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PubMed1980

Resistant ventricular arrhythmias treated with lorcainide, a new antiarrhythmic drug.

A 68-year-old patient developed increasingly frequent episodes of ventricular and supraventricular arrhythmias over the past five years. During the last 12 months, he was admitted to the hospital on several occasions with complex arrhythmias including multifocal PVCs, bigeminy, trigeminy, ventricular tachycardia, and atrial flutter and fibrillation. Large and frequent doses of quinidine, procainamide, disopyramide, propranolol, and digoxin failed to suppress his arrhythmias. He had no previous history of myocardial infarction or other heart diseases. Coronary arteriography revealed no obstruction of any major arteries or their branches. A new antiarrhythmic drug, lorcainide, was given intravenously and it suppressed all PVCs, including bigeminy and ventricular tachycardia. All his arrhythmias have been completely suppressed by oral regimens of lorcainide, 100 mg four times daily, for the past four months. This is the first case of oral treatment of ventricular arrhythmias with lorcainide in this country.

Administration, Oral↗
PubMed1999

[Radiofrequency ablation in auricular flutter. Predictive factors of primary success and medium term results].

Ninety-one consecutive patients underwent radiofrequency ablation of chronic or paroxysmal atrial flutter. The average age of the patients was 66. There was a previous history of atrial fibrillation in 38% of cases and of cardiac surgery in 14.3% of cases. The primary success rate was 79% (92% in cases of common flutter). The predictive factors of success were the type of flutter (p < 0.001), left ventricular (p < 0.01) and left atrial dimensions (p < 0.01) at echocardiography. The length of the cavo-tricuspid isthmus measured by echocardiography had no influence on the initial result but, in primary success, did affect the parameters of the procedure (duration and number of applications of radiofrequency energy). After an average of 11 +/- 2 months, sinus rhythm was maintained in 67% of patients. There were recurrences of flutter in 27.5% of cases and of atrial fibrillation in 5.5% of cases: 85% of these episodes occurred during the first six months after ablation. A second procedure was carried out in 12 patients for recurrence of flutter (92% primary success rate). After an average follow-up of 8.4 months, 4 patients had a recurrence and required a third procedure (100% success rate). In cases of failure of ablation, the rhythm was converted by a shock or atrial pacing: 47.3% of these patients remained in sinus rhythm with antiarrhythmic therapy with a 12 month follow-up. Radiofrequency ablation of atrial flutter is, therefore, a safe method, the difficulty of which is mainly related to anatomical factors: the medium-term results are better than those of other therapeutic methods.

Atrial Flutter↗
PubMed2004

Echo-guided endomyocardial biopsy in heart transplant recipients.

After heart transplantation the effect of immunosuppression is monitored by histopathology of endomyocardial biopsy (EMB). EMB is usually carried out under X-ray guidance. Between January 1998 and March 2003, 1,262 biopsies were collected under echo-guidance in 156 patients. The biopsy access was gained through the internal jugular vein, by the standard catheterization technique. The average time of the procedure was 17 min. Four or five specimens were obtained from each patient, with a success rate of 96%. Complications involved two episodes of partial pneumothorax in one patient, atrial flutter in another and ventricular fibrillation in three patients. Conversion from echo to X-ray guidance was indicated in 11 patients. No case of significant tricuspid regurgitation related to the EMB procedure was recorded. The echo-guided endomyocardial biopsy appears to be a prospective alternative to the conventional approach under X-ray guidance. Its duration is comparable, it eliminates X-ray exposure, enables continuous echocardiographic monitoring and can be performed at the bedside.

Adolescent↗
PubMed2006

Left ventricular dysfunction in atrial fibrillation: restoration of sinus rhythm by the Cox-maze procedure significantly improves systolic function and functional status.

