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PubMedDate not supplied

Pseudoconduction of atrial flutter of a recipient atrium.

A nine-year-old girl had an episode of atrial flutter and a nonsustained wide QRS tachycardia during her initial hospitalization after orthotopic heart transplantation. Evaluation of her ECG and telemetric tracing revealed atrial flutter of the recipient atrium and sinus rhythm of the donor atrium. The wide QRS tachycardia was an accelerated ventricular rhythm that was also found on subsequent 24-hour ambulatory ECG monitoring. Timely recognition of recipient atrial arrhythmias prevents inappropriate clinical intervention.

Atrial Flutter↗
PubMed2002

Conversion of recent-onset atrial fibrillation or flutter with ibutilide after amiodarone has failed.

OBJECTIVE: To evaluate whether ibutilide can convert atrial fibrillation or flutter in patients in whom amiodarone has failed. DESIGN AND SETTING: Clinical study in a university hospital intensive care unit (ICU). PATIENTS: Twenty-six patients were studied, in whom atrial fibrillation or flutter persisted for a maximum of 6 h at maximum. Patients were monitored continuously during the arrhythmia. Medical conversion was necessary due to symptomatic or hemodynamic causes. INTERVENTIONS: All patients initially received amiodarone (150 mg i.v.) and after 2 h of persistent arrhythmia ibutilide (1 mg or, without success and body weight > 70 kg, 2 mg i.v.). Before the administration of ibutilide 1 g magnesium was administered, and high normal levels of potassium serum levels were achieved (4.5-5.0 mmol/l). RESULTS. After amiodarone atrial flutter persisted in 73% and atrial fibrillation in 27% of patients. After ibutilide the QT interval was prolonged from 327 +/- 61 to 387 +/- 62 ms. The QTc interval increased from 456 +/-32 to 461 +/- 66 ms. Conversion to normal sinus rhythm was achieved in 22 of 27 of cases. Nonsustained torsade de pointes tachycardia was seen in three patients (11%). No patient showed sustained ventricular tachycardia. Patients with proarrhythmic effects were characterized by a decreased left ventricular function. CONCLUSIONS: In ICU patients ibutilide led to conversion to sinus rhythm in 81.5% of patients in whom amiodarone was unsuccessful. Nonsustained tachycardias were seen in 11%; sustained ventricular tachycardia was not seen. Ibutilide seems to be well suitable for conversion of recent onset atrial fibrillation or flutter and had no severe side effects in this study population.

Aged↗
PubMed1997

Restoring Sinus Rhythm in Patients With Atrial Flutter and Fibrillation: Pharmacologic or Electrical Cardioversion?

Atrial fibrillation and atrial flutter, the most frequently encountered tachyarrhythmias requiring treatment, have become a major focus for clinical and basic research in recent years. Restoration and maintenance of sinus rhythmn, having been shown to improve exercise capacity, alleviate symptoms, and reduce the incidence of thromboembolic events, may be the optimal management strategy. Identification of the safest, most efficacious and cost-effective means of restoring sinus rhythm is necessary prior to the institution of optimal antiarrhythmic therapy to maintain sinus rhythm. Potential advantages of pharmacologic compared with electrical cardioversion include lack of need for general anesthesia and likely lower cost. Pharmacologic conversion include lack of need for general anesthesia and likely lower cost. Pharmacologic conversion has been accomplished with drugs that prolong atrial refractorinerss, including class Ia (quinidine, procainamide, disopyramide), class Ic (flecainide, propafenone), and class II (sotalol, amiodarone) compounds. The so-called pure class III agents were created to overcome the blocker side effects of sotalol and the complex pharmacodynamic profile of amiodarone. Two such agents are dofetilide, which selectively blocks the rapid component of the delayed rectifier current (Ikr) and ibutilide, which augments the slow inward sodium current, with a smaller component of action mediated by the block of Ikr. Reported overall conversion rates for recent onset atrial fibrillation and atrial flutter were 31% and 54% for difetilide, respectively, and 29-31% and 38-63%, respectively, for ibutilide. Proarrhythmia, manifested as polymorphic ventricular tachycardia requiring cardioversion, was a significant early side effect of both agents. Data from clinical trtials with these new agents, combined with increasing nowledge of the electrophysiologic substrate for these arrhythmias, has renewed initerest in the development of safer, more efficacious class IIIdrugs for atrial fibrillation and atrial flutter conversion.

