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PubMed1997

Thromboembolism in chronic atrial flutter: is the risk underestimated?

OBJECTIVES: We sought to evaluate the risk of thromboembolic events in the presence of chronic atrial flutter and to determine the impact of anticoagulation therapy, if any, on this risk. BACKGROUND: Thromboembolic events are thought to be rare after cardioversion of atrial flutter. METHODS: This study was a retrospective analysis of 110 consecutive patients referred to the electrophysiology laboratory for cardioversion of chronic atrial flutter from 1986 to 1996. Atrial flutter was present for at least 6 months. Of the 110 patients reviewed, 100 had adequate information available regarding the effectiveness of anticoagulation (mean age 64 years, range 27 to 86; 75 men, 25 women; mean left ventricular ejection fraction 42%). RESULTS: Thirteen patients (13%) had a thromboembolic event. Of these, seven were attributable to causes other than atrial flutter. In the remaining six patients (6%), thromboembolic events occurred during a rhythm of atrial flutter or after cardioversion to sinus rhythm. Other causes of thromboembolism were excluded. Effective anticoagulation was associated with a decreased risk of thromboembolism (p = 0.026). CONCLUSIONS: Patients with chronic atrial flutter are at an increased risk of thromboembolic events. Effective anticoagulation may decrease this risk.

Adult↗
PubMed1977

Echocardiographic findings in left ventricular to right atrial shunts.

The echocardiographic abnormalities of tricuspid valve motion in 2 patients with left ventricular to right atrial shunts are described. In both patients the abnormal anatomy was defined at surgery, in one patient the shunt being above the tricuspid valve leaflets (supravalvar) and in the other patient through the septal leaflet (intravalvar). Different patterns of tricuspid valve systolic fluttering were seen in these two cases and the possible reasons for this are discussed. After surgical closure of the defects the systolic fluttering of the tricuspid valve was no longer observed. Echocardiography appears to be useful in detecting the presence of left ventricular to right atrial shunts which otherwise may be difficult to diagnose.

Adult↗
PubMed1997

Magnesium substitution and postoperative arrhythmias in patients undergoing coronary artery bypass grafting.

Sixty coronary artery bypass grafting patients were randomized to receive either magnesium sulphate or placebo for 4 days postoperatively. The magnesium substitution reduced the duration of atrial fibrillation or flutter (p < 0.05), but not the number of patients developing these arrhythmias. The number of ventricular ectopic beats was also reduced among patients receiving magnesium sulphate compared to placebo (p < 0.05). To evaluate whether the anti-arrhythmic effect of magnesium sulphate was explained by a faster resumption of cellular potassium postoperatively, skeletal muscle electrolyte concentrations were measured pre-operatively and on the third day postoperatively. No significant difference was found in skeletal muscle potassium or magnesium contents on the third day postoperatively when comparing the two groups. The serum magnesium level declined postoperatively in the placebo group, whereas an increase was found in patients receiving magnesium sulphate. We suggest magnesium substitution as a routine postoperatively, because this treatment seems to reduce the severity of postoperative arrhythmias.

Atrial Fibrillation↗
PubMed1987

[Silent aortic insufficiency mimicking dilated cardiomyopathy].

The authors report 6 cases of severe and silent aortic insufficiency having simulated in all aspects the picture of a dilated cardiomyopathy at the stage of cardiac insufficiency with primary manifestations. They insist on signs leading to the diagnosis of this clinical entity: past history of rheumatism, signs of electrical left ventricular hypertrophy in the absence of arterial hypertension, aortic calcifications and mostly presence of a discrete mitral diastolic fluttering during echocardiographic examination. Supra-sigmoid aortic angiography confirms the diagnosis of severe aortic regurgitation. In order to explain the non-perception of the murmur, they invoke the alteration of the transmission secondary to an air cushion (3 cases the association of another valvulopathy with murmur (1 case) and mainly the decrease of the leakage by increase of the left ventricular telediastolic pressure and the decrease of the diastolic aortic pressure, with diminution of the turbulences. The advantage of knowing this entity rests on the possibility of valve replacement, even at the stage of myocardial failure, since the satisfactory long-term post-operative evolution in 4 patients stands in contrast with the dangerous nature of a spontaneous evolution.

