilata- 6 in Abnormalities were found in almost the atria, and 22 in skeletal muscle. tion and subsequent constriction were all cases and these could be seen to falls Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from Proceedings of the British Cardiac Society 145 into four groups which could be ranked recovered. Frusemide 40 mg. intra- puter, designed for the purpose, has in progressive severity as assessed from venously produced significant improve- been used to detect ventricular ectopic the clinical state. Serial readings in ment in right atrial oxygen saturation beats and measure their coupling inter- individual patients during the course and pressure in the patients with pul- vals during high speed replay of the of their illness showed that the pattern monary congestion. Observations with- tapes. The computer output has been of abnormality need not be static, and out any intervention showed no changes. further processed to obtain the ectopic movement from one group to another The mechanism of these responses rate, distribution of extrasystoles in occurred and was accompanied by and the therapeutic implications were diastole, and the intervals between appropriate clinical change. discussed. them. It appeared that as clinical deteriora- Extrasystoles appearing on the T tion occurred and left heart pressures wave or fixed to the end of the T wave rose, the enlarged atrial contraction Cardiovascular effects of penta- of the preceding beat are shown, and component, the 'a' wave, diminished in zocine in patients with acute other pattems emerge which are ex- size, and at very high diastolic pressures myocardial infarction plicable by the presence of an ectopic in the left heart was replaced by a ventricular pacemaker. From this in- pathological rapid filling wave. This D. E. _Jewitt, B. J. Maurer and formation the time course of ectopic process could be seen to reverse with P. J. Hubner (both introduced), and beats over the monitoring period has recurrence of the 'a' wave as the pres- J. P. Shillingford been studied. sures fell and clinical improvement oc- curred. The presence of an enlarged 'a' The narcotic antagonist pentazocine has wave was not necessarily accompanied been shown to possess comparable Five-year trial of clofibrate in by a fourth heart sound; hence phono- analgesic potency to heroin, methadone, ischaemic heart disease cardiography alone may give insufficient and morphine when given to patients information. with pain after myocardial infarction. H. A. Dewar The technique is repeatable, safe, and In bedside studies, we have evaluated painless, and the pattern of change gives the haemodynamic effects of intra- During the past five years a double- a reliable indication of the left heart venous pentazocine 30-60 mg. in I5 blind controlled trial has been conduc- diastolic pressures. patients with acute infarction. A signi- ted by a group of physicians in the ficant rise in mean pulmonary artery Newcastle upon Tyne region of the pressure (control 20 + 3 mm. Hg to influence ofclofibrate (Atromid-S) upon Expansion of plasma volume in 33 ± 3 mm. Hg at IO minutes) and mean the natural history of established acute cardiac infarction aortic pressure (control 98 + 6 mm. Hg ischaemic heart disease. Nearly 500 to I I7 ± 10 mm. Hg at IO minutes) patients were divided by random selec- John Coltart (introduced) and occurred in all patients. The rise in tion into treated and control groups

J7ohn Hamer systemic pressure resulted from an in- which proved to be closely comparable http://heart.bmj.com/ crease in total peripheral resistance, in respect of nearly all important para- The effect of rapid expansion of the since cardiac output and heart rate were meters. In a substantial majority of the plasma volume on the mixed venous unchanged. To elucidate the mechanism treated group the serum cholesterol fell oxygen saturation and central venous of these changes pentazocine was given significantly and this fall was main- pressure has been studied in I4 patients to 5 patients with severe angina under- tained throughout the trial period. Side with recent uncomplicated cardiac in- going investigation before surgery. effects from the drug were very few. farction and 5 patients with cardiogenic After pentazocine in these patients, the Forty-four of the treated group were shock. The findings are contrasted with rise in peripheral resistance and sys- withdrawn, and 29 of the controls. Of the effect of diuretic treatment in 8 was those 27 per cent) ofthe temic arterial pressure associated remaining (I3.5 on September 25, 2021 by guest. Protected copyright. ; patients with recent cardiac infarction with a clear increase in left ventricular treated group died compared with 48 and radiological evidence of pulmonary end-diastolic pressure (mean control (21.4 per cent) of the controls. The dif- congestion. I4 mm. Hg rising to 22 mm. Hg at IO ference is