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PubMed1984

Pathophysiology of re-entrant dysrhythmias.

Re-entry was demonstrated as a self-perpetuating mechanism as early as 1906. It may lead to single-cycle electrocardiographic phenomena as well as reciprocating tachycardias. Factors favouring re-entry are as follows. Unidirectional or temporary local block of conduction, a mechanism always involved in initiation of reciprocating rhythms but also of importance for the maintenance of the arrhythmia. Increased myocardial mass. Decreased conduction velocity. Accelerated repolarization, e.g. short refractoriness. Increased dispersion of refractoriness. Regular reciprocating tachycardias utilize re-entrant mechanisms and are found in all components of the excitable cardiac tissue. Examples of such arrhythmias are reciprocating sinus tachycardia (RST), reciprocating atrial tachycardia (RAT), reciprocating junctional tachycardia (RJT), reciprocating atrioventricular tachycardia in connection with accessory pathways and ventricular tachycardia in the chronic stages of myocardial infarction. Re-entry mechanisms are also involved in fibrillation and flutter, in atria as well as in ventricles.

Arrhythmias, Cardiac↗
PubMed1986

Evolution of a hereditary cardiac conduction and muscle disorder: a study involving a family with six generations affected.

This study describes six generations of a family with autosomal dominant cardiac conduction system and myocardial disease with recognizable clinical stages. A 20 year follow-up of nine family members, a medical questionnaire of 196, electrocardiographic screening of 91, noninvasive testing of 20, and catheterization with endomyocardial biopsy of six are the basis of this report. The clinical stages are as follows: Stage I occurs in the second and third decades of life and is characterized by an absence of symptoms, normal heart size, sinus bradycardia, and premature atrial contractions. Stage II is marked by first-degree atrioventricular block in the third and fourth decades. Stage III occurs in the fourth and fifth decades and is accompanied by chest pain, fatigue, lightheadedness, and advanced atrioventricular block followed by the development of atrial fibrillation or flutter. Stage IV, in the fifth and sixth decades of life, is characterized by congestive heart failure and recurrent ventricular arrhythmias. Light microscopy of right ventricular endomyocardial biopsy specimens from patients in stage II revealed very mild fibrosis; electron microscopy of the specimens demonstrated mild dilatation of tubules, mitochondrial swelling, and minimal myofibrillar loss. Biopsy specimens from patients with stage III disease were similar to those from patients with stage II disease except for an increase of myofibrillar loss. The stage IV specimens had diffuse fibrosis and more severe tubular dilatation, mitochondrial cristolysis, and myofibrillar loss. At autopsy in the proband, the atrial changes were more severe than the ventricular and were especially marked in the sinoatrial and atrial myocardium. Early recognition of the disease and use of pacemakers and antiarrhythmic agents have proved beneficial for affected family members. Thorough family studies of patients with conduction system disease and/or dilated cardiomyopathy are necessary to better understand the hereditary basis and natural course of this category of disease.

Adolescent↗
PubMed2002

[Electrocardiographic changes after heart transplantation].

Electrocardiographic (ECG) changes are described after heart transplantation in almost 75% patients. During the early postoperative period the usual finding are conduction disorders which in 3-5% call for implantation of a pacemaker. The most frequent persisting disorder is bundle branch block which is of clinical importance only when it has a progressive character. The incidence of postoperative atrial fibrillation or flutter is lower as compared with other cardiosurgical operations and their sudden development may be associated with acute rejection. Ventricular arrhythmias develop as a rule as a complication of advanced coronary disease of the graft and are frequently the cause of sudden death. Before the introduction of cyclosporin A a relatively reliable sign of acute rejection was a reduction of the QRS complex voltage. During contemporary treatment ECG changes develop only in severe forms of rejection, incipient changes can be recorded only by an intracardial electrogram.

Arrhythmias, Cardiac↗
PubMedDate not supplied

[Anti-arrhythmia properties of pyromecaine].

Antiarrhythmic activity of the local anesthetic pyromecaine has been studied. The drug has been shown to eliminate flutter of the atria provoked by electrical stimulation of the myocardium, by aconitin, strophanthine and barium chloride. It prevents ventricular fibrillation arising due to calcium chloride poisoning. The drug exhibits marked antiarrhythmic properties. It is similar to lidocaine but less toxic and has a broader therapeutic range. It does not produce any adverse action on myocardial contractility or conduction. Pyromecaine has been demonstrated to exert appreciable antiarrhythmic activity in patients. The Pharmacological Committee of the USSR Ministry of Health approved pyromecaine for use in medical practice as an antiarrhythmic drug.