BACKGROUND: Atrial flutter or fibrillation with rapid, uncontrolled ventricular response may lead to left ventricular dysfunction, and conversion to sinus rhythm with control of heart rate can improve left ventricular ejection fraction. Little is known about the effects of the Cox-maze procedure on this form of tachycardia-induced cardiomyopathy. METHODS: Four hundred forty-three patients underwent the Cox-maze procedure from 1993 to 2002. Ninety-nine had atrial flutter or fibrillation without associated valvular or congenital heart disease, and 37 (37%) had decreased left ventricular function (ejection fraction < 0.35 in 11 [severe], ejection fraction 0.36 to 0.45 in 8 [moderate], and ejection fraction 0.46 to 0.55 in 18 [mild]). Ages of these 37 patients (34 male) ranged from 35 to 74 years (median, 55 years). RESULTS: Atrial flutter or fibrillation was present for 3 months to 19 years (median, 48 months) preoperatively, and 24 patients (65%) exhibited symptoms of heart failure. Preoperative ejection fraction ranged from 0.25 to 0.55 (median, 0.45). At last follow-up (median, 63 months), the Cox-maze procedure eliminated atrial flutter or fibrillation in all but 1 patient, and the greatest improvement was observed in patients with severe preoperative impairment (0.31 to 0.53; p = 0.01, preoperative versus follow-up), and patients with preoperative chronic atrial flutter or fibrillation (0.43 to 0.55; p < 0.05 preoperative versus follow-up). This improvement was observed immediately postoperatively and was sustained at last follow-up. Further, improvement in left ventricular function correlated with enhancement of functional status. CONCLUSIONS: In some patients, atrial flutter or fibrillation may be the cause rather than the consequence of left ventricular dysfunction. Importantly, systolic function and functional status can be significantly improved with the restoration of sinus rhythm by the Cox-maze procedure.

Adult↗
PubMed2003

Radiofrequency catheter ablation of various kinds of arrhythmias guided by virtual electrograms using a noncontact, computerized mapping system.

Three-dimensional visualization of cardiac activation has become important for providing further insights into the pathophysiological mechanisms of arrhythmias and to increase the efficacy of catheter ablation. The noncontact mapping system enables a single-beat analysis of the reconstructed geometry of the cardiac chamber. In 8 patients with various kinds of arrhythmias (3 with atrial flutter, 2 with right ventricular outflow tract ventricular tachycardia, 1 with idiopathic left ventricular tachycardia, 1 with atrioventricular nodal reentrant tachycardia and 1 with concealed Wolff-Perkinson-White syndrome), non-contact mapping using an EnSite 3000 system was performed for the guidance of catheter ablation. The optimal sites for successful ablation were detected and all of these arrhythmias were successfully eliminated with the radiofrequency energy applications without any adverse effects. The computerized EnSite 3000 mapping system described here computes accurate isopotential maps that are a useful guide for catheter ablation.

Adult↗
PubMed1988

[Prenatal diagnosis and treatment of auricular flutter. Apropos of a case and review of the literature].

In newborns, atrial flutter is a rare, but severe condition. Late diagnosis was usual and based on fetal ECG. Now, fetal ultrasonography can differentiate in utero atrial flutter and other supra ventricular tachycardias; so it can be treated before development of cardiac failure. Among numerous and various available drugs, digoxin is universally recommended, but the delayed effect and the maternal serum levels to obtain effective fetal concentration of digoxin are not well known. Furthermore, endogenous "digoxin-like" substances have been found in maternal blood in late pregnancy; this finding raises the problem of the validity of monitoring the treatment only by serum digoxin levels. A case of atrial flutter, diagnosed in utero by ultrasonography and treated by digoxin before development of cardiac failure is reported. Neonatal echocardiography showed an aneurysm of the atrial septum, which needed simple monitoring. Its responsibility in the pathogenesis of the arrhythmia is unclear. Numerous cases of aneurysm of the atrial septum have been reported in healthy adults without atrial arrhythmias.

Adult↗
PubMed1986

[Intravenous sotalol in the acute treatment of supraventricular tachycardias].

The effects of intravenous sotalol (0.5 mg/kg in 6 minutes) were studied in 23 patients with supraventricular tachycardia (ventricular rate greater than 120 bpm) after failure of placebo (isotonic dextrose). Thirteen patients had atrial flutter or fibrillation and 10 a junctional tachycardia of recent onset. Sinus rhythm was restored in 4 of the patients with atrial flutter or fibrillation and the ventricular rate was slowed significantly in 3 patients (less than 100 bpm). In 3 other patients the ventricular rate decreased (31 to 35 p. 100) but remained above 100 bpm. Sinus rhythm was restored in 3 of the 10 patients with a junctional tachycardia five to twelve minutes after beginning the injection. A slight slowing of the heart rate (13 to 27 p. 100) was observed in the other 7 patients but the frequency remained over 100 bpm. Overall, a satisfactory result was obtained in 10 patients (43 p. 100) including 7 cases in which sinus rhythm was restored. Sotalol was well tolerated in 21 patients; one patient complained of cold in the legs and one patient developed asymptomatic bradycardia (46 bpm). This study shows that intravenous sotalol may be useful in the emergency treatment of supraventricular tachycardia.