significant. Thirty-eight (I9 Right atrial pressure and oxygen minutes). The raised mean pulmonary per cent) of the treated group sustained saturation measurements give a useful artery pressure reflected this change. new non-fatal infarcts compared with 49 guide to the haemodynamic state of the An afterload stress of this type is un- (22 per cent) of the controls. patient without undue risk or distur- desirable in patients with acute myo- bance. The right atrial oxygen satura- cardial infarction. ,4tion is a good index of changes in the Mitral valve replacement using cardiac output. There was a high cor- homograft semilunar valves relation between the initial right atrial Computer analysis of ventricular oxygen saturation and the coronary ectopic rhythms in myocardial J. Keith Ross prognostic index. infarction The uncomplicated patients were Since April I968, 57 mitral valves have given a rapid infusion of 500 ml. of 5 C. W. Vellani and J. M. M. Neilson been replaced in patients whose ages per cent glucose, and showed a signifi- (introduced by K. W. Donald and ranged from 25 to 64 years, using homo- ,_cant increase in right atrial oxygen M. F. Oliver) graft semilunar valves. In 17 instances saturation; right atrial pressure did not this was combined with homograft re- change and pulmonary congestion was The electrocardiograms of 200 patients #placement of the aortic valve and in 5 not produced. Three of the five patients with myocardial infarction have been triple valve replacement was under- with shock showed improvement in recorded continuously on magnetic taken, IO patients having had previous right atrial oxygen saturation or pres- tape for 24-48 hours after admission to a mitral valve surgery. The majority (49) sure, and two of these patients coronary care unit. An analogue com- of the homograft valves were placed on I0 Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from 146 Proceedings of the British Cardiac Society

the atrial side of the mitral annulus en- (with normal ejection fraction) tended valvar replacement with either a graft closed in a supporting fabric cylinder. to occur in patients with preoperative or a prosthetic valve. In the normal sub- The remaining 8 were mounted on mitral regugitation rather than stenosis. jects and in the patients before opera- cloth-covered metal or polypropylene These studies indicate that left ven- tion the levels of plasma fibrinogen were supports and placed in the mitral tricular and homograft functions are respectively 26I mg./ioo ml. (± 8-o6) orifice in the same way as a prosthetic usually good in patients several months and 300 mg./ioo ml. (±roI8o). There valve. after operation; and that pulmonary was an early postoperative increase in There were 6 hospital deaths, 2 with homografts may be more likely to fibrinogen in all patients, which was not isolated mitral valve replacement and 4 develop regurgitation than aortic. significantly different between those with multivalve procedures. None was with grafts and those with prostheses attributable to the fact that a homograft (grafts: 480 mg./ioo ml. (+ I547); had been used. Of the 5 late deaths, 3 Replacement of pulmonary valve prostheses: 458 mg./ioo ml. (I+I597)). were considered to be due to valve and pulmonary artery with fascia This was followed by a fall with time. failure and related to the method of lata However, whereas one year after opera- valve processing that had been used. tion the levels remained high in the All patients have been anticoagulated Christopher Lincoln, Marcel Geens patients with prosthetic valves (310 for three months after operation. There (both introduced), Donald Ross, and ml. Marian Ionescu mg./ioo (+ 8-40)), in those with have been two documented cerebral grafts the levels fell and were not signi- emboli to date, both with full recovery. The need for pulmonary valve replace- ficantly different from the normal sub- Details of postoperative investiga- jects (273 mg./ioo ml. (±io08o) and tions carried out in the longer survivors ment and reconstruction of the pul- monary artery arises (i) in patients 26I mg./ioo ml. (± 8-o6)). Analysis were given, together with an appraisal of showed that the levels of plasma the functional results achieved. with severe pulmonary stenosis or pul- monary atresia suitable for radical cor- fibrinogen in patients with grafts were rection, and (2) when the aortic valve significantly lower than in those with prostheses (p

