Third-degree inter-atrial block and supraventricular tachyarrhythmias.
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Atrial Function, Left↗
Biomedical subjects
A Martinez-Rubio
Publications and source records attributed to A Martinez-Rubio.
Efficacy and safety of d,l-sotalol in patients with ventricular tachycardia and in survivors of cardiac arrest.
OBJECTIVE: The aim of this study was to assess the antiarrhythmic efficacy and safety of d,l-sotalol in patients with ventricular tachycardia (VT) or ventricular fibrillation (VF) and in survivors of cardiac arrest and to identify the factors that are associated with arrhythmia suppression and therefore might be helpful in predicting drug efficacy. BACKGROUND: Despite increasing use of the class III antiarrhythmic agent d,l-sotalol, data on its short- and long-term efficacy in a large patient cohort are lacking. Information on its long-term tolerability and safety is limited. METHODS: A total of 396 patients with inducible sustained VT or VF (VT/VF) underwent programmed stimulation before and after receiving oral d,l-sotalol (240 to 640 mg/day). Patients in whom VT/VF was rendered either noninducible or more difficult to induce (more extrastimuli or faster drive cycle length needed for VT/VF induction) were discharged on a regimen of oral d,l-sotalol. RESULTS: d,l-Sotalol suppressed VT/VF in 151 patients (38.1%) and rendered the arrhythmia more difficult to induce in 76 patients (19.2%). The extent of drug-induced prolongation of right ventricular refractoriness and a shorter VT cycle length at baseline were independent predictors of immediate drug efficacy. Torsade de pointes developed in seven patients (1.8%). Two hundred ten patients (53%) continued to receive d,l-sotalol and were followed up for 34 +/- 18 months (mean +/- SD). The actuarial rates for the absence of arrhythmic recurrence (either VT/VF or sudden death) at 1 and 3 years were 89% and 77%, respectively. Actuarial rates for overall survival at 1 and 3 years were 94% and 86%, respectively. VT/VF suppression by d,l-sotalol was an independent discriminant variable that separated patients with and without arrhythmia recurrence. However, noninducibility of VT/VF did not predict freedom from sudden death. CONCLUSION: Oral d,l-sotalol is effective and safe in patients with VT/VF. However, sudden cardiac death develops in a significant proportion of patients, and programmed stimulation seems to be of limited value for its prediction.
Administration, Oral↗
Are there gender differences in patients with coronary artery disease presenting with spontaneous sustained ventricular tachycardia and ventricular fibrillation?
The incidence of coronary artery disease (CAD) is greater in men than in women. The aim of the study was to analyze whether any gender-related differences in patients with CAD and documented spontaneous sustained ventricular tachyarrhythmias exist, and which parameters influence the induction of sustained ventricular tachyarrhythmias. The data of 250 patients [43 women (17.2%) and 207 men (82.8%)] with spontaneous sustained ventricular tachycardia [n = 190 (76%)] and fibrillation [n = 60 (24%)] who underwent coronary and left ventricular angiography, electrophysiological study, and signal-averaging electrocardiogram (ECG) form the basis of this analysis. No gender-related differences could be observed in age, number of diseased coronary arteries, history, location and number of myocardial infarctions, presence of left ventricular aneurysm, ejection fraction, type of spontaneous or induced arrhythmias, right ventricular effective refractory period, and signal-averaged ECG parameters. Age, presence of previous myocardial infarction, and ejection fraction were significant predictors (p < 0.001) of inducibility of sustained ventricular tachyarrhythmias. Once CAD has begun, female and male patients present similar clinical and electrophysiologic characteristics. Thus, both genders should benefit similarly from diagnostic and therapeutic approaches if they are referred to the hospital or to invasive interventions at similar intervals in the course of their illness.
Age Factors↗
Comparison and combination of late potentials and spectral turbulence analysis to predict arrhythmic events after myocardial infarction in the Post-Infarction Late Potential (PILP) Study.
