Br J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from British Heart Journal, I972, 34, 20I-209. Proceedings of the British Cardiac Society

THE AUTUMN MEETING of the in Dublin on 23 March I972 were pro- mittee that the utmost flexibility re- British Cardiac Society was held at the ceeding satisfactorily. garding the training schedules must be Royal College of Physicians, London, maintained with regard to the order in on Thursday and Friday, 4 and 5 5 The Secretary reported that arrange- which training should be taken, and the November 197I. The President, SIR ments had been made to hold the next background oftrainees. No training pro- JOHN McMICHAEL, took the Chair Autumn Meeting on 9 and I0 November gramme should be so rigid that its at 9.30 a.m. during Private Business. At I972 at the Royal College of Physicians, requirements would permit people with the Scientific Session which followed, but the possibility was being explored unorthodox backgrounds but of special the Chair was taken by ALASTAIR of holding the dinner elsewhere. brilliance to be excluded. HUNTER. The recommendations had been pre- 6 The Secretary reported that the sented to the members of Council, who Private Business Annual General Meeting in 1973 would had added their comments and suggest- I The President reported with deep be held on I2 April in Glasgow, im- ions, and the report had been discussed regret the deaths of Twort and Doris mediately before the meeting of the and agreed provisionally at the meeting Baker. Association of Physicians. of the full Committee for Higher 2 The Minutes of the Annual General Medical Training in October. Meeting having been published in the Journal (I97I, 33, 607-6I6) were taken 7 Goodwin reported that the findings as read and confirmed. of the Cardiology Committee of the 9 Davison and Oram reported on the Royal College of Physicians on Career results of discussions they had had with 3 The Treasurer reported that the Structure in Cardiology had gone to the Dr. Lees of the Department of Health Society's investments stood at nearly Department of Health, but no official and Social Security on cardiological £12,ooo. In line with stock market reaction to the report had been received. technicians' pay and conditions. They prices there had been some recent felt that they had had a full opportunity appreciation in value. He had recently 8 Goodwin, as Chairman of the to explain the position and they were reviewed the holdings with the Society's Specialist Advisory Committee on hopeful that a sympathetic view would Broker who was generally satisfied with Cardiology of the Joint Committee on be taken of the need for appropriate the behaviour of the shares and recom- Higher Medical Training, reported that salary scales for cardiological tech- mended no change at this time. the Committee had now formulated nicians. http://heart.bmj.com/ £i,ooo had been taken out of the provisional recommendations for train- Deposit Account and invested in 8J% ing programmes for Groups I and II Bass Charrington Debentures for the cardiological consultant work, and for 10 The Secretary informed the Society Sinking Fund, bringing this to £I,5OO, paediatric cardiology. It seemed likely that a memorandum had been received with s500 left on deposit, on Broker's that the Groups II and III outlined in from Dr. Lees of the Department of advice, for easy availability. the Report ofthe Cardiology Committee Health and Social Security with regard Expenses of all kinds were rising of the Royal College of Physicians on to the possibility of interference with inexorably, and though he was exploring Cardiological Staffing and Career Struc- the function of demand pacemakers. ways and means of getting work done ture could in future be merged. The Dr. Lees was anxious to establish a on September 26, 2021 by guest. Protected copyright. more cheaply most increases had to be Specialist Advisory Committee had register of demand pacemakers, and accepted. Members' subscriptions just recommended 8 years training for members were requested to notify Dr. about covered current expenses; but Group I and II and Paediatric Car- Lees of the name and address of any the actual position would be known diology, which included i year pre- patient, and the make and model of the when the books for 197I were closed at registration jobs, 3 years general medical pacemaker being used. the end of the year. training, and 4 years (in the case of Following the Scientific Meeting on The financial accounts of the VI Group I) and 3 years (in the case of the Thursday, the Thomas Lewis World Congress of Cardiology had now Group II) in specialist training in Lecture - 'Function of Nerves of the been closed and the Society had re- a Special Cardiac Medical-Surgical Heart' - was given by Linden. ceived a further kI,967-26. It had been Centre. The 4th year for Group I After the Scientific Meeting on the agreed that £5oo should be given from should include some general medicine. Friday, the National Heart Hospital St. the Society to the Lord Alexander Paediatric Cardiology presented addi- Cyres Lecture - 'The Skeleton in Heart Appeal Fund of the British Heart tional difficulties, but should include 2 