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PubMed2001

Mechanisms of antiarrhythmic drug action on termination of atrial flutter.

Atrial flutter is an important arrhythmia in clinical practice. Although the reentrant circuit of human typical atrial flutter is well characterized, the action of antiarrhythmic drugs on this tachycardia is less understood. Based on the recent clinical trials, pure Class III drugs like ibutilide or dofetilide are more effective in acute termination of human atrial flutter than Class I drugs like procainamide or flecainide. The mechanisms of drug induced termination of atrial flutter include refractory block due to cycle length oscillation, fixed block due to a reduced safety factor for conduction, or a collision of opposing wavefronts due to loss of the lateral boundaries or return reexcitation. Because ventricular proarrhythmia is a major concern with ibutilide or dofetilide therapy, development of new drugs with more specific target profiles is a future direction for treatment of human atrial flutter.

Animals↗
PubMed1997

[Diagnostic and therapeutic potential of transesophageal cardiac pacing in the management of patients with arrhythmias].

BACKGROUND: Transoesophageal cardiostimulation is a semiinvasive method of stimulation of atrii enabling the performance of the programmed atrial stimulation without the inevitability of an invasive vascular approach. This method was used in 124 patients with the following indication spectrum. Diagnostic indications: total 82%, paroxysmal supraventricular tachycardia (SVT), and WPW sy-22%, tachycardia with wide QRS-complex-8%. SSS syndrome and bradycardia-20%, sycopes and collapses with unclear etiology-13%, palpitations-11%, control of antiarrhythmic therapy-4%, and other states-6%. Therapeutic indications: total-18%, versions of paroxysmal SVT and flutter of atrii. RESULTS: The patients with SVT were assumed to develop the arrhythmogenic mechanism--AV nodal re-entry tachycardia in 80%, orthodrome AV-re-entry tachycardia in 30%, and flutter of atrii in 20%. All patients with WPW-syndrome were stratified by the use of this method. The origin of this state from ventricular arrhythmia was verified in 40% of patients with tachycardia with a wide QRS complex. In coincidence with other indications, the diagnostic benefit of transoesophageal cardiostimulation was evaluated as follows: syncopes-68%, palpitations-64%, syndrome SSS and bradycardia-48%. The therapeutic indication of SVT version and flutter of atrii, was totally successful in 40%, partly successful in 45% and unsuccessful in 15% of patients. CONCLUSION: Transoesophageal cardiostimulation has contributed to the assessment of the diagnosis in 69% of patients and has acutely managed arrhythmia in 85% of cases. According to our experience, this method is effective in the initial management of patients with arrhythmia. Its low technical and economic demands make its wider utilisation appropriate in clinical practice of internal medicine. (Tab. 4, Fig. 9, Ref. 22).

Arrhythmias, Cardiac↗
PubMed1991

[Nonpharmacological therapy of supraventricular arrhythmia].

Between 1985 and 1990, 1242 patients with supraventricular arrhythmias were followed-up at our Institution. Six hundred and twenty patients had atrial fibrillation or flutter; 7 of them (1%) underwent modulation of atrioventricular conduction. Four hundred and twenty-eight patients had ventricular preexcitation; in 23 (5%) surgical or transcatheter ablation of an accessory pathway were performed. Atrioventricular node reentrant tachycardias were diagnosed in 111 patients; 8 patients (7%) underwent antitachycardia pacemaker implantation. Surgical and catheter ablative techniques eliminate the substrate of the tachycardia; death and complete A-V block (paraseptal pathways) are at this moment rarely reported. Antitachycardia pacemakers do not offer a definitive therapy. For their safeness and effectiveness they are still indicated in patients with A-V node reentrant tachycardias, until technological development will reduce the risks of ablative techniques.

Arrhythmias, Cardiac↗
PubMed2002

Twenty-five years' experience with the arterial switch operation.

