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PubMed2001

Current management of symptomatic atrial fibrillation.

Atrial fibrillation (AF) is the most commonly encountered sustained arrhythmia. Heart rate control, reduction of symptoms, and prevention of embolism are major goals of treatment. Whether the strategy of cardioversion with subsequent maintenance of sinus rhythm has an advantage over heart rate control is under active investigation. Digoxin, non-dihydropyridine calcium channel antagonists, beta-adrenoceptor antagonists (beta-blockers), and amiodarone are the pharmacologic agents most commonly used to achieve rate control. In patients with drug-resistant AF, atrioventricular nodal ablation (or modification) with implantation of a permanent pacemaker is an alternative therapy. Conversion to sinus rhythm can best be achieved by electrical cardioversion. In selected patients, pharmacologic cardioversion can also be attempted. The use of antiarrhythmic drugs for the maintenance of sinus rhythm depends on several factors: (i) the nature of the arrhythmia (first attack, paroxysmal AF with frequent attacks, paroxysmal AF with infrequent attacks, or persistent AF); (ii) the associated symptoms; (iii) and the risk of severe adverse effects associated with the chosen drug. If the administration of an antiarrhythmic drug is appropriate, the choice of the drug must be tailored to the specific characteristics of the given patient. In lone AF, class Ic antiarrhythmic drugs are the best tolerated. These agents should be combined with a calcium channel antagonist or a beta-blocker to prevent rapid ventricular response in the case of conversion of AF to atrial flutter. In this situation, catheter ablation of atrial flutter at the isthmus (hybrid therapy) should be performed. All class I antiarrhythmic agents should be avoided in patients with structural heart disease. Alternative approaches that may be used if sinus rhythm cannot be maintained with drug therapy include: (i) the ablation of arrhythmogenic pulmonary veins; (ii) the implantation of an atrial defibrillator; (iii) the use of specific pacing sites; (iv) or pacing modes. Whether these approaches will reach clinical relevance merits further investigation. Intraoperative catheter ablation or surgical ablation (maze procedure) seems a promising approach for curing AF in patients undergoing cardiac surgery. Among all of the available treatment options, the most consistent proof of efficacy in reducing mortality and morbidity from AF exists for antithrombotic treatment.

Adrenergic beta-Antagonists↗
PubMed1981

[Digitalization of the arrhythmic heart patient].

Digitalis combines a longstanding tradition with constant up-to-dateness. Kinetic maintenance therapy is very often required for heart patients with arrhythmia as one of their most striking clinical manifestations. The well-known questions of paroxystic tachycardia, flutter and atrial fibrillation are examined, and attention is concentrated on ventricular extrasystole, sinoatrial node disease, and Wolff-Parkinson-White syndrome. It is clear that combinations with recently introduced antiarrhythmic drugs, and administration of diuretics and electrolytes, and the employment of electrical stimulation have facilitated the long-term treatment of the chronic arrhythmic heart patient and brought about the better utilisation of digitalic substances. Their arrhythmogenic potential, however, cannot be overlooked.

Arrhythmias, Cardiac↗
PubMed2006

Multiple premature beats triggered ventricular arrhythmias during pilsicainide infusion in a patient with inferior ST-segment elevation.

A 17-year-old man was referred to our hospital for treatment of common paroxysmal atrial flutter. His electrocardiogram at rest showed subtle ST-segment elevation in leads II, III, and aV(F). Intravenous pilsicainide caused further ST-segment elevation in the inferior leads, new ST-segment depression in leads V2-V6, two distinct forms of premature ventricular complexes (PVCs) triggering short runs of polymorphic ventricular tachycardia (VT). An infusion of isoproterenol suppressed these arrhythmias and normalized the ST-segment. Pilsicainide may induce PVCs and polymorphic VT in atypical Brugada syndrome.

Adolescent↗
PubMed1996

Elucidating the mechanisms of atrial flutter cycle length variability using power spectral analysis techniques.