Disease' - was given by Jefferson. Foundation; that £i,ooo should be held years' adult cardiology and 2 years' The Society dined together at the in reserve to assist members with some paediatric cardiology in addition to Royal College of Physicians, with of their travelling expenses to attend the general paediatrics and neonatal paedi- McMichael in the Chair. The guests VII World Congress; and the remainder atric training, probably to be taken in included Professor J. N. Morris. The be put into the Society's general fund. the 3 years of general professional President spoke about recent develop- training. ments including progress in the creation 4 The Secretary reported that arrange- Goodwin emphasized most strongly of chairs of cardiology by the British ments for the Annual General Meeting the firm recommendation of his Com- Heart Foundation. Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from

202 Proceedings of the British Cardiac Society

Nitrous oxide analgesia in acute patient the thrombus extended to the with acute myocardial infarction. High myocardial infarction popliteal vein. When such extension was frequency phonocardiograms were re- noted these patients were given anti- corded from the left atrial border and F. Kerr, D. J. Ewing, J. B. Irving coagulants. Over 50 per cent of the apex on several occasions in all patients. (all introduced), and B. J. Kirby thrombi were found in the first 72 pressures were mea- hours. No patient in this series sus- sured with a flow guided catheter. Many drugs used for pain relief in myo- tained a major pulmonary embolus. The Simultaneous electrocardiograms were cardial infarction have circulatory incidence found in these patients is very also obtained. effects. An agent that relieves pain with- similar to that recorded in patients who Atrial sounds were present in all out major haemodynamic effect would have recently undergone surgery. cases. The interval between the P wave be advantageous. In IS patients with of the electrocardiogram and the initial acute myocardial infarction we studied deflexion of the atrial sound of the the analgesic and cardiorespiratory pro- Atrial gallop in diagnosis of early phonocardiogram (PG interval) was perties of a 50 per cent nitrous oxide 50 coronary heart disease measured. The ratio of PG interval to per cent oxygen mixture (Entonox, the PR interval of the electrocardio- B.O.C.). During a control period the P. G. F. Nixon and H. J. N. Bethell gram progressively increased from 8i patients breathed air via an air force (introduced) per cent on the first day to 89-3 per cent mask connected to a demand valve. on the fourth day, demonstrating that With a three-way tap, transfer to Ento- The clinical diagnosis of early coronary with resolution of the infarction, the nox, breathed through a similar assem- heart disease traditionally depends upon atrial sound moved towards the first bly, was accomplished without the the history and the electrocardiogram, heart sound. Those patients with a com- patient's knowledge. In 5 patients the little of importance being expected or plicated clinical course had a signifi- cardiac index was measured with indo- obtained from the examination of the cantly smaller PG/PR ratio than those cyanine green and intra-arterial pres- and pulsations. patients whose course was entirely sures recorded at 5-minute intervals. The purpose of this communication uncomplicated. After a 20-minute control period Enton- is to report findings from a series of I59 There was a significant correlation ox was administered for 30 minutes: cases of coronary heart disease without between this ratio and the pulmonary mean fell 5/minute, mean evidence of myocardial infarction, hy- artery diastolic pressure, suggesting arterial pressure remained constant, car- pertension, or valvar disease. that those patients with the greatest diac index fell 0o4 I./min per m2n, and One hundred and eleven patients had degree of left ventricular dysfunction systemic rose 334 classical angina pectoris and the resting had the shortest PG intervals (r=o052, dynes sec cm-5/m2. Blood gases in 6 electrocardiogram was abnormal in 21 y=37-I 4x, P < OcOOI). patients showed a rise in arterial Po2 of (i8%). In the remaining 48 patients, It is concluded that in acute myocar- 35 mmHg during Entonox administra- the diagnosis of coronary heart disease dial infarction an atrial sound is univer-

tion, returning to the control level on was made from abnormalities of the sally present and that the PG interval http://heart.bmj.com/ withdrawal. Complete pain relief was electrocardiogram at rest or after exer- reflects alterations in the clinical and demonstrated in all patients with no cise. The resting electrocardiogram was haemodynamic state of the patient. significant side-effects. We conclude abnormal in 24 (50%). that Entonox is a safe and effective In io8 of the patients, the heart analgesic in acute myocardial infarction. sounds and pulsations were recorded by Lowering of blood cholesterol by low frequency phonocardiography and dietary recommendations in apex cardiography, with the patient in middle-aged men A study of the incidence of venous the left lateral or semilateral position.