Anesthetics, Local↗
PubMed2001

Radiofrequency catheter ablation of common-type atrial flutter guided by conventional versus electroanatomical mapping.

Radiofrequency catheter (RF) ablation aiming the complete conduction block of the cavotricuspid isthmus has become treatment of choice for common type atrial flutter. Different approaches to guide the ablation procedure are used. For the conventional approach multipolar catheters in the right atrium and in the coronary sinus are required to detect the induction of conduction block via the isthmus. RF current is applied starting at the ventricular site of the cavotricuspid isthmus under fluoroscopic control to recognise dislocation of the ablation catheter and to avoid potential complications. Three-dimensional electroanatomic (CARTO) activation mapping can be helpful to guide atrial flutter ablation. By the help of a magnetic sensor, embedded in the tip of the mapping catheter, a virtual frame of the cavotricuspid isthmus will be reconstructed. The middle region between the virtual septal and posterolateral border of the cavotricuspid isthmus will be targeted for the ablation lesion line. Both approaches have been shown to be associated with a high acute success rate and a low recurrence rate. The major difference is that the CARTO system leads to a substantial reduction of fluoroscopic time required for atrial flutter ablation. Thus, CARTO-guided ablation directed at the cavotricuspid isthmus represent a modern method for rapid and successful treatment of common-type atrial flutter with low radiation exposure. (Fig. 4, Ref. 16.)

Atrial Flutter↗
PubMed1977

Bi-morphic atrial flutter.

A case of atrial flutter whose classic "saw-tooth" morphology, resistant to full doses of digoxin and quinidine, was changed to an unusual form by low energy direct current shock is presented. The atrial and ventricular rates remained identical in spite of the different F wave pattern before and after attempted cardioversions. 0.5 mg digoxin was given after cardioversion failed and the patient reverted to normal sinus rhythm. This case strengthens the theory of rapidly discharging atrial focus as a mechanism of atrial flutter and the case for a change in intra-atrial conductions as cause for change in atrial electrograms.

Adult↗
PubMed2000

Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial.

BACKGROUND: Arrhythmias cause much morbidity and mortality after myocardial infarction, but in previous trials, antiarrhythmic drug therapy has not been convincingly effective. Dofetilide, a new class III agent, was investigated for effects on all-cause mortality and morbidity in patients with left-ventricular dysfunction after myocardial infarction. METHODS: In 37 Danish coronary-care units, 1510 patients with severe left-ventricular dysfunction (wall motion index < or = 1.2, corresponding to ejection fraction < or = 0.35) were enrolled in a randomised, double-blind study comparing dofetilide (n=749) with placebo (n=761). The primary endpoint was all-cause mortality. Secondary endpoints included cardiac and arrhythmic mortality and total arrhythmic deaths. Analyses were by intention to treat. FINDINGS: No significant differences were found between the dofetilide and placebo groups in all-cause mortality (230 [31%] vs 243 [32%]), cardiac mortality (191 [26%] vs 212 [28%]), or total arrhythmic deaths (129 [17%] vs 140 [18%]). Atrial fibrillation or flutter was present in 8% of the patients at study entry. In these patients, dofetilide was significantly better than placebo at restoring sinus rhythm (25 of 59 vs seven of 56; p=0.002). There were seven cases of torsade de pointes ventricular tachycardia, all in the dofetilide group. INTERPRETATION: In patients with severe left-ventricular dysfunction and recent myocardial infarction, treatment with dofetilide did not affect all-cause mortality, cardiac mortality, or total arrhythmic deaths. Dofetilide was effective in treating atrial fibrillation or flutter in this population.

Adult↗
PubMed1990

[Frequency of the onset of supraventricular tachyarrhythmias as a function of underlying heart disease].

The prevalence of inducible ventricular arrhythmias is related to the underlying pathology. This study was undertaken to determine the prevalence of supraventricular tachyarrhythmias (SVT), atrial tachycardia, flutter or fibrillation, sustained for over 30 seconds. Programmed atrial stimulation was used to deliver 1 or 2 extrastimuli during sinus and paced rhythm in 230 subjects without obvious cardiac disease (149 without and 81 with spontaneous SVT) and 432 patients with documented cardiac pathology (407 without and 25 with spontaneous SVT). The incidence of inducible SVT with respect to that of spontaneous SVT and in relation to cardiac pathology was as follows: (table; see text) The prevalence of inducible SVT in patients without spontaneous SVT was related to the type of pathology: (table; see text) These results show that in patients with spontaneous SVT the induction of the arrhythmia was facilitated by the presence of underlying cardiac pathology (sensitivity increasing from 67% to 88%). In patients without spontaneous SVT, the nature of the underlying disease was related to the prevalence of inducible SVT, the risk being major in SA block, right ventricular dysplasia and mitral valve prolapse (60-80%) and moderate in dilated CMP and myocardial infarction (35 to 40%).

