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PubMed1993

The use of propafenone in the treatment of tachyarrhythmias in children.

Propafenone was given to 60 children (mean age 4.5 years) with paroxysmal re-entrant supraventricular tachycardia (rSVT: 41 cases), postoperative automatic junctional tachycardia (JET: eight cases), automatic atrial tachycardia (AT:four cases), ventricular tachycardia (VT:four cases) and atrial flutter (AF: three cases). In acute cases (29) propafenone was administered intravenously (mean dose 1.3 +/- 0.5 mg.kg-1) chronic oral treatment (mean dose of either 11 +/- 3.3 mg.kg.day-1 or 265 +/- 78 mg.m-2 x day-1) was given to 48 children, in 2-3 divided doses. Overall efficacy was 76% for acute and 69% for chronic treatment, with best results in paroxysmal rSVT. It was effective in 89% acutely of those treated acutely and in 69% of those administered chronically. The efficacy of propafenone in the prevention of rSVT was strictly related to the incidence of attacks before treatment:propafenone was indeed inefficacious in 6/11, 6/14 and 0/12 of patients with daily, weekly and monthly attacks respectively. Side effects were observed in 25% of patients: 6% required suspension of therapy due to pro-arrhythmic effects in one patient on intravenous administration, peripheral neuropathy in one case and hypotension in two postoperative JET patients. In conclusion, its efficacy and limited side effects make propafenone a relatively safe and very useful drug in the treatment of various tachyarrhythmias. However, risk of unpredictable toxic levels requires careful use of the drug especially in the first days of treatment, when a daily monitoring of ECG is strongly recommended.

Administration, Oral↗
PubMed1987

Cardiac dysrhythmia following pneumonectomy. Clinical correlates and prognostic significance.

Cardiac tachydysrhythmias occurred in 53 (22 percent) of 236 consecutive patients undergoing pneumonectomy. All patients had preoperative electrocardiograms which showed normal sinus rhythm. Patients did not receive digitalis before surgery. Atrial fibrillation was the most common dysrhythmia (64 percent; 34/53), followed by supraventricular tachycardia (23 percent; 12/53) and atrial flutter (13 percent; 7/53). No episodes of ventricular tachycardia were documented. Elevated concentrations of cardiac enzymes were associated with 12 (28 percent) of 43 tachydysrhythmias. Recurrent or persistent dysrhythmias were documented in 29 (55 percent) of 53 patients despite medical management or electrocardioversion (or both). Thirty-one percent (9/29) of these patients subsequently died during their hospitalization. There was no correlation between standard preoperative pulmonary function tests and the incidence of postoperative dysrhythmia. In addition, there was no correlation of dysrhythmia with postoperative diagnoses, surgical staging for lung cancer, postoperative arterial blood gas levels, or the fact that a completion pneumonectomy or chest wall resection was undertaken. An increased incidence of tachydysrhythmia was noted in patients undergoing intrapericardial dissections and those who developed postoperative interstitial or perihilar pulmonary edema. Twenty-five percent (13) of the patients experiencing tachydysrhythmias died within 30 days following their pneumonectomy. We conclude that tachydysrhythmias after pneumonectomy are associated with significant mortality, have poor correlation to preoperative pulmonary function, and occur more frequently following intrapericardial dissection and in patients who develop postoperative interstitial pulmonary edema or perihilar pulmonary edema.

Arrhythmias, Cardiac↗
PubMedDate not supplied

Tachyarrhythmia therapy utilizing electrical stimulation: a review.