thrombosis following myocardial The tracings were examined for fourth A. G. Shaper, Jean W. Marr, on September 26, 2021 by guest. Protected copyright. infarction heart sounds and enlargement of the J. A. Heady, and J. N. Morris (last atrial components ('A' waves) of the three all introduced) B.J. Maurer and R. Wray (introduced) apex cardiogram. In the 7I patients in the classical angina group, the tracings Male civil servants aged 40-49 years, Using the 125I-fibrinogen isotope tech- were abnormal in 65 per cent, and the who had previously participated in a nique, ioO patients with acute myocar- resting electrocardiogram abnormal in questionnaire on leisure activity, took dial infarction have been studied to 17 per cent. part in a further study designed to assess define the incidence of venous thrombo- It is concluded that physical examina- whether a significant reduction in sis complicating this illness. None of the tion in the left lateral position, by reveal- blood cholesterol level could be achieved patients was given anticoagulants rou- ing palpable and audible atrial gallop in a free-living population by simple tinely, but in IO patients anticoagulants rhythm, may be more useful than the dietary recommendations. The study were employed at an early stage in the resting electrocardiogram in detecting involved 5 visits over a 6-month period illness for reasons other than the treat- early coronary heart disease. and included physical examinations, ment of venous thrombosis. Of the go , detailed dietary patients who were not given anticoagu- studies, biochemical measurements (in- lants, 34 (37%) developed a calf vein Significance of atrial sound in cluding blood cholesterol, triglycerides, thrombosis. None of the IO patients acute myocardial infarction uric acid, glucose, fatty acid patterns), given anticoagulants developed throm- and studies of the blood fibrinolytic bosis. In IO ofthe 34 patients the throm- E. D. Bennett, C. R. Smithen (both activity. Two groups of men were given bus was bilateral. In all, the thrombus introduced), and E. Sowton dietary advice and two groups remained began in the calf. In 7 limbs the throm- as the controls. bus extended to involve the veins of the The incidence and significance of the The control groups showed an in- thigh and the femoral vein. In one atrial sound was assessed in 20 patients crease in blood cholesterol level over the Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from Proceedings of the British Cardiac Society 203 winter months of the study. The groups two-thirds. There were no significant Data from I60oo cardiac catheterizations given dietary advice showed a fall in changes at the second investigation. performed at 3 separate hospitals from blood cholesterol level on reassessment Mixed venous oxygen saturations were I January 1970, to 30 June 1971, have at 6 weeks and maintained this lowered also unchanged. been stored using a digital computer. A level at 4 months. Body weight increased A self-rating depression scale has specially designed form is used on which in the control group and fell in the diet- been used to assess possible changes in can be recorded not only the numerical ary group, but within the diet group, mood. data derived from the procedure but there was no significant relation between A short film showing the exercises also, by means of a coding system, a the amount of weight change and the used in training is available. description ofthe technique of catheter- amount of cholesterol change in indi- ization, the chambers and vessels en- vidual subjects. The control group was tered and details of angiocardiography. then provided with the dietary recom- Initial experiences of routine In addition it is possible to record the mendations and all subjects will be re- automated electrocardiographic effect of interventions such as the ad- examined at I2 months from the start interpretation ministration of drugs. The diagnostic of the study. coding permits not only a statement of Changes in skinfold thickness, blood P. W. Macfarlane (introduced) and the diagnosis but also allows the expres- pressure, and fibrinolytic activity were T. D. V. Lawrie sion of clinical doubt about the nature also observed over the initial 6 months and severity of the lesion. of the study. Relations between diet and In a previous communication to the Print-outs are sent to the participating these measurements will be discussed British Cardiac Society a technique for hospitals weekly; a copy of the original with reference to the possible signifi- electrocardiographic interpretation by form is retained for reference until the cance of this study to the primary pre- computer was described and results print-out is available. vention of coronary heart disease. discussed. The present communication Programmes have been written to per- reports the initial experiences of intro- mit a wide range of data retrieval and ducing the method into a large general analysis, and some results of such Supervised physical training after teaching hospital for routine purposes. analyses will be presented. The project myocardial infarction During the first six months of opera- is a first step towards constructing a tion, 3,455 3-lead electrocardiograms comprehensive system of data retrieval C. M. Morgans (introduced by were interpreted by a computer sited relating to hospital cardiological prac- D. W. Barritt) within the hospital. The number re- tice, while the co-operative nature of corded monthly was increased gradually the project increases the pool of data Supervised physical training in men and in the sixth month was 725, repre- available for analysis. aged 35 to 65 recently recovered from senting almost 40 per cent of the total myocardial infarction is being studied. hospital requirement. Twenty-three men form the exercise In parallel with this introduction, a Cardiovascular data analysis on a group and 22 are controls. The exercis- series of lectures was given to medical small digital computer http://heart.bmj.com/ ing patients trained