Ventricular late potentials detected at the end of the QRS complex by the signal-averaged ECG have been shown to predict arrhythmic events after acute myocardial infarction. Spectral turbulence analysis is a novel technique for detecting abnormalities of cardiac electric activation inside the QRS complex. The purpose of this study was to combine these two analysis methods in order to increase the predictive power of the signal-averaged ECG in post-infarction patients. The study comprised a prospective series of 778 males under 66 years of age who survived the acute phase of myocardial infarction. Signal-averaged ECG recordings were performed before hospital discharge 2 to 3 weeks after infarction. The original Simson method was used for recording and analysing the time-domain signal-averaged ECG. Spectral turbulence analysis was performed using the same averaged vector magnitude QRS complexes (Del Mar Avionics). During the follow-up period of 6 months, 33 patients (4.2%) had an arrhythmic event (sustained monomorphic ventricular tachycardia in 13 cases, ventricular fibrillation in eight cases and sudden cardiac death in 12 cases). The predictive power of late potentials in the time domain, spectral turbulence analysis and their combinations were tested together with clinical variables using the Cox regression method.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Catheter ablation of ventricular tachycardia in patients with coronary heart disease.
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Catheter Ablation↗
[High frequency current catheter ablation in ventricular tachycardia].
Since its introduction into clinical practice in 1982, catheter ablation has evolved as a first-line mode of non-pharmacological therapy in patients with atrioventricular nodal reentrant tachycardia and in patients with atrioventricular tachycardia involving an accessory pathway. The initial experience was based on the use of direct current for ablative purposes. However, since severe complications have been observed using this energy source, radiofrequency (RF) current catheter ablation is now the most frequently used technique. Efficacy rates are high (> 80%) in patients with idiopathic ventricular tachycardia and bundle-branch reentrant tachycardia. In addition, the technique also has a relatively high acute success-rate in patients with incessant ventricular tachycardia. However, RF current catheter ablation is less effective in patients with drug-resistant, chronic, sustained ventricular tachycardia after myocardial infarction or in the presence of dilated cardiomyopathy. Further improvements which include new criteria for the localization of the origin of ventricular tachycardia as well as technical improvements are particularly needed in this subgroup of patients. Thus, RF current catheter ablation in patients with ventricular tachycardia can be considered a promising new mode of non-pharmacological therapy. The efficacy rate of the procedure is highly dependent on the presence and type of organic heart disease as well as the mechanisms underlying ventricular tachycardia. Due to the limited experience, especially with respect to the long-term results, RF current catheter ablation is still an experimental mode of antiarrhythmic treatment.
Cardiomyopathy, Dilated↗
[In vitro validation of intravascular ultrasound, computerized and magnetic resonance tomography in diagnosis of atherosclerotic vascular segments in comparison with direct magnification radiography].
The depiction of atherosclerotic vessel abnormalities is a prerequisite for percutaneous interventional therapy and long-term observations of peripheral artery disease. The aim of this in-vitro study was to determine the potentials and limitations of 12.5 and 20 MHz intravascular ultrasound, computed tomography and magnetic resonance (MR) imaging in comparison to direct magnification radiography for the localization and quantification of peripheral vessel wall calcifications. Forty-three postmortem, human iliac segments were examined by intravascular ultrasound (12.5 and 20 MHz), computed tomography and magnetic resonance tomography (gradient echo-and spin echo-technique). For comparative analysis, each segment was divided into eight sectors of 45 degrees each; using all five methods, the presence of calcified wall areas was examined in each sector, and luminal area (42 segments) and plaque area (32 isolated plaques) were quantitatively estimated. In the sonograms, the circumferential extension of the boundary between intima and media was measured. 122 of 344 sectors showed regional vessel wall calcifications. Sensitivity of 20 MHz intravascular ultrasound was 73% versus 59% with the 12.5 probe, specificity was 97% with 20 MHz, 96% with 12.5 MHz. Sensitivity of both 12.5 and 20 MHz intravascular ultrasound was higher with increased thickness of the calcified structures. 20 MHz ultrasound identified the intima-media boundary averaging 146.8 degrees of the vessel circumference; the corresponding value of 131.8 degree with 12.5 MHz did not differ significantly. Computed tomography detected calcifications with a sensitivity of 88%, specificity was 88%. With MR imaging, sensitivity of the gradient echo-technique was 94% versus a sensitivity of 86% with spin echo-technique. Quantification of luminal and plaque areas showed that luminal area was precisely estimated only by 20 MHz ultrasound (no significant difference to direct magnification radiography), whereas all other techniques showed significant overestimation. Plaque areas were markedly overestimated by computed tomography and MR imaging, too. In an in vitro set-up, intravascular ultrasound, MR tomography and computed tomography do not allow an authentic depiction of peripheral vessel wall architecture. Limited resolution, subintimal shadowing and and distortion are the main limitations of these new techniques so that details of regional vessel wall calcifications cannot be presented thoroughly. Relevant over-estimation of luminal and plaque areas must be considered.
