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PubMed1975

[Anti-arrhythmic therapy with verapamil by intravenous infusion].

Rapid and slow venous infusion of various doses of Verapamil in a mixed series of 185 cases of arrhythmia since 1968 is reported. Results and electrophysiological and ECG changes observed for each type of arrhythmia examined are considered separately: atrial fibrillation-flutter, supraventricular paroxystic tachycardia (atrial and/or junctional), and hyperkinetic ventricular arrhythmia. An association of i.v. Verapamil and a quinidine salt per os is suggested as an alternative to cardioversion in cases of recent atrial fibrillation-flutter. Results obtained in the treatment of arrhythmia due to electrical instability following angina and of angina following arrhythmia are also described. A study of His potentials as the premiss for using Verapamil in subjects with stimulus conductivity changes, including W.P.W. syndrome, is also reported. I.v. Verapamil was used in association with atrial and/or ventricular electrostimulation, and/or with electrical counter-shock in cases of arrhythmia (mostly supraventricular) that were especially refractory. Attention is drawn to the use of Verapamil in the control of arrhythmia after electrical cardioversion.

Adolescent↗
PubMed1996

Two hearts beating as one: radiofrequency ablation of the His bundle in a heterotopic heart transplant patient.

We describe a 54-year-old man with heterotopic heart transplantation, who had severe exertional angina and dyspnea related to native heart ischemic disease. Because of drug resistant atrial fibrillation and atrial flutter of the native heart with fast ventricular response (130 beats/min), right-sided radiofrequency ablation of the His bundle was undertaken, followed by permanent pacemaker linkage of donor and native hearts. The procedure was successful and uneventful. Remarkable relief of symptoms was achieved.

Atrial Fibrillation↗
PubMed1988

Twenty-four-hour electrocardiography in a healthy elderly population.

Twenty-four hour electrocardiography was performed in fifteen 73-year-old and seventeen 82-year-old subjects without known cardiovascular disease. They were selected from a representative population of elderly people. All subjects showed supraventricular premature beats. Supraventricular tachycardia was seen in 63%. Eighty-four percent showed ventricular premature beats (VPBs), and more than two VPB configuration types were seen in 23% of the subjects. Episodes of intermittent atrial flutter and fibrillation, higher-degree atrioventricular blocks and ventricular tachycardia were absent or rare.

Aged↗
PubMed1987

[Treatment of arrhythmia by intracardiac electrocoagulation].

Since July 1982, 12 patients have undergone catheter ablation for refractory arrhythmias. The ablated pathway was the His bundle in 8 patients, an accessory pathway in 3 patients and a ventricular reentrant circuit in 1 patient. The 8 patients in whom the His bundle was ablated comprised 3 cases of atrial flutter, 3 cases of atrial fibrillation, 1 case of atrio-ventricular tachycardia and 1 case of junctional reentrant tachycardia. Results were complete heart block in 6 of these cases, right bundle branch block and first degree a-v block in 1 case and first degree a-v block in the last case. A pacemaker was implanted in 7 patients. The total amount of energy used varied from 50 to 400 joules. In none of these 3 patients did tachyarrhythmia recur. The 3 cases with ablation of the accessory pathway comprised one success, one partial success and one failure. The energy used was 60 to 100 joules. The patient treated for ventricular tachycardia has had no new episodes of tachycardia 4 months after the procedure. The energy used was 200 joules. The mean follow-up for the 12 patients is 12 +/- 7 months. Apart from 2 episodes of thrombophlebitis, no serious complication was noted. Catheter ablation technique is a new and effective treatment for refractory supraventricular tachyarrhythmias. Concerning ventricular arrhythmias, our experience is not sufficient to allow conclusions to be drawn.

Adult↗
PubMed1979

[Medical management of tachycardias (author's transl)].