three times weekly staff to explain the diagnostic principles for three months in a hospital gym- of 3-lead electrocardiography. This C. J. Mills (introduced) and nasium. The control group received facilitated acceptance and minimized I. T. Gabe routine aftercare. criticism of the computer interpreta- Parameters measured before and if tions. The general problem of analysing data possible after three months include Significantly erroneous interpreta- during cardiovascular investigation has heart rate, pulmonary artery pressure, tions totalled under 4 per cent, while a become greater in recent years with the and venous oxygen saturation, mea- further 4-5 per cent of computer reports increase in the number of variables re- sured at rest and during supine exercise had minor discrepancies. These results corded and with the necessity to mea- on September 26, 2021 by guest. Protected copyright. on a bicycle ergometer, using a float have led to further modifications to sure records in a more detailed way. To catheter. wave recognition techniques and cri- facilitate such analysis, a small digital One patient in each group has died. teria, together with insistence on higher computer - a PDP-I2 - has been pro- A significant (P

Intracellular action potential in surprisingly we could do this in the Alpha-adrenergic blockade in hypertrophic obstructive cardio- other case with type A conduction. treatment of heart failure myopathy Though Case 3 had type B WPW con- duction, we were unable to initiate an S. H. Taylor, P. A. Majid, and D. 7. Coltart and S. J. Meldrum arrhythmia nor did he suffer from B. Sharma (the last two introduced) (both introduced by John Hamer) paroxysmal tachycardia. In Cases i and 2, His bundle electrography showed The adrenergic alpha-receptor blocking Some skeletal muscular dystrophies are only mild pre-excitation during sinus drug, phentolamine, was administered known to be associated with cardio- rhythm, though in one the degree varied to I2 patients with severe progressive myopathy, and Meerschwam and Hoots- spontaneously: pacing caused the His-V left ventricular failure due to ischaemic mans (197I) have reported abnormal interval to decrease sharply to zero as heart disease. The rationale for the use electromyographic potentials in the the major part of depolarization oc- of this drug in this circumstance was skeletal muscles of patients with hyper- curred via the presumed bypass. In based on two considerations; that the trophic obstructive cardiomyopathy. In Case 3, with conspicuous pre-excitation reflex increase in systemic resistance view of these findings we have studied in sinus rhythm, a similar response that accompanies the onset of pumping the intracellular action potential in occurred on pacing. The fourth patient failure may further aggravate the left specimens of myocardium removed at had the syndrome of a short PR and ventricular failure by increasing the operation in 2 patients with hypertro- normal QRS interval, with a short P-His pressure-work load on the ; phic obstructive cardiomyopathy, using interval on the electrogram; he suffers that in heart failure the redistribution of the microelectrode technique, and com- from paroxysmal atrial flutter. the towards the heart and pared the findings with action potentials The possible mechanisms for the lungs may further increase left ventricu- in tissue from other hypertrophied different modes of conduction seen in lar dilatation. The drug was adminis- . pre-excitation were presented, with tered intravenously in a dose of I-2 Repolarization was greatly prolonged special reference to the occurrence of mg/min sufficient to lower the systemic in the tissue and the rate of depolariza- arrhythmias and their control. arterial by 20-30 mmHg. tion was reduced. There were also This resulted in an immediate relief of characteristic abnormalities in the effec- symptoms simultaneously with a sub- tive refractory period and the contrac- Effects of glucagon on myocardial stantial reduction in the left ventricular tile response. The usual 'quinidine- contractility and end-diastolic and pulmonary artery like' effect of propranolol on the action mean pressures, and a significant in- potential could be demonstrated. John Hamer, Derek Gibson, and crease in and cardiac The findings of an abnormal myo- John Coltart (introduced) output. These changes were maintained cardial and skeletal muscle potential in throughout the three-hour period of patients with hypertrophic obstructive Intravenous glucagon has been recom- infusion. Patients who were able to cardiomyopathy support the view that mended as an inotropic agent in the exercise also had a significant improve- http://heart.bmj.com/ this condition might be a generalized management of low cardiac output ment in symptoms, an increase in the muscular dystrophy with early major states. cardiac output, and a decrease in the cardiac manifestations. We have investigated the effect of 2 left ventricular end-diastolic pressure or 3 mg glucagon intravenously at car- response to exercise. Chest x-rays Reference diac catheterization in 3 patients with showed a conspicuous clearing of pul- Meerschwam, I. S., and Hootsmans, W. J. serious aortic stenosis, using thermo- monary oedema and reduction in heart M. (I97i). An electromyographic study dilution curves to measure left ventricu- size after the drug. The benefits of this in hypertrophic obstructive cardiomyo- lar volume. There was a striking rise in treatment are probably predominantly pathy. In Ciba Foundation Study Group cardiac output (from 4.4 to 6-3 I./min), due to the effects ofthe drug in lowering on September 26, 2021 by guest. Protected copyright. No. 37: Hypertrophic Obstructive Car- due to moderate increases in heart rate the systemic vascular resistance thus diomyopathy, p. 55. Ed. by G. E. W. 8I Wolstenholme and M. O'Connor. (from tO go per min) and stroke reducing the cardiac pressure-work load Churchill, London. volume. There was a considerable in- and volume. However, the drug may crease in