Arteriosclerosis↗
The role of implantable cardioverter defibrillators in dilated cardiomyopathy.
Depending on the severity of the disease, patients with dilative cardiomyopathy (DCM) have a poor prognosis. No definite data are available to show that complex ventricular ectopy, the presence of ventricular late potentials, or programmed electrical stimulation in patients without symptoms with DCM identify patients at risk of sudden cardiac death. Although poor left ventricular function seems to be the most potent predictor of total cardiac death, the prediction of sudden death in patients without symptoms with DCM is poor. Studies with either class I antiarrhythmic drugs or amiodarone have not yet demonstrated a reduction in total mortality rates or sudden death. The usefulness of an implantable cardioverter defibrillator (ICD) in patients without symptoms with DCM is currently under investigation. The usefulness of serial electropharmacologic testing for patients with documented sustained ventricular tachycardia or ventricular fibrillation and DCM is still controversial. Because most patients with DCM and VT or out-of-hospital cardiac arrest have either no inducible ventricular tachyarrhythmia at baseline or the reproducibility of ventricular tachycardia/ventricular fibrillation induction is poor, implantation of an ICD should be considered in most of these patients. The indication for implantation of an ICD should be made on clinical judgment of the patient's functional status and other prognosis-limiting factors, such as rapid progression of heart failure, end-stage heart failure, and age.
Anti-Arrhythmia Agents↗
Role of programmed ventricular stimulation in patients with idiopathic dilated cardiomyopathy and documented sustained ventricular tachyarrhythmias: inducibility and prognostic value in 102 patients.
The role of programmed ventricular stimulation (PVS) in patients at high risk of sudden death related to idiopathic dilated cardiomyopathy (DCM) is still controversial. The possible reason is that most study series have been too small or that only a few patients had documented sustained ventricular tachyarrhythmias. This study therefore, looked at PVS performed in 102 patients with DCM and documented sustained ventricular tachycardia (VT; n = 63) or ventricular fibrillation (VF; n = 39). Sustained VT was induced in 27 of 63 patients (43%) with documented sustained VT and in 14 of 39 patients (36%) with documented VF (ns). VF was induced in nine patients (14%) with a history of sustained VT and in seven (18%) with a history of VF (ns). At a mean follow-up of 32 +/- 15 months, sudden death occurred in 14 (14%) patients, a rate similar in both patients with documented VT and VF (ns). Incidence of sudden death at 36 months was 6% in patients with inducible sustained VT/VF compared to 29% in patients without inducible VT/VF (P < 0.05). A favourable drug regimen (response to drug and no intolerable side effects) was obtained by serial drug testing in 25 of all 102 patients (25%). A cardioverter defibrillator (ICD) was implanted in 32 patients, in 63% of whom discharges were observed during 18 +/- 11 months of follow-up; only one patient (3%) died suddenly. Thus, in patients with DCM, there was no relationship between documented and inducible ventricular tachyarrhythmias, and initiation of sustained VT or VF had little prognostic value for the prediction of subsequent sudden death. Wherever antiarrhythmic drug therapy was of limited value, implantation of an ICD may improve the prognosis of these high risk patients.
Anti-Arrhythmia Agents↗
Efficacy of ajmaline and propafenone in patients with accessory pathways: a prospective randomized study.