Adolescent↗
PubMed1980

The automatic implantable defibrillator.

The automatic implantable defibrillator is an electronic device programmed to monitor the cardiac rhythm continuously, to recognize ventricular fibrillation and ventricular tachyarrhythmias characterized by sinusoidal waveform, and to deliver corrective difibrillatory discharges when indicated. Three patients suffering from recurrent malignant ventricular arrhythmias refractory to medical therapy underwent permanent implantation of this device. Seven episodes of ventricular tachycardia and flutter-fibrillation were documented during the weeks following the implantations; two were induced at electrophysiologic studies and five occurred spontaneously. All were correctly identified and six were automatically reverted to normal sinus rhythm by the implanted device; one induced episode was cardioverted externally before the unit could recycle. Although many problems remain to be solved and the ultimate value of this therapeutic modality has to be determined, a new approach to prevention of sudden death in patients at high risk of developing lethal ventricular arrhythmias has become available.

Adolescent↗
PubMed1994

Arrhythmias in mitral valve prolapse: relation to anterior mitral leaflet thickening, clinical variables, and color Doppler echocardiographic parameters.

Atrial and ventricular arrhythmias have been reported with variable incidence in symptomatic patients with mitral valve prolapse (MVP). The role of clinical and echocardiographic parameters as predictors for arrhythmias still needs to be clarified. One hundred nineteen consecutive patients (56 women and 63 men, mean age 40 +/- 17 years) with echocardiographically diagnosed MVP were examined. A complete echocardiographic study (M-mode, two-dimensional, and Doppler) and 24-hour electrocardiographic monitoring were performed in all patients. Complex atrial arrhythmias (CAAs) included atrial couplets, atrial tachycardia, and paroxysmal or sustained atrial flutter or fibrillation. Complex ventricular arrhythmias (CVAs) included multiform ventricular premature contractions (VPCs), VPC couplets, and runs of three or more sequential VPCs (salvos of ventricular tachycardia). The relation between complex arrhythmias and clinical parameters (age and gender) and echocardiographic parameters (left atrial and left ventricular dimensions, anterior mitral leaflet thickness [AMLT], and presence and severity of mitral regurgitation) was evaluated by multiple logistic regression analysis. CAA were present in 14% of patients and CVA in 30%. According to multiple logistic modeling, CAA correlated separately in the univariate analysis with age, presence of MR, and left ventricular and left atrial diameters; age was the only independent predictor (p < 0.001). CVA, in the univariate analysis, correlated with age, female gender, left ventricular end-diastolic diameter, and AMLT; only female gender and AMLT were independent predictors in the multivariate analysis (p < 0.01). The incidence of mitral regurgitation (59%) was higher than expected in a general population of MVP patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Cardiac arrhythmia in patients undergoing surgical repair of Ebstein's anomaly.

BACKGROUND: Arrhythmias remain an unsolved problem in Ebstein's anomaly. The aim of this study was to investigate the evolution of arrhythmias after surgical repair. METHODS: Forty-five patients with Ebstein's anomaly and arrhythmias were studied. Mean age was 33 +/- 15 years. Twenty-four patients (53%) had paroxysmal supraventricular tachycardia, 12 (27%) had atrial fibrillation or flutter, 8 (18%) had ventricular preexcitation (Wolff-Parkinson-White syndrome), and 1 (2%) had a nonsustained ventricular tachycardia. Surgical technique included detachment of the tricuspid anterior leaflet and suture on the atrioventricular annulus associated with right ventricular longitudinal plication. RESULTS: There were four hospital deaths (9%). A pacemaker was implanted early after operation in 5 patients (11%). During a mean follow-up of 57 +/- 50 months (range, 4 to 226 months), there were six additional deaths, three of which were sudden. Two patients were lost to follow-up. Of the 33 surviving patients, 8 (24%) continued to have symptomatic arrhythmias, and 15 (45%) were in permanent sinus rhythm. Of the 24 patients with preoperative paroxysmal supraventricular tachycardia and the 12 with atrial fibrillation or flutter preoperatively, 9 and 2 of the survivors, respectively, have had no further episodes of arrhythmia. The incidence of arrhythmia with or without symptoms was reduced to 39% (13/33) of the surviving patients. CONCLUSIONS: Arrhythmia is not totally abolished after operation. However, patients with Ebstein's anomaly and arrhythmia show substantial improvement after conservative surgical intervention.