end-diastolic volume, but also directly support the metabolism of mean circumferential shortening rate, the failing heart by release of the sup- an index of contractility, was unchanged pression of insulin secretion, and its Spectrum of pre-excitation and its or fell. Left ventricular systolic pres- bronchodilator action may also con- elucidation by His bundle electro- sures rose slightly and there was a con- tribute to the relief of symptoms in graphy siderable increase in wall force, possibly patients with cardiac asthma. This due to the Starling effect in the larger approach to the treatment of severe Dennis Krikler, Charles Smithen left ventricle. heart failure may usefully complement (introduced), and Edgar Sowton The maintenance of the shortening conventional treatment with digitalis velocity in the presence of an increase in and diuretics and may be of particular We review 4 patients with different as- wall force may be an indication of some value in situations were digitalis is pects of the pre-excitation syndrome, inotropic effect, but there is no evidence contraindicated. studied by His bundle electrography. of an increase in contractility which Two had type A Wolff-Parkinson- could produce the observed rise in car- White conduction, both with recurrent diac output. It seems likely that a rise Beat-to-beat analysis of left paroxysmal tachycardia. In one, ven- in splanchnic blood flow is produced, ventricular pressure-volume tricular extrasystoles appeared to be im- and that the cardiac changes are largely relations in atrial fibrillation in portant in the production of the secondary to the increase in venous man arrhythmias; tachycardia could not be return. The therapeutic value of this re- initiated by right heart stimulation, but sponse in cardiac disease is questionable. D. G. Gibson Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from

Proceedings of the British Cardiac Society 205

Using an echocardiographic method of recurrent ventricular tachyarrhyth- The findings are discussed in relation during diagnostic cardiac catheteriza- mias. to the implications for surgical treat- tion, simultaneous records of left ven- ment and to accepted concepts of pul- tricular dimensions and left ventricular monary circulation development. and aortic pressures were made for Familial atrial cardiomyopathy periods of up to 50 consecutive cardiac with heart block cycles in patients with atrial fibrillation. Significance of continuous From these data, end-diastolic, end- R. E. Nagle, B. Smith, and murmurs in cyanotic congenital systolic, and stroke volumes were deter- D. 0. Williams (last two introduced) heart disease mined and correlated with intraven- tricular pressure, allowing the diastolic We have studied a cardiomyopathy Fergus Macartney, Philip Deverall distensibility of the left ventricle to be affecting 3 out of 5 sibs, characterized (introduced), and Olive Scott described, and pressure-volume loops by first degree heart block and ectopic to be constructed for single cardiac supraventricular rhythms progressing Six patients (age 3-25 years) with ven- cycles. Left ventricular wall tension, over some years to persistent atrial tricular septal defect and 'pulmonary derived from cavity diameter and sys- standstill, with complete loss ofresponse atresia' were studied in whom the entire tolic pressure, and mean circumferen- to direct atrial stimulation. At least 2 pulmonary blood supply was from large tial fibre shortening rate, derived from children of one of the patients appear 'bronchial' arteries arising distal to the stroke volume, cavity diameter, and to be similarly affected. ascending aorta, and not from a per- ejection time, were determined on a We have found only 4 previously sistent ductus arteriosus (PDA). All had beat-to-beat basis, and were shown to reported cases of this arrhythmia, 3 of continuous murmurs. Selective 'bron- correlate with previous intervals. whom occurred in a family with amyloid chial' arteriography showed detailed The relation between left ventricular disease. Post-mortem examination of a anatomy. To evaluate the likely result tension-time, an index of myocardial member of the family showed no evi- of surgical anastomosis of a right ven- oxygen consumption, and external car- dence of this condition. tricular conduit to a suitable point in a diac work was also shown to be depen- bronchial artery, pulmonary resistance dent on diastolic filling time and stroke (Rp) was measured as the total resistance volume. These methods can thus be Systemic arterial supply to lungs to flow distal to that point, as deter- used to examine the interrelations be- in pulmonary atresia and its mined by bronchial artery catheteriza- tween various aspects of left ventricular relation to pulmonary artery tion and the Fick technique. function in a single patient, as well as development Of 12 'bronchial' arteries catheter- giving a more complete description of ized, only one had significant orificial cardiac performance in the presence of Keith Jefferson, Simon Rees, and stenosis. Rp in the 5 patients without atrial fibrillation on a beat-to-beat basis. Jane Somerville such stenosis was 2I-65 units m2 (mean

40), breathing room air. Breathing IOO http://heart.bmj.com/ The pattern of systemic arterial supply per cent oxygen produced a rise in pul- Reversion of ventricular tachy- to the lungs and its relation to pulmon- monary flow in 4 patients, but Rp re- cardia by pacemaker stimulation ary artery development has been studied mained severely raised (I4-39 units M2; angiographically in 30 patients with pul- mean 34) implying inoperability by the M. A. Bennett (introduced) and monary atresia and ventricular septal above technique. B. L. Pentecost defect. Necropsy findings were available By contrast, 2 patients whose entire in 3 of the patients. The findings reveal pulmonary flow traversed a persistent Transvenous cardiac pacing has been that the systemic arteries fall into two ductus arteriosus, had severe ductal