Aortic Valve Insufficiency↗
PubMed1995

Pharmacodynamic, pharmacokinetic and antiarrhythmic properties of d-sotalol, the dextro-isomer of sotalol.

In recent years, there has been a major shift from the use of antiarrhythmic drugs that act by slowing conduction to those that exert their beneficial actions by lengthening cardiac repolarisation. Such a shift is occurring because sodium channel blockers may increase mortality, especially in patients with structural heart disease, and because drugs such as sotalol and amiodarone are effective, with a potential for decreasing arrhythmic mortality. In this context, the electrophysiological and antiarrhythmic properties of d-sotalol, the dextro-isomer of sotalol, are of major importance. d-Sotalol is essentially devoid of beta-blocking actions and may be considered a pure class III compound. It has been assumed that its clinical efficacy would approximate that of amiodarone and sotalol, but without the complex adverse effect profile of amiodarone and the adverse beta-blocker effects of racemic sotalol. d-Sotalol has pharmacokinetic properties that resemble those of the racemate. It lengthens the QT/QTc interval but does not affect other electrocardiographic (ECG) intervals. It increases the refractory period in the atria, ventricles, bypass tracts and the His-Purkinje system while minimally slowing the heart rate. In preliminary studies, it had a weak suppressant effect on premature ventricular contractions, prevented inducibility of ventricular tachycardia or fibrillation in about 40% of patients, and demonstrated the potential to terminate atrial flutter and fibrillation and maintain stability of sinus rhythm during prophylactic administration. The drug exhibits little or no negative inotropic actions. Thus, it is likely to be better tolerated in patients with congestive heart failure dependent on sympathetic stimulation for compensation. Because it produces less bradycardic effect than the racemate, it is believed that the drug might induce a lower rate of torsade de pointes. The role of d-sotalol in controlling cardiac arrhythmias is being addressed in a number controlled clinical trials. However, one such double-blind, placebo-controlled trial, Survival With Oral d-Sotalol (or SWORD), in survivors of myocardial infarction with depressed ventricular function was recently terminated prematurely because of a strikingly greater all-cause mortality compared with placebo (4.6 versus 2.6%). These preliminary findings, still to be fully analysed and interpreted for clinical significance, nevertheless raise valid concerns regarding the currently popular concept of controlling cardiac arrhythmias by the selective or isolated prolongation of repolarisation ('pure' class III action) as an antiarrhythmic principle.

Animals↗
PubMed2000

Comparison of echocardiographic markers of embolism in atrial flutter and fibrillation: frequency of protruding atherosclerotic plaques in the thoracic aorta.

