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Biomedical subjects

R Slama

Publications and source records attributed to R Slama.

At least 19 recordsLinked to original sources
PubMed1992

Flecainide in quinidine-resistant atrial fibrillation.

Flecainide (100 mg twice daily) was used for prevention of paroxysmal atrial fibrillation (PAF) in 52 patients with frequent symptomatic attacks that were resistant or intolerant to quinidine (600-900 mg/day). Underlying heart disease was present in only 8 cases and left ventricular ejection fraction was always greater than 30%. No patient had had a myocardial infarction. Vagally induced PAF was clinically documented in 35 patients. Amiodarone, previously used and ineffective, was combined with flecainide in 33 patients. After 1-5.8 years of follow-up, complete disappearance of PAF was observed in 38 patients (73%). The success rate was slightly higher in patients with vagally induced PAF (p = 0.07). Extracardiac side effects necessitated withdrawal in only 3 cases. Permanent pacemaker was needed in 7 patients on amiodarone and flecainide because of excessive sinus bradycardia. Two patients, with previously documented atrial flutter, experienced presyncopal episodes of atrial flutter with 1:1 atrioventricular (AV) conduction and wide QRS complex. No death occurred during the follow-up. In this series, quinidine proved to be unsuccessful in 46 patients and it was withdrawn in 6. We concluded that flecainide is efficient and well tolerated for long-term prevention of PAF in patients resistant to quinidine. The possibility of 1:1 AV conduction during atrial flutter may suggest the use of verapamil or beta blockers in combination with flecainide in patients with previously documented atrial flutter.

Amiodarone↗
PubMed1992

Improvement of digital coronary angiography: high resolution processing coupled with a real time functional synchronization procedure.

The use of Digital Subtraction Angiography in coronary applications is restricted by the difficulty in: 1. Obtaining a good resolution of the distal branches. 2. Avoiding, for the purpose of subtraction, the motion artifacts induced by artery and background displacement during the cardiac and respiratory cycles. 3. Preserving the dynamic vascular motion. 4. And storing the digital dynamic information on a permanent support. We used for this study an angiography system, based upon a high resolution 45 MIPS-32 Mbyte image processor, interfaced with a 2.75 Gbyte Winchester drive allowing the real time storage of either 30 frames/s in the 512*512*8 bits matrix or of 7.5 f/s in the 1024*1024*8 bits matrix. To preserve the most important dynamic informations on the basis of the 7.5 f/s maximal storage rate, we developed a synchronization device able to recognize in real time, from chronologic delays derived by using both ECG and Aortic Pressure curves, the functional End-Diastolic (ED) and the End-Systolic (ES) positions, even in the case of heart rates varying during the procedure. The ED and the ES images are stored together with the Mid-Systolic (MS), the 1/3-Diastolic (1/3D) and 2/3-Diastolic (2/3D) images. To establish the validity of this sampling method, which uses a reduced number of frames per cardiac cycle, 7200 coronary injections performed during 450 routine coronary angiographies were compared by two independent observers (A and B), using: first a Digital (D) 5 frames/cycle sequence, and secondly a cine Film (F) 50 frames/s sequence acquired immediately after the corresponding D injection. The D technique resulted in the best image and diagnostic quality, particularly when the F quality was estimated 'fair' or 'poor' by both observers, and in an important reduction on X-Ray doses. The visualisation of the sequential ED, MS, ES, 1/3D and 2/3D frames gives the possibility: 1. of saving the dynamic information, as a regular sample of functional images can be displayed with a cine loop technique. 2. of facilitating cardiac synchronized subtractions. 3. of reducing the amount of frames per cycle, thus allowing an important reduction of X-ray doses and the digital and permanent storage of the most important cardiac cycles.

Angiography, Digital Subtraction↗
PubMed1992

Efficacy of beta-blocking agents in reducing the number of shocks in patients implanted with first-generation automatic defibrillators.