The review is structured in such a way as to fall naturally into four main sections. These are as follows: clinical overview of the common mechanisms leading to the generation of tachyarrhythmias; commonly used sensing techniques and algorithms for the detection of tachyarrhythmias; electrical stimulation algorithms used to terminate many of the rhythms; existing implantable devices and a brief look at the future. The clinical overview introduces the reader unfamiliar with tachyarrhythmias to such mechanisms as sinus tachycardia, supraventricular tachycardias (SVTs), ventricular tachycardia, 'torsade de pointes', and ventricular fibrillation. SVT includes paroxysmal SVT, atrial flutter, atrial tachycardia and junctional tachycardia (enhanced automaticity). Also there is a brief introduction to alternative therapies (drugs, surgery etc.) The sensing techniques section covers input signal processing to enable the R wave to be adequately detected; while the tachycardia detection algorithms section discusses such areas as simple rate detect, rate of change of rate detect, stability of rate, the so-called probability density function technique and some other more complex detection algorithms. The section on electrical stimulation algorithms used for tachycardia therapy discusses burst pacing techniques, special cases such as automatically decrementing bursts and automatically incrementing bursts, defibrillation shock therapy (since fibrillation is a form of tachyarrhythmia) and several other more complex algorithms. The review finishes up with a discussion of current implantable antitachy pacemakers and defibrillators. There is also a speculative look at the future to enable the reader to obtain a full picture.

Algorithms↗
PubMed1975

Massive digoxin intoxication. Report of a case with serum digoxin level correlation.

The clinical course is described of a patient who took an overdose of 15 mg of digoxin in a suicidal attempt. He developed several cardiac arrhythmias like atrial fibrillation, atrial flutter, sino-atrial block. atrio-ventricular block 3 degree and ventricular extrasystoles. His plasma digoxin level rose to 38.7 ng/ml as determined by radioimmunoassay. He was treated with Aprindine and recovered without sequelae. A survey of the complications of acute massive digoxin intoxication is offered as well as a summary of treatment.

Arrhythmias, Cardiac↗
PubMed2002

[Endocavitary ablation for arrhythmias. New modalities of radiofrequency applications. New energy types].

Radiofrequency remains the reference energy type for catheter ablation of rhythm disorders. In the classic indications, which are atrial flutter or tachycardia, nodal re-entry and Wolff-Parkinson-White syndrome, this energy source has the best cost-efficiency-safety ratio, subject to strict conditions of use. Some new modalities of application have further improved performance, especially active irrigation of the electrode which allows induction of deeper lesions which is very useful for the ablation of difficult atrial flutters, epicardial fascicles of Kent and ischaemic ventricular tachycardias. The only emerging alternative energy type, in the framework of classical ablation, is cold, for which the principal advantages are the homogenous and slightly thrombogenic character for the lesion involved, and the possibility of reversible applications tests which are especially useful in the ablation of structures at risk. The situation is more open-ended concerning research on ablation for atrial fibrillation or the so-called new energy types, such as ultrasound and laser, whilst recognising a renewal in interest, especially for circumferential ablation of the pulmonary veins to isolate the ectopic venous foci. Mechanical energy such as luminous energy is emitted across a catheter balloon deployed at the orifice of the vein, perpendicular to its axis, aiming to reach a continuous circumferential lesion with a minimum of applications. Equally radiofrequency has been undergoing significant evolution for this application, such as by the development of porous catheter balloons with a liquid electrode, as well as by the development of deployable circumferential catheters. Ablation is use for atrial fibrillation, by endocavity atrial segmentation remains a field of research in which radiofrequency retains an important place. It is delivered via multi-electrode catheters according to the new application modalities, either pulsed or by phase interval, which secure better efficacy by better continuity of the line of block. Research is equally underway on the use of microwaves and cold in this application.

Atrial Fibrillation↗
PubMed1992

Clinical use of digitalis.

Digitalis should be used for slowing a rapid ventricular rate in atrial fibrillation or atrial flutter unassociated with the preexcitation syndrome. Digitalis may be used to convert paroxysmal supraventricular tachycardia to sinus rhythm. Patients with the tachycardia-bradycardia syndrome should receive maintenance doses of digitalis after pacemaker implantation. Digitalis should not be used for treating CHF with normal LV systolic function unless a supraventricular tachyarrhythmia is present. Conflicting studies have been reported as to the efficacy of digoxin in the treatment of patients with CHF in sinus rhythm. Digoxin may be used for treating CHF with abnormal LV systolic function which does not respond to diuretics and ACE inhibitors or in patients unable to tolerate ACE inhibitor or other vasodilator therapy. Digitalis has a low toxic-therapeutic ratio, especially in elderly persons. Digoxin-specific Fab antibody fragments may be used for treating digitalis toxicity refractory to conventional measures with a treatment response in at least 90% of patients with advanced and potentially life-threatening digitalis toxicity.