ventricular end-diastolic pressure but agent. In this study the heart rate has which tends to preserve the pulsatility of not mean left atrial pressure in i6 been controlled by atrial pacing. Six lung capillary blood flow. patients with chronic rheumatic heart patients with aortic Starr-Edwards disease. In 7 patients with ischaemic prosthesis were studied during routine heart disease, maximum urine flow was catheterization at least six months after Electrical stimulation of heart in higher than in those with chronic operation. Changes in the time taken study of patients with the Wolff- rheumatic heart disease and similar in- for the ball of the prosthesis to cross the Parkinson-White syndrome type A crease of left ventricular end-diastolic cage were used to assess alterations in myocardial contractility. Measurements H. J7. J. Wellens, R. M. Schuilenburg, pressure. These results reflect a close and D. relation between proximal tubular were made from a phonocardiogram and Durrer sodium reabsorption and cardiac state central aortic pressure tracing. Pul- Using previously described methods, we and suggest that inappropriate sodium monary artery pressure and cardiac out- studied the changes which followed reabsorption at this site may contribute put were also recorded. Measurements electrically induced right and left atrial to fluid retention in heart disease. were made before and after the injection and ventricular premature beats in six of 5 mg. glucagon into the pulmonary patients with the Wolff-Parkinson- artery. White syndrome type A (Rosenbaum's Insulin secretion in severe heart The heart rate increased by approxi- classification). We found that: (i) dur- failure mately 20 per cent in all patients. ing regular driving at identical rates Systemic arterial pressure rose by I2 per from right and left atrium, the greatest P. A. Majid, B. Sharma, B. C. cent. Ball travel time and mean systolic amount of pre-excitation was seen after Pakrashi, (all introduced), and S. H. ejection rate, both indicators of myo- left atrial stimulation; (2) a tachycardia Taylor cardial contractility, did not change could easily be both initiated and ter- after glucagon when controlling the minated by way of a single premature Insulin secretion has been shown to be heart rate. beat from the left side of the heart. In severely suppressed in patients with the We therefore conclude that glucagon most instances this was impossible using low cardiac output state associated with has no positive inotropic action inde- right-sided premature beats; (3) when cardiogenic shock after myocardial in- pendent of heart rate. during a tachycardia with antegrade farction. Insulin secretion tests were AV conduction via the His bundle, left therefore carried out in 8 patients with and right atrial activation were regis- severe congestive heart failure due to Pulmonary arterial compliance in tered simultaneously, left atrial activa- valvular or ischaemic heart disease. All health and disease tion preceded right atrial activation by were found to have a significant sup- a considerable time (7o-IOO msec.). pression of insulin secretion in response S. R. Reuben, J. Butler (both These results are in agreement with a to intravenous tolbutamide. After 4 introduced), and G. de J. Lee circus movement or reciprocal mecha- weeks of intensive medical treatment, http://heart.bmj.com/ the insulin secretion tests were repeated Lung capillary blood flow is pulsatile. nism using the AV junction - His path- in the 6 patients who survived. In 3 An increase in precapillary resistance way in the one, and the anomalous AV patients who made a good clinical might be expected to attenuate this connexion in the other, direction as a response to treatment the insulin secre- pulsatility. However, simultaneous mea- causal mechanism for tachycardias in tion response had returned to normal. surements of instantaneous pulmonary Wolff-Parkinson-White syndrome type In the 3 patients in whom the clinical arterial pressure, flow, and lung capillary A. They also suggest that the greater response to treatment was limited, the blood flow in the dog have shown that part of the circus movement is loca- the pulmonary arterial compliance (C) lized on the left side of the heart. insulin secretion response was still The finding that the time relations of

falls as arteriolar resistance (R) rises on September 25, 2021 by guest. Protected copyright. severely impaired. It is suggested that the tachycardia could, in only one 2 the suppression of insulin in severe due to hypoxia or serotonin infusion. heart failure is due to a combination of Consequently the time constant (R x C) patient, be influenced by left-sided low pancreatic blood flow, possibly remains unaltered and the lung capillary premature beats suggests that the spa- preventing an adequate stimulus reach- flow pulsatility is preserved over a range tial dimensions of such a circus move- ing the pancreas, and a high level of of pulmonary arterial pressures. ment are small and that the anomalous circulating catecholamines which by The autoregulation of lung capillary AV connexion is situated not far away causing an increase in alpha-receptor flow pulsatility has also been studied in from the AV junction. activity suppresses insulin production. patients having routine cardiac cathe- terization for diseases causing pul- Exploration of