Adult↗
PubMed1992

Flecainide therapy in patients treated for supraventricular tachycardia with near normal left ventricular function.

Concerns about the safety and efficacy of class IC antiarrhythmic agents have arisen as a result of the recent CAST data. We reviewed records of 175 consecutive patients treated with flecainide between July 1, 1988 and July 5, 1989. One hundred ten patients with normal or mildly impaired left ventricular function and symptomatic supraventricular arrhythmias were identified. Follow-up data were obtained on 102 patients for a mean of 14 months. The average duration of flecainide therapy was 13 months. Tachyarrhythmias treated included atrial fibrillation/flutter, atrioventricular reentry, and atrioventricular nodal reentry. Flecainide provided effective antiarrhythmic therapy in 62% of the patients and was discontinued in 38% of the patients. Left atrial size did not predict treatment failure. Two patients developed proarrhythmic events (nonsustained ventricular tachycardia). There were no deaths during the follow-up period. In conclusion, flecainide provides safe and effective therapy for supraventricular tachyarrhythmias in patients with normal or mildly impaired left ventricular function.

Atrial Fibrillation↗
PubMed1995

Efficacy and proarrhythmia of oral sotalol in pediatric patients.

OBJECTIVES: This study sought to assess the efficacy of oral sotalol for various arrhythmias in pediatric patients and to evaluate the incidence of proarrhythmia and systemic side effects. BACKGROUND: Sotalol is a beta-adrenergic blocking agent with additional class III antiarrhythmic properties. Experience in pediatric patients is limited. Data concerning the incidence of proarrhythmia in children are lacking. METHODS: Seventy-one pediatric patients (mean age 7.3 years) with various supraventricular and ventricular tachyarrhythmias were treated with oral sotalol. All the patients were admitted to the hospital for initiation of sotalol therapy. Antiarrhythmic and proarrhythmic effects of sotalol were assessed by daily surface electrocardiograms (ECGs) during the in-hospital phase and by serial Holter monitoring. RESULTS: Sotalol was either completely (27 [66%] of 41 patients) or partially effective (11 [27%] of 41) in 38 (93%) of 41 patients with supraventricular reentrant tachycardias. In patients with atrial flutter predominantly after operation for congenital heart disease, sotalol was effective in 84% of patients (completely in 9 of 19 and partially in 7 of 19). Ventricular tachycardia was completely (3 of 11) or partially (4 of 11) controlled in 64% of children. Proarrhythmia occurred in seven patients (10%) and consisted of symptomatic bradycardia from sinoatrial block and high grade atrioventricular (AV) block, respectively, in two children; asymptomatic high grade AV block in one; torsade de pointes in one; and relevant increased ventricular ectopic activity in three. Proarrhythmia required drug discontinuation in four patients. Mean duration of treatment for all patients was 18 months (range 1 to 40). CONCLUSIONS: Sotalol was an effective antiarrhythmic drug for a wide range of pediatric tachyarrhythmias. The considerable number of patients with proarrhythmic effects indicates the need for initiation of treatment on an inpatient basis and close monitoring by serial Holter electrocardiography.

Administration, Oral↗
PubMed2002

New insights into onset mechanisms of atrial fibrillation and flutter after coronary artery bypass graft surgery.

OBJECTIVE: To determine by means of a monitoring study the onset mechanisms of atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG). PATIENTS AND DESIGN: During elective CABG, 81 patients had one bipolar atrial and one ventricular epicardial electrode attached. These were connected to a Vitatron 900E external pacing device, which monitored the patients for four consecutive days. 12 lead ECGs were obtained if AF was clinically detected and Holter ECGs were obtained in 8 (33%) of these patients. RESULTS: 24 patients (30%) developed paroxysmal AF (50%), atrial flutter (17%), or both (33%). The number of AF episodes varied from 1-169 a day (median 5) and were usually of short duration (median 2.25 minutes). Pacemaker diagnostics showed much intrapatient and interpatient variability in onset mechanisms but the majority of AF onsets (71%) were preceded by either short runs of AF or multiple atrial extrasystoles. The final trigger was a conducted atrial extrasystole in 72% of cases. There were no bradycardic triggers. The Holter ECGs confirmed the device's data. CONCLUSIONS: The onset mechanisms of post-CABG AF are dominated by atrial extrasystoles with multiple atrial extrasystoles and short runs of AF preceding the main AF onset in the majority of cases. These results have major implications for the development of new preventive pacing algorithms.