The efficacy of beta-blockers was tested in 11 patients who avoided sudden death as a result of ventricular tachycardia or fibrillation due to coronary artery disease or non-ischaemic underlying heart disease, after implantation of an automatic defibrillator. Ten patients initially tolerated acebutolol despite prior class III or IV heart failure in six cases; nadolol replaced acebutolol in nine cases for long-term therapy. In these 10 patients, periods of treatment with and without beta-blocking agent were available, making possible a crossover comparison, during a follow-up lasting 31.6 +/- 17.8 months. One hundred and ten shocks were delivered: 14 were considered as probably inappropriate and ruled out, leaving the remaining 96 shocks to be analysed. The monthly rate of shocks was lower during beta-blocking treatment: 0.12 +/- 0.24 vs. 1.09 +/- 1.41 (P = 0.03). While taking beta-blockers, only four patients received shocks, compared to 10 (i.e. all cases) not administered beta-blockers (P less than 0.01). Despite the technical limitations of the study, since only a few spontaneous shocks could be documented on ECG recordings, the efficacy of beta-blockers in preventing occurrence of severe ventricular tachyarrhythmias seems likely, and deserves further investigations using new implanted devices with improved memory functions.

Acebutolol↗
PubMed1992

[Pro-arrhythmia effect of pyridostigmine. Apropos of a case].

A coronary patient with myasthenia gravis with a previous myocardial infarction presented with severe ventricular arrhythmias after the replacement of neostigmine by pyridostigmine for the treatment of the myasthenia. These arrhythmias were resistant to antiarrhythmic therapy associating betablockers and amiodarone throughout treatment with pyridostigmine but regressed when this drug was withdrawn. A test of reintroduction of pyridostigmine under medical surveillance led to the reappearance of the ventricular hyperexcitability, so confirming the responsibility of this drug. This would seem to be the first reported case of severe ventricular arrhythmias due to a proarrhythmic effect of pyridostigmine. The possible mechanisms of this effect are discussed.

Coronary Disease↗
PubMed1992

[Clinical aspects of polymorphic ventricular tachycardia].

Polymorphic ventricular tachycardia is defined as constant change of the QRS morphology. The diagnosis has important etiological, therapeutic and prognostic implications. This term covers several different entities which may be artificially distinguished by the electrocardiographic appearances during tachycardia, by changes of the resting electrocardiogramme, the mode of onset, the presence or absence of underlying cardiac disease and of intercurrent drug therapy. However, as the resting ECG may not be available in an emergency situation, or difficult to interpret, the clinical context is the key to diagnosis and treatment. Polymorphic ventricular tachycardia is classified according to the absence or presence of underlying cardiac disease respectively as torsades de pointe with long QT, torsades de pointe with a short coupling interval and catecholamine-induced ventricular tachycardia of childhood on the one hand, and, iatrogenic torsades de pointe, ventricular tachycardia in acute or chronic infarction and other cardiac diseases, on the other hand. Finally, the authors discuss the problem of polymorphic ventricular tachycardia induced by programmed ventricular stimulation.

Anti-Arrhythmia Agents↗
PubMed1992

[Value of signal-averaged electrocardiogram in ventricular arrhythmia without apparent heart disease].

Signal-averaged electrocardiography was performed in 132 subjects with various ventricular arrhythmias without clinically apparent heart disease and compared with the results obtained in a series of 45 normal subjects. The latter enabled definition of the following criteria of normality: QRS duration after averaging < 113 ms; Simson vector of the last 40 ms (RMS40) > or = 17 microV; low amplitude signal duration over 40 microV < 38 ms for a high pass bidirectional filter of 40-300 Hz. Complementary investigations (echo or angiography), performed in all cases, showed underlying abnormalities in 26 patients: 13 right ventricular dysplasias, 7 cardiomyopathies, 3 mitral valve prolapses and 3 minor congenital heart defects. These investigations were normal in the remaining 106 subjects. Of the 26 patients with cardiac disease, 15 had 3 criteria of positivity for late ventricular potentials, 6 had 2 criteria and the other 5 had no criteria of late ventricular potentials. Therefore, 81% of cases with cardiac disease had at least 2 diagnostic criteria of late ventricular potentials whereas only 4% of those without cardiac disease, and in the control group, had criteria of positivity (p < 0.001). Using these criteria, the predictive value of signal-averaged electrocardiography for the detection of underlying cardiac disease was good when 2 criteria are required for diagnosis of late ventricular potentials: sensitivity 81%, specificity 96%; predictive value of a positive test 78%, predictive value of a negative test 97%. Signal-averaged electrocardiography is therefore a good non-invasive method of diagnosing underlying cardiac disease in patients with ventricular arrhythmias without clinically apparent heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Long-term follow-up after sustained monomorphic ventricular tachycardia: Causes, pump failure, and empiric antiarrhythmic therapy that modify survival.