OBJECTIVE: The arterial switch operation was introduced in 1976 to correct transposition of the great arteries and has since replaced atrial palliation. This study examines the long-term outcomes of the arterial switch operation. METHODS: Included in the study were 195 patients who underwent the arterial switch operation from 1977 through June 2000. Patients were evaluated for functional class, pulmonary stenosis, left ventricular function, arrhythmias, aortic sequelae, and coronary disease. RESULTS: Overall perioperative mortality was 15%, but rates dropped in the last 5 years to 4% for complex transposition and 0% for simple transposition. Of 151 survivors, 2 died late; 1 died of persisting pulmonary hypertension and 1 died of ventricular fibrillation after coronary pathologic changes. At last follow-up, a total of 145 patients were in New York Heart Association functional class I and 4 patients were in class II. The most frequent complication was pulmonary stenosis, necessitating 45 reinterventions in 26 patients. Left ventricular dysfunction was noted in 5 patients. Arrhythmias were seen in 5 patients: 2 patients had ventricular fibrillation (1 died and 1 required a defibrillator implantation), 1 had sick sinus syndrome, 1 had atrial flutter, and 1 had a single attack of supraventricular tachycardia. Aortic valve incompetence was absent or trivial in 146 patients, 3 had mild incompetence, 1 had moderate incompetence, and 1 had severe incompetence. Coronary sequelae were found in 5 of the 61 patients who underwent angiography. CONCLUSION: Long-term clinical outcome of the arterial switch operation is good, and perioperative mortality is now low. Morbidity is dominated by pulmonary stenosis and coronary artery disease, with the potential for lethal arrhythmias.

Arrhythmias, Cardiac↗
PubMed1984

Subcostal M-mode echocardiography of the right atrial wall for differentiation of supraventricular tachyarrhythmias with aberration from ventricular tachycardia.

Atrial contractions can be reliably detected by subcostal M-mode echocardiography of the right atrial wall. Recognition of various rhythm disturbances, especially tachyarrhythmias, is facilitated in the simultaneously recorded nondiagnostic ECG. Differentiation between supraventricular tachycardias with aberration and ventricular tachycardia with atrioventricular dissociation is alleviated. However, this technique is of limited value in the diagnosis of ventricular tachycardia with retroconduction and is not useful in differentiating supraventricular tachycardias with wide QRS from ventricular tachycardia when atrial fibrillation coexists.

Atrial Fibrillation↗
PubMed1995

New developments and treatment strategies in patients with supraventricular tachyarrhythmias.

The mechanisms, clinical presentation and therapy of supraventricular tachycardias are discussed. The therapy has changed from palliation by means of anti-arrhythmic drugs into definitive cure by ablation of the arrhythmia substrate. Radiofrequency energy causes tissue damage by heating and appears to be a safe method for catheter ablation of supraventricular tachycardias. We report a 97% success rate for radiofrequency ablation of 195 accessory atrioventricular pathways thereby curing these patients from circus-movement tachycardia and paroxysmal atrial fibrillation. Complications occurred in 3% of patients. One hundred seventy-two patients with atrioventricular nodal reentrant tachycardia, caused by reentry within dual AV-nodal pathways, were treated by selectively ablating one of the pathways with non-inducibility of the arrhythmia afterwards in 97% of the cases. Nine percent of patients had a recurrence but were successfully treated in a second session. The procedure was complicated by complete AV-block in 4% of patients. The disappointing medical treatment of atrial fibrillation and the fact that atrial fibrillation can be the cause of a reversible form of heart failure (tachycardiomyopathy), induced the clinical application of alternative forms of treatment. Ablation of the normal atrioventricular conduction system by using radiofrequency energy was performed with a 100% success rate in 121 patients. After implantation of a ventricular pacemaker it is possible to control and regulate the ventricular rhythm leading to rate control and amelioration of ventricular performance.

Atrial Fibrillation↗
PubMed2000

[Complications and risk of high frequency catheter ablation of tachycardiac arrhythmias].