Journal Article↗
PubMed1997

Intra-atrial reentrant tachycardia after palliation of congenital heart disease: characterization of multiple macroreentrant circuits using fluoroscopically based three-dimensional endocardial mapping.

INTRODUCTION: The anatomic substrate of intra-atrial reentrant tachycardia (IART) following congenital heart surgery is poorly understood, but is presumed to be different than common atrial flutter. METHODS AND RESULTS: To study the mechanisms of IART, we used a new technique for high-density endocardial mapping using recordings from a multipolar basket recording catheter (25 bipolar pairs). For each recording, biplane fluorographic reference points were digitized to obtain the spatial locations of electrode pairs, and activation times were calculated using temporal reference points from the surface ECG. Using custom software, data were combined to create three-dimensional atrial activation sequence maps, which were displayed as animated sequences. Using this technique, recordings were made in induced and/or spontaneous IART in 8 patients following congenital heart surgery (5 Fontan, 2 tetralogy of Fallot repair, 1 ventricular septal defect repair), and in 3 patients with normal intracardiac anatomy (1 with type I atrial flutter). Ten discrete IART activation sequences were recorded; 2 patients had 2 sequences each. IART maps were constructed using a median of 108 electrode positions (range 27 to 197) from a median of 6 recordings/sequence (range 3 to 11). Sinus or paced atrial rhythms were also recorded, and maps were created in a similar fashion. Visual analysis of activation sequences of sinus and paced rhythm were anatomically concordant with known mechanisms of atrial activation. IART sequences revealed diverse mechanisms; only 1 IART circuit was similar to that associated with common atrial flutter. Activation wavefront emergence from presumed zones of slow conduction, lines of conduction block, and apparent bystander activation were observed. CONCLUSIONS: High-density atrial activation sequence maps demonstrate that IART following congenital heart surgery utilizes diverse circuits and is distinct from common atrial flutter. The technique used to create these three-dimensional activation sequences may improve understanding of these complex atrial arrhythmias and assist in the development of ablative therapies.

Adolescent↗
PubMed1985

Atrial tachyarrhythmias after cardiac surgery: results of disopyramide therapy.

Of 1,247 consecutive patients who underwent cardiac surgery, 297 (24%) developed a post-operative atrial tachyarrhythmia. Of these patients, 201 were suitable for treatment according to the study protocol. All patients were initially given digoxin 0.75 mg intravenously (i.v.). After two hours, those 156 patients whose atrial arrhythmias persisted were given a 2 mg/kg loading dose of disopyramide (i.v.), followed by a constant i.v. infusion (0.4 mg kg-1 h-1) or oral therapy (600 mg daily). Within a further 12 hours, 75 patients (48%) reverted to sinus rhythm, 24 within one hour. Thus 120/201 patients (60%) reverted to sinus rhythm within 14 hours of commencing therapy. Reversion rates of those patients with both atrial fibrillation and flutter (AF/AFL) were significantly lower than those with AF (p less than 0.001) or AFL (p less than 0.02) alone. A further 70 patients reverted to sinus rhythm in one to 13 (mean four) days on continued drug therapy. Elective cardioversion restored sinus rhythm in six subjects. Atrial arrhythmias persisted in five patients (2.5%) at hospital discharge. Side-effects of disopyramide were noted in 19% of patients. Urinary retention was common (11.5%). Four patients with atrial flutter developed 1:1 atrioventricular conduction with the disopyramide loading dose. One patient with atrial fibrillation developed ventricular tachycardia during injection of the loading dose of disopyramide, but was successfully cardioverted to sinus rhythm. Two further patients developed significant hypotension (less than 90 mmHg systolic). Disopyramide is effective in the treatment of post-operative atrial tachyarrhythmias, but its routine use in this situation may be associated with an unacceptably high incidence of side-effects.