Guidelines for a step-wise plan of treatment of tachycardias have been compiled based on clinical empirical experience and with the aid of surface electrocardiograms, intracardial electrograms and stimulation techniques. The plan is primarily with the aid of surface electrocardiograms, intracardial electrograms and stimulation techniques. The plan is primarily oriented with respect to the antiarrhythmic efficacy, the adverse reactions and the practicability of the respective agents. Any type of tachycardia, including premature atrial or ventricular contractions, may be regarded as indication for treatment. Treatment is not indicated only in those asymptomatic patients with rare and evanescent tachycardias and in those with less than 300 premature contractions per hour. Beta-adrenergic blockers are the drugs of choice for the persistent sinus tachycardia. Should the latter agents be contraindicated, propafenon, amiodarone or aprindine may be administered. Verapamil and/or digitalis are indicated only for suppression of paroxysmal sinus tachycardias. Atrial premature contractions are best managed with guinidine or disopyramid. An acute reduction of rapid ventricular rates associated with atrial tachycardias, atrial flutter or fibrillation can best be attained through the administration of verapamil prior to digitalis or beta-adrenergic blockers. Re-establishment of sinus rhythm and prophylactic suppression of the latter should be undertaken with quinidine or disopyramid in combination with digitalis and/or either a beta-adrenergic blocker or intravenously-administered verapamil. Verapamil is the drug of choice for initial management of AV-junctional tachycardia for which a combination with digitalis may be considered. An alternative combination is that of a beta-adrenergic blocker and digitalis. For the acute treatment of ventricular tachycardias, lidocain has proved most effective. Although ajmaline and/or propafenon may be given should no response be obtained, electrical cardioversion would be more appropriate. To prevent ventricular tachycardia or when treatment is indicated for ventricular premature beats, ajmaline, propafenon, quinidine, disopyramid or mexiletine, occasionally in combination with a beta-adrenergic blocker should be employed. Verapamil and/or ajmaline, are usually very effective for termination of reciprocal tachycardias. Ajmaline or propafenon in combination with a beta-adrenergic blocker is recommended for the prophylactic treatment of reciprocal tachycardia. In patients who additionally have bradycardia, prolonged QT-intervals or pre-excitation syndromes, the guidelines should be modified accordingly.

Anti-Arrhythmia Agents↗
PubMed1989

[Efficacy of propafenone in supraventricular arrhythmias].

We evaluated the results of intravenous administration of propafenone in 44 patients with rapid symptomatic supraventricular arrhythmia of less than 1 month duration. Mean age was 54 years and 22 were females. Propafenone, 2 mg/kg was given over 15 min and blood pressure and heart rate were monitored in the following hour. Sixteen out of 19 (84%) episodes of paroxysmal supraventricular tachycardia in 15 patients reverted to sinus rhythm at a mean interval of 11 min. None of 14 patients with atrial flutter reverted to sinus rhythm, but the ventricular rate decreased from 143 +/- 38 to 110 +/- 41 (p less than 0.02). The mechanism involved was slowing of the atrial cycle with associated increase A-V block in 7 patients. One patient experienced 1:1 conduction at a rate of 214 per min. Twenty seven % of 15 patients with atrial fibrillation reverted to sinus rhythm; ventricular rate decreased from 134 +/- 40 to 98 +/- 22 (p less than 0.05) in the remaining cases. There were no significant side effects of the drug and systolic blood pressure decreased from 109 +/- 27 to 99 +/- 30 beats per min (p less than 0.05) with no change in diastolic pressure.

Adult↗
PubMed2006

Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors.

OBJECTIVE: We hypothesized that histopathology predicts survival without cardiac transplantation in patients with biopsy-proven myocarditis. BACKGROUND: The role of endomyocardial biopsy in diagnosing myocarditis remains controversial. Histopathology has been integrated with clinical and hemodynamic features to predict prognosis. However, the influence of histopathology on survival > 5 years has not been explored. METHODS: We retrospectively identified 112 consecutive patients with histopathologic confirmation of myocarditis. We examined these patients' clinical presentation, hemodynamic assessment, hospital course, and treatment. We selected 14 variables that might influence survival without cardiac transplantation. RESULTS: A total of 62 (55%) of 112 patients had lymphocytic myocarditis; 88 (79%) and 63 (56%) were alive without cardiac transplantation at 1 and 5 years, respectively. Median follow-up was a mean 95.5 months and median 74.5 months. Among the 55 with complete data of the 14 candidate predictor variables, age, sex, and clinical presentation with congestive heart failure and ventricular (ventricular tachycardia or fibrillation) or atrial arrhythmias (atrial fibrillation or flutter) did not predict the study end point of death or need for transplantation. In univariate analysis, pulmonary capillary wedge pressure > or = 15 mm Hg significantly predicted the study end point. In multivariate analysis, pulmonary capillary wedge pressure > or = 15 mm Hg and histopathology of lymphocytic, granulomatous, or giant cell myocarditis each significantly predicted mortality or transplant (P = .047, P = .013, and P = .054, respectively) on cumulative survival without cardiac transplantation. CONCLUSIONS: Histopathology predicts long-term survival in patients with myocarditis. Clinical presentation, including presentation with congestive heart failure, ventricular tachycardia/ventricular fibrillation, or atrial fibrillation/atrial flutter, does not predict survival without transplantation. Endomyocardial biopsy can play a role in predicting transplant-free survival in patients with myocarditis.

