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EUROPEAN CONGRESS OF CARDIOLOGY

THE European Society of Cardiology was broughtinto being in 1950, through the initiative, two yearsearlier, of the Belgian Society of Cardiology. The new

society’s first congress was held in London on Sept. 9-12,under the chairmanship of Sir JOHN PARKINSON. The

proeeedings, attended by 510 delegates from 22 countries,comprised a symposium on the surgical treatment ofmitral stenosis and 88 other communications.On the eve of the opening, members of the congress were

received at the Royal College of Physicians by the president,Sir Russell Brain. Receptions were also held by the Universityof London, the British Council, and the Ciba Foundation, anda garden party was given on Sept. 13 by Sir John and LadyParkinson at their Hampstead home.At the official banquet on Sept. 12 Sir JOHN PARKINSON

said he hoped that the visitors, when they came again toEngland, would feel that they had friends here. The congresscould not compete with the gathering of the InternationalSociety of Cardiology in Paris in 1950, " or what awaitsus in Washington in 1954 " ; but he hoped that the progressrecorded would be continued and solidified. Mr. lAIN MACLEOD,Minister of Health, read a message from the Foreign Secretary,3ir. Eden, commending the congress as part of the movementtowards European cooperation. Among the reasons, he said,

why cardiology must become increasingly important were thatheart-disease was now the chief cause of death, that it wasmuch feared, and that exciting progress was being made inits study. The congress had been both successful and happy ;and, turning to the chairman, Mr. Macleod added :

"

May Isay how proud we are in this country to have such a dis-tinguished figure in this field ? " Prof. GL STAV JSrYLiN,president of the society, expressed his hopes for the develop-ment in Europe of

" this splendid companionship in cardio-logy." Prof. PIERRE RIJLANT said that in London, underSir John Parkinson’s chairmanship, the society had found anexceptional climate in which differences were never translatedinto conflicts. He paid tribute also to Dr. Shirley Smith,secretary of the congress, for his long-continued and successfulwork on its behalf. Dr. IRVIXG WRIGHT, fresh from con-gresses in the Americas, both North and South, broughtgreetings from their members-and also an Inca rib he hadpersonally disinterred and proposed to present to Prof.Charles Laubry, hon. president of the congress, in symbolicrecognition of his status as father of cardiology. Professor

Laubry, though resolved, he said, to keep silence, could notrefrain from speaking of the jours inoubliables the congresshad enjoyed, concluding with especially grateful and gracefulwords about the Chairman and Lady Parkinson and aboutDr. Evan Bedford, chairman of the organising committee.

. SURGERY OF MITRAL STENOSIS

This symposium must have convinced those whoheard it that thoracic surgeons will for some years bevery busy operating on stenosed mitral valves. Theflood of patients has already started ; and Dr. J. F.0"-B’EILL alluded to 800 mitral commissurotomies per-formed by Bailey, Glover, himself, and other associatesin Philadelphia, with a 4% mortality-rate.

Dr. MAURICE CAMPBELL, of Guy’s Hospital, London,gave an account of a large series of mitral valvotomiesby R. C. Brock. He analysed in some detail the first100 cases operated on and showed that the mortality-ratehad steadily fallen. Mr. G. A. MASON (Newcastle uponTyne) had 6 deaths in 70 cases ; and Mr. HOLMESSELLORS reported 64 operations without a death. Manyspeakers agreed that the patients’ postoperative statewas strikingly better in 50% of cases, and considerablybetter in 25-30%. Two remarks which a year agomight have produced a sense of drama caused scarcelya ripple. One was by Dr. PAUL WOOD : " It is estimatedthat there are about 150,000 cases of rheumatic heart-disease with predominant mitral stenosis in GreatBritain between the ages of 18 and 41, and of theseprobably at least half will require valvotomy sooner orlater." And the other by Dr. CAMPBELL : " Mitral

valvotomy should be considered in all patients withmitral stenosis who are progressively disabled." Through-out the symposium ran the view that the operationwas now firmly established as a routine measure on theContinent and in Great Britain, and that the resultswere generally satisfactory with a mortality-rate notexceeding 4-8%.Xo speaker advocated surgical treatment as a prophy-

lactic measure for patients with symptomless stenosis,and none hinted that such early operations are at presentjustified on the basis that they may prevent later damageto the pulmonary vascular tree. In this respect it is

interesting that, while physiological studies have repeat-edly shown that operation reduces the pulmonaryarterial hypertension, this fall is not immediate ; indeedit may take place only after many months. Most of thepatients selected for surgery had exertional dyspncea orattacks of pulmonary oedema or haemoptysis, with

physiological evidence of pulmonary hypertension.Dr. CAMPBELL, Prof. PIERRE SOULIE. Prof. ROGER