BACKGROUND: The mechanism of the small beat-to-beat variations in cycle length of atrial flutter in humans has not been fully explained. We investigated the beat-to-beat control of atrial flutter cycle length using time and frequency analysis techniques. METHODS AND RESULTS: Mean, SD, and power spectra of atrial cycle lengths were calculated from atrial recordings in 28 patients with type I atrial flutter. In control patients, mean and SD values of atrial cycle length were 265 +/- 37 and 4.9 +/- 1.7 ms. Power spectra contained two or three major peaks with 10.6 +/- 9.2% in band 1 (0.0 to 0.18 Hz), 26.7 +/- 15.9% in band 2 (0.18 to 0.6 Hz), and 63.1 +/- 17.7% in band 3 (0.6 to 2.2 Hz). Isoproterenol infusion (n = 8) increased percentage of total power in band 1 (7.1 +/- 5.6% to 25.7 +/- 18.9%, P < .001). Percentage of total power in band 1 was less in patients receiving (n = 5) versus not receiving (n = 18) oral beta-blockers (2.2 +/- 1.9% versus 10.6 +/- 9.2%, P = .003). Standard deviation (2.5 +/- 1.3 versus 4.9 +/- 1.7 ms, P = .009) and total power (2025 +/- 1350 versus 9768 +/- 8874 ms2, P = .005) were less in heart transplant recipients (n = 5) than control patients. Increases in respiratory rate (n = 6) shifted band 2 frequency peak to higher frequencies (0.26 +/- 0.13 to 0.38 +/- 0.18 Hz, P < .05). Atrial cycle length was longer and monophasic action potential duration was shorter during inspiration than during expiration. Band 3 frequency peak was correlated with heart rate (r = .797, P < .0001). CONCLUSIONS: Atrial flutter cycle length variability has an underlying periodic pattern that is detected by spectral analysis. Atrial flutter is modulated on a beat-to-beat basis by an interplay between the autonomic nervous and respiratory systems and the ventricular rate.

Adrenergic beta-Antagonists↗
PubMed1996

Radiofrequency ablation of atrial flutter and atrial tachycardias in patients with permanent indwelling catheters.

UNLABELLED: The presence of chronic indwelling leads in the area targeted for RF ablation may pose a technical challenge and reduce the chance of success of the ablation. In addition, application of lesions in close proximity to pacemaker leads or other permanent catheters could affect their function. Fourteen patients referred for RF ablation of atrial flutter/fibrillation and atrial tachycardia, who had a permanent dual chamber pacemaker (10 patients), ICD (1 patient), or both (3 patients) were studied to assess the safety, efficacy, and effects of the ablative procedure on device function. Lead impedance, R and P wave amplitude, and pacing threshold of the defibrillator and pacemaker were measured before and after ablation. The procedure was successful in all patients. In one patient who underwent both atrial flutter and atrial fibrillation ablation, the atrial pacing threshold increased from 1.0 preablation to 2.0 V postablation. No P wave was detectable after ablation. In another patient, the P wave amplitude went from 4.0 to 2.0 mV postablation. In both patients the device converted to the power reset mode. No changes were observed in the remaining patients. Postablation defibrillator testing showed no malfunction. Follow-up reinterrogation of the devices revealed no alterations. IN CONCLUSION: (1) RF ablation of atrial flutter and/or tachycardia is feasible even in patients with multiple chronic atrial and ventricular indwelling catheters; and (2) RF applications in close proximity of defibrillator and pacing catheters does not appear to alter their function unless lesions are produced in the area surrounding the distal pacing electrode.

Aged↗
PubMed1995

Effect of exercise on cycle length in atrial flutter.

OBJECTIVE: To examine the effect of exercise on cycle length in atrial flutter. PATIENTS: 15 patients with chronic atrial flutter. Seven patients were taking digoxin and six verapamil; two were not taking medication. METHODS: All patients underwent bicycle ergometry. Flutter cycle length was measured at rest and at peak exercise. RESULTS: Mean flutter cycle length increased from 245 ms to 256 ms (P = 0.002). Six patients developed 1:1 atrioventricular conduction. Significant increases in flutter cycle length were observed irrespective of development of 1:1 atrioventricular conduction and use of digoxin and verapamil. CONCLUSION: Exercise prolongs flutter cycle length. This effect would promote development of 1:1 atrioventricular conduction during exercise, causing inordinately high ventricular rates.

Adult↗
PubMed1997

Ibutilide. A review of its pharmacological properties and clinical potential in the acute management of atrial flutter and fibrillation.