Analysis of Variance↗
PubMed1997

Dofetilide: first of a new generation of class III agents.

Dofetilide (Pfizer, Sandwich, Kent, UK) is a novel, highly specific class III methanesulfonanilide anti-arrhythmic drug. At nanomolar concentrations this agent prolongs both the atrial and ventricular effective refractory periods and action potential duration. Dofetilide's mechanism of action relies on potent blockade of the rapidly activating, inwardly rectifying component of the delayed rectifier potassium current (Ikr), the main current responsible for cardiac repolarisation. Dofetilide does not appear to interact with other cardiac ionic channels, and this explains its minimal effects upon conduction velocity, myocardial contractility and systemic haemodynamics. Dofetilide's mechanism of action makes it suitable for the termination of supraventricular and ventricular tachyarrhythmias. Small scale clinical trials have provided encouraging results, with preliminary data confirming its efficacy in the termination of atrial fibrillation and atrial flutter, and in increasing the electrical threshold for inducible ventricular tachycardia/fibrillation. The results of large scale, randomised, placebo-controlled trials are awaited in order to establish dofetilide's role in clinical practice. Due to its very specific mode of action, dofetilide has very few systemic side-effects. Dofetilide represents a novel and promising new class III agent.

Journal Article↗
PubMed1979

Echocardiographic diagnosis of congenital left ventricular - right atrial communication.

2 patients, aged 8 mth and 48 yr, referred for a clinical diagnosis of ventricular septal defect, were studied by ultrasound. In both a fluttering and an anterior bowing of the systolic segment of the tricuspid valve was found, consistent with a left ventricular--right atrial communication. Diagnosis was confirmed by angiography and open-heart surgery, showing in 1 patient a supravalvular defect, and an infravalvular one in the other. The postoperative echocardiograms of the tricuspid valve were normal. Ultrasound appears to be a safe and simple method in detecting this rare cardiac abnormality.

Echocardiography↗
PubMed2001

Predictors of atrial flutter with 1:1 conduction in patients treated with class I antiarrhythmic drugs for atrial tachyarrhythmias.

OBJECTIVES: The purpose of the study was to look for the predictor factors of atrial proarrhythmic effects of class I antiarrhythmic drugs. BACKGROUND: Class I antiarrhythmic drugs may induce or exacerbate cardiac arrhythmias. The predictors of ventricular proarrhythmia are known. The predictors of atrial flutter with 1:1 conduction are unknown. METHODS: Clinical history, EGG, signal-averaged EGG (SAECG) and electrophysiologic study were analysed in 24 cases of 1:1 atrial flutter with class I AA drugs and in 100 control patients without history of 1:1 atrial flutter with class I AA drugs. RESULTS: The ages of patients varied from 46 to 78 years. Underlying heart disease was present in nine patients. The surface EGG revealed the presence of a short PR interval (PR<0.13 ms), visible in leads V5, V6 in eight (35%) patients with normal P wave duration; in other patients with prolonged P wave duration, PR seemed normaL On SAECG recording, there was a pseudofusion between P wave and QRS complex. The electrophysiologic study revealed some signs indicating a rapid AV nodal conduction (short AH interval or rate of 2nd degree AV block at atrial pacing >200 beats/mm) in 19 of the 23 studied patients. All patients, except one, had at least one sign indicating a rapid AV nodal conduction (short PR and/or P wave-QRS complex continuity on SAECG). In the control group, seven patients (7%) had a short PR interval (P<0.01) and 11 (11%) had a pseudofusion between P wave and QRS complex on SAECG (P<0.001). The P wave-QRS complex pseudofusion on SAECG had a sensitivity of 100% and a specificity of 89% for the prediction of an atrial proarrhythmic effect with class I antiarrhythmic drug. CONCLUSION: We recommend avoiding class I AA drugs in patients with a short PR interval on surface EGG and to record SAECG in those with apparently normal PR interval to detect a continuity between P wave and QRS complex, which could indicate a rapid AV nodal conduction, predisposing to 1:1 atrial flutter with the drug.