Clinical Trials as Topic↗
PubMed1997

Caffeine and cardiac arrhythmias. An experimental study in dogs with review of literature.

In spite of widespread belief among clinicians that caffeinated drinks are linked with palpitations, tachycardia and dysrhythmia there is paucity of documentary evidence. We investigated the arrhythmogenic activity of caffeine in canine model. The alkaloid was given i.v. to perform 51 experiments in 13 anesthetized dogs in three different doses. The Low dose generated significant Sinus (S) bradycardia (70%; p < 0.006, S. arrhythmia (70%; p < 0.02), S. arrest (50%; p < 0.04), Atrial (A) ectopics (40%; p < 0.016), Wandering of pacemaker (WPM) (50%; p < 0.04), and Ventricular premature contractions (VPC--unifocal 40%; p < 0.05) as compared with control ECGs. Medium dose induced significant S. arrhythmia (62%; p < 0.001), A. ectopics (25%; p < 0.01), A. tachycardia (25%; p < 0.01), WPM (25%; p < 0.01), VPCs--unifocal (50%; p < 0.002), multifocal (25%; p < 0.01), couplets (25%; p < 0.01) and interpolated (25%; p < 0.01). High dose of caffeine revealed significant S. arrhythmia (56%; p < 0.002), A. ectopics (44%; p < 0.005), A. tachycardia (32%; p < 0.01), WPM (32%; p < 0.01) and VPCs--unifocal (64%; p < 0.001), multifocal (32%, p < 0.01), couplets (32%, p < 0.01), interpolated (32%; p < 0.01) and Ventricular tachycardia (VT) (20%; p < 0.01). A. flutter and fibrillation each were observed in two experiments only. In conclusion, these data indicate a dose dependent arrhythmogenecity of caffeine. Small dose, mostly, generated, benign arrhythmias due to vagal stimulation. More severe arrhythmias like VT, multifocal VPC. A. flutter and A. fibrillation were generated with higher dose of caffeine. Mechanism remains uncertain as caffeine has multiple actions. Further studies in human beings with normal and compromised myocardium may elucidate arrhythmogenic effects of caffeine.

Animals↗
PubMed1998

[Time of occurrence of paroxysmal atrial fibrillation in Holter monitoring in patients with coronary heart disease and in patients with hypertension].

Paroxysmal atrial fibrillation (PAF) often accompany coronary heart disease (CHD), and primary hypertension (PH). The aim of the study was to evaluate the time of occurrence and duration of paroxysmal atrial fibrillation (PAF) identified from Holter recordings in 63 patients (27 women and 36 men) with CHD (n = 45) and PH (n = 18). No pharmacological treatment was applied before and during the examination. All patients were in sinus rhythm at the start and the end of the recording which lasted for 24 hours. PAF were defined as the occurrence of at least four beats of supraventricular origin, with no visible P or flutter waves. The time of onset, duration, ventricular rate and symptoms of each PAF were noted. There were 219 paroxysms recorded in 63 patients which occurred more often by day than by night, the time of duration was 0.9-240 s. Of the total, 16.3% of episodes with CHD and 9.5% episodes in patients with PH occurred between the hours 8:00-10:00 and between 16:00 and 18:00; 9.1% and 21% respectively. We concluded that in patients with CHD and with H most of the episodes (95%) are silent, they occurred more often during the day activity (particularly between the hours of 8:00 and 10:00 and 16:00-18:00 in both groups). In patients with CHD we observed the third peak of occurrence of PAF between the hours 22:00-0:00.

Adult↗
PubMed1997

[Echocardiographic factors predicting the maintenance of sinus rhythm one year after cardioversion for non-valvular atrial arrhythmias].