Radiofrequency catheter ablation has established itself as a first line therapy for the curative treatment of many patients with supraventricular or atrioventricular tachycardias and also for selected types of ventricular tachycardia. The success rates of catheter ablation of various types of cardiac arrhythmias are impressively high. Procedure related complications can be attributed to the invasive nature of the technique (e.g., bleeding or other vascular complications, radiation exposure) but may also occur as a specific complication related to the type of intervention performed (e.g., complete AV-block following attempted modification of the AV-node). In patients undergoing radiofrequency ablation procedures, radiation exposure carries a small but measurable risk of malignancy and hereditary disorders. The risk of fatal malignancy has been calculated to be approximately 1/1000 per hour of fluoroscopy and the risk of significant hereditary disorders approximately 10 per 1 million live births per hour fluoroscopy time. However, it is important to realize that these risks are age and sex dependent being higher in young and/or female patients. For the physician performing catheter ablation procedures no significant risks related to fluoroscopy exposure may be expected as long as all established tools for protection are used. Based on the results of large single center studies and multicenter investigations, complications during or after radiofrequency catheter ablation of supraventricular or atrioventricular arrhythmias may occur in 4-5% of cases. Severe complications (life threatening or permanently disabling complications) may occur in approximately 1-2% of patients treated. In patients undergoing ablation of ventricular tachycardia, a higher incidence of total procedure related complications between 5-7% and severe complications (3-4%) may be expected. The higher incidence of complications in patients with ventricular tachycardia when compared to catheter ablation of supraventricular or atrioventricular tachycardia may be explained by the fact that many patients with ventricular tachycardia suffer from severe cardiovascular disease.

Adult↗
PubMed1990

[Fulguration of the bundle of His. Description of 3 new cases].

With the purpose to call attention to the clinical utility of fulguration of the His bundle (a therapeutic procedure somewhat neglected in Italy) 3 new cases are presented. All patients had a long history of supraventricular tachyarrhythmias refractory to conventional treatment. Patients 1 and 2, in whom surgical correction of tetralogy of Fallot and mitral valve replacement, respectively, had been performed several years before, had chronic atrial tachycardia with congestive heart failure. Patient 3 suffered from persistent atrial flutter, in the absence of demonstrable organic heart disease. Three shocks of 320 J were necessary to induce complete AV block in patient 1 and 2. In patient 3, a single discharge (320 J) resulted in interruption of AV conduction. Twenty-four hours after the procedure, a rate-responsive ventricular pacemaker was implanted in all patients. The success of the procedure was confirmed 3 months later, during transitory pacemaker inhibition. Patients 1 and 3 exhibited atrial tachycardia and atrial flutter, respectively, but complete AV block was still present, with junctional escape rhythm at a rate of 40 and 45 b/min; in patient 2 atrial tachycardia with high degree AV block, and a mean ventricular rate of 75 b/min, were observed. Refinement of transcatheter ablative techniques is desirable. However, even in the present status, catheter ablation of the His bundle is an effective, low-risk procedure for patients with refractory supraventricular tachyarrhythmias.

Adult↗
PubMed1985

Experimental evaluation and initial clinical application of new self-adhesive defibrillation electrodes.

We evaluated the efficacy of self-adhesive electrode pads for defibrillation and cardioversion in animals and patients. In 11 anesthetized dogs, the success rate of shocks given to terminate electrically-induced ventricular fibrillation was similar for both self-adhesive electrode pads and hand-held electrode paddles; success rate approached 100% at energies of 125-150 joules. Eighty patients undergoing defibrillation or elective cardioversion received shocks from self-adhesive pads. In all but 2 patients defibrillation or cardioversion was achieved at least once using these pads. The pads were equally effective from either apex-anterior or apex-posterior positions. The transthoracic impedance using self-adhesive pads was 75 +/- 21 ohms, similar to transthoracic impedance we previously reported when using standard hand-held paddles. No complications occurred with the use of the pads. We conclude that self-adhesive electrode pads are effective for defibrillation and cardioversion.

Animals↗
PubMed1994

Initiation of ventricular fibrillation by atrial fibrillation.