Adult↗
PubMed1989

The diagnostic sensitivity of electrophysiologic testing in patients with syncope caused by transient bradycardia.

Although electrophysiologic testing accurately delineates abnormalities in patients with fixed cardiac-conduction defects, its sensitivity in identifying transient rhythm disturbances is unknown. We prospectively studied 21 patients who had electrocardiographically documented intermittent atrioventricular block (n = 13) or sinus pauses (n = 8) causing syncope, but whose cardiac rhythm had reverted to normal by the time of referral. There were 14 men and 7 women, with a mean age (+/- SD) of 63 +/- 13 years. Fourteen patients had organic heart disease, and 8 were taking cardioactive medications. Electrophysiologic testing was performed before the implantation of a permanent pacemaker. Only three of the eight patients with documented sinus pauses had abnormalities during their tests that suggested the correct diagnosis (sensitivity, 37.5 percent), including a prolonged sinus-node recovery time in one and carotid-sinus hypersensitivity in two. Three of the eight patients had abnormalities detected that were unrelated to syncope, including atrial flutter, dual atrioventricular nodal pathways, and sustained monomorphic ventricular tachycardia. Of the 13 patients with documented atrioventricular block, only 2 had abnormalities suggesting the correct diagnosis (sensitivity, 15.4 percent). Additional observations unrelated to syncope among these 13 patients included abnormal sinus-node function, atrial flutter, and atrial fibrillation causing hypotension. These preliminary observations suggest that a negative electrophysiologic test in a patient with a normal cardiac rhythm who has experienced syncope does not exclude a transient bradyarrhythmia as a cause of the syncope. Furthermore, electrophysiologic testing may sometimes reveal unrelated rhythm disturbances that may mistakenly be designated as the cause of the syncope.

Aged↗
PubMed2000

[Initial experience with an implantable loop recorder in patients with unexplained syncope].

Patients with recurrent syncope undiagnosed after extensive noninvasive and invasive testing pose a diagnostic and therapeutic dilemma. Holter monitoring is non-diagnostic in 90% of cases. Recent developments in loop recorder technology permit longterm ECG monitoring in patients with recurrent unexplained syncope. The implantable loop recorder monitors a single lead electrogram continuously using 2 sensing electrodes on the device shell. The device was implanted in 20 patients (11 male, 9 female) with the history of recurrent syncope. During a mean follow-up of 12+/-6 months after device implantation, 11 patients (55%) experienced syncope (8 pts) or presyncope (3 pts). In the remaining 9 patients, no syncope occurred. In all 11 patients with syncope or presyncope during follow-up, loop recording definitively determined whether an arrhythmia was the cause of symptoms or not. Diagnosis included bradycardia in one patient, tachycardia in two patients, in one patient two rhythm disturbances were revealed: frequent ventricular premature beats with bigemini and atrial flutter. Two patients had a neurocardiogenic syncope. Syncope was nonarrhythmic in 5 patients. An implantable loop recorder is useful for establishing the diagnosis if symptoms are recurrent but too infrequent for conventional monitoring techniques.

Aged↗
PubMed1993

Effectiveness and costs of digoxin treatment for atrial fibrillation and flutter.