We analyzed the actuarial cardiac mortality rate of 295 consecutive patients with sustained monomorphic ventricular tachycardia who were referred to us between 1978 and 1988. Patients were divided into four groups: group I of 156 patients with coronary disease, group II of 55 patients with nonischemic left ventricular disease, group III of 65 patients with right ventricular disease, and group IV of 19 patients without detectable heart disease. Patients were treated empirically according to a prospective schema: (1) class I antiarrhythmic drugs, (2) in case of recurrence of ventricular tachycardia: amiodarone or beta-blockers, (3) in case of recurrence of ventricular tachycardia: drug combinations or surgery. The mean follow-up duration was 61 +/- 40 months after the first occurrence of ventricular tachycardia, and the clinical outcome was known in 67.5% of patients at 5 years. The actuarial mortality rates were considerably higher in groups I and II compared with those in groups III and IV (p less than 0.01). The mortality rate was slightly higher in group I than in group II (p less than 0.05). In groups I and II, actuarial mortality rate were much higher when left ventricular ejection fraction was less than 0.30 (p less than 0.01). Comparisons between treatments showed no difference in actuarial mortality rates in patients with ventricular tachycardia and left ventricular ejection fraction greater than 0.30.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1991

Sudden cardiac death, implanted defibrillation, and clinical electrophysiology.

A mere 25 years ago, the technique of external defibrillation became the starting point for the development of clinical electrophysiology by permitting routine use of endocavitary programmed electrical stimulation of the heart without undue risk. Major advances in knowledge of clinical arrhythmias and the understanding of their mechanisms were, thus, permitted. Mirowski's implanted defibrillator also constituted a major breakthrough therapeutically; unfortunately, however, some 10 years later, it has not yet induced similarly hoped for consequences in terms of progressing knowledge concerning lethal arrhythmias, largely due to the absence of Holter functions in the implanted devices. As a result of this, in our opinion, better established therapeutic indications are still needed. The reasons for the present situation, we believe, may be partly technical but are conceptual as well. The key point is that even the clear demonstration of the great practical efficacy of a therapeutic tool does not exempt us from the obligation of determining the mechanisms of this effect.

Arrhythmias, Cardiac↗
PubMed1991

[Implantable automatic defibrillator. Evaluation after 8 years of use].

The thirty nine patients (30 men and 9 women, mean age 49 +/- 14 years) who were implanted with an automatic cardioverter defibrillator (AICD) between October 1982 and April 1990 were reviewed retrospectively. This group included 22 patients with ischaemic cardiomyopathy (55%), 9 primary cardiomyopathies (23%) 5 ventricular tachycardias in patients with normal hearts (13%), 1 case of arrhythmogenic right ventricular dysplasia and two of mitral valve prolapse. The mean ejection fraction for the whole group was 38 +/- 14%. The indication for implantation of the AICD was life-threatening ventricular arrhythmias for which other forms of treatment were either ineffective (29 patients), impossible to assess (9 patients) or poorly tolerated (1 patient). Two patients died during the perioperative period and the follow-up is too short in two other cases. Therefore, 35 patients were studied over an average of 23.7 +/- 16 months. During follow-up, 5 patients died, 3 of progressive cardiac failure and 2 suddenly, one of whom was waiting for a replacement of an exhausted generator. The AICD never functioned in 40% of patients. In addition, it was impossible to determine for the majority of shocks delivered if they had been triggered by a sustained ventricular arrhythmia. Long term tolerance was generally good but two patients developed cardiac constriction induced by the epicardial patch electrodes. The results of this review confirm the efficacy of AICD in preventing sudden death at the expense of a low operative mortality and with good long term tolerance. Quite a large proportion of AICDs never functioned and the interpretation of the delivered shocks remains questionable.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