used with success in the prevention of groups. In one group the arteries were stenosis, but lacked the usual continu- on September 26, 2021 by guest. Protected copyright. recurrent drug-resistant ventricular small, multiple, tortuous, and uncount- ous murmur probably because of in- tachyarrhythmias. Despite pacing, how- able in number, with widespread sites adequate ductal flow. ever, ventricular tachycardia and fibril- oforigin from the aorta and its branches, We conclude that a continuous mur- lation may recur. With the pacing and in patients with this type of arterial mur is an unreliable guide to anatomy catheter situated in the right ventricle, supply the central pulmonary arteries or pulmonary resistance in such patients. the reversion of ventricular tachycardia were invariably present. Full develop- to sinus rhythm was achieved by pacing, ment of the central pulmonary arteries in seven patients after acute myocardial was also present when the ductus was Twelve years follow-up after infarction. The technique involved patent. surgical correction of Fallot's pacing at a rate in excess of the existing In the other group, the systemic tetralogy in childhood tachycardia until ventricular capture arteries were much larger, less tortuous was achieved. Cessation of pacing after and countable, varying from one to five Riaz Haider, P. Finnegan, S. Sanchos- a few seconds was usually followed by in number. With one exception they Fomos (all introduced), L. D. Abrams, sinus rhythm. Because ventricular arose from the descending aorta below S. P. Singh, and C. G. Parsons tachyarrhythmias were recurrent in the the isthmus and entered the lungs via presence of sinus rhythm, the ventricu- the hilum to become continuous with Eight patients have been reassessed lar capture rate was sometimes slowed the hilar pulmonary arteries, at which approximately I2 years after one-stage to the point when ventricular premature point there was usually a stenosed seg- correction of Fallot's tetralogy. It has beats first appeared. The heart was then ment. been shown that right atrial mean pres- paced slightly in excess of this critical Patients with larger arteries as the sure, right ventricular systolic and end- rate. The technique of reversion seems sole source of supply to the lungs had diastolic pressures, pulmonary artery a useful extension to the employment absent or incompletely formed central pressure, and pulmonary vascular re- of transvenous pacing in the prevention pulmonary arteries. sistance were all essentially normal at Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from 2o6 Proceedings of the British Cardiac Society rest and during exercise. Arterial oxy- fascial conduit at the valve site. Pulmon- Changes in serum and urinary gen saturation was within the normal ary arteriography in one patient re- magnesium levels in patients range. The systolic pressure gradient vealed mild pulmonary incompetence. undergoing open heart surgery across the right ventricular outflow The value offascia lata reconstruction tract was less than 20 numHg at rest in of the right ventricular outlet appears to M. P. Holden (introduced), all patients. The right ventricular/sys- be limited by the high incidence of post- M. I. Ionescu, and G. H. Wooler temic ratio ranged from 14 to 42 per operative pulmonary stenosis. cent. The response of cardiac output to Magnesium is quantitatively the fourth exercise, and the relation between oxy- most important cation in the body after gen consumption and cardiac output sodium, potassium, and calcium, par- were normal. No patient had a shunt at Influence ofextracellular potassium ticularly in myocardial function. There ventricular level. concentration on ouabain effects in is increasing evidence that divalent By the methods employed we were human cultured cells cations are essential controlling factors unable to show any significant abnor- in the transfer ofmonovalent ions across mality of cardiac function at rest or D. McCall, J. V. Lamb (both cellular membranes. For these reasons, during exertion. There was no detect- introduced), and T. D. V. Lawrie we investigated possible changes in able difference in the cardiac function serum and urinary magnesium levels in of patients with a competent pulmonary Experiments have been carried out to patients undergoing open-heart pro- valve and those with incompetence determine the effects of prolonged cedures. associated with a prosthetic patch in the ouabain treatment on the ionic contents Fifty patients were studied and a con- right ventricular outflow tract and/or of a strain of cultured cells derived trol group of 33 patients undergoing pulmonary artery. initially from human right atrium general thoracic operations was investi- It is concluded that in these 8 patients (Girardi et al., I958). Preliminary ex- gated at the same time. cardiac function is normal 12 years after periments showed that sensitivity to Some patients with mitral disease, in total correction of Fallot's tetralogy and cardiac glycosides was similar to other congestive heart failure and receiving that the prognosis appears to be good human tissues. Treatment of the cells diuretics, had low serum magnesium even when there is residual pulmonary with low concentrations of ouabain, in- levels before operation. incompetence. cluding those concentrations that would The serum magnesium levels in all be encountered in clinical practice, for patients fell during and re- varying intervals of time from 8 hours mained low for the first 3 postoperative to 5 days, was carried out. The intra- days. The levels in the serum were nor- Late results of fascia lata cellular Na rose, and intracellular K mal by the time of discharge from hos- reconstruction of the right fell, to new steady levels, and these new pital 2 to 3 weeks later. There was a ventricular outlet levels were linearly related to the con- decreased amount of magnesium in the