electrical activation monary hypertension. Pulmonary arte- in hypertrophic infundibular Effect of glucagon on myocardial rial pressure and flow were measured, aortic stenosis (obstructive function at controlled heart rates using catheter-tip transducers, during lung capillary flow measurement by the cardiomyopathy) R. Balcon, C. Smithen (introduced), N20-body plethysmograph method. R. Th. van Dam, J. P. Roos, and and G. E. Sowton The pulmonary arterial compliance in D. Durrer patients with normal pulmonary artery 4ilucagon has been reported to have a pressures was 2-5 ml./mm. Hg. With During surgical correction of left ventri- beneficial effect on left ventricular func- mild pulmonary hypertension (mean cular outflow obstruction, we studied tion. Its use in patients with myocardial pulmonary arterial pressure 35 mm. the time course of activation at the failure after cardiac infarction has there- Hg), compliance was peS ml./mm. Hg. epicardial surfaces of both ventricles ,fore been proposed. These effects may Thus so far, in patients with mild pul- and in several parts of the left ventricle be related to the increase in heart rate monary hypertension, pulmonary arte- and the interventricular septum. In the that usually occurs as a result of this rial compliance falls as resistance rises, process of this investigation, the design Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from 148 Proceedings of the British Cardiac Society

of the multipolar intramural needle RPs of both tissues to sudden rate single heart cells. We therefore suggest electrodes had to be adapted to the un- changes is reflected in the conduction that during lignocaine administration usual thickness of the hypertrophic left of premature impulses. An early pre- more cells must be stimulated to pro- ventricular wall and interventricular mature beat originating in the bundle- voke a propagated premature beat, septum. The pluriformity of this condi- branches reaches the myocardium when which may explain the post-infarction tion, which causes a diversity in the it has recovered its excitability and is antiarrhythmic effect of this drug. electrocardiographic signs, also gives conducted without difficulty. A second rise to a degree of nonuniformity in our early premature beat meets refractory findings. These may be broadly sum- myocardium and is delayed by up to Control of cardiac function by RR marized as follows. (i) Left ventricular 70 msec. intervals in patients with atrial subendocardial excitation is retarded in fibrillation a varying degree, probably because of a conduction delay in the anterior division Effect of lignocaine on excitability F. L. Meijler, J. Strackee, B. Johansen, of the left bundle-branch. (2) At both cycle of dog and rabbit heart and H. Schneider surfaces of the interventricular septum, and in the divisions of left and right A. N. E. Zimmerman, E. 0. Robles de Control of cardiac function in patients bundle situated on them, activation Medina, P. H. A. Poll, and F. L. with atrial fibrillation has been attri- starts at normal time intervals. (3) Meijler buted to varying end-diastolic filling Conduction across the hypertrophic due to changes in cycle length. In iso- interventricular septum and left ven- The antiarrhythmic effect of lignocaine lated hearts and myocardial strips the tricular wall occurs at an approximately on the heart after myocardial infarction direct effect of RR' interval on con- normal velocity, but takes a relatively is well established. However, the work- tractile behaviour is well established. long time because of their increased ing mechanism of the lignocaine effect This effect also may explain (at least diameter. still gives rise to controversy. Until now, partly) the contractile behaviour of the the effect of lignocaine on the ex'citabi- intact heart in patients with atrial lity cycle of the heart has been studied fibrillation. In atrial fibrillation RR' Effect of sudden changes in heart with bipolar stimulation electrodes intervals are random. rate on refractory periods of only; i.e. with both electrodes in direct We studied 6 patients with atrial ventricular myocardium and contact with the heart muscle. In this fibrillation and a prosthetic mitral valve. specialized conducting system in way the strength-interval curves are a The opening and closing sounds of the dogs heart summation of anodal and cathodal valve, and the electrocardiogram, were stimulation thresholds, which may cause recorded on magnetic tape. The time M. J7. J7anse and R. Th. van Dam confusion. between closure and opening of the We studied the influence of lignocaine valve (valve closure time), and the RR' Isolated dogs' hearts with total AV on anodal and cathodal thresholds interval, were measured on Iooo suc- http://heart.bmj.com/ block were perfused according to the separately of the dog heart in situ, the cessive beats. Serial cross-correlation Langendorff