[Life expectancy after a first attack of sustained monomorphic ventricular tachycardia. Apropos of 295 patients with a follow-up of more than 5 years].

Analysis of actuarial cardiac mortality of 295 patients after a first attack of sustained monomorphic ventricular tachycardia followed up for an average of 5.1 years showed that: the aetiology was the main prognostic factor. Patients with a normal left ventricle had a zero 5 year mortality rate (normal heart) or 3% (arrhythmogenic right ventricular dysplasia) compared with 24% in patients with cardiomyopathy and 40% with myocardial infarction: p less than 0.01. Similar results were obtained if sudden death was considered; in patients with left-ventricular disease, the role of pump function assessed by the ejection fraction was essential: the 5 year mortality was 14.5% (cardiomyopathy) and 30% (myocardial infarction) if this was greater than 0.3 compared to 43% and 51% respectively when less than 0.3 (p less than 0.01); the heart rate of spontaneous ventricular tachycardia and that of tachycardia induced during endocavitary investigation had no influence on the mortality. However, the mortality following a first tachycardia with syncope was higher than that following a well tolerated tachycardia (p less than 0.5 if the ejection fraction less than or equal to 0.3 and p less than 0.001 if greater than 0.3).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1990

[Floating left atrial thrombus in 2 cases of severe mitral stenosis].

The authors report two operated cases of floating left atrial thrombus. Both patients had severe mitral stenosis, atrial fibrillation and dilatation of the left atrium. In the first case, the patient had no anticoagulant therapy; in the second case, the observance of anticoagulant therapy was irregular. Neither patient complained of syncope. The diagnosis was made in both cases by two-dimensional echocardiography which, in addition to confirming the severe mitral stenosis, showed a round, free-floating intra-atrial mass, rebounding from wall to wall and repeatedly engaging itself into the mitral orifice. The risk of prolonged engagement of the thrombus in the mitral orifice, causing syncope or sudden death, justifies urgent surgery associating thrombectomy and treatment of mitral stenosis every time this problem is encountered.

Adult↗
PubMed1990

[Signal-averaged electrocardiography in right ventricular dysplasia].

The authors report their experience of signal-averaged electrocardiography (SAE) in arrhythmogenic right ventricular dysplasia (ARVD) in a study comparing the results in 40 control subjects, 21 patients with ARVD with episodes of sustained monomorphic ventricular tachycardia (VT) (Group I), 7 patients with ARVD without sustained VT (Group II) and 10 asymptomatic members of the families of patients in Group I (Group III). There were significant differences in the results of SAE in the time domain between the control group and Group I, patients with "classical" ARVD. The RMS 40 (root mean square of the last 40 ms of the QRS complex) was the most sensitive parameter but the specificity was less than the averaged QRS width and the low amplitude signal duration. The results in Group II were more varied, some patients having clearly abnormal SAE and others strictly normal recordings. In Group III, the investigation was normal. Spectral analysis after Fourier transformation did not show significant differences between the 3 groups. A difference was observed between the diffuse and localised forms of ARVD in Groups I and II: the localised forms had a shorter QRS width and low amplitude signal duration than the diffuse forms. Also, there was a relationship in Group I between age and duration of QRS and delayed potential which increased and with the RMS 40 or 50 which decreased. This is an argument in favour of the progressive nature of ARVD with respect to time.

Adult↗
PubMed1990

[Massive delayed-action verapamil poisoning].