Angina Pectoris↗
PubMed1993

Combined use of esmolol and digoxin in the acute treatment of atrial fibrillation or flutter.

Safety and efficacy of simultaneous use of intravenous digoxin and esmolol in the control of rapid heart rate in 21 patients with atrial fibrillation or flutter was assessed. The mean age was 67 (range 40 to 90) years. Seven patients had class III congestive heart failure, with left ventricular ejection fraction between 18% and 61%. Baseline mean heart rate was 143 +/- 4. After 0.25 mg or 0.5 mg intravenous digoxin, esmolol was titrated with initial boluses from 2 mg/min to 16 mg/min in 25 minutes. A tolerated dose of esmolol infusion was adjusted for up to 48 hours. Rapid control of heart rate (29% decrease with heart rate 101 +/- 4) occurred at a mean interval of 21 minutes. Minimum heart rate was 87 +/- 4 at 90 minutes of treatment. Conversion to sinus rhythm occurred in five patients (25%), and one patient experienced mild transient congestive heart failure. No symptomatic hypotension or bronchospasm occurred. In conclusion, simultaneous use of digoxin and esmolol is effective in safely and rapidly controlling heart rate in atrial fibrillation or flutter.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

[Radiofrequency ablation in the treatment of tachyarrhythmias. Experience concerning 1,000 consecutive patients].

Several reports have demonstrated that radiofrequency catheter ablation provides effective control of a variety of tachyarrhythmias. This report details the results of radiofrequency catheter ablation in 1,000 consecutive patients with a wide variety of tachyarrhythmias treated in the Instituto Nacional de Cardiología "Ignacio Chavez". Tachyarrhythmias were associated with the presence of an accessory pathway in 700 patients (70%). Dual accessory pathways were present in 21 patients, giving a total of 722 accessory pathways. The mechanism of the arrhythmia was AV nodal reentrant tachycardia in 204 patients (20.4%). Ablation of the reentrant circuit of atrial flutter within the right atrium was attempted in 56 (5.6%) patients and a primary atrial tachycardia in five patients (0.5%). AV node ablation and permanent pacemaker implantation were performed in 17 patients (1.7%). Finally we performed radiofrequency catheter ablation in 22 (2.2%) patients with ventricular tachycardia. Radiofrequency catheter ablation was successful in 630 of 700 (90%) patients with accessory pathways with a complication rate of 9/700 (1.2%) and a recurrence rate of 73 (12.4%). AV nodal reentry was successfully abolished in 190 of 204 (93%) patients by selective ablation of the slow pathway in 168/180 (93.3%) patients and the fast pathway in 22/24 (92%) patients. The complication rate of this group was 7/204 (3.4%) with a recurrence rate of 30 patients (14.2%). The reentrant circuit of atrial flutter was ablated successfully in 41 of 56 (73%). Four/five (80%) of patients with primary atrial tachycardia were successfully ablated. Complete AV block was achieved in 17/17 patients with atrial fibrillation or flutter treated by AV nodal ablation without complications or recurrence. The procedure was successful in 17/22 (77%) of patients with ventricular tachycardia. The results of this series of patients demonstrate the safety and efficacy of radiofrequency ablation for the treatment of a wide variety of tachyarrhythmias with high rate of success 899/1,000 (89.9%) and with an 1 1.8% of recurrence, low risk of complications (1.5%) and no mortality.

Adolescent↗
PubMed1987

Termination of spontaneous atrial flutter by transesophageal pacing.

Transesophageal atrial pacing using the constant-rate technique was performed in 26 patients presenting with spontaneous atrial flutter (atrial cycle length between 180 and 270 ms). All but one patient had been treated with one or more antiarrhythmic agents (digoxin, quinidine, procainamide, propranolol, verapamil, diltiazem, and propafenone) within the previous 12 hours. Transesophageal atrial pacing at cycle lengths between 80 and 180 ms was successful in terminating atrial flutter in 22 patients: immediate reversion to sinus rhythm in 16, following transient sinus pause in one, following a brief period of atrial fibrillation in three, and following longer periods of atrial fibrillation in another two. No post-conversion ventricular arrhythmia and no other complications were observed. All patients experienced only a mild burning discomfort during the procedure. It is concluded that atrial pacing via the esophagus is a safe and noninvasive technique of terminating spontaneous atrial flutter. The effectiveness of this technique is comparable to endocardial or epicardial atrial pacing.