In a prospective randomized study, we assessed the electrophysiologic effects and the efficacy of ajmaline versus propafenone in patients with accessory pathways (APs). During initiated atrioventricular (AV) reentrant tachycardia or atrial fibrillation (AF), ajmaline (1 mg/kg as bolus followed by infusion of 15 micrograms/kg/min) or propafenone (2 mg/kg, followed by infusion of 30 micrograms/kg/min.) were randomly administered intravenously (i.v.) in 40 patients with APs. AV reentrant tachycardia terminated in 15 of 16 patients (94%) on ajmaline and in 12 of 15 patients (80%, NS) on propafenone. AF ceased in 4 of 4 patients receiving ajmaline and in 3 of 5 patients receiving propafenone (n.s.). During continuous infusion of drugs, AV reentrant tachycardia became noninducible in 10 (50%) patients receiving ajmaline, as compared with 6 (32%) receiving propafenone (NS). Both drugs significantly prolonged the anterograde and retrograde effective refractory periods (ERPs) of the AP. There were no significant differences in changes in electrophysiologic parameters between the two drugs. Ajmaline and propafenone are highly effective and safe in terminating and preventing reinitiation of AV reentrant tachycardia or AF in patients with APs. Both drugs significantly prolonged the anterograde and retrograde ERPs of the APs.
Accessory Nerve↗
Recurrence and late block of accessory pathway conduction following radiofrequency catheter ablation.
INTRODUCTION: Many issues regarding the recurrence of accessory pathway conduction and the long-term outcome of late block of accessory pathway conduction are still unknown or controversial. METHODS AND RESULTS: Data from 217 patients who underwent an initially successful radiofrequency ablation of accessory pathways and 7 patients with late block of accessory pathway conduction following an initially unsuccessful ablation were analyzed. During a mean follow-up of 19 +/- 11 months, accessory pathway conduction resumed in 21 (10%) of 217 patients following an initially successful ablation and in 6 (86%) of 7 patients with late block of accessory pathway conduction (P < 0.01). After initially successful ablations, the recurrence rates of accessory pathway conduction at 1, 3, and 6 months were 5.9%, 7.4%, and 11.3%, respectively. A late electrophysiologic study at 6 months uncovered recurrence in only 1 of 124 asymptomatic patients, but failed to detect the late recurrence in 2 patients in whom the accessory pathway conduction resumed after more than 6 months. Multivariate analysis revealed that independent predictors for recurrence of accessory pathway conduction were concealed accessory pathway, presence of transient effect of radiofrequency pulse, and more than 5 pulses required for initial cure. Accessory pathway location, length of the tip electrode of the ablation catheter, and repeat radiofrequency pulses ("safety pulses") after effective pulses did not predict resumption of accessory pathway conduction. CONCLUSIONS: After initially successful ablation, the recurrence rates of accessory pathway conduction at 1, 3, and 6 months were 5.9%, 7.4%, and 11.3%, respectively. Late electrophysiologic testing had little prognostic value in asymptomatic patients following successful ablation. Application of "safety pulses" did not prevent recurrence. Late block of accessory pathway conduction did not predict long-term efficacy.
Adolescent↗
Electrophysiologic variables characterizing the induction of ventricular tachycardia versus ventricular fibrillation after myocardial infarction: relation between ventricular late potentials and coupling intervals for the induction of sustained ventricular tachyarrhythmias.