The potential additional embolic risk of protruding aortic plaques > or = 4 mm and left atrial abnormalities such as thrombus, spontaneous echocardiographic contrast (SEC), low left atrial appendage velocity, recently has been shown in patients with atrial fibrillation (AF). However, the presence and potential role of transesophageal echocardiographic (TEE)-detected protruding aortic plaques > or = 4 mm have not been systematically evaluated in patients with atrial flutter. Among 2493 patients evaluated by TEE, 271 consecutive patients with atrial flutter (n = 41) and AF (n = 230) > or = 2 days duration were included in the study. Clinical and echocardiographic characteristics in consecutive patients with atrial flutter were compared to those in patients with AF, especially atrial morphology and function and atherosclerotic disease of the thoracic aorta. Clinical characteristics of patients with atrial flutter and AF were similar with regard to age (68 +/- 13 and 67 +/- 12, P = 0.628), sex ratio (men, 66% and 54%, P = 0.212), and previous embolic events (5% and 15%, P = 0.126), respectively. The frequency of protruding atherosclerotic plaques > or = 4 mm (12% and 11%, P = 0.919) and SEC (15% and 14%, P = 0.847) in the thoracic aorta was similar in patients with atrial flutter and AF. Left atrial appendage area was smaller (3.1 +/- 0.7 and 6.0 +/- 3.0 cm(2), P = 0.001), left atrial appendage SEC was less frequent (17% and 37%, P = 0.024), and left atrial appendage emptying velocity was higher (47 +/- 10 and 30 +/- 10 cm/s, P = 0.030) in patients with atrial flutter as compared to those with AF. There was no difference between the two groups regarding left ventricular fractional shortening (30 +/- 10% and 33 +/- 13%, P = 0.630), rheumatic valvular disease (5% and 12%, P = 0. 301), left atrial diameter (43 +/- 7 and 45 +/- 8 mm, P = 0.134), right atrial area (16 +/- 4 and 17 +/- 6 cm(2), P = 0.384), left atrial SEC (39% and 53%, P = 0.124), or atrial thrombus ( 2% and 3%, P = 0.888) respectively. Our results point to the high prevalence of protruding atherosclerotic plaques in the thoracic aorta in patients with atrial flutter.

Aged↗
PubMed1998

[Ambulatory catheter ablation. Indications, results and risks].

The purpose of this study was to test the efficacy, feasibility, and safety of outpatient radiofrequency catheter ablation in 162 consecutive patients. There were 83 men and 79 women at a mean age of 47 + 15 years; 13 patients underwent 2 and 1 patient 3 ablation procedures. In 167 cases patients suffered from highly symptomatic paroxysmal tachycardia associated with presyncope or syncope in 74. Severe palpitations were present in 7 cases and recurrent syncope in 1 case. One patient had an asymptomatic Wolff-Parkinson-White syndrome with a shortest RR-interval during atrial fibrillation of 150 ms. The mechanism of tachycardia was found to be atrioventricular nodal reentry in 78 cases, atrioventricular reentry involving an accessory atrioventricular pathway in 56, atrial fibrillation in 16, atrial flutter of the common type in 15, ectopic atrial tachycardia in 8, and idiopathic ventricular tachycardia in 3. Catheter ablation was performed in these 176 cases at an overall success rate of 86%. In 148 cases patients could be treated on an outpatient basis and were discharged after a maximal observation time of 3 hours in 28, and 24 hours in another 120 cases. Short-term follow-up was uneventful in these patients. After 28 ablation procedures patients had to be admitted to the hospital, because of pain at the puncture sites or after pacemaker implantation in 15 cases, because of minor complications in 12, and because of pericardial tamponade in 1 case. Another severe complication occurred in 1 patient after successful ablation of right atrial tachycardia. Three days after discharge the patient suffered from pulmonary embolism originating from a thrombus at the ablation site. After hospital admission the patient recovered completely. In general, complication rate was 2.27%. This study shows that catheter ablation can be performed effectively and safety on an outpatient basis.

Adult↗
PubMedDate not supplied

New antiarrhythmic drug in pediatric use: sotalol.

Sotalol is a noncardioselective beta-blocking agent with additional class III antiarrhythmic properties (action potential duration prolongation). These combined electrophysiologic effects make it a valuable drug for treating various arrhythmias. Its effectiveness for suppressing supraventricular reentrant tachycardias in children is well documented. Atrial flutter in children can be effectively managed in a high percentage of those treated. Ventricular arrhythmias in children can be adequately controlled by the administration of oral sotalol. Side effects are those typically seen during the course of treatment with a beta-blocker and lead to discontinuation of the drug in 3-6% of children. Proarrhythmia is another concern after sotalol administration. Increased ventricular ectopy, impairment of atrioventricular conduction, and suppression of sinus node activity with exacerbation of bradycardia (especially in children with sinus node dysfunction) may be found in a considerable number of treated patients, usually within a few days of sotalol initiation. Sotalol is an effective antiarrhythmic drug, but its potential side effects warrant inpatient treatment initially and close electrocardiographic monitoring.