centration of ouabain used. urine during the first 3 postoperative http://heart.bmj.com/ Fergus J. Macartney, Olive Scott, Reducing the extracellular K con- days. and Marian I. Ionescu centration increased the changes in the The biological importance of mag- ionic contents of the cells brought about nesium and its role in myocardial func- Twenty previously reported patients by the low concentrations of glycoside, tion was reviewed and the value of mag- who have survived reconstruction of whereas in the presence of increased nesium therapy discussed. The clinical the right ventricular outlet with a fascia extracellular K concentration the oua- effects of giving magnesium to these lata composite graft have been followed bain had a less obvious effect. Both of patients and those undergoing cardio- for up to I9 months. All are symp- these effects were significant (P

At each concentration of K however, on September 26, 2021 by guest. Protected copyright. exercise tolerance, requiring no medica- the 24-hour ionic levels remained linear- tion. All have pulmonary ejection ly related to ouabain concentration. 'Jet lesion' in aortic valve systolic murmurs and three have mur- In a further series of experiments the endocarditis murs of pulmonary incompetence. The cells were exposed to tritiated ouabain, cardiothoracic ratio on x-ray has re- in concentrations identical to those used L. Gonzalez-Lavin (introduced), mained unchanged from before opera- in the preceding experiments, for 24 Jane Somerville, and Donald N. Ross tion in each case. hours. The amount of glycoside bound However, postoperative cardiac at the end ofthis time was dependent on During the course of infective endo- catheterization in 8 patients (6 to i6 the concentration of ouabain used and carditis the aortic valve is frequently months after operation) has revealed, inversely related to the extracellular K affected and becomes regurgitant. The in each case, a systolic pressure gradient concentration. resulting jet of blood disseminates the between the right ventricle and pul- It is concluded that extracellular K infecting bacteria in a retrograde fashion monary artery, resulting in a right ven- influences the effect of the glycoside by that may impinge on the mitral valve tricular systolic pressure of 40-I12 modifying the amount of the glycoside with variable destructive effects and mmHg. The gradient across the valve bound to the cell membrane. aggravate the already compromised left graft varied from 5-70 mm, while the ventricular function. gradient between graft tube and pul- Reference From June I963 to December I970, monary artery was o-40 mm. Selective 292 patients were operated upon at the right ventricular angiocardiography has Girardi, A. J., Warren, J., Goldman, C., and JefEries, B. (1958). Growth and CF National Heart Hospital for aortic re- shown satisfactory motion of the fascial antigenicity of measles virus in cells gurgitation; in 94 of them the regurgita- valve cusps in 3 patients, but in 2 the deriving from human heart. Proceedings tion was a result of bacterial endocar- cusps could not be visualized and in 3 of the Society for Experimental Biology ditis. Of these 94 patients, I9 were there was considerable narrowing of the and Medicine, 98, i8. found to have secondary infective in- Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from Proceedings of the British Cardiac Society 207

volvement of the mitral valve. This 'jet formed a consecutive series undergoing Radiological, electrocardiographic, lesion' may be present in the form of mitral valve replacement with Starr- phonocardiographic, and haemodyna- pitting, ulcerations, vegetations, or per- Edwards prostheses, models 6I20 (Silas- mic data are presented together with the forations, or in a combination of these tic ball) and 6300 (Stellite ball, cloth clinical results. manifestations and possibly with associ- covered cage). The preoperative find- ated rupture of chordae tendinae. Its ings have been correlated with surgical presence has been consistently in the mortality. Mitral valve replacement using anterior cusp of the mitral valve. The Postoperative catheter studies have fresh 'unstented' semilunar valve mitral valve lesion can often be corrected been carried out on 33 of the 76 sur- homografts with a conservative procedure, as in I4 vivors. The subjective results, good in of the I9 presented patients. about one-third of cases, have been Magdi Yacoub, Malcolm Towers, and An awareness of the frequent co- compared with the objective clinical, Walter Somerville existing 'jet lesion' phenomenon in radiological, and haemodynamic find- aortic valve endocarditis is essential as ings, with often a surprising lack of Unstented fresh semilunar valve homo- surgical attention to both valves is im- positive correlation. grafts were used to replace the mitral perative to achieve a good haemo- Obstruction and leakage have been valve in i6o patients ranging in age dynamic result. important causes of late failure, and a between 9 and 70 years. The aortic total of 8 repeat operations have been valve was replaced at the same time in carried out on 6 patients for these rea- 42 patients and the tricuspid valve in 5 Development of a pump and its sons. Myocardial failure, persistent pul- patients. The total hospital mortality use in prolonged left ventricular monary hypertension, and persistent was 8 per cent; there were 2 deaths in bypass tricuspid regurgitation have all con- the last 73 single mitral replacements. tributed to the production of dis- The indication for operation was severe C. R. W. Gray (introduced) and appointing late results, and an attempt mitral valve disease, unsuitable for mit- C. E. Drew has been made to relate these to the ral valvotomy or repair. preoperative findings. We believe that mounting semilunar During the past 5 years a ventricular An appraisal has been made of the valve homografts on rigid stents inter- type pump has been developed, which quality of life attained for the survivors feres with their function. The tech- is unique in that the ventricle, valves, of this operation. nique used in this series avoids the use and cannulae are formed from a single of a rigid