OBJECTIVES: The aim of this study was to analyze the relations between the presence of ventricular conduction delay and the necessary coupling intervals for the induction of sustained ventricular tachyarrhythmias. METHODS: The electrophysiologic and signal-averaged electrocardiographic (ECG) data from 83 patients with previous myocardial infarction and inducible sustained monomorphic ventricular tachycardia (n = 71) and ventricular fibrillation (n = 12) were analyzed. RESULTS: The sum of the coupling intervals needed for inducing ventricular tachycardia and ventricular fibrillation was 485 +/- 59 ms and 387 +/- 36 ms, respectively (p < 0.001). The mean difference between the effective refractory period and the second coupling interval for the induction of ventricular tachycardia and ventricular fibrillation was -3 +/- 40 ms and 24 +/- 29 ms, respectively (p < 0.02). QRS duration and duration of terminal low amplitude signals of the QRS complex (p < 0.004) were longer in patients with inducible ventricular tachycardia than in patients with inducible ventricular fibrillation. The root mean square of the voltage during the last 40 ms of QRS complex was lower in patients with inducible ventricular tachycardia than in patients with inducible ventricular fibrillation (p < 0.007). Patients with inducible ventricular tachycardia presented with a greater prevalence of ventricular late potentials than that of patients with inducible ventricular fibrillation (p < 0.007). For arrhythmia induction, significantly shorter coupling intervals were necessary in patients without than in patients with ventricular late potentials. A positive correlation was found between the cycle length of the induced ventricular tachycardia and the filtered QRS duration as well as with the sum of the coupling intervals. CONCLUSIONS: Induction of ventricular fibrillation requires shorter coupling intervals than does induction of ventricular tachycardia. The presence of ventricular conduction delay seems to be a marker of facilitated induction of sustained monomorphic ventricular tachycardia rather than of ventricular fibrillation. The coupling intervals required to induce ventricular tachycardia or fibrillation are longer in patients with than in those without an abnormal signal-averaged ECG.
Adult↗
Complete bilateral oculomotor palsy: the only clinical sign of subarachnoid hemorrhage in leukemia.
We report the original case of a patient with acute myelogenous leukemia who presented with a painless, complete bilateral oculomotor palsy during induction chemotherapy. Headache, signs of meningeal irritation or further neurological symptoms were absent throughout the course of illness. The CT revealed a subarachnoid hemorrhage (SAH). Within a day of the onset of symptoms, the oculomotor palsy subsided completely with no residual damage. To our knowledge, this is the first described case of SAH in leukemia with complete bilateral oculomotor palsy being the only clinical symptom. Furthermore, the spontaneous remission of this pathological condition is an extremely rare event.
Aged↗
Catheter ablation of ventricular tachycardia using radiofrequency current.
Catheter ablation techniques have evolved as an alternative to map-guided surgery and proven effective in a variety of supraventricular tachyarrhythmias. Direct current catheter ablation has been shown to be effective in about 50 to 70% of cases. Approximately, 60% of patients with structural heart disease and monomorphic ventricular tachycardia were successfully treated using direct current ablation techniques. This overall success rate and possible risks associated with the use of direct current have stimulated the search for other energy sources appropriate for catheter ablation. Presently, only a few preliminary reports on the clinical efficacy of radiofrequency energy for the treatment of ventricular tachyarrhythmias in man exist. 23 patients with identifiable heart disease at a mean age of 52 +/- 17 years underwent radiofrequency catheter ablation. 16 patients had coronary artery disease, one patient dilative cardiomyopathy and six patients had arrhythmogenic right ventricular disease. All patients presented with chronic current sustained ventricular tachycardia. After detailed endocardial catheter mapping radiofrequency energy was applied at the site of earliest ventricular activation during ventricular tachycardia which could be entrained during fixed rate ventricular pacing at the site of origin of ventricular tachycardia. At all ablation sites a long latency between the stimulus and QRS complex was noted. Of 23 patients 18 were treated with radiofrequency alone whereas in five patients a second ablation procedure using direct current was performed. Following the ablation procedures, 14 patients (61%) remained free of ventricular tachycardia. One patient died due to congestive heart failure 21 months following ablation.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Catheterization↗
Effects of enflurane on inducibility of ventricular tachycardia.
The effects of enflurane on cardiac electrophysiologic parameters and on inducibility of ventricular tachycardia (VT) by programmed stimulation were studied in 12 patients (11 men, 1 woman, mean age +/- standard deviation 55 +/- 8 years) with drug refractory sustained monomorphic VT who underwent transcatheter ablation with high-energy direct-current shocks. One catheter ablation procedure was performed in 10 patients, whereas 2 ablation sessions were necessary in 2 patients. Programmed ventricular stimulation was performed on 2 separate days (mean interval 19). There were 2 baseline studies, 1 several days before ("baseline study I") and the second at the beginning of the ablation procedure ("baseline study II") while the patient was awake and nonsedated. The third programmed stimulation study was done 15 to 30 minutes after administration of anesthesia with enflurane, oxygen and nitrous oxide ("enflurane study"). Rate of sinus rhythm, QRS duration, PQ interval and ventricular effective refractory period were unaltered, whereas QTc interval increased significantly after initiation of anesthesia. Before and after induction of general anesthesia, clinical VT was inducible in all patients. However, in 1 patient, induction of VT was only possible by pacing in the left ventricle after enflurane administration. Based on these data, it is concluded that general anesthesia with enflurane, oxygen and nitrous oxide has no marked influence on inducibility of clinical VTs. Therefore, this type of anesthesia may be useful for nonpharmacologic, ablative procedures requiring general anesthesia.