Echocardiographic factors predictive of the maintenance of sinus rhythm after successful cardioversion were investigated in 94 patients with non-valvular atrial arrhythmias of recent onset. Seventy-five patients with atrial fibrillation and 19 with atrial flutter admitted for reduction of their arrhythmias underwent transthoracic and transoesophageal echocardiography. After excluding a thrombus in the left atrial appendage or checking that it had disappeared (5 patients), and electrical (n = 74) or pharmacological (n = 20) cardioversion was successfully performed. The maintenance of sinus rhythm (n = 44) or recurrence of arrhythmia (n = 50) were controlled every 3 months for one year. The mean value of the peak positive blood flow in the left atrial appendage was 38 +/- 20 cm/s for the whole group. It was not possible to identify an echocardiographic parameter predictive of maintenance of sinus rhythm at one year either in the whole group or in the subgroups with atrial flutter or atrial fibrillation. In the group in atrial flutter, the mean value of the peak positive blood flow in the left atrial appendage was significantly greater than in the group with atrial fibrillation: 49 +/- 22 cm/s vs 35 +/- 18 cm/s, respectively; p < 0.05. The peak of positive flow in the left atrial appendage was statistically related to indirect parameters of left atrial function and of left ventricular function in the group with atrial fibrillation but only with parameters of left ventricular function in the smaller group with atrial flutter.

Aged↗
PubMed2001

Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot.

BACKGROUND: Chronic pulmonary regurgitation after repair of tetralogy of Fallot (TOF) may lead to right ventricular dilatation, which may be accompanied by ventricular tachycardia and sudden death. We aimed to examine the effects of pulmonary valve replacement (PVR) on (1) certain electrocardiographic markers predictive of monomorphic ventricular arrhythmia and sudden death and (2) sustained atrial flutter/fibrillation and monomorphic ventricular tachycardia. METHODS AND RESULTS: We studied 70 patients who underwent PVR for pulmonary regurgitation and/or right ventricular outflow tract obstruction late after repair of TOF. Maximum QRS duration and QT dispersion were measured from standard ECGs before PVR and at the latest follow-up. Arrhythmia was defined as sustained atrial flutter/fibrillation or sustained monomorphic ventricular tachycardia. Concomitant intraoperative electrophysiological mapping and/or cryoablation were performed in 9 patients (60%) with preexisting ventricular tachycardia and 6 patients (50%) with preexisting atrial flutter. QRS duration remained unchanged in the study group (P=0.46), but it was significantly prolonged (P<0.001) in a comparable group of patients with repaired TOF who did not undergo PVR. At a mean follow-up of 4.7 years, the incidence of ventricular tachycardia diminished from 22% to 9% (P<0.001), and atrial flutter/fibrillation decreased from 17% to 12% (P=0.32). Intraoperative ablation prevented recurrence of preexisting tachyarrhythmia (0 of 15 patients). CONCLUSIONS: PVR in patients with previous TOF repair and chronic pulmonary regurgitation leads to stabilization of QRS duration and, in conjunction with intraoperative cryoablation, to a decrease in the incidence of preexisting atrial and ventricular tachyarrhythmia. When applicable, this combined approach should be used in patients late after repair of TOF.

Adolescent↗
PubMed1998

Atrial fibrillation after radiofrequency ablation of type I atrial flutter: time to onset, determinants, and clinical course.

BACKGROUND: The occurrence of atrial fibrillation after ablation of type I atrial flutter remains an important clinical problem. To gain further insight into the pathogenesis and significance of postablation atrial fibrillation, we examined the time to onset, determinants, and clinical course of atrial fibrillation after ablation of type I flutter in a large patient cohort. METHODS AND RESULTS: Of 110 consecutive patients with ablation of type I atrial flutter, atrial fibrillation was documented in 28 (25%) during a mean follow-up of 20.1+/-9.2 months (cumulative probability of 12% at 1 month, 23% at 1 year, and 30% at 2 years). Among 17 clinical and procedural variables, only a history of spontaneous atrial fibrillation (relative risk 3.9, 95% confidence intervals 1.8 to 8.8, P=0.001) and left ventricular ejection fraction <50% (relative risk 3.8, 95% confidence intervals 1.7 to 8.5, P=0.001) were significant and independent predictors of subsequent atrial fibrillation. The presence of both these characteristics identified a high-risk group with a 74% occurrence of atrial fibrillation. Patients with only 1 of these characteristics were at intermediate risk (20%), and those with neither characteristic were at lowest risk (10%). The determinants and clinical course of atrial fibrillation did not differ between an early (< or = 1 month) compared with a later onset. Atrial fibrillation was persistent and recurrent, requiring long-term therapy in 18 patients, including 12 of 19 (63%) with prior atrial fibrillation and left ventricular dysfunction. CONCLUSIONS: Atrial fibrillation after type I flutter ablation is primarily determined by the presence of a preexisting structural and electrophysiological substrate. These data should be considered in planning postablation management. The persistent risk of atrial fibrillation in this population also suggests a potentially important role for atrial fibrillation as a trigger rather than a consequence of type I atrial flutter.