Adrenergic beta-Antagonists↗
PubMed1991

Temporary external DDD pacing after cardiac operations.

Temporary atrial and ventricular pacing in the DVI, VVI, and AOO modes using atrioventricular sequential DVI devices is routinely used in cardiac operations. This study evaluated a new temporary external DDD pacemaker (Medtronic 5345 External Pulse Generator) capable of ten pacing modes. Thirty-nine devices have been applied to 38 adult patients (27 male, 11 female) after a variety of open heart procedures. Group 1 had atrial pacing wires placed 1.5 to 2.0 cm apart superiorly on the right atrium, group 2 had atrial wires placed 1.0 to 1.5 cm apart on the right atrial free wall, and group 3 had atrial wires placed on the right atrial free wall 0.8 cm apart, using a Silastic ring for fixation. Ventricular wires were placed on the free wall (group 1) or the diaphragmatic surface (groups 2 and 3) of the right ventricle. Postoperative atrial and ventricular sensing and pacing thresholds were obtained on return to the intensive care unit; analysis of variance demonstrated a significantly greater atrial sensing threshold in group 3. Four patients in group 1 permanently lost atrial sensing, 1 patient in group 2 intermittently lost atrial sensing at 24 hours with return at 36 hours postoperatively, and 1 patient in group 1 lost ventricular sensing capability. All other patients had adequate atrial and ventricular sensing capability documented until elective pacemaker removal (mean, 166 hours; range, 17 to 667.5 hours). Nineteen patients required some form of temporary pacing postoperatively; 11 patients demonstrated hemodynamic benefit from a pacing mode that is not available on the currently used DVI devices, and 7 of these required true DDD pacing capability. Six patients benefited from atrial pacing with adequate atrial sensing and simultaneous ventricular backup. Burst pacing with the device was used successfully to treat postoperative atrial flutter in 2 patients. We conclude that temporary external DDD pacing is feasible and effective in postoperative cardiac surgical patients. Atrial sensing is possible in most patients but electrode positioning is important for adequate thresholds. In some patients, hemodynamic as well as electrophysiologic improvement can be demonstrated with universal DDD pacing capability as compared with standard DVI pacing.

Adult↗
PubMed2005

Arrhythmias after orthotopic heart transplantation.

BACKGROUND: Arrhythmias frequently occur after orthotopic heart transplantation (OHT). METHODS AND RESULTS: The most common are ventricular premature complexes, atrial premature complexes, sinus or junctional bradycardia, atrial fibrillation, and atrial flutter, all of which have varying clinical significance depending on associated or causative conditions. Unique etiologic factors such as allograft rejection, transplant coronary artery disease, and altered anatomy and autonomic nervous system changes require that arrhythmias be treated differently after OHT compared with the general population. CONCLUSION: The potentially severe ramifications of allograft rejection and coronary artery disease make treatment of these disorders in the setting of arrhythmias as important as treating the arrhythmias themselves. At the same time, autonomic denervation and altered anatomy after transplantation complicate drug and device therapies.

Arrhythmias, Cardiac↗
PubMed1996

Drug therapy for prevention of atrial fibrillation.

Atrial fibrillation is not a homogeneous entity, and many factors are responsible for a number of different behaviors, clinical consequences, and reactions to therapy. Therefore, the conventional evaluation of preventive treatments is not really adapted to provide the correct answers to difficult problems of therapeutic indications, as the 2 components of the benefit-risk ratio are not really known. Like ventricular fibrillation, atrial fibrillation may be primary or secondary to organized tachyarrhythmias, and reentrant flutter or automatic atrial tachycardia may well form the actual target for treatment. The automatic nervous system is never absent as a determinant of the onset of arrhythmia, and the vagal as well as the sympathetic action may predominate and explain why a treatment may or may not be effective in situations that are identical only in appearance. The electrophysiologic milieu formed by the atrial tissue probably accounts for the perpetuation of the process of atrial fibrillation or its self-termination, and drugs themselves may contribute to modify the milieu in a way that in the end may be favorable or not. Finally, the presence or the absence of heart disease and heart failure largely contributes to the state of the vagosympathetic balance, to the hemodynamic consequences of atrial fibrillation, and ultimately to the proper toxic effects of drugs. The overall consequence of these complex situations is that any precise therapeutic decision algorithm for atrial fibrillation is always simplistic and that any global evaluation of drug efficacy or toxicity is not really meaningful as long as the category of patients treated is not precisely determined: no drug appears better or worse than others, but simply more or less adapted to various situations.