Ibutilide is the first 'pure' class III antiarrhythmic drug to become available. Its predominant action is prolongation of the myocardial action potential duration. This appears to be achieved by a unique ionic mechanism of action that involves activation of a late inward sodium current and possibly blockade of the rapidly activating component of the cardiac delayed rectifier potassium current. Intravenous ibutilide 0.01 to 0.025 mg/kg or 1 to 2 mg successfully converted atrial flutter or fibrillation to sinus rhythm in 33 to 49% of patients in 2 placebo-controlled trials involving 439 patients with sustained arrhythmia. In a third trial in 300 patients who developed atrial flutter or fibrillation after cardiac surgery, ibutilide 2 mg successfully converted the arrhythmia in 57% of patients. The mean times to conversion were < or = 30 minutes in these trials. In 3 comparative trials, ibutilide was significantly more effective than racemic sotalol or procainamide in terminating atrial flutter or fibrillation. The pretreatment duration of the arrhythmia is an important predictor of the success of ibutilide treatment; the greatest conversion rates are achieved when the arrhythmia is of recent onset (i.e. < or = 30 days' duration). Ibutilide is more effective in terminating atrial flutter than atrial fibrillation. Adverse events associated with ibutilide are predominantly cardiovascular. Sustained polymorphic ventricular tachycardia developed in 1.7%, and non-sustained polymorphic ventricular tachycardia in 2.7%, of 586 patients treated with ibutilide in clinical trials. However, no proarrhythmia-related deaths have been reported with the use of ibutilide. The drug has minimal haemodynamic effects and is associated with few noncardiovascular adverse events. Thus, ibutilide is a useful agent for the pharmacological cardioversion of recent-onset atrial fibrillation or flutter, provided that adequate steps are taken to monitor for proarrhythmic events. The drug causes few noncardiovascular adverse events and has minimal haemodynamic effects. Furthermore, it appears to be more effective than procainamide (especially in patients with atrial flutter) and racemic sotalol.

Anti-Arrhythmia Agents↗
PubMed1990

Perioperative arrhythmias after Fontan repair.

Arrhythmias are well-recognized sequelae of the Fontan repair. A prospective analysis of perioperative arrhythmias after Fontan repair was performed. Thirty-three patients had 24-hour ambulatory monitoring on the day before surgery and for 24 hours immediately after surgery; the 27 surviving patients had an additional 24-hour study on the seventh postoperative day. The most common preoperative rhythm was normal sinus, which was present in 79%. Hemodynamically significant preoperative arrhythmias were present in only two patients-atrial flutter (n = 1) and complete heart block (n = 1). Other asymptomatic preoperative arrhythmias included ectopic atrial rhythm (n = 2), supraventricular tachycardia (n = 1), accelerated junctional rhythm (n = 1), and frequent ventricular premature beats (n = 1). On the first postoperative day, the most common rhythm was accelerated junctional rhythm, which was present in 48%. Hemodynamically significant arrhythmias were present in nine patients (27%) -rapid accelerated junctional rhythm (rate, greater than 190 beats/min) (n = 3), complete heart block (n = 2), atrial flutter (n = 2), supraventricular tachycardia (n = 1), and ventricular tachycardia (n = 1). Three of six deaths occurring between postoperative days 2 and 7 were in patients with rapid accelerated junctional rhythm and associated low cardiac output. On the seventh postoperative day, the most common rhythm was normal sinus, which was present in 41%. Nine of the 27 surviving patients had complete resolution of their arrhythmias between postoperative days 2 and 7. On postoperative day 7, hemodynamically significant arrhythmias were present in four patients-atrial flutter (n = 2) and complete heart block (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias, Cardiac↗
PubMed1987

Flecainide acetate for conversion of acute supraventricular tachycardia to sinus rhythm.

The efficacy of intravenous flecainide acetate (maximum 2 mg/kg or 150 mg given at a rate of 15 mg/min) was assessed in patients with acute supraventricular tachycardia (SVT) (within 24 hours). Fifty patients were studied, 46 with spontaneous SVT and 4 with induced SVT at electrophysiologic assessment. Conversion to sinus rhythm was achieved within 45 minutes in 76%: in 25 patients with atrial fibrillation (76% conversion), 15 with atrioventricular (AV) nodal or AV reentrant tachycardia (100% conversion) and 10 with atrial flutter or atrial reentrant tachycardia (40% conversion). Adverse effects were noted in 21 patients (42%): paresthesia in 9, drowsiness in 8, nausea in 2, accelerated ventricular rate in 5, ventricular tachycardia in 1, sinus bradycardia in 1 and hypotension in 5. Adverse effects were associated with larger dosage and atrial flutter or atrial reentrant tachycardia. Thus, flecainide acetate is effective in converting to sinus rhythm acute atrial fibrillation and AV nodal and AV reentrant tachycardias, but not atrial flutter or atrial reentrant tachycardia.