Atrial Fibrillation↗
PubMed1983

Determinants of recurrent atrial flutter after cardioversion.

Eighteen male patients (mean age 59 years) who were electrically cardioverted for pure atrial flutter were retrospectively studied to determine those factors influencing the maintenance of regular sinus rhythm or reversion to atrial flutter. Six months after successful cardioversion, 10 patients (55%) had recurrent atrial flutter and eight patients (45%) were still in sinus rhythm. The two groups were not significantly different with respect to age, symptomatology, abnormalities on the 12 lead electrocardiogram (during sinus rhythm), or the administration of digoxin and a class Ia antiarrhythmic agent (after cardioversion). There was a trend for those patients with recurrent atrial flutter to have a higher incidence of underlying heart disease and previous episodes of atrial flutter than the non-recurrent group. There were statistically significant differences between the recurrent and non-recurrent groups with respect to echocardiographically determined left atrial size and left ventricular ejection fraction. Patients with a left atrial size greater than 45 mm or with an ejection fraction less than 45% were all at high risk for recurrent atrial flutter after successful cardioversion.

Aged↗
PubMed1998

Ventricular performance and quality of life in patients who underwent radiofrequency AV junction ablation and permanent pacemaker implantation due to medically refractory atrial tachyarrhythmias.

UNLABELLED: In patients with drug refractory atrial tachyarrhythmias and previous failed attempts of ablation of the arrhythmia substrate, radiofrequency (RF) modulation or ablation of the atrioventricular (AV) junction is an alternative procedure. AIM: Of this study was to assess the efficacy and long term results of RF AV junction ablation in conjunction with permanent pacemaker implantation, in the management of patients with drug resistant atrial tachyarrhythmias. METHODS: Between 4/92 and 1/97, 46 patients (30 male, 16 female, 67 +/- 12 years) underwent RF AV junction ablation because of paroxysmal atrial fibrillation (24 patients), chronic atrial fibrillation (13 patients), atrial flutter (5 patients) and atrial tachycardia (4 patients). The underlying heart disease was dilated cardiomyopathy (16), ischemic heart disease (9), hypertensive heart disease (6), hypertrophic cardiomyopathy (3), atrial septal defect (2) and non structural heart disease (10). The duration of symptoms was 6.4 +/- 3.5 years at a maximal heart rate 169 +/- 24 bpm. The hospital admissions in the last 12 months were 8.2 +/- 3 per patient. The failed antiarrhythmic drugs were 3.5 +/- 2.1. The functional NYHA class was 2.7 +/- 0.6. Patients with atrial flutter and atrial tachycardia had previous failed attempts of RF ablation of the arrhythmia substrate. Thirty patients had a compromised left ventricular systolic function with LVEF below 50% (mean 34 +/- 9%). AV junction ablation was achieved in all patients after 4 +/- 2.5 RF applications. Post ablation, the selected pacing mode was DDD-R for the 33 patients with paroxysmal atrial tachyarrhythmias and VVI-R for the 13 pts with chronic atrial fibrillation. The dual chamber pacemakers implanted had the option of automatic mode switch. RESULTS: During the follow-up period of 28 +/- 13 months (6-47), AV conduction recovered in 1 patient. Antiarrhythmic treatment was necessary in only 7 patients. Post ablation the new functional NYHA class was 1.4 +/- 0.8 (p < 0.001). Post ablation hospital admissions, including ordinary pacemaker follow-up visits, were 4 +/- 1 per patient per year (p < 0.001). Six months after the procedure the LVEF of the study population was increased from 42 +/- 16% to 50 +/- 14% (p = NS). In the 30 patients with heart failure the LVEF was significantly increased to 46 +/- 8% (p < 0.05). Symptomatic relief or significant improvement was observed in all patients as showed by the answers given in a customized questionnaire before and after the procedure. CONCLUSIONS: In patients with drug refractory atrial tachyarrhythmias, RF AV junction ablation and permanent pacemaker implantation is an alternative therapy with excellent long term results in terms of arrhythmia control, ventricular performance and quality of life.