We report the case of a patient who developed spontaneously a ventricular fibrillation during atrial fibrillation, 8 min after a perfusion of isoproterenol was stopped. Two mechanisms could explain the ventricular arrhythmia: silent ischaemia and a long-short cycle sequence just before ventricular fibrillation.

Atrial Fibrillation↗
PubMed1985

Oral verapamil fails to prevent supraventricular tachycardia following coronary artery surgery.

A prospective randomised trial was performed on 100 patients undergoing coronary artery bypass grafting without concomitant procedure. The study group commenced oral verapamil 40 mg three times daily on the first post-operative day while the control group received no antiarrhythmic agents. The pre-operative characteristics of both groups were similar with the exception of the incidence of hyperlipidemia which was greater in the verapamil group (P = 0.04). Myocardial protection was achieved with cold crystalloid cardioplegia. Cardiopulmonary bypass times, aortic cross clamp times and graft numbers were similar for both groups. Nine patients were excluded on the first post-operative day; the remainder were studied for 8 days. Supraventricular tachyarrhythmias (atrial fibrillation, atrial flutter or paroxysmal supraventricular tachycardia) were detected in 8 patients in the study group (n = 44) and in 5 patients in the control group (n = 47). The difference was not significant (P = 0.3). The ventricular rate in patients taking verapamil who developed supraventricular tachycardia was 138 +/- 14.9 compared with 156.8 +/- 17.9 in the control group, but the difference failed to reach significant levels (P = 0.065). In conclusion, prophylactic oral verapamil 40 mg given three times daily after coronary artery surgery failed to decrease the incidence of post-operative supraventricular tachycardia or to significantly influence the ventricular rate if tachycardia developed.

Administration, Oral↗
PubMed2002

Radiofrequency ablation of cardiac arrhythmias using a three-dimensional real-time position management and mapping system.

A recently developed three-dimensional real-time position management system (RPM) uses an ultrasound ranging technique that enables multiple distance measurements between two reference catheters and a mapping catheter each equipped with ultrasound transducers. In addition to three-dimensional representation of the catheters and ablation sites it displays real-time movements of catheters (including the tip and shaft). A recently released version of the system enables additional geometry reconstruction of the heart chamber and activation mapping. This study included 21 patients (mean age 59 +/- 14.5 years) referred for radiofrequency catheter ablation of various arrhythmias. Geometry was reconstructed by tracing the endocardial contour of the respective heart chambers. Global and local color coded activation maps were constructed to confirm the nature of arrhythmia and to guide ablation. Spontaneous or induced arrhythmias were typical atrial flutter (n = 8), atypical atrial flutter (n = 3), atrioventricular nodal reentrant tachycardia (n = 3), atrial tachycardia (n = 2), atrial fibrillation (n = 2), ventricular tachycardia (n = 2), and Wolff-Parkinson-White syndrome (n = 1). Geometry reconstruction and mapping of arrhythmias were possible in 20 of 21 patients. RPM-guided radiofrequency ablation was successful in 19 (95%) of 20 patients. Due to difficulties in steering the RPM mapping/ablation catheter, in 6 (28%) successfully mapped patients, radiofrequency ablation was performed using another catheter. In one patient, the RPM-guided map was inconclusive and in another patient, ablation failed due to multiple reentrant circuits. No complications were observed. In conclusion, the new RPM system enables geometry reconstruction and three-dimensional positioning of the ablation catheters, reconstruction of the activation maps, marking of anatomic structures and reproducible tracking of multiple ablation sites. The system could be used to guide radiofrequency ablation of atrial and ventricular arrhythmias.

Arrhythmias, Cardiac↗
PubMed2001

[Late complications following early childhood atrial switch operations for d-transposition of the great arteries. Incidence, diagnosis and therapy].