FROMENT, and Dr. WOOD expressed opinions regardingthe choice of cases that seemed acceptable to the

members. Although patients in the ’teens are occasion-ally operated on, most of those selected have been

aged 21-35. Those whose main lesion is thought to beactive rheumatic infection or aortic valvular disease ormitral regurgitation are excluded ; but minor aorticdisease and mitral regurgitation accompanying mitralstenosis as the major mechanical factor are not regardedas contra-indications. Functional tricuspid regurgitationcomplicating mitral stenosis may well be an indicationfor surgery. Auricular fibrillation is associated with a

higher mortality, but a good result is still possible.Patients with high pulmonary-artery blood-pressures-even above 100 mm. Hg-can often be operated onwith excellent results ; cardiac catheterisation carriedout 6-12 months after operation commonly shows afall in pressure to half the previous value. Earlierattacks of congestive heart-failure and minor cerebralembolism do not preclude operation; indeed embolism,whether pulmonary or systemic, is often an indicationfor valvotomy, lest worse befall the patient.Many speakers gave detailed accounts of physiological

investigations. This work has proved that the haemo-dynamic state of the lungs is considerably improvedby successful valvotomy. Dr. LARS WERKO (Stockholm)described catheterisation studies which showed that,while operation may result in a remarkable fall in

pulmonary blood-pressure, slight exercise may stillcause the pressure to increase abnormally. This wasconfirmed bv other members.Commonly the stenosed orifice. as felt by the surgeon’s

finger, rneasures 1 cm. by 1/2 cm., and through such anorifice a regurgitant stream is often palpable. Afterdivision of the commissures of the valve this regurgitationusually disappears, and the valve resumes a more normalaction. Many of the operations of commissurotomyhave been performed by the digital method, but it is

becoming increasingly clear that valves commonly requireinstrumental division and Dr. 0’-NEILL said thatin Philadelphia only 1300 of the valves have beenrefashioned entirely by the use of the finger.From all accounts, both by surgeons and by physicians,

it is clear that the exact diagnosis of considerable mitralregurgitation remains a dit&culty ; and the congresswas not inclined to accept as infallible the classicalclinical physical signs of this lesion. In a number ofinstances significant mitral incompetence had beensuspected but at operation the surgeon found thisabsent or only slight; while on other occasions a confident

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preoperative diagnosis of pure mitral stenosis was

proved wrong, a grossly incompetent valve being found.Little confidence can be placed in the physical sign ofexpansile pulsation of the left atrium seen on radiologicalscreening, but Dr. W. BRIGDEN and Dr. A. LEATHAMthought that the most important radiological sign ofmitral incompetence was obvious systolic expansion ofthe left auricle, especially when. seen in the anteriorview. Many others present must have agreed with theiropinion that slight systolic backward movement in theright oblique view does not indicate mitral incompetence,since it is commonly seen with predominant mitralstenosis. Members agreed that mitral incompetenceis associated with a longer and more benign course, isnot unusually complicated by bacterial endocarditis,affects males more commonly than females, and is oftenunassociated with a history of rheumatic disorder. Theabsence of right ventricular hypertrophy - and a loudsystolic murmur extending up to the second sound arestill important signs of incompetence, especially whenassociated with enlargement of the left ventricle withoutaortic disease. Some speakers placed great reliance onthe absence of a loud first sound, and of the openingsnap so characteristic of mitral stenosis.The vast amount of research that has been carried

out and is continuing, with regard especially to hsemo-dynamics, should not obscure the fact that most of thepatients for commissurotomy or valvotomy can beassessed by history-taking, physical examination, carefulradiographic examination, and electrocardiography ; andcentres without the facilities for cardiac catheterisationcan take comfort from Dr. CAMPBELL’S view that

generally the decision for or against surgical treatmentcan be made on clinical evidence alone.

SOME OTHER TOPICS

ELECTROCARDIOGRAPHY

Dr. J OSEPII LAMBERT (Spa, Belgium) described a studyof electrocardiographic (E.C.G.) leads over the abdominalwall. Lead VE (ensiform cartilage) will usually demon-strate an anterior infarct and also one involving theseptum. Lead VO (at the level of the umbilicus) and leadVEO (midway between VE and VO) usually show pos-terior and posterolateral infarcts. On occasion theseleads demonstrate infarction not disclosed by theorthodox leads.