Acute Disease↗
PubMed2000

Early outcome of initiating amiodarone for atrial fibrillation in advanced heart failure.

BACKGROUND: Little information exists about the early outcomes of initiating amiodarone for atrial fibrillation in patients with advanced heart failure. This study assessed the initial rate of success and complications of amiodarone therapy initiated for patients with atrial fibrillation during hospitalization for heart failure. METHODS: We reviewed medical records for 37 consecutive patients with left ventricular ejection fractions </=40% who underwent initiation of amiodarone for atrial fibrillation during hospitalization on a heart failure service. RESULTS: Atrial fibrillation was present in 35 (95%) and atrial flutter in 2 (5%), with mean duration of 30 months. New York Heart Association class was 3.1 (+/-1.1). Left ventricular ejection fraction was 24% +/- 7%. All patients had received oral amiodarone with an initial dose of 1.2 +/- 0.2 g/day. Bradyarrhythmia led to discontinuation of digoxin in 12 (32%) patients and to permanent pacemaker placement in 7 (19%) patients. Conversion to sinus rhythm occurred spontaneously in 2 patients and after electrical cardioversion in 26 patients, for an initial success of 76%. After a median follow-up of 9.5 months, 21 of 37 (57%) patients remained in sinus or atrial-paced rhythm. Amiodarone complications occurred after discharge in 5 (14%) patients, 4 with hypothyroidism. CONCLUSIONS: Amiodarone with electrical cardioversion has a high initial success rate for treatment of atrial fibrillation in patients with heart failure with advanced systolic dysfunction. The major early side effect was bradyarrhythmia, frequently requiring discontinuation of digoxin or permanent pacemaker placement.

Administration, Oral↗
PubMed1987

Flecainide and encainide.

Flecainide and encainide (class IC) are presently under clinical evaluation in Italy. They prolong the duration of the QRS but not the period of ventricular repolarisation: the prolongation of QT is due solely to the prolongation of the Q-J. Flecainide and encainide are extremely powerful and are suitable for the treatment of reciprocating supraventricular paroxysmal tachycardia and of persistent reciprocating tachycardia, the prophylaxis of WPW atrial fibrillation including cases with a short anterograde refractory period of the anomalous pathway and the treatment of ventricular ectopic beats and ventricular tachycardia. Both drugs are probably effective for the treatment of atrial fibrillation. However, in the case of atrial flutter they are of little effect of sinus rhythm cardioversion; on the other hand they significantly prolong the duration of the A-A interval, with variable results on ventricular rate. Flecainide and encainide have 'parodoxical' arrhythmogenic effects, related to administration dosages, severity of the arrhythmia and seriousness of cardiopathy. Encainide shows peculiar pharmacokinetics due to hepatic oxidating metabolisation and to production of metabolites; among these the O-demethylencainide and the 3-methoxy-O-demethylencainide have an antiarrhythmic activity, which is probably more important than the encainide parent and is longer-lasting. There are 'extensive', 'poor' and 'non-metaboliser' subjects. This results in wide pharmacokinetic inter- and intraindividual variability which must be taken into account during clinical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Anilides↗
PubMed1975

The effects of practolol on the dysrhythmias complicating acute ischemic heart disease.

The cardioselective beta-adrenoceptor blocking agent practolol was used in the management of ventricular and supraventricular dysrhythmias associated with acute myocardial infarction in 134 patients, and in the management of these dysrhythmias in 19 atients with acute myocardial ischemia. Practolol was frequently effective in controlling ventricular dysrhythmias which occurred within the first 24 hours after the onset of symptoms of acute myocardial infarction. It was also effective in controlling the ventricular dysrhythmias which occurred after resuscitation from ventricular fibrillation. It was of particular value when therapeutic doses of lidocaine had been ineffective. Practolol was much less effective in controlling ventricular dysrhythmias which occurred more than 24 hours after acute infarction. Atrial fibrillation and atrial flutter were infrequently abolished by practolol in undigitalized patients after acute myocardial infarction. There was no correlation between the effectiveness of practolol and the blood concentration of the drug. One adverse effect of practolol was the occurence of sinus bradycardia with or without an increase in the frequency of ventricular ectopic beats. Bradycardia was sometimes accompanied by hypotension. Severe hypotension occasionally occurred in the absence of bradycardia.