Adolescent↗
PubMed1980

Cardiac arrhythmias: mechanisms and management: II. Electrocardiographic analysis of cardiac arrhythmias.

Optimal diagnosis may require continuous monitoring, intracardiac studies, or provocative electrophysiologic testing, in addition to the standard 12-lead ECG. One must keep in mind that clinical significance is largely a function of the patient's clinical condition and of the arrhythmia's site of origin. In general, supraventricular arrhythmias are less threatening than ventricular.

Adolescent↗
PubMed1980

[Hemodynamic and electrophysiologic effects of the new calcium antagonist Ro 11-1781 (author's transl)].

In a 3-part study the new calcium-antagonist Ro 11-1781 was investigated in respect to hemodynamic, electrophysiologic and antiarrhythmic effects. In the first part of the investigation, systolic time intervals were determined as an indicator of left ventricular performance in 10 patients without cardiac disease before and 5 min after i.v. injection of Ro 11-1781 (1 mg/kg/body weight). At the same time blood pressure was measured. There was a significant decrease in systolic and diastolic blood pressure (p < 0.01). Due to the resulting activation of the sympathetic nervous system by baroreflex, heart rate increased by 7 bpm (p < 0.01), there was a shortening of the pre-ejection period PEPc by 15 ms (p < 0.01), whereas left ventricular ejection time LVETc was not changed significantly. The ratio PEPc/LVETc decreased significantly (p < 0.01), reflecting the increase of left ventricular contractility, which results from the activation of the sympathetic nervous system. The PQ interval was increased (16 ms, p less than 0.01), an atrioventricular block however was not seen. In the second part of the investigation, sinus node function was studied in 8 patients by His-bundle electrography and programmed stimulation of the right atrium. There was no significant change in sinus-node recovery time, sinu-atrial conduction time, sinus-node rate and atrial conduction time in response to Ro 11-1781. However, in 2 patients with sinus-bradyarrhythmia a second-degree sinu-atrial block was provoked by the calcium-antagonist. The drug was shown to have a negative dromotrope effect to the AV node, reflected by an increase of the PQ interval (p < 0.01), AH interval (p < 0.01) and a decrease (p < 0.01) of the maximal 1:1 conduction of the AV node, whereas the HV interval was not changed significantly. The antiarrhythmic effects of Ro 11-1781 were studied in 13 patients with atrial flutter, atrial fibrillation or paroxysmal supraventricular tachycardia: In 10 patients the injection of the calcium-antagonist produced a marked decrease in ventricular rate for a short time reflecting a neagative dromotrope effect in the AV node. In 5 patients conversion to sinus rhythm was observed.

Adult↗
PubMed1975

The course of acute myocardial infarction. Feasibility of early discharge of the uncomplicated patient.

This report represents our experience with 522 consecutive patients with acute myocardial infarction admitted directly to the Duke Coronary Care Unit. Fifty items of information were used to characterize the patients, their hospital course and follow-up. Serious complications included death, ventricular tachycardia or fibrillation, second- or third-degree heart block, pulmonary edema, cardiogenic shock, persistent sinus tachycardia or hypotension, atrial flutter or fibrillation, and extension of infarction. Forty-nine percent of the patients (252 of 522) experienced a serious complication. All patients who experienced any serious complications had at least one of the above during the first four days of hospitalization. Patients who survived through day 4 were subgrouped on the basis of the occurrence (complicated) or lack of occurrence (uncomplicated) of the above on day 5. Complicated patients had a subsequent hospital mortality of 14% and an incidence of late serious complications of 51%. Patients who were uncomplicated through day 4 had a subsequent hospital mortality of zero and an incidence of late serious complications of zero. These data suggest that it would be feasible and ethically justified to conduct a prospective clinical trial of early discharge (7th day) in patients who meet the above criteria for uncomplicated. The potential economic savings through earlier discharge in uncomplicated patients are of major significance.

Arrhythmias, Cardiac↗
PubMed1998

Use of atrial and ventricular electrograms from a dual chamber implantable cardioverter defibrillator to elucidate a complex dysrhythmia.

Stored intracardiac electrograms provided by third-generation ICDs have proved their use in the analysis of the mechanism of tachydysrhythmic events. There are cases in which the analysis of ventricular electrograms is insufficient for the elucidation of certain dysrhythmias. The availability of atrial electrograms provided by dual chamber ICDs improves the diagnostic capability of electrogram analysis and could prove most useful especially in complex dysrhythmias.

Aged↗