Aged↗
PubMed1996

Efficacy of ibutilide for termination of atrial fibrillation and flutter.

The clinical utility of ibutilide fumarate (Corvert) for the acute conversion of atrial tachyarrhythmias to normal sinus rhythm has been demonstrated in several randomized, placebo-controlled clinical trials. The efficacy of intravenous ibutilide for rapid conversion of atrial flutter is in the range of 50-70%, whereas its efficacy for conversion of atrial fibrillation is 30-50%. Approximately 80% of atrial tachyarrhythmias that terminate do so within 30 minutes from the initiation of the intravenous infusion. Ibutilide is more effective than either intravenous procainamide or intravenous sotalol for conversion of atrial fibrillation and atrial flutter to sinus rhythm. Age, presence of structural heart disease, gender and concomitant medication do not appear to influence the efficacy of ibutilide; however, shorter duration of atrial fibrillation is a strong predictor of successful termination. Plasma concentration of ibutilide and QTc interval prolongation are not directly correlated with the success rate for conversion of atrial tachyarrhythmias. Ibutilide's greater efficacy compared with other antiarrhythmic drugs may be related to its ability to cause greater prolongation of atrial monophasic action potential duration relative to atrial cycle length. Termination of atrial flutter with ibutilide was preceded by increased atrial cycle length variability. Ibutilide rapidly and effectively converts atrial fibrillation and atrial flutter to sinus rhythm when administered as a 1-mg total dose followed by a second 1-mg dose. It should be used in conjunction with continuous electrocardiographic monitoring for at least 4 hours after the termination of the infusion, or until the QTc interval returns to baseline. Hypokalemia and hypomagnesemia should be corrected before the start of the infusion. An external cardiac defibrillator, intravenous magnesium, and an external transcutaneous cardiac pacemaker should be readily available for immediate use in the event that palymorphic ventricular tachyarrhythmias occur. Ibutilide is a new intravenous agent that safely and rapidly converts atrial fibrillation and atrial flutter to sinus rhythm.

Anti-Arrhythmia Agents↗
PubMed1992

Proarrhythmia in patients treated for atrial fibrillation or flutter.

OBJECTIVE: To review data on the type, mechanism, and prevalence of the proarrhythmic effect of drugs used to treat atrial fibrillation or flutter. DATA SOURCES: English-language literature from the early 1960s to the present was identified by manual search of the literature; relevant articles were reviewed. Pertinent earlier studies were identified from references in the articles reviewed and were included when relevant. STUDY SELECTION: All studies, controlled and uncontrolled, as well as individual case reports that contained data convincingly linking atrial antiarrhythmic therapy to a proarrhythmic side effect were included. DATA EXTRACTION: Key data were extracted from each article in studies in which a causal relationship between the use of a drug and a proarrhythmic response appeared likely. DATA SYNTHESIS: Antiarrhythmic therapy aimed at stabilizing the atrium may have adverse effects on the ventricle including torsade de pointes and, less commonly, sustained ventricular tachycardia. Different antiarrhythmic agents appear to have differing potentials for this proarrhythmic response, which is most common with class 1A agents. Other proarrhythmic responses to atrial antiarrhythmic agents include the acceleration of the ventricular response either by enhancing atrioventricular nodal or bypass tract conduction or by converting atrial fibrillation to flutter with 1:1 conduction. Calcium-channel blocking agents and, less commonly, digoxin may perpetuate the duration of paroxysmal atrial fibrillation, and virtually all agents can cause sinus node dysfunction or atrioventricular block. CONCLUSIONS: Although drug therapy for atrial fibrillation or flutter is generally well tolerated, the potential exists for uncommon but serious proarrhythmic effects. Knowledge of the risk factors and symptoms of these adverse reactions will help to further reduce this risk.

