[Electrotherapy of threatening arrhythmias in acute phase of myocardial infarct].
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Arrhythmias, Cardiac↗
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Cardiac flutter and fibrillation.
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Arrhythmias, Cardiac↗
[Data on disopyridamide therapy of some arrhythmias].
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Arrhythmias, Cardiac↗
[Electrocardiographic aspects of atrial fibrillations].
The electrocardiographic analysis of atrial fibrillation is usually easy. However, some cases may be difficult to interpret: the organisation and voltage of the fibrillation waves can be very variable leading to appearances of atypical flutter in cases with large "f" waves or, conversely, in cases with low voltage fibrillation, to those of sinus mode dysfunction. The ventricular response may be slow: the conduction is usually delayed in the atrioventricular node where concealed conduction plays an important role in determining the ventricular response. Regular ventriculogrammes correspond to a junctional or ventricular escape rhythms. Aberrant conduction in the His-Purkinje system may sometimes be observed after long diastoles (phase 4 block) but often terminates short, preceded by long cycles (phase 3 block). It is usually easy to differentiate them from ventricular ectopics or preexcitation by careful examination and application of classical diagnostic criteria.
Atrial Fibrillation↗
The cumulative risks of prolapsing mitral valve. 40 years of follow-up.
Prolapsing mitral valve is a common cardiac condition, occurring in approximately 16 million people in the United States alone. Primary prolapsing mitral valve may be familial or nonfamilial and may be associated with myxomatous degeneration of the mitral valve leaflets, such as occurs in Marfan syndrome and other connective tissue disorders. Secondary forms may be associated with such entities as rheumatic fever (especially after commissurotomy) and coronary artery disease (in the presence of ruptured chordae tendineae), and with such congenital conditions as interatrial defect and primary cardiomyopathy with outflow tract obstruction. Prolapsing mitral valve is characterized by late systolic murmur, mid-systolic click, or both. Arrhythmias occur in the form of benign premature atrial contraction, premature nodal contraction, and paroxysmal atrial tachycardia. As the patient ages, atrial flutter and atrial fibrillation tend to develop. In some chronic cases, especially those involving atrial fibrillation, systemic emboli may occur. Rare premature ventricular contractions may be largely benign, whereas more frequent premature ventricular contractions may lead to severe arrhythmic complexes such as ventricular tachycardia or ventricular fibrillation. With advancing age, atrioventricular conduction defects of varying degrees or sick sinus syndrome may necessitate a pacemaker installation. About one quarter of prolapsing mitral valve cases progress, with increasing mitral insufficiency and increasing enlargement of the left atrium and left ventricle, which at times leads to congestive heart failure. Coronary artery disease may occur with the severity commensurate with the patient's age group. About three quarters of patients with prolapsing mitral valve syndrome lead normal lives.
Disease Progression↗
Prognostic factors in acute myocardial infarction.
The hospital courses of 882 consecutive patients with acute myocardial infarction admitted to the coronary care unit (CCU) during a 3-year period were evaluated. Their courses after discharge from the CCU were assessed with reference to the following serious complications which had occurred during their stay in the CCU; ventricular tachycardia or fibrillation, second-or third-degree heart block, pulmonary oedema, cardiogenic shock persistent sinus tachycardia, persistent hypotension, atrial flutter or fibrillation, or extension, or extension of infarction. Of the 494 patients (56%) with one or more of these complications, 38 (8%) died of cardiac causes in hospital after transfer from the CCU. Of 388 patients (44%) in the uncomplicated group, only 2(0,5%) died of cardiac causes after transfer from the CCU. The same patients were classified according to the Coronary Prognostic Index (CPI) of Norris. None of the 54% of patients with a CPI of less than 6 units died in hospital after transfer from the CCU. It is proposed that patients with a CPI of less than 6 units and with none of the listed serious complications during their CCU stay could safely be discharged from hospital earlier than is customary.