technique. Electrodes on isolated perfused rabbit heart, and the functions between RR' interval and the right and left bundle-branches and rabbit heart in situ. Lignocaine was ad- valve closure time were computed. The in the ventricular myocardium were ministered at therapeutic levels during first order cross-correlation coefficient used for stimulating and recording. perfusion of the isolated heart or at a was larger than o-8, the second order Square wave cathodal current pulses constant infusion rate in the intact cross-correlation coefficient, though (2 msec. duration) of 15 times diastolic animal. small, was negative in all patients. threshold strength were used to deter- The anodal threshold was found to be These results were compared with the mine the refractory period (RP) of both conspicuously raised by lignocaine, serial cross-correlation functions be- on September 25, 2021 by guest. Protected copyright. tissues. During steady state frequencies while the cathodal threshold was only tween RR' interval and aortic blood W the RP of the bundle-branches exceeds slightly influenced. With anodal stimu- flow in 3 patients with atrial fibrillation that of the myocardium; at faster rates lation during lignocaine administration during cardiac operations. The first both RPs shorten and the difference the absolute refractory period was order cross-correlation coefficient be- diminishes. By way of a special stimula- shortened, while the cathodal absolute tween RR' interval and either stroke tion pattern, the RP after each beat of a refractory period remained virtually volume or peak flow velocity was close new, suddenly accelerated rate could be unchanged. All hearts, whether isolated to o 9. The second and a number of determined. In the bundle-branches, or in situ, behaved similarly, i.e., anodal higher order coefficients were slightly shortening of the RP after the first beat thresholds and absolute refractory negative. greatly exceeds that in myocardium; the periods were more influenced by ligno- This indicates that valve closure time bundle RP becomes even shorter than caine than were cathodal thresholds. (approximately equal to the duration of \ the myocardial RP. After the second We also studied the effect of changing mechanical systole of the left ventricle) beat the bundle RP lengthens again, the size of the electrodes (without add- and stroke volume are controlled by the + exceeding the myocardial RP by 40 ing lignocaine) on the anodal and the duration of preceding RR' interval(s). msec. The alternation between shorter cathodal excitability curve. Increasing This type of control is similar to that of and longer RP in odd and even beats the size of the anodal electrode had the myocardial contractility by RR' inter- continues for more than 20 beats, same effect as lignocaine on the anodal vals in isolated mammalian hearts dur-,. gradually decreasing in size. The myo- excitability cycle, while the effect of the ing random stimulation. It thus seems cardial RP is shortened considerably size of cathodal electrode on the ex- probable that cardiac function in by the first two beats, the influence of citability curve was negligible. patients with atrial fibrillation is at least the next beats being less; a steady state Microelectrode studies have shown partly controlled by the direct effect of is reached after several hundred beats. that lignocaine has little or no effect on (changing) RR' intervals on myocardial The difference in adaptation of the the electrophysiological properties of contractile behaviour. Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from Proceedings of the British Cardiac Society I49

An on-line system for the auto- records is a prerequisite for perfecting Experiments on long-term matic processing of vectorcardio- the diagnostic part. The output part preservation of rat heart grams finally gives the results of the wave- form analysis and diagnostic classifica- F. G. J. Offerijns G. van Herpen, J. H. van Bemmel, tion, together with a summary of the J. S. Duisterhout, L. G. Bierwolf, secondary patient information by tele- It is generally understood that long- and S. term preservation of an organ will be B. Versteeg, J. Hengeveld type and plotter. possible only in the frozen state. Ex- A highly automated processing system periments were conducted on the in- has been developed for analysis and clas- fluence of low temperatures (below Studies on cardiac excitation and o°C.) on the survival of the isolated sification of vector-electrocardiograms clinical implications using a PDP-9 computer. In this pro- rat's heart. Cryoprotective substances, ject, started some years ago, experience D. Durrer for example dimethyl sulphoxide, were is being obtained with vectorcardio- added to the perfusion fluid. The entry gram processing to reach finally the A general description was given of the of dimethyl sulphoxide into the extra- stage