Anti-Arrhythmia Agents↗
PubMedDate not supplied

Fetal echocardiography: a large clinical experience and follow-up.

We reviewed our experience with 382 fetal echocardiograms. Complete studies were not possible for three pregnancies because of either fetal position or maternal obesity. Studies were performed for fetal arrhythmia (28%), maternal factors (21%), fetal anomaly (11%) and family history of congenital heart disease (40%). There was a recurrence of heart disease in two of 153 patients (1.3%). Arrhythmia was the most common finding (82 of 382 patients). Premature atrial and ventricular contractions were the most common arrhythmia, and structural defects were present in four of 58 patients (6.8%) with premature contractions. Fetal heart defects (n = 44) were identified in 40 of 382 (10%) referrals. The defects were complete atrioventricular block (13), ventricular septal defect (4), atrioventricular canal (5), cardiac mass (3), ectopia cordis (2), thoracopagus (2), hypoplastic left ventricle (2), hypoplastic right ventricle (2), atrial flutter (2), pulmonic stenosis (1), single ventricle (2), Uhl's anomaly (1), Ebstein's anomaly (1), mitral atresia (1), d-transposition of the great vessels (1), tetralogy of Fallot with absent pulmonary valve (1), and atrial septal defect and ventricular septal defect (1). There were three false positive (99% specificity) and two false negative (95% sensitivity) fetal echocardiograms. The survival rates for referred patients with heart defects was: live born and perinatal survivor, 54%; perinatal death, 31%; still birth, 11%; and termination of pregnancy, 4%. Fetal echocardiography is accurate, and the abnormalities detected appear to be more severe than those detected on newborn screening.

Arrhythmias, Cardiac↗
PubMed2005

The novel antiarrhythmic drug dronedarone: comparison with amiodarone.

Dronedarone is a noniodinated benzofuran derivative that has been developed to overcome the limiting iodine-associated adverse effects of the commonly used antiarrhythmic drug, amiodarone. It displays a wide cellular electrophysiological spectrum largely similar to amiodarone, inhibiting the potassium currents I(Kr), I(Ks), I(KI), I(KACh), and I(sus), as well as sodium currents and L-type calcium currents in isolated cardiomyocytes. In addition, dronedarone exhibits antiadrenergic properties. In vivo, dronedarone has been shown to be more effective than amiodarone in several arrhythmia models, particularly in preventing ischemia- and reperfusion-induced ventricular fibrillation and in reducing mortality. However, an increased incidence of torsades de pointes with dronedarone in dogs shows that possible proarrhythmic effects of dronedarone require further evaluation. The clinical trails DAFNE, EURIDIS, and ADONIS indicated safety, antiarrhythmic efficacy and low proarrhythmic potential of the drug in low-risk patients. In contrast, the increased incidence of death in the dronedarone group of the discontinued ANDROMEDA trial raises safety concerns for patients with congestive heart failure and moderate to severe left ventricular dysfunction. Dronedarone appears to be effective in preventing relapses of atrial fibrillation and atrial flutter. Torsades de pointes, the most severe adverse effect associated with amiodarone, has not yet been reported in humans with dronedarone. Unlike amiodarone, dronedarone had little effect on thyroid function and hormone levels in animal models and had no significant effects on human thyroid function in clinical trials. In conclusion, dronedarone could be a useful drug for prevention of atrial fibrillation and atrial flutter relapses in low-risk patients. However, further experimental studies and long-term clinical trials are required to provide additional evidence of efficacy and safety of dronedarone.

Amiodarone↗
PubMed1992

Early and late arrhythmias after the Fontan operation: predisposing factors and clinical consequences.