Aged↗
PubMedDate not supplied

Atrial flutter.

Atrial flutter is a supraventricular tachydysrhythmia believed to arise from electrophysiologic disturbances in the atria. It tends to be an unstable rhythm and is usually associated with intrinsic cardiac or pulmonary disease or adverse extrinsic influences on the heart. It is due to either a reentry mechanism or an increased atrial automaticity. Atrial depolarization is regular at a rate of 260 to 340 beats per minute. With a normal atrioventricular (AV) node there is usually a physiologic second-degree block with resultant 2:1 conduction. Higher degrees of AV block can occur in patients with AV nodal disease, increased vagal tone, or when certain drugs are in use. One-to-one conduction may occur in patients with accessory AV nodal pathways. In this situation, serious adverse effects are often seen, including palpitations, dizziness, syncope, angina, and dyspnea. Electrical cardioversion is the safest and most reliable way of terminating atrial flutter and its use should not be delayed in an unstable patient. In the nonemergent situation a variety of medications alone or in combination can be used to convert the rhythm or slow ventricular response.

Atrial Flutter↗
PubMed1979

Metoprolol in the treatment of supraventricular tachyarrhythmias.

Twenty one patients with either paroxysmal supraventricular tachycardia (group A), atrial flutter (group B), or atrial fibrillation (group C) were treated with intravenous metoprolol in the dose range 2--20 mg. Sinus rhythm was restored in 3 out of 6 patients in group A, 3 out of 7 patients in group B and one out of 8 patients in group C. In patients who did not convert to sinus rhythm a remarkable decrease in ventricular rate occurred in 3 patients with atrial flutter and 4 patients with atrial fibrillation. In patients with systolic blood pressure greater than 100 mm Hg but without an acute myocardial infarction the risk of hypotension necessitating treatment was small. Metoprolol appears to be an effective and safe drug in the treatment of supraventricular tachycardia.

Adult↗
PubMed1982

Coronary artery to left ventricle fistulas: echocardiographic features.

The echocardiographic features of a coronary artery fistula that drains into the left ventricle were described in two patients. The clinical picture mimicked moderate to severe aortic insufficiency; however, M-mode echocardiogram revealed unusual features. Diastolic fluttering of the anterior mitral leaflet and the septum was absent in the first patient, while the second patient had marked diastolic fluttering of the posterior mitral leaflet and the left ventricular wall at the atrioventricular junction. In both, the coronary artery fistula could be visualized by cross-sectional echocardiography. Contrast echocardiography performed during cardiac catheterization in the second patient demonstrated that the diastolic fluttering of the posterior mitral leaflet was related to the jetting of blood from the coronary artery fistula.

Adult↗
PubMed1988

Use of Holter functions of the implantable pacemaker to control antiarrhythmic therapy of supraventricular and ventricular recurrent tachycardias.

Holter functions of pacemakers were studied in a total of nine patients with paroxysmal atrial flutter (Group I--a Quintech DD 931 pacemaker, manufactured by Vitatron Medical, The Netherlands), and in 11 patients with recurrent postinfarction ventricular tachycardia (Group II--a DPG P 21 diagnostic pulse generator, Vitatron Medical. Seven patients (35%) were excluded from the study for myopotential interference. Group I patients were given six antiarrhythmic drugs for eight weeks each, with only prajmalin and amiodarone significantly shortening flutter duration. Group II patients were administered, according to the results of programmed extrastimulation, amiodarone alone or in combination with Class I antiarrhythmic drugs for a long period of time. While no recurrent tachycardias or sudden death were noted during treatment, pacemaker detected non-lethal ventricular tachycardia occurred in two, and sudden death without confirmed arrhythmia in one patient once the treatment had been discontinued for serious side effects (p less than 0.05). Diagnostic stimulation using bipelar sensing to eliminate myopotential interference might become a major method for long-term monitoring.

