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(Br Heart3 1994;71:196-201) There is still no consensus on the most suitable heart valve replacement for women of childbearing age. Mechanical valves carry a risk of thromboembolism and the need for anticoagulation whereas bioprostheses have a lower thromboembolic risk but are not as durable, particularly in the young. There is controversy about the safest anticoagulant regimen during pregnancy. Early reports of pregnancy in women with mechanical valves were usually of anecdotal cases: they were inspired by disaster rather than by success. Most of these reports came from the United States where overanticoagulation was the rule because of the use of thromboplastins of low responsiveness.' There is still no universal adoption of the International Normalised Ratio (INR)

Summary:To examine whether QTc and QTc dispersion across the leads of a surface electrocardiogram (ECG) are different in patients with hypertrophic cardiomyopathy (HCM) compared with normal subjects, we measured QT and calculated QTc in all 12 leads of a surface ECG in 24 patients with HCM and in 20 age-and sex-matched normal control subjects. Maximal QTc was prolonged in HCM patients (465 f 24 ms) compared with controls (410f20 ms) (p < 0.001). QTc dispersion defined as the difference of maximum-minimum QTc was also greater in HCM patients (71 f21 ms) compared with normals (35 f l l ms) (p <0.001). A correlation was found between the degree of left ventricular hypertrophy expressed by the maximal wall thickness and maximal QTc (r =0.48, p < 0.02). However, QTc dispersion did not correlate with maximal wall thickness. Thus, patients with HCM show a prolonged QTc (>440 ms) and increased QTc dispersion compared with normal subjects. In addition, the degree of left ventricular hypertrophy correlates with maximal QTc. The presence of a prolonged QT with increased regional dispersion may be associated with the occurrence of serious ventricular arrhythmia and sudden death in HCM.

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SUMMARY The diagnosis of cardiac sarcoidosis, particularly when there is no overt systemic involvement, is frequently delayed because of its varied manifestations. Focal left ventricular wall motion abnormalities were recognised in five patients with sarcoidosis. Three patients showed abnormal regional wall motion in the basal portion of the ventricular septum and free wall with sparing of the apex. The angiographic appearances supported the echocardiographic findings which were atypical of ischaemic heart disease. The remaining two patients both had diffuse left ventricular hypokinesia, with a focal abnormality that was most pronounced in the anteroapical region; this pattern is often seen with coronary disease.The recognition by echocardiography or angiography of focal abnormalities of wall motion affecting the basal portion of the ventricular septum should suggest the possibility of myocardial sarcoidosis even in the absence of recognised systemic manifestations.Focal abnormalities of left ventricular wall motion are uncommon except in coronary artery disease in which the distribution is dependent on coronary artery anatomy. It is therefore unusual to find wall motion abnormalities localised to the basal part of the septum with sparing of the apical portion. This report of five cases shows that although sarcoid granuloma can occur anywhere in the heart a pattern of fibrosis distinct from coronary disease may be recognised by echocardiography and angiography. Accepted for publication 23 October 1986 coronary angiography, and cross sectional echocardiography. Three patients shared several clinical characteristics. None of these three had clinical evidence of heart failure. All had normal physical examination, normal laboratory indices of bone marrow, renal, and hepatic function. All had left anterior hemiblock and right bundle branch block. Left ventricular end diastolic and pulmonary artery pressures were normal and there was no disease of the major epicardial coronary arteries. The table summarises the investigations that were performed to assess disease activity and distribution.In patient 1 systemic sarcoidosis was not diagnosed during life. He presented with a two year history of palpitation and ventricular tachycardia associated with syncope and evidence of a progressive conduction system disturbance. During cross sectional echocardiography from the parasternal long axis view (fig la) the basal part of the ventricular septum was thin and akinetic with increased echo reflectivity and paradoxical systolic motion. The same abnormality was seen in serial short axis views at the level of mitral valve and papillary muscle (fig 2). The apical third of the ventricular septum, the posterior wall of the ventricle, and the right ventricular free wall were normal. Left 256

BACKGROUND Syncope and sudden death in hypertrophic cardiomyopathy may have a hemodynamic basis. The presence of a small ventricular cavity with high intracavity pressures may activate left ventricular baroreceptors and cause reflex hypotension as described in other populations with syncope. METHODS AND RESULTS To investigate this potential mechanism of syncope in hypertrophic cardiomyopathy, we studied 17 patients with a history of syncope (syncopal), 19 without syncope (nonsyncopal), and nine normal control subjects by using a head-up tilt test. Head-up tilt at 60 degrees for 45 minutes was followed by 10-minute tilts during incremental doses of isoprenaline. Heart rate, blood pressure, and two-dimensional and Doppler echocardiography were monitored throughout. On tilting, hypertrophic cardiomyopathy patients showed a decline in mean arterial pressure of -5 +/- 6 mm Hg (p less than 0.001) compared with no change in control subjects (0.2 +/- 6 mm Hg, p = 0.9). Left ventricular outflow tract velocity decreased on tilting in control subjects (-8 +/- 6 cm/sec, p = 0.004) but increased in the syncopal and nonsyncopal patients (20 +/- 50 cm/sec, p = 0.05). Reflex hypotension with or without bradycardia, associated with syncope or presyncope, was induced in seven syncopal patients, two nonsyncopal patients, and two control subjects (p = 0.05). The early response to tilt in these subjects was characterized by maintenance of blood pressure but a greater increase in left ventricular fractional shortening than in the other subjects (10 +/- 8% versus 1 +/- 1%, p = 0.002). The onset of hypotension was associated with a trend toward further decreases in left ventricular diameters, outflow tract velocity, and transmitral flow velocities. In the remaining patients who had a negative test, transient hypotension (systolic pressure less than 100 mm Hg) occurred in seven syncopal patients and three nonsyncopal patients compared with none of the control subjects (p = 0.01). In total, hypotension was demonstrated in 82% of syncopal patients compared with 26% of nonsyncopal patients and 22% of control subjects (p = 0.001). CONCLUSIONS Patients with hypertrophic cardiomyopathy and a history of syncope frequently display hypotension during head-up tilt. In some cases, sudden hypotension occurs and is usually associated with bradycardia and a reduced cavity size, findings compatible with activation of a ventricular baroreflex. In other cases, transient hypotension occurs and could be explained by an impairment of baroreceptor function. These mechanisms may contribute to the occurrence of syncope in daily life.

Antibiotic prophylaxis is recommended for endoscopic procedures if the patient is at high risk of endocarditis or of symptomatic bacteraemia as a consequence of immunosuppression or neutropenia. In most circumstances parenteral amoxycillin and gentamicin are recommended. The addition of parenteral metronidazole is recommended in patients with neutropenia. Vancomycin or teicoplanin are recommended in patients allergic to penicillin. Antibiotic prophylaxis is recommended for all patients undergoing ERCP with evidence of biliary stasis or pancreatic pseudocyst. Oral ciprofloxacin or parenteral gentamicin (or parenteral quinolone, cephalosporin or ureidopenicillin) are recommended for ERCP.