prosthesis in the normally silicone rubber moulding. The surface mobile mitral ring, preserves the sinuses presented to blood is smooth, making Mitral valve repair: results at 5 of Valsalva of the homograft, prevents anticoagulation unnecessary. and Io years any protrusion into the ventricular The drive system is hydraulic so that cavity or outflow tract, and excludes all in the event of rupture of a silicone R. _5. Donnelly (introduced), prosthetic material from the circulation. part, blood can only mix with normal D. R. Smith, M. I. Ionescu, and The longest follow-up has been 27 http://heart.bmj.com/ saline. The control system is pneumatic G. H. Wooler months. There were 6 late deaths un- and permits independent variation of related to homograft function. Mor- systolic and diastolic duration and stroke Results are presented from 46 patients bidity comprised transient haemolytic volume. surviving open conservative surgery for anaemia (i), and fungus endocarditis Thirty-five experiments have been mitral valve disease between I957 and (2) requiring re-replacement. Three performed on calves. Bypass from left I966. At the present time 36 patients patients have residual pulmonary or atrium to aorta was attempted for 24 have been traced and reviewed. All 36 myocardial disease. The remaining hours. The bypass was then discon- patients underwent surgery 5 years or patients are improved. Haemodynamic tinued and the animal allowed to sur- more ago, and I4 of these underwent findings (22 patients) in general support on September 26, 2021 by guest. Protected copyright. vive. Monitoring of blood pressures, surgery I0 years or more ago. the favourable clinical result. Anti- blood gases, haematological and bio- In order to give the results more coagulants were not used. There was no t chemical parameters was performed relevance to present-day practice, the thromboembolism or evidence of homo- throughout bypass. Postmortem histo- cases have been divided into those in graft degeneration diring the period of logical studies were carried out. whom annuloplasty would be indicated follow-up. Short cine loops illustrating the mode today, i.e. with either a dilated annulus of action of the pump and its operation alone or a dilated annulus with minimal during bypass were shown. cusp and chordal involvement, and Late results of replacement of A brief reference to the clinical appli- those with what would now be con- aortic valve in aortic wall disease cation of the pump was given. sidered poor indications for repair, i.e. with significant cusp and chordal A. M. Rowshanzamir, M. P. Singh disease. (both introduced), and H. H. Bentall Clinical and haemodynamic At 5 years 22 out of 24 patients and at results of mitral valve replacement I0 years 5 out of 6 patients with good Aneurysm ofthe ascending aorta, associ- with Starr-Edwards prosthesis indications for repair were in class I or ated with aortic valve regurgitation, has II of the N.Y.H.A. functional classifica- been treated by replacement of the 5T. S. Wright (introduced, tion. These results contrasted conspicu- ascending aorta by a graft with trans- E. Wyn Jones, C. S. McKendrick, ously with those in which attempts were plantation of the coronary arteries into N. Coulshed, and E. J. Epstein made to repair valves with significant the graft, and simultaneous replacement cusp disease though a small number of of the aortic valve in ii patients. Clinical and haemodynamic data have these patients have survived without Nine patients had Marfan's disease, been analysed on I00 patients who further operation for I2 and 13 years. one had yaws, and one had syphilis. Br Heart J: first published as 10.1136/hrt.34.2.201 on 1 February 1972. Downloaded from 208 Proceedings of the British Cardiac Society

Nine patients are alive and well, eight patients have been studied: with ischae- Venous grafts in treatment of back at work and one convalescing. mic heart disease proved, with it sus- coronary heart disease: H. Post- The first case in which this new tech- pected on clinical grounds alone, and operative findings nique was used was reported in I968, normal controls. and the follow-up of these patients is From study of 30 patients our results Charles Smithen (introduced), Edgar described. indicate that measurement of the chan- Sowton, John Dow, and Donald Ross ges induced by atrial pacing in the lac- tate concentration of blood from the Ten patients who had venous bypass coronary sinus provides a reliable semi- operations for severe angina pectoris Diagnosis of organic tricuspid quantitative method of assessing the were reinvestigated from 3 to 6 months valve disease severity of ischaemic heart disease and after operation. In 9 patients there was detecting its presence when results of significant clinical improvement and 8 P. J. Molloy and J. Cleland less sophisticated methods are equivocal. were totally free from pain despite ex- (introduced) tensive physical exertion. All these patients had at least one graft patent Thirty-five patients who had tricuspid and functioning well, with good distal valve replacement have been studied. run-off: the last had no clinical improve- All save one were in the course of mul- Venous grafts in treatment of ment and both grafts were blocked. tiple valve replacement. Preoperative coronary heart disease: I. Pre- Nine patients had no angina pectoris diagnosis was made in a few cases early operative and operative findings or ST segment depression during maxi- in the series but became more accurate mal exercise; the last was the patient later. Principal diagnostic points were, Richard Sutton, Lorenzo Gonzalez- with no functioning graft. The mean enlargement of the right atrium in the Lavin (both introduced), Keith total work performed during the exer- absence of pulmonary hypertension or Jefferson, Lawson McDonald, Michael cise test increased by i86 per cent from frank congestive failure, the presence of Petch (introduced), and Donald Ross a mean of 137I kpm before operation to a raised in the a mean of 3786 kpm after (P