An 18-year old woman developed cardiogenic shock after ingestion of 16.8 g of a sustained release form of verapamil. Severe left ventricular diastolic dysfunction was demonstrated. For the first time muscular involvement was observed with myalgia and elevation of the MM isoenzyme of creatinine kinase. The efficacy isoproterenol and the need for prolonged treatment are emphasised.

Adolescent↗
PubMed1990

[Late potentials and arrhythmogenic right ventricular dysplasia].

The authors report on their experience in investigating late potentials (LPs) in arrhythmogenic right ventricular dysplasia (ARVD), by comparing 35 patients with ARVD with 40 control subjects. The values of QRS and RMS40 and the duration of the LP showed a marked difference between the control group and the ARVDs, particularly if sustained VT was present. In this case, 68 per cent of patients were found to have LPs (with at least 2 out of 3 parameters abnormal) versus 50 per cent in the ARVDs without sustained VT and 5 per cent in the controls. There was a difference between the diffuse forms (10 per cent) and the localized forms (25 per cent) of ARVD: the LPs were markedly more obvious in the diffuse forms. Likewise, there was a clear relationship between age and the criteria for LPs in ARVD with sustained VT. This is an argument in favour of the evolutive character of the disease, which could be observed directly in a few cases in which the examinations were repeated over the course of time.

Adult↗
PubMed1989

Surgery for the Wolff-Parkinson-White syndrome in 73 consecutive patients: what have we learnt from intraoperative mapping?

Intraoperative epicardial mapping data obtained in 73 consecutive patients operated upon for the Wolff-Parkinson-White syndrome were reviewed. Fifty-six patients had single and 17 patients had multiple accessory pathways. Except for right free wall pathways, all bypass tracts were divided using an endocardial approach. There were 2 operative deaths, 1 of which occurred after a concomitant mitral valve replacement. A total of 78 of the 87 pathways present in the 71 survivors were successfully ablated (90%). All failures occurred in patients with left posterior septal pathways. Epicardial mapping performed prior to bypass was found helpful in identifying multiple distinct accessory pathways which had been missed preoperatively. This occurred in 6 patients and led to appropriate combinations of classic operative approaches which resulted in all of these pathways being successfully divided. Further, by demonstrating that Kent bundles often presented as multiple closely-spaced or arborized accessory pathways, intraoperative mapping led to widening of the margins of surgical dissection, and in particular to an additional left atriotomy in all cases of left posterior septal accessory pathways which resulted in a substantial improvement in our rate of success.

Adolescent↗
PubMed1989

Occult gastrointestinal bleeding in high-risk intensive care unit patients receiving antacid prophylaxis: frequency and significance.

Gastroccult reagent was used every 4 h to detect blood in gastric juice in 41 ICU patients at risk of GI bleeding (GB) and receiving antacid prophylaxis (gastric pH greater than 3.5). Of the present patients, 27% (11/41) had at least one episode of occult GB (three consecutive positive determinations; a total of 14 episodes). Endoscopy identified acute gastroduodenal mucosal lesions (stress ulcers) as the most frequent lesion in this group (eight patients). Sepsis was the most frequent underlying condition associated with occult GB due to stress ulcer. Hematemesis occurred in 36% (4/11) of patients with occult GB and was due to stress ulcer in three patients and to benign gastric tumor in one. No overt GB occurred in the absence of previous occult GB. We conclude that: a) risk of GB persists in critically ill ICU patients in spite of antacid prophylaxis (gastric pH greater than 3.5); b) high-risk patients can be identified through periodic testing for the presence of blood in gastric juice using the reagent; c) when occult GB occurs, treatment should be based on the endoscopy results. In the absence of acute gastroduodenal mucosal lesions, antacid prophylaxis should not be modified, and specific treatment of the identified lesion(s) should be initiated. In the presence of stress lesions, antacid prophylaxis should be reinforced if the pH of the gastric content is less than 3.5 and a septic complication should be actively sought if the pH is greater than 3.5.

Adult↗