Clinical outcomes and costs associated with the use of digoxin in atrial fibrillation and flutter were evaluated in a prospective, observational study at 18 academic medical centers in the United States. Data were collected on 115 patients (aged > 18 years) with atrial fibrillation or flutter who were treated with digoxin for rapid ventricular rate (> or = 120 beats/min). The median time to ventricular rate control (i.e., resting ventricular rate < 100 beats/min, decrease in ventricular rate of > 20%, or sinus rhythm) was 11.6 hours from the first dose of digoxin for all evaluable patients (n = 105) and 9.5 hours for those only receiving digoxin (n = 64). Before ventricular rate control, the mean +/- SD dose of digoxin administered was 0.80 +/- 0.74 mg, and a mean of 1.4 +/- 1.8 serum digoxin concentrations were ordered per patient. Concomitant beta-blocker or calcium antagonist therapy was instituted in 47 patients (41%); in 19 of these, combination therapy was initiated within 2 hours. Adenosine was administered to 13 patients (11%). Patients spent a median of 4 days (range 1 to 25) in the hospital; 28% spent time in a coronary/intensive care unit and 79% in a telemetry bed. Loss of control (i.e., resting ventricular rate returned to > 120 beats/min) occurred at least once in 50% of patients and was associated with a longer hospital stay (p < 0.05). Based on 1991 data, the estimated mean hospital bed cost for patients with atrial fibrillation or flutter was $3,169 +/- $3,174.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1999

Usefulness of intravenous propofol anesthesia for radiofrequency catheter ablation in patients with tachyarrhythmias: infeasibility for pediatric patients with ectopic atrial tachycardia.

General anesthesia is sometimes required during radiofrequency catheter ablation (RFCA) of various tachyarrhythmias because of an anticipated prolonged procedure and the need to ensure stability during critical ablation. In this study, we examine the feasibility of using propofol anesthesia for RFCA procedure. There were 150 patients (78 male, 72 female; mean age 30 years, range 4-96 years) in the study. Electrophysiologic study was performed before and during propofol infusion in the initial 20 patients and was performed only during propofol infusion in the remaining 130 patients. In the initial 20 patients, propofol infusion increased the sinus rate and facilitated AV nodal conduction. The accessory pathway effective refractory period, as well as the sinus node recovery time, atrial effective refractory period, and ventricular effective refractory period were not significantly changed. There were 152 tachyarrhythmias in 150 patients (24 atrial flutter, 31 AV nodal reentrant tachycardia, 68 AV reciprocating tachycardia, 12 ventricular tachycardia, and 17 atrial tachycardia). Most (148/152) tachycardias remained inducible after anesthesia and RFCA was performed uneventfully. However, in four of the seven pediatric patients with ectopic atrial tachycardia, the tachycardia terminated after propofol infusion and could not be induced by isoproterenol infusion. Consequently, RFCA could not be performed. Intravenous propofol anesthesia is feasible during RFCA for most tachyarrhythmias except for ectopic atrial tachycardia in children.

Adolescent↗
PubMed1989

Hyperthyroid-induced atrial flutter-fibrillation with profound sinoatrial nodal pauses due to small doses of digoxin, verapamil, and propranolol.

Atrial fibrillation due to hyperthyroidism is characterized by a rapid ventricular response which is typically resistant to digoxin therapy. We report a patient with atrial flutter-fibrillation who developed cyclic sinus node dysfunction with profound ventricular pauses in response to small doses of digoxin, verapamil, and propranolol, which resolved with discontinuation of the medications. Caution is necessary to avoid paradoxical ventricular slowing when treating hyperthyroid-induced atrial fibrillation.

Arrhythmias, Cardiac↗
PubMed1982

Subcostal M-mode echocardiography of the right atrial wall in the diagnosis of cardiac arrhythmias.

The M-mode echocardiogram of the right atrial (RA) wall can be easily recorded in each person from the subcostal location. In a normal RA wall motion pattern, atrial contraction is represented by a markedly prominent posterior motion. The presence or absence of atrial contractions in the subcostal RA wall echocardiogram, their amplitude, and their timing may help in the diagnosis of cardiac arrhythmias with the simultaneously recorded non-diagnostic electrocardiogram. Flat and hidden P waves can be accurately identified throughout the cardiac cycle. It is possible to distinguish between atrial, ventricular, and nodal premature beats and to recognize atrial fibrillation, atrial flutter, paroxysmal atrial tachycardia, paroxysmal atrial tachycardia with block, atrioventricular (AV) nodal tachycardia, and supraventricular tachycardias with aberrant ventricular conduction. The diagnosis of wandering pacemaker, AV dissociation, sinoatrial block, and AV block is facilitated. On the basis of study of 60 patients with various rhythm disturbances, it was concluded that analysis of the subcostal RA wall echocardiogram is a new, helpful noninvasive approach in the diagnosis of cardiac arrhythmias.