Adolescent↗
PubMed1984

The clinical results of amiodarone in cardiac arrhythmias: optimal dosing.

Amiodarone hydrochloride is a relatively new antiarrhythmic agent, the properties of which differ in a significant manner electrophysiologically, pharmacokinetically and structurally from those of conventional as well as other investigational antidysrhythmic compounds. It is also pharmacologically unique in so far as its fundamental action on cardiac muscle following chronic therapy differs markedly from that found during the intravenous administration; its I.V. action is dominated by the lengthening of intranodal (AV) conduction time and the effective refractory period of the AV node, the electrophysiologic basis for which is unclear but accounts for the slowing of the ventricular response in atrial flutter and fibrillation and the variable conversion rate of narrow QRS reentrant paroxysmal supraventricular tachycardia. Intravenous amiodarone is ineffective in most other arrhythmias; it does not lengthen repolarization, nor does it prolong the effective refractory period of atria, ventricle, His-Purkinje system or the accessory pathways of the heart in the WPW syndrome. In contrast, chronically administered amiodarone lengthens repolarization and the effective refractory period of all cardiac tissues as a function of dose and duration of therapy consistent with its wide spectrum of antiarrhythmic activity in the prophylactic control of supraventricular and ventricular tachyarrhythmias. The nature of the slow onset of action of the oral drug is not well-understood; it may be due to the slow formation of active metabolites or the gradual and selective inhibition of T3 action on the myocardium since the effects of amiodarone on cardiac repolarization are identical to those of hypothyroidism and are negated by the concomitant administration of thyroxine. Serum reverse T3 levels increase as a function of dose and duration of amiodarone therapy and tentative data indicate that serial measurements of rT3 levels may provide a reliable index for gauging efficacy and toxicity of amiodarone during chronic therapy. The role of serum drug and metabolite levels appears less reliable in this regard. The exceedingly long and variable elimination half-life of amiodarone necessitates individualized loading and maintenance dosage regimens, and the latency of onset of antiarrhythmic action during oral therapy is not shortened by intravenous bolus injections or sustained infusions. However, the judicious choice of oral dosage as discussed herein permits the development of an effective prophylactic regimen for most patients with supraventricular and ventricular tachyarrhythmias; when the lowest dosage regimen to control a particular arrhythmia is identified, limiting side

Amiodarone↗
PubMed1981

[Double Wenckebach phenomenon at nodal and His levels. Electrophysiological demonstration in slow and irregular flutter].

The authors describe the analysis of a case of atrial flutter with a slow ventricular response, the block being 9:2 with a first RR interval measuring between 3 and 4 PP intervals and a second RR interval between 5 and 6 PP intervals, the second of the 2 RR intervals being exactly 9 PP intervals. The only possible explanation of this sequence is firstly a 3:1 intranodal block (Wenckebach 3:2 in the central zone N of the node and 2:1 block at the nodo-hisian junction) followed by a 3:2 infra- or intra-hisian Wenckebach phenomenon. The His bundle recordings during flutter confirmed this hypothesis with the recording of a 3:2 block after the H potential. When sinus rhythm was restored at atrial level, the intrahisian conduction defect persisted (2:1 or 3:2 Wenckebach block).

Aged↗
PubMed1991

Surgical treatment of tachyarrhythmias.