BACKGROUND AND OBJECTIVE: The atrial switch operation in patients with transposition of the great arteries have been replaced by the arterial switch operation in the neonatal period. However, an increasing number of atrial switch survivors has now reached adulthood. This study was aimed at evaluating the incidence and patterns of typical late complications in order to describe diagnostic and therapeutic options. PATIENTS AND METHODS: We retrospectively analysed the data of 40 adolescent and adult patients, who had an atrial switch operation a mean of 17,9 years ago (23 Senning, 17 Mustard operations). The mean age of the patients is 19,3 years with 40 % females. The follow up time in our institution was 4,7 years. RESULTS: The most frequent complications were cardiac rhythm disturbances (47,5 % loss of sinus rhythm, 22,5 % intermittent atrial flutter, 22,5 % junctional rhythm, 7,5 % paroxysmal supraventricular tachycardia, 17,5 % sick sinus syndrome, 5 % premature ventricular contractions), severe tricuspid regurgitation (15 %), severe right ventricular failure (5 %), baffle leaks (27,5 %), baffle obstructions (17,5 %), and pulmonary artery hypertension. CONCLUSION: The data demonstrate that adult patients who underwent atrial switch operation in early childhood need long term follow-up to allow early recognition and treatment of late complications, even in asymptomatic patients.

Adolescent↗
PubMed1984

[Clinical application of two-dimensional echocardiography in fetal cardiac arrhythmias].

Fetal echocardiography was performed in 16 patients referred for the evaluation of cardiac arrhythmias at 29 to 39 weeks' gestation and in 5 normal fetuses for the control. In all fetuses, the heart could be visualized by two-dimensional echocardiography. Monitoring the four-chamber view by two-dimensional echocardiography, we examined recorded the contraction sequence of the atrial and ventricular walls and the ventricular septum by single or dual M-mode echocardiograms, and could diagnose various arrhythmias including atrial flutter, complete and incomplete heart blocks, premature contractions and sinus arrhythmias. These arrhythmias frequently accompanied with heart failure, which was evaluated fairly well by total cardiac dimensions echocardiographically determined. Ascites, pleural effusion, pericardial effusion and skin edema were mostly observed in severe congestive heart failure.

Arrhythmias, Cardiac↗
PubMed1981

[Visualization of the false tendon in the left ventricle with echocardiography and its clinical significance (author's transl)].

Echocardiographic features of the false tendon in th left ventricle and its clinical significance were reported. The subjects consisted of 132 consecutive patients, in whom the left ventricle was satisfactorily examined from various aspects with two-dimensional echocardiography. In general, the false tendon was detected in the long axis view of the left ventricle from the apical approach. It was detected in 61 of 132 consecutive patients with echocardiography. The incidence did not seem to be related to the kinds of underlying conditions. The false tendon was usually a string, a few millimeters in width, crossing the ventricular cavity from the vicinity of the papillary muscles to the interventricular septum. In a few patients it looked as Y-figure and net like. Sometimes, several sticks of the false tendon were detected. It was observed to be stretched in diastole and relaxed in systole. On the M-mode echocardiogram the false tendon was displayed as a linear echo moving with heart beat. The false tendon revealed near the interventricular septum, exhibited a motion so similar to that of the interventricular septum that it should be carefully differentiated from the echo of the left ventricular surface of the septum. In 2 patients of valvular heart disease, it was observed to be fluttered in diastole. Echocardiography was more useful in detecting the false tendon than left ventriculography.

Aged↗
PubMed1993

[Clinical effectiveness, adverse effects and complications of intravenous administration of ATP in paroxysmal tachycardia].

Forty patients with paroxysmal tachycardias were studied. After intravenous bolus administration of ATP, 10-20 mg sinus rhythm restored in 24 patients with nodal reciprocal tachycardia or Wolff-Parkinson-White syndrome. In patients with ventricular tachycardia, antidromal paroxysmal tachycardia in the presence of the Wolff-Parkinson-White syndrome and atrial flutter, bolus administration of ATP made the diagnosis more precise. Adverse reactions were seen in 75% of patients. There was a case of cardiac asystole, 50 sec long, with symptoms of clinical death. The sick sinus syndrome and atrioventricular block are regarded as a contraindication for bolus administration of ATP due to binodal dysfunction induced by the agent.

Adenosine Triphosphate↗