Arrhythmias, Cardiac↗
PubMed2001

Radiofrequency ablation in pediatric and adult patients: comparative results.

BACKGROUND: Radiofrequency (RF) catheter ablation has been widely and successfully employed to cure adult and pediatric patients of a variety of arrhythmias. Only limited data exist which compare the results in these two groups. The aim of this study was to compare the efficacy and safety of RF catheter ablation in pediatric versus adult patients performed by an adult electrophysiology (EP) team. METHODS: The study group included 327 consecutive pediatric (n=47) and adult (n=280) patients, aged 7-82 years (mean 40+/-19), with symptomatic tachyarrhythmias, who underwent RF ablation during the last 6 years. All but ten patients underwent a full EP study during the same session. Procedures were performed in all but five patients with use of local anesthesia and deep or light sedation. The left heart was approached with use of transaortic (n=36) or transseptal (n=55) or both (n=6) techniques. RF ablation was performed for manifest or concealed accessory pathways in 132 patients, AV nodal slow pathway in 119, atrial tachycardia in 24, atrial flutter in 15, atrial fibrillation in one, ventricular tachycardia in 29, and AV node/His bundle in 7 patients. RESULTS: RF ablation was successful in 271 (96.8%) patients in the adult group and in all patients (100%) in the pediatric group, with a mean of 15+/-18 (median: 8) vs 12+/-10 (median: 8) RF applications respectively (P=NS). Complications occurred in four patients (1.4%) in the adult group and in one patient (2.1%) in the pediatric group (P=NS). Fluoroscopy time averaged 43+/-40 min vs 39+/-27 min and procedures lasted for 3.0+/-1.9 hours vs 2.8+/-1.4 hours respectively (P=NS). During long-term follow-up of 25+/-19 months, there were 12 (4.4%) recurrences among the adult patients, and three (6.4%) recurrences in children, with nine of them successfully treated with repeat RF ablation. Procedural variables were dependent on the type of arrhythmia ablated, rather than on patient's age. Patients with multiple accessory pathways or atrial flutter required the greatest number of RF applications and the longest fluoroscopy exposure and duration of the procedure; the lowest values of these variables concerned ablation of the slow AV nodal pathway or the AV node/His bundle. CONCLUSION: RF ablation in adult and pediatric patients performed by an adult EP team is equally efficacious and safe offering cure of symptomatic cardiac tachyarrhythmias in both patient populations.

Adolescent↗
PubMed1993

Automated interpretation of cardiac arrhythmias. Design and evaluation of a computerized model.

Historically, the development of computerized models that utilize the deductive methods used by clinicians for the interpretation of cardiac arrhythmias have been limited by the absence of a consistently reliable means of detecting atrial activation. In this study, a theoretical model was developed with a hierarchical organization of problem-solving strategies utilizing automated analysis of atrial activation from a commercially available esophageal pill electrode and ventricular activation from a simultaneously recorded surface electrocardiographic lead. The theoretical model was then tested in 21 patients with 1 or more of 28 distinct supraventricular and ventricular arrhythmias. Of the 641 individual cardiac cycles analyzed, 636 (99.2%) were correctly identified. The accuracy of a contextual, that is, more comprehensive, interpretation of consecutive cardiac cycles was 638/641 (99.5%). The following cardiac arrhythmias were identified: sinus rhythm, sinus bradycardia, atrial premature depolarizations, atrial flutter, and supraventricular tachycardias with normal and aberrant ventricular conduction, first-degree and second-degree heart block; junctional escape, junctional rhythm, idioventricular rhythm, ventricular premature depolarization, and ventricular tachycardia with and without retrograde activation; atrial bigeminy, atrial trigeminy, atrial couplets, ventricular bigeminy, ventricular trigeminy, and ventricular couplets. This study represents the first computerized model ever developed to incorporate the morphology and timing of atrial activation with the morphology and timing of ventricular activation for arrhythmia diagnosis. Such modeling appears to be capable of achieving accurate interpretation of spontaneous, complex clinical cardiac arrhythmias and atrioventricular relationships.

Arrhythmias, Cardiac↗