Tachyarrhythmia surgery should be divided into two separate groups: supraventricular and ventricular. Supraventricular tachyarrhythmias (SVT): The first surgical cure of the Wolff-Parkinson-White syndrome (WPW) in 1968 led to a better understanding of the pathophysiology and anatomy of this syndrome. WPW should now be classified by its anatomical location as defined by the preoperative and intraoperative mapping. At present, there are two surgical approaches for WPW, endocardial or epicardial. Improvement of the surgical results has broadened the indications for surgery of WPW, making it the most commonly performed operation for SVT. Surgical treatment is briefly discussed for AV nodal reentrant tachycardia, ectopic (focal) atrial tachycardia, atrial flutter, and atrial fibrillation. Ventricular tachyarrhythmias (VT): Different types of direct operations have been applied to the treatment of VT in ischemic heart disease. Because of the fairly high mortality and recurrence rate of these major operations in patients with poor ventricular function, there is now a marked increase in the use of implantable cardioverter-defibrillators as an indirect surgical approach.

Arrhythmias, Cardiac↗
PubMed2000

The management of heart failure--an overview.

National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given "risk reduction", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies.

Adrenergic beta-Antagonists↗
PubMed1989

[Possible pro-arrhythmic effects of vagal stimulation maneuvers].

Vagal stimulation manoeuvres are currently used in clinical practice both for diagnostic and therapeutic purposes. Such manoeuvres are not, however, without risk. The Authors describe the case of a patient in whom, in the past, a Lown-Ganong-Levine syndrome had been diagnosed. During a vagal stimulation, performed because of a suspected paroxysmal supraventricular tachycardia crisis, a sudden increase of ventricular rate, up to 280 b/min, occurred. At the end of this paroxysm, the presence of an atrial flutter was ascertained. The high ventricular rate was thus attributed to an 1:1 A-V conduction which occurred because of the performed manoeuvres. The possibility of causing not only hypokinetic but also potentially dangerous hyperkinetic arrhythmias must be held in consideration; the vagal stimulation manoeuvres therefore should not be performed without the possibility of electrocardiographic monitoring.

Atrial Flutter↗
PubMed1980

Propranolol for prevention of postoperative cardiac arrhythmias: a randomized study.

Two hundred twenty-three patients were randomly selected to receive propranolol, 10 mg orally every 6 hours, or to serve as controls after coronary artery bypass grafting. The study began at the time of discharge from the intensive care unit. Patients were ineligible if they had cardiac arrhythmias while in the intensive care unit, low cardiac output requiring catecholamine support, or bradycardia requiring a pacemaker. In the control group, cardiac arrhythmias for which treatment was necessary developed in 31 of 136 patients (23%), atrial fibrillation or flutter in 24 patients (18%), and ventricular arrhythmias in 7 (5%). In the group receiving propranolol, cardiac arrhythmias requiring treatment developed in 9 of 87 patients (10%), atrial fibrillation or flutter in 7 (8%), and ventricular arrhythmias in 2 (2%). The difference in frequency with which cardiac arrhythmias occurred between the two groups is significantly different (p less than 0.05). We conclude that propranolol is effective in the prevention of cardiac arrhythmias following coronary artery bypass grafting.

Arrhythmias, Cardiac↗
PubMed2003

Mode switching failure during atrial flutter: the '2:1 lock-in' phenomenon.

AIMS: To evaluate incidence and mechanism of a special form of automatic mode switching (MS) failure in patients with atrial flutter. METHODS AND RESULTS: Retrospectively the charts of 134 patients implanted with dual chamber pacemakers with MS algorithms were reviewed. Seven patients (5.2%) were identified that presented with sustained rapid ventricular pacing resulting from atrial flutter with failure of automatic MS. Since this form of MS failure implies 2:1 tracking of atrial flutter, it was coined '2:1 lock-in'. A theoretical timing model was developed to clarify the mechanism of this special form of MS failure. Prerequisites for the '2:1 lock-in' phenomenon are: (1). the sum of the AV delay and the post ventricular blanking (PVAB) must be longer than the cycle length of the atrial flutter, (2). the tachycardia detection rate must be higher than half the atrial flutter rate and (3). the maximum tracking rate (MTR) must be higher than half the atrial flutter rate. Recommendations for programming in order to avoid this specific form of MS failure are made accordingly and parallel algorithms for flutter detection are discussed. CONCLUSION: '2:1 lock-in' is a typical form of MS failure in patients with atrial flutter and the mechanism is closely linked to the typical atrial sensing windows.

Algorithms↗