Anti-Arrhythmia Agents↗
PubMed2006

Characterizing dual atrioventricular nodal physiology in pediatric patients with atrioventricular nodal reentrant tachycardia.

INTRODUCTION: Dual atrioventricular (AV) nodal physiology, defined as an AH jump > or =50 msec with a 10 msec decrease in A1A2, is the substrate for atrioventricular nodal reentrant tachycardia (AVNRT) and yet it is present in a minority of pediatric patients with AVNRT. Our objective was to characterize dual AV nodal physiology as it pertains to a pediatric population. METHODS/RESULTS: We retrospectively reviewed invasive electrophysiology studies in 92 patients with AVNRT (age12.1 +/- 3.7 yrs) and in 46 controls without AVNRT (age 13.3 +/- 3.7 yrs). Diagnoses in controls: syncope (N = 31), palpitations (N = 6), atrial flutter (N = 3), history of atrial tachycardia with no inducible arrhythmia (N = 3), and ventricular tachycardia (N = 3). General anesthesia was used in 49% of AVNRT and 52% of controls, P = 0.86. There were no differences in PR, AH, HV, or AV block cycle length. With A1A2 atrial stimulation, AVNRT patients had a significantly longer maximum AH achieved (324 +/- 104 msec vs 255 +/- 67 msec, P = 0.001), and a shorter AVNERP (276 +/- 49 msec vs 313 +/- 68 msec P = 0.0005). An AH jump > or =50 msec was found in 42% of AVNRT versus 30% of controls (P = 0.2). Using a ROC graph we found that an AH jump of any size is a poor predictor of AVNRT. With atrial overdrive pacing, PR > or = RR was seen more commonly in AVNRT versus controls, (55/91(60%) vs 6/46 (13%) P = 0.000). CONCLUSIONS: Neither the common definition of dual AV nodes or redefining an AH jump as some value <50 msec are reliable methods to define dual AV nodes or to predict AVNRT in pediatric patients. PR > or = RR is a relatively good predictor of AVNRT.

Adolescent↗
PubMed1985

The proarrhythmic effects of flecainide.

Flecainide acetate, a new potent class I antiarrhythmic agent, was administered to 152 patients (orally to 46, intravenously to 106) over a period of 22 months. Seven patients developed proarrhythmic effects. The only conduction abnormalities induced were PR interval prolongation and QRS complex widening, and no patient developed significant sinus bradyarrhythmias; patients with known serious abnormalities of impulse generation or conduction were excluded from this study. Five patients, of whom only 3 had pre-existing ventricular arrhythmias, developed ventricular tachycardia or ventricular fibrillation. QT and QTc interval prolongation was observed, but was due to QRS complex widening rather than an increase in the JT interval. A patient with Wolff-Parkinson-White syndrome had an inducible orthodromic atrioventricular tachycardia before flecainide administration, but only an antidromic tachycardia was induced after taking the drug. In 1 patient, flecainide administration resulted in an increase of atrial flutter cycle length, which resulted in the development of 1:1 atrioventricular conduction rate, and, overall, a faster ventricular rate. Two patients who developed ventricular arrhythmias were taking other antiarrhythmic agents, and in this series proarrhythmic effects occurred with both normal and high flecainide concentrations. Other published series are also summarised.

Adult↗