Aged↗
Acute and long-term efficacy of oral propafenone in patients with ventricular tachyarrhythmias.
The class Ic antiarrhythmic agent propafenone was studied by repeated electrophysiologic testing in 54 patients (43 male, aged 54 +/- 10 years, mean ejection fraction of 37.3 +/- 16.9%) with ventricular tachyarrhythmias. Forty patients (74%) had coronary artery disease. Programmed ventricular stimulation (S2, S2S3 during sinus rhythm and/or during S1S1 = 500, 430, 370, and 330 ms) off antiarrhythmic drugs induced sustained ventricular tachycardia, flutter, or fibrillation in all patients. After 450-900 mg of oral propafenone/day for 4-7 days, 51 patients were restudied. In the remaining three patients, spontaneous ventricular tachycardia occurred on drug therapy. Tachycardia induction was suppressed in 9 of 51 patients restudied (18%) and rendered more difficult to induce (basic stimulation drive greater than or equal to 40 beats/min higher than at control study) in another 7 patients (14%) (overall efficacy of 31%). The tachycardia rate decreased from 220 +/- 43 to 177 +/- 44 beats/min (p less than 0.01). The right ventricular effective refractory period increased from 232 +/- 22 to 252 +/- 22 ms (p less than 0.001). Responders to propafenone therapy had higher rates of inducible ventricular tachycardia at control (greater than 230 beats/min: 43%; less than or equal to 230 beats/min: 21%; p less than 0.05), higher ejection fractions, and lower left ventricular end-diastolic pressures than nonresponders. Eleven of the 16 patients showing a positive response to propafenone therapy in electrophysiologic testing were discharged on propafenone alone. During follow-up (17 +/- 12 months), nine patients remained free from ventricular tachycardia, one patient had a relapse, and one patient died of noncardiac death.(ABSTRACT TRUNCATED AT 250 WORDS)
Administration, Oral↗
Diagnostic value of electrocardiographic variables to predict the presence of ventricular late potentials.
To test the hypothesis that the presence of ventricular late potentials in the highly amplified, averaged and filtered surface electrocardiogram (ECG) can be predicted from the conventional surface ECG, 211 patients with and without previously documented sustained ventricular tachycardia outside the acute phase of myocardial infarction were studied. The presence of left ventricular akinesia or aneurysm was significantly correlated with the ECG score (based on Q wave duration, R wave duration and amplitude ratio). The mean ECG score in patients without ventricular tachycardia was 3.4 +/- 3.5 points compared with 5.5 +/- 3.9 points (p less than 0.001) in patients with ventricular tachycardia. The presence of late potentials was positively correlated with the ECG score in the whole cohort of patients. This was also the case in the subgroup of patients without a history of sustained ventricular tachycardia. In contrast, in patients with ventricular tachycardia, the presence of late potentials was independent of their ECG score. Using linear discriminant function analyses to predict the presence of late potentials, a history of ventricular tachycardia alone and the ECG score alone had a high predictive power (high standardized coefficients). If combinations of variables were analyzed including estimates of left ventricular function (presence of aneurysm or akinesia; ejection fraction), the ECG score and a history of ventricular tachycardia still ranked highest. The influence of ejection fraction if used in combination with other variables for the prediction of late potentials was relatively small (standardized coefficient of 0.4). In conclusion, the surface ECG can be used in patients previously free of sustained ventricular tachycardia to predict the presence of ventricular late potentials.(ABSTRACT TRUNCATED AT 250 WORDS)
Electrocardiography↗