of instantaneous classification spatial distribution and temporal se- cellular and intracellular space was with a direct feed-back of the results to quence of the excitation fronts in the studied by means of dimethyl sul- the physician. ventricles obtained in 7 isolated normal phoxide labelled with tritium. We In our system the emphasis is on human hearts. investigated freezing and reanimation of extreme patient coding, almost com- Excitation is delivered by the anterior the organ in relation to its weight and pletely automated recording, signal pre- fasciculus of the left bundle-branch to age. It was possible to freeze to - 30°C. processing, and the elimination of the upper part of the anterior para- and to reanimate hearts from young rats human errors. Part of the system is an septal endocardium and to the middle (7-20 days old). automated recording station where the left septal surface, and by the posterior vectorcardiogram together with coding fasciculus to the middle posterior para- signals are stored on analogue magnetic septal endocardium. Stereophonic auscultation and tape, and patient information is punched Activation rapidly expands from stereophonic display on paper tape. The input system fur- these three foci of initial depolarization, ther contains specially engineered appa- and envelops the left ventricular cavity, G. E. Freud ratus such as a decoder, a real time probably distributed by the subendo- control unit, and an i8 bits input/output cardial conduction system. At the same The phonocardiogram can be taken buffer. In this way a two-way communi- time, a radial spread of excitation begins synchronously with two microphones cation is set up between computer and in the left ventricular wall, directed to- attached some distance apart on the recording station, which enables the wards the epicardial surface, and in a chest wall. The sound record gives on computer to do the processing comple- left-to-right direction across the inter- auscultation a stereophonic impression. tely automatically. ventricular septum which is mainly From this stereophonic record the ear http://heart.bmj.com/ The computer program consists of activated from the left side. can make a reasonable estimation of the two main parts: (i) input and wave- The right bundle-branch excites the origin of a given sound. As the ear is a form analysis, and (2) diagnostic clas- inner surface of the pretrabecular area subjective instrument, we tried to dis- sification and output. and adjoining part of the interventri- play the information about the localiza- The input part is run on a priority cular septum; further right ventricular tion in such a way that the eye could base and completes the input of a activation is predominantly tangential. understand the information. The appa- patient record once started. It decodes Epicardial breakthrough in the left ratus used for this splices the informa- the coded signals, checks whether the ventricle occurs in two areas overlying tion from both signals on the basis of ; patient identification code is still cor- the terminal portions of the anterior and relative loudness and the evidence of on September 25, 2021 by guest. Protected copyright. rect, and digitizes the X, Y, and Z sig- posterior fasciculi of the left bundle distance derived from the absolute loud- nals. The analysis program localizes the branch. The apex of the left ventricle is ness. To match eye and ear charac- QRS complexes, selects a zero-level, activated relatively late. Terminal exci- teristics a number of non-linear steps is identifies essential landmarks and com- tation occurs in the posterobasal left necessary, after which a reasonably putes a variety of other desired para- and right ventricles, in the postero- interpretable picture is obtained. Exam- meters. Input and analysis are per- superior part of the interventricular ples were shown. formed simultaneously, reducing septum and in the crista terminalis, >computation time by about 40 per cent. where the activation wave spreading For a vector record of about 30 seconds from the interventricular septum meets Ischaemic heart disease risk this part of the program takes IO excitation progressing in the pulmonary factors in young managers -seconds. conus. The diagnostic part implies the clas- Some of the clinical implications of J. Nieveen, J. J. M. L. Chappin, sification of vectorcardiograms with the disturbances in this activation pattern, J. F. May, L. A. Hartman, E. van de help of computed parameters. Two caused by bundle-branch block, fasci- Wall, and A. A. Wouda main approaches are used: one in which culus block, intramural block or intra- various statistical discrimination meth- septal conduction delay are demon- An investigation of risk factors for .ods are applied to patient material of strated by observations made in vivo or ischaemic heart disease was performed well-defined disease categories, the in isolated human hearts. The theoreti- in 2 parts. other in which a diagnostic logic is cal consequences of these data, regard- (i) An inquiry among the members of compiled from diagnostic criteria in ing cancellation, 'silent regions', and Netherlands Junior Chambers of Com- ? practical use. Either way, acquiring the electrical position theory were dis- merce (30 to 40-year-old men in indus- greater numbers of reliable patient cussed. try, official world, and free professions). Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from iSo Proceedings of the British Cardiac Society