Dr. WiLLiAM EvAs (London) reaffirmed his convictionthat unipolar limb leads provided no additional help,and that V leads held no advantage over CR leads.He reviewed the E.C.G.s recorded in 1000 consecutive

patients with myocardial infarction. Of particularinterest were the various minor abnormalities which heconsidered represented " restricted infarction "—i.e.,iufarction of limited extent. An important conclusionwas that in restricted infarction the ultimate prognosiswas no less serious than in cases with E.c.G. evidence ofmore extensive myocardial injury. Immediate prognosiswas affected adversely by the presence of triple rhythm,considerable cardiac enlargement, or pulmonary con-

gestion.° AXTICOAGULAXTS

Dr. IpviNG AVRI4C;IIT York) concluded from astudy of American experience that the treatment of

myocardial infarction with anticoagulants lowered themortality by one-third and reduced the incidence ofthrumho-embolic complications from 36% 0 to 14°o.He considered that the cost and effort of such treatmentwere probably unwarranted in mild or moderatelysevere cases, but that ideally all cases should be treatedand to wait for the first incident was hazardous. Ithad been confirmed that Tromexan ’ was a better drugthan diconmarol in that there was quicker control of theprothromhin-tiiuc and a quicker return to normal afterstopping the drug ; but the two drugs were equallyeffective from the anticoagulant point of view. Tro-

mexan should be given in divided doses 2-3 times a day.’ Cyclocoumarol,’ one of the new anticoagulants undertrial, belonged to the dicoumarol group. It had a longeraction, which might persist for 10-14 days after cessationof treatment. Dr. Wright referred to the value ofvitamin K1 in producing prompt cessation of anti-

coagulant action ; but owing to the resistance to anti-coagulants which might arise and last for several daysthis preparation was of no value if a further course oftherapy was planned. Substitutes for heparin were

being synthesised, and were cheaper. One of these was’ Paritol,’ but occasionally this gave rise to untowardeffects in the form of shock or of alopecia. Dr. Wrightattributed the apparent increase in the incidence ofthrombo-embolic disorders to increased awareness of thecondition.

In the subsequent discussion a speaker expressed thedoubts felt by many physicians as to whether they them-selves would be treated by anticoagulants.

OCCLUSION AND INFARCTION

Dr. P. J. D. SNOw, Dr. A. MORGAN JONES, and Dr.K. DABER (Manchester), employing Schlesinger’s coronaryinjection technique, had failed to confirm the finding ofBlumgart that coronary occlusion commonly took placewithout myocardial infarction. In their experienceinfarction was. usually associated with occlusion.Recanalisation was common.

CORONARY ARTERIOGRAPHY

Prof. E. COELHO (Lisbon) showed that the coronaryarterial tree could be filled with radio-opaque dyein living subjects by means of retrograde catheterisationfrom the radial artery.

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FALLOT’S TETRAD

Dr. R. HEI[M DE BALSAC (Paris) reported a radiologicalstudy of 400 cases of Fallot’s tetrad. Contrary to theusual teaching, he had found the picture very variable.

PULMONARY STENOSIS

Dr. GuNNAR JÖNSSON (Stockholm) described his tech-nique of selective visualisation of the pulmonary arteryand conus by means of angiocardioscopy with cardiaccatheterisation to localise the substance injected.

Dr. CAMPBELL gave the results of 102 cases of varyingtypes of pulmonary stenosis operated on by Mr. R. C.Brock. The overall mortality was 18%, and the resultsin two-thirds of the cases in each group good. In infundi-bular stenosis the results were good in half the cases, andthe mortality was higher than in other types.Some difference of opinion was expressed as to whether

patients should be operated on who were symptom-freebut had a high right ventricular pressure. Dr. PAULWooD pointed out that there was often a disappointinglyslight drop in pressure after operation ; but Dr. JOHAYKARTELL (Stockholm) said this might well fall in duecourse from a reduction of hypertrophy in the infundibularregion. COARCTATION OF AORTA

Dr. KARTELL discussed the experience of 108 cases ofcoarctation of the aorta operated on by Prof. C. Crafoordin Stockholm. There had been 7% deaths. All but 1of the patients had been under the age of 30.

EXPERIMENTAL HYPOTHERMIA

Dr. A. JUVENELLE (Stockholm) described someremarkable work on dogs whose body-temperature waslowered to less than 20C during operation. Metabolismwas so lowered that blood-flow requirements (from anextracorporeal artificial circulation) were reduced to only10°o 0 of normal. Ventricular fibrillation occurred atthese low temperatures, but did no apparent harnt:and sinus rhythm was restored during re-warming bymeans of electric shocks. There were great possibilitiesin the future for operating on man under such con-

ditions, particularly as regards operating on the ’drvheart.