Anti-Arrhythmia Agents↗
PubMed1999

The occurrence and prognostic significance of atrial fibrillation/-flutter following acute myocardial infarction. TRACE Study group. TRAndolapril Cardiac Evalution.

AIMS: To investigate the occurrence and prognostic significance of atrial fibrillation/-flutter following acute myocardial infarction. METHODS AND RESULTS: The occurrence and prognostic significance of atrial fibrillation/-flutter were studied in 6676 consecutive patients with acute myocardial infarction screened in 27 centres in Denmark for inclusion into the TRAndolapril Cardiac Evaluation (TRACE) study. Information about occurrence of atrial fibrillation/-flutter during hospitalization was prospectively collected for the following three periods: day 1-2, day 3-4 and from day 5 until discharge. A total of 1395 patients (21%) suffered from atrial fibrillation/-flutter in one or more of the specified periods during hospitalization. Patients with atrial fibrillation/-flutter were significantly older, a significantly greater proportion were women, left ventricular systolic dysfunction was more extensive, thrombolytic therapy was received less frequently, and anterior Q wave myocardial infarction was experienced more frequently than patients without atrial fibrillation/-flutter. History of acute myocardial infarction and/or angina pectoris was similar in patients with and without atrial fibrillation/-flutter, whereas significantly more patients with atrial fibrillation/-flutter had a history of hypertension, congestive heart failure, diabetes mellitus, pulmonary disease and stroke. The unadjusted in-hospital mortality rate was significantly higher in patients with atrial fibrillation/-flutter in one or more of the specified periods during hospitalization (18%) than in patients without atrial fibrillation/-flutter (9%), P<0.001. After adjustment for baseline characteristics, the presence of atrial fibrillation/-flutter was still associated with increased in-hospital mortality; odds ratio=1.5 (95% Cl: 1.2-1.8), P<0.001. In patients surviving hospitalization, the unadjusted 5-year mortality rate was also significantly higher in patients suffering from atrial fibrillation/-flutter (56%) than in patients without atrial fibrillation/-flutter (34%), P<0.001. After adjustment for important prognostic baseline characteristics, the presence of atrial fibrillation/-flutter was still associated with an increased mortality, relative risk=1.3 (95% Cl: 1.2-1.4). Subgroup analysis revealed that sustained atrial fibrillation/-flutter during hospitalization was associated with the highest risk of dying, relative risk=1.4 (95% Cl: 1.2-1.7). CONCLUSION: Atrial fibrillation/-flutter often occurs after acute myocardial infarction and our analysis demonstrated that it was an independent predictor of an increased short and long-term mortality.

Aged↗
PubMed1981

[Limits of quantitative evaluation methods].

Technical considerations limit the arrhythmias quantifiable by Holter monitoring to atrial and ventricular extrasystoles. However, benign atrial extrasystoles are often neglected and are not considered a target of importance for the study of antiarrhythmic drugs. As regards quantification of ventricular extrasystoles, possible causes of bias should be recognised: the exclusion of patients with dominant irregular and/or wide QRS rhythms, the failure to take global heart rate into account, the qualitative approach to assessment of important parameters such as QRS morphology, coupling interval, grouping which are only considered statistically in terms of prevalence. As a result of these limitations major arrhythmias both at atrial level (salvos of extrasystoles, atrial tachycardia, flutter, fibrillation) and junctional (paroxysmal reciprocating tachycardia) and ventricular levels (ventricular tachycardias of differing origins and types) are systematically disregarded by quantitative standardised protocols, although modern antiarrhythmic agents have been introduced precisely for their treatment. To consider minor arrhythmias more reliable models for study than serious ones because they are easier to quantity, is an error which has been well demonstrated, as in many respects we still do not know how to quantify relatively important parameters. A good example of this situation is the confusion and contradictions in the literature about the long-term prognosis of myocardial infarction evaluated by methods of counting ventricular extrasystoles: the most formal conclusions are drawn from reports containing the least and most qualitative data and which include bias unrelated to the techniques, chosen consciously or not by the authors.

Anti-Arrhythmia Agents↗