Questions were posed on living, eating, the results, use was made of the index of and in 3, QRS changes indicative of a smoking, drinking, and working habits, merit (I) devised by Kuipers. In this myocardial lesion were also present. complaints, diseases, family, weight, index both the fractions correct-positive Typical increases in enzyme levels were physical activity, stress, recreation, and and correct-negative predictions are noted in 4 cases. The coronary arteries holidays (response 605 =75%). represented. It ranges from o (no asso- were free of obstructive lesions in all (2) A pilot study of 36 northern mem- ciation) to i (perfect association). cases, but the left ventriculogram was bers, composed of anamnesis, general The history appeared to have the pathological in 3. One case had a recur- examination, glucose tolerance test, highest predictive value. The exercise rence six months later, with the same blood cholesterol, triglycerides, lipids, test scored very low, but it should be anterior localization of the electrical uric acid, x-ray of thorax, electrocardio- appreciated that precisely in the most disturbance. A second coronary angio- gram, vectorcardiogram, telemetry, car- pathological and most easily diagnosable gram now revealed a total obstruction dioscan, photoelectric plethysmography, cases the test is not practicable. In 68 in the anterior descending artery. In and lung function. Results: 75 per cent cases the statements by the 3 methods another patient, 36 weeks pregnant at physically inactive, 41 per cent over- with the highest index of merit (the the onset of symptoms, a fusiform weight, and 46 per cent cigarette smok- history, the vectorcardiogram, and the aneurysm of the anterior descending ing. The pilot study revealed among serum lipoprotein level) were concor- artery (without narrowing) was demon- others, 9 abnormal glucose tolerance dant: in these cases the association with strated. The aetiology of these cases tests, I9 with more or less disturbed the coronary arteriogram was excellent, remains obscure. The differential diag- lipid metabolism, 3 abnormal electro- I being o 94. In IOI cases the history nosis was discussed. cardiograms, and 3I diets containing 4I and the vectorcardiogram agreed; in per cent abundance of fat. this group I was o 84. In the total mate- Probably the same high percentage of rial the highest index of merit was Congenital coronary artery risk factors holds for comparable groups obtained if, in the remaining cases in fistula: report of 17 cases with a of Dutch people. To stop the increase of which the history and the vectorcardio- note on natural history of lesion mortality from infarction one should gram were contradictory, the decision strongly stimulate physical activity, stop was made on the basis of the serum f,- J. J. F. de Nef, P. J. Varghese, and or lessen cigarette smoking, and eat less lipoprotein content. This yielded an G. Losekoot index calories. Periodic preventive examina- of merit of o-68 (± o-o6). Thus in A retrospective co-operative study of tion of the population should be con- a considerable proportion of cases I7 patients sidered in the near future. coronary arteriography was the only with congenital coronary method in which it could be determined artery fistula was undertaken, focusing whether the patient had coronary artery mainly on the natural history of this Comparison of coronary angio- disease. In addition the coronary ar- lesion. gram with other parameters teriogram was the only method which The most common site of this fistula (history, electrocardiogram, conveyed the correct information con- was the right coronary artery, and the http://heart.bmj.com/ vectorcardiogram, two-step test, cerning the severity and localization of right ventricle was the site of drainage serum lipids) in patients with the obstructive lesions. There appeared in a majority of the patients. There ginal complaints to be no consistent relation to the were three ways in which the fistula angiogram of the left ventricle. terminated. In most cases the artery A. V. G. Bruschke, A. W. Hanssen By a careful evaluation of the data entered straight into the chamber. In a and G. van Herpen obtained by less agressive methods and few patients the involved vessel ended more particularly by combining the in an aneurysm which