OBJECTIVE: To study the incidence, predisposing factors, and clinical significance of arrhythmias early and late after the Fontan operation for congenital heart disease. PATIENTS AND METHODS: All 104 consecutive patients undergoing Fontan repair from 1975 to 1988 were studied retrospectively. Hospital records were reviewed for perioperative arrhythmia. Clinical information and annual electrocardiograms were available for all 78 hospital survivors during a follow up of up to 13 years (mean 3.7 years). Ambulatory electrocardiographic monitoring was performed in 67 patients (81%). RESULTS: Eleven patients (10.6%) developed a perioperative tachycardia (eight, atrial flutter; three, His bundle tachycardia). Multivariate analysis showed that raised preoperative mean pulmonary artery pressure and low aortic saturation were significant risk factors for the development of atrial flutter (r2 = 0.32, p = 0.0001) but not for His bundle tachycardia. Despite intensive medical treatment 10 of these 11 patients died. At the last visit 72 (92%) of the 78 patients were in sinus rhythm on their standard 12 lead electrocardiogram. Junctional rhythm was present in three patients, two patients had atrial flutter, and one had a paced rhythm. Ambulatory monitoring did not show important bradycardia or ventricular arrhythmias. Actuarial survival free of supraventricular arrhythmia was 82% at eight years after operation. Multivariate analysis identified older age, increased right atrial size, and raised mean preoperative pulmonary artery pressure as risk factors for arrhythmia during intermediate follow-up (r2 = 0.46, p less than 0.001). Late tachycardias, in contrast to those occurring in the perioperative period, were not associated with an increased mortality. CONCLUSIONS: Except for his bundle tachycardia in the perioperative period, early and late arrhythmias after a Fontan operation seem to be a consequence of adverse preoperative and postoperative haemodynamic function. The perioperative outcome is therefore poor even when the patient can be restored to sinus rhythm. Medical and surgical modifications to improve the haemodynamic disturbances associated with arrhythmias are therefore indicated.

Analysis of Variance↗
PubMed1988

A fourth criterion for transient entrainment: the electrogram equivalent of progressive fusion.

Prior data pertaining to transient entrainment and associated phenomena have been best explained by pacing capture of a reentrant circuit. On this basis, we hypothesized that rapid pacing from a single site of two different constant pacing rates could constantly capture an appropriately selected bipolar electrogram recording site from one direction with a constant stimulus-to-electrogram interval during pacing at one rate, yet be constantly captured from another direction with a different constant stimulus-to-electrogram interval when pacing at a different constant pacing rate. To test this hypothesis, we studied a group of patients, each with a representative tachycardia (ventricular tachycardia, circus-movement tachycardia involving an atrioventricular bypass pathway, atrial tachycardia, and atrial flutter). For each tachycardia, pacing was performed from a single site for at least two different constant rates faster than the spontaneous rate of the tachycardia. We observed in these patients that a local bipolar recording site was constantly captured from different directions at two different pacing rates without interrupting the tachycardia at pacing termination. The evidence that the same site was captured from a different direction at two different pacing rates was supported by demonstrating a change in conduction time to that site associated with a change in the bipolar electrogram morphology at that site when comparing pacing at each rate. The mean conduction time (stimulus-to-recording site electrogram interval) was 319 +/- 69 msec while pacing at a mean cycle length of 265 +/- 50 msec, yet only 81 +/- 38 msec while pacing at a second mean cycle length of 233 +/- 51 msec, a mean change in conduction time of 238 +/- 56 msec. Remarkably, the faster pacing rate resulted in a shorter conduction time. The fact that the same electrode recording site was activated from different directions without interruption of the spontaneous tachycardia at pacing termination is difficult to explain on any mechanistic basis other than reentry. Also, these changes in conduction time and electrogram morphology occurred in parallel with the demonstration of progressive fusion beats on the electrocardiogram, the latter being an established criterion for transient entrainment.(ABSTRACT TRUNCATED AT 400 WORDS)

Atrial Flutter↗
PubMed2001

[Protocols for the treatment of supraventricular tachycardias in the fetus].

The protocols mentioned are used by Utrecht University Hospital for the treatment of foetal supraventricular tachycardias. In the case of atrial flutters the pregnant woman is treated with sotalol administered orally and, if no sinus rhythm is obtained nor a reduced ventricular rhythm occurs, subsequently with digoxin. If there is no hydrops foetalis then this is also the treatment regimen for other forms of foetal supraventricular tachycardia. In the case of hydrops foetalis the treatment is more aggressive: digoxin intravenously or flecanide orally; if the rhythm does not convert into a sinus rhythm nor a reduced ventricular rhythm occurs then both of these medications are administered; if that also proves to be insufficient then direct foetal therapy can be considered.