Aged↗
PubMedDate not supplied

[The termination of auricular flutter by noninvasive programmed electrical stimulation using a permanent AAI-mode pacemaker].

We describe a case of a 15-year-old boy with an atrial septal defect who three years after the direct closure of the defect presented with atrial flutter type I according to Wells's classification. He was then electrically cardioverted but presented immediately sinus bradycardia and a ventricular escape rhythm that required epicardial pacing (Intermedics 292-03 DASH) in the AAI mode. We report here the successful termination of a new episode of atrial flutter into sinus rhythm with a noninvasive programmed stimulation using his previously implanted pacing system.

Adolescent↗
PubMed1978

The echocardiographic profile of patients after Mustard's operation.

In order to establish an echocardiographic profile of patients with simple transposition after Mustard's operation, we examined the M-mode records of 10 patients who were found to be free of significant abnormalities at follow-up cardiac catheterization. When compared with established normals, right ventricular wall thicknesses and cavity dimensions were increased, while left ventricular wall thicknesses and cavity dimensions fell below the mean. The wall thicknesses, cavity dimensions and ratios of right ventricular preejection period/ejection time and left ventricular preejection period/ejection time were appropriate for the physiologic role of the ventricles rather than their morphologic identity. In each patient, a portion of the intra-atrial baffle was identified behind the pulmonary root. There was variation in baffle position and baffle mobility within the group, as well as in individual echograms. A variety of valve motion abnormalities were noted; these included diastolic flutter of the atrioventricular valves in all 10 patients and systolic anterior motion of the mitral valve in six patients. Paradoxical septal motion was found in nine patients. Although only minimal or no left ventricular outflow gradients were found at catheterization, nine patients had narrowing of the left ventricular outflow tract, 10 had systolic flutter of the pulmonary valve and eight had early partial closure of the pulmonary valve. The finding of a large number of echocardiographic abnormalities in a group of patients with good hemodynamic results suggests that these echocardiographic features are to be expected after Mustard's opration. Furthermore, the reversal of the physiologic role of the ventricles must be considered when interpreting the echocardiographic dimensions and systolic time intervals.

Aorta↗
PubMed1996

Significance and prevalence of inducible atrial tachyarrhythmias in patients undergoing electrophysiologic study for presyncope or syncope.

The purpose of the study was to report the prevalence of inducible supraventricular tachyarrhythmias (SVTA) in 827 consecutive patients aged 17 to 90 years who did not have spontaneous documented SVTA and who had unexplained presyncope and/or syncope. The electrophysiologic study (EPS) included programmed atrial and ventricular stimulation up to two extrastimuli at three cycle lengths, and the study of sino-atrial and AV conduction. The results were as follows. EPS was normal in 386 patients. Inducible junctional tachycardia or atrial flutter and fibrillation was the only finding in 187 patients (23%). In the remaining patients we found ventricular tachycardia in 103 (12%), heart block in 67 (8%), sick sinus syndrome in 56 (7%) and increased vagal tone in 28 (3%). The presence of an underlying heart disease (47%) and salvos of atrial premature beats on Holter monitoring (39%) were significantly correlated with the induction of SVTA. However, the comparison with similar groups without syncope indicates that only the induction of SVTA in patients with hypertrophic cardiomyopathy and mitral valve prolapse was significantly correlated with the history of syncope. In patients without heart disease or with prior myocardial infarction or decreased left ventricular function, the induction of SVTA, which is not associated with hypotension in the supine position, could require an induction after head-up tilting, because of the lack of specificity of programmed stimulation in these patients. Programmed atrial stimulation should be systematically performed in patients with unexplained syncope, in particular in those with hypertropic cardiomyopathy and mitral valve prolapse, who require a specific treatment, if a SVTA is induced. In other patients the results of programmed atrial stimulation should be interpreted cautiously.

Adolescent↗