opened into the From a total ofapproximately 750 selec- chamber, and in others the vessel ended tive results of various parameters, it ap- coronary arteriographies at St. peared to be possible to delineate the in a convolution of vessels before on September 25, 2021 by guest. Protected copyright. Antonius Hospital, Utrecht, a contin- indications for coronary arteriography emptying into the chamber. uous series of I50 patients was selected more clearly. Most of the patients were under 20 for further analysis. Only patients in years of age and were asymptomatic. whom no other cardiac abnormality The symptoms and cardiomegaly on the than that attributable to ischaemia could chest x-ray were well correlated with be detected, were accepted for this Myocardial infarction with normal coronary arteriography the size and duration of the shunt. All study. patients above the age of 35 had The primary aim of our study was to A. Bloch, A. V. G. Bruschke, symptoms. evaluate the diagnostic importance of K. J. J. Bruyneel, and G. van Herpen A continuous murmur was present in the coronary arteriogram by studying all patients. The site of maximum in-; the statistical association of its results to Cases presenting with the signs and tensity of the murmur is closely related those obtained by the history, the elec- symptoms of acute myocardial infarc- to the site of drainage and is helpful in trocardiogram, the vectorcardiogram, tion in which subsequent coronary the diagnosis of this lesion. Diagnosis the two-step exercise test, the serum angiography did not reveal any obstruc- was confirmed at cardiac catheriza- t cholesterol level, and the serum ,B-lipo- tion of the coronary arteries have been tion and angiocardiography. Pulmonary protein level. The investigation also rarely reported. In this communication, hypertension as a complication occurred gave us the opportunity to study the 5 such cases were presented, out of a in the presence of congestive heart reliability of a number of criteria by series of about 8oo coronary angio- failure, and also when the left atrium which the data of the various methods graphies. was the site of drainage of the fistula. are interpreted. The relation between All cases were of acute onset (some- Eleven patients were operated upon. the coronary arteriogram and the angio- times with a previous history of angina Indications for operation and the prog- gram of the left ventricle was also pectoris); in all, the electrocardiogram nosis of the non-surgical group of; studied. For the statistical evaluation of showed acute changes of repolarization, patients were discussed. Br Heart J: first published as 10.1136/hrt.33.1.142 on 1 January 1971. Downloaded from Proceedings of the British Cardiac Society 151

Threshold analysis of implanted functioning and exit block has not quantitative estimation ofthe extent of a pacemakers developed. myocardial infarction as well as of the However, monitoring of the stimula- time course of enzyme shed-out. H. J. Th. Thalen, Jw. van den Berg, tion threshold of an implanted unit has After a myocardial infarction plasma J. N. Homan van der Heide, and not been possible so far. To overcome enzyme levels are measured every 4 to 6 J. Nieveen this disadvantage the threshold pace- hours for a few days. The half-life times maker has been developed. In I968 the of these enzymes in the plasma are cal- The follow-up of pacemaker patients first of these stimulators was implanted culated from the downslope ofthe curve has become one of the problems of in patients. Operation and clinical obtained, by fitting an exponential de- cardiology today. Special pacemaker results were discussed. cay curve by the least-square method clinics have been started, where pace- with the aid of a computer. With the maker analysis is made by peripheral half-life times known, a release-curve pulse, electrocardiogram, and x-ray of the enzymes from the infarcted area monitoring. New analysis methods have Quantitation of enzyme release can be plotted and the total amount of been developed by feeding the pace- from infarcted heart muscle enzymes released into one litre of maker impulse into an oscilloscope and plasma can be calculated. As the enzyme photographing from the oscilloscope S. A. G. . Witteveen, W. Th. activity of one gram of myocardial screen. Because of the Hermens, L. Hollaar, and H. C. fast time base of Hemker tissue, which was calculated from an oscilloscope, a full analysis of the samples of heart tissue obtained at car- impulse is possible this way. Defects of A method is given by which the plasma diac surgery, is known, the area of stimulator and electrodes can be diag- enzyme levels, estimated by a routine infarction losing its enzymes into one nosed, even when the pacemaker is still technique, can be used to obtain a litre of plasma can be estimated. http://heart.bmj.com/ on September 25, 2021 by guest. Protected copyright.