Anti-Arrhythmia Agents↗
PubMed2001

The Mount Sinai Hospital clinicalpathological conference: a 45-year-old man with Pompe's disease and dilated cardiomyopathy.

This is an unusual case of a 45-year-old man, born in Ecuador, with evidence of profound left ventricular dysfunction, dilated cardiomyopathy and marked myocardial hypertrophy. Preceding events were advanced atrioventricular block (necessitating pacemaker implantation) and atrial flutter. The diagnosis of Pompe's disease was established by endomyocardial biopsy and appropriate staining, which indicated abnormal glycogen storage.

Cardiomyopathy, Dilated↗
PubMed2004

Specific cardiac disorders in 402 consecutive patients with ischaemic cardioembolic stroke.

BACKGROUND: To determine the cardiological substrate in acute stroke patients presenting with a cardioembolic stroke subtype. METHODS: Data of 402 consecutive patients with cardioembolic stroke (cerebral infarction, n=347; transient ischaemic attack, n=55) were collected from a prospective hospital-based stroke registry in which data on 2000 stroke patients over a 10-year period were included. In all patients, specific cardiac disorders were identified by physical examination and results of electrocardiography and transthoracic echocardiography. Holter monitoring and more sensitive techniques of cardiac imaging were used in selected cases. RESULTS: Cardioembolic cerebral ischaemia accounted for 20% of all acute strokes (25% of ischaemic cerebrovascular events). Cardiac sources of embolism included the following: (a) structural cardiac disorders associated with arrhythmia (n=232), the most frequent being left ventricular hypertrophic hypertensive disease (n=120) and rheumatic mitral valve disease (n=49); (b) structural cardiac disease with sustained sinus rhythm (n=81), the most frequent being systolic left ventricular dysfunction of both ischaemic (n=35) or non-ischaemic (n=24) aetiology; and (c) isolated atrial dysrhythmia (atrial fibrillation, n=88 and atrial flutter, n=1). CONCLUSIONS: Hypertrophic hypertensive cardiac disease complicated with atrial fibrillation was the most frequent cardiac source of emboli in cardioembolic stroke. Other important cardiac sources were isolated atrial fibrillation, rheumatic mitral valve disease, and systolic left ventricular dysfunction of ischaemic and non-ischaemic cause. The incidence of traditional emboligenous-prone cardiac disorders, such as mitral valve prolapse and mitral annular calcification was low.

Aged↗
PubMed1980

Non-invasive diagnosis of subpulmonary outflow tract obstruction.

We have studied the echocardiographic and phonocardiographic findings in 18 patients with obstruction to ventricular outflow at subpulmonary valve level. The aetiology was congenital in 13 patients, a result of hypertrophic cardiomyopathy in three, and infiltration of the right ventricular outflow tract by glycogen or lymphoma in the remaining two. Abnormal systolic motion of the pulmonary valve, fluttering, and early or midsystolic closure were seen in 16 of 17 patients in whom the cusps were visualised. Normal pulmonary valve motion was found in one patient with coexisting pulmonary valve stenosis. In congenital infundibular stenosis the delay of the pulmonary component of the second heart sound (P2) was related to the severity of the obstruction. A pulmonary ejection sound, defined as a high-frequency sound occurring at the moment of full pulmonary valve opening, was absent except in the patient with coexisting pulmonary valve stenosis. In hypertrophic cardiomyopathy with obstruction to the right ventricular outflow, the ejection systolic murmur was softer with inspiration, a finding that contrasts with the respiratory variation seen with fixed obstruction. Recognition of these abnormalities should allow an accurate non-invasive diagnosis to be made and permit assessment of severity when P2 can be recorded.

Adolescent↗