Acute Disease↗
[Pharmacotherapy of supraventricular arrhythmias. What comes, what remains, what goes?].
Supraventricular tachycardias consist of AV-nodal-reentrant-tachycardias, atrioventricular tachycardias with accessory pathways (WPW-syndrome), atrial tachycardias, atrial fibrillation and atrial flutter. Only specific ECG interpretation with an exact arrhythmia classification offers the way to perform modern differential therapy including drug treatment and also interventional therapy modalities. In atrial fibrillation, drug treatment is still first-line therapy: physicians have to make a decision either to follow the rate or rhythm control concept. In case of rhythm control, drug therapy is tailored to the individual patient taking into account the patients symptomatology, left ventricular ejection fraction and nature and degree of an underlying cardiac disease. Drug refractory symptomatic atrial fibrillation patients should be considered for interventional treatment like pulmonary vein ablation. Recurrent typical right atrial flutter, AV-nodal-reentrant-tachycardia and all forms of atrioventricular tachycardias however are indications for catheter ablation; long-term drug treatment will only be performed in rare cases.
Anti-Arrhythmia Agents↗
The effect on atrial and ventricular intracellular potentials, and other pharmacological actions of L9146, a non-halogenated benzo(b)thiophene related to amiodarone.
L9146 was synthesised in the hope of eliminating the unwanted side-effects of amiodarone which has been shown to be effective in the control of atrial fibrillation, flutter, and in pre-excitation syndromes such as Wolff-Parkinson-White syndrome. L9146 has pharmacological and electrophysiological effects similar to those of amiodarone. It is an antagonist of both alpha and beta adrenoceptor-mediated cardiovascular effects of a noncompetitive type. It lowers vascular resistance briefly, and causes a longer lasting bradycardia. It moderately reduces the maximum rate of depolarisation (MRD), conduction velocity, and totally suppresses ventricular pacemakers activated by high doses of isoprenaline. In addition, L9146 greatly prolongs action potential duration (APD) in atrial and ventricular muscle. In normal ventricular conducting tissue the action potential duration (APD) is shorter in the bundle of His than in the false tendons, and shorter still in the ventricular muscle. L9146 lengthened APD throughout, but particularly in the proximal portion, and even more in the muscle, so that APD became uniform. The decrement of conduction of premature action potentials was increased to the point at which slowly conducting premature AP's were eliminated altogether.
Action Potentials↗
Arrhythmias after cardiac transplantation.
The etiology and clinical significance of sustained arrhythmias, and atrial and ventricular premature complexes (APCs and VPCs, respectively) after heart transplantation are controversial. Fifty adult recipients surviving > 2 weeks were studied by continuous telemetry while in the hospital and by ambulatory electrocardiographic monitoring at 2, 4, 6, 12 and 24 weeks after transplantation. The median APC frequency was greater among subjects who experienced allograft rejection in the early postoperative period (0.7/hour, range 0 to 23) than among those who did not (0.2/hour, range 0 to 10.4) (p = 0.04). The APC frequency in all subjects decreased from 0.25/hour (range 0 to 23) early to 0/hour (0 to 14) later (p = 0.04). Atrial flutter was the most frequent sustained arrhythmia; it was recorded in 5 of 21 rejectors and in 1 of 29 nonrejectors (p = 0.04), and 11 of 16 episodes (69%) were related to acute rejection temporally. VPCs were recorded in all patients early after transplantation, but the median frequency subsequently decreased from 4.6/hour (range 0.5 to 470) early to 1.25/hour (range 0 to 225) later (p < 0.001). VPC frequency was unrelated to rejection. Sustained ventricular tachycardia was recorded once and was caused by the proarrhythmic effect of flecainide. Thus, APCs and VPCs occur frequently after transplantation. Frequent APCs are associated with rejection, whereas the main determinant of VPC frequency is time after transplantation. Atrial flutter is closely associated with rejection and should be regarded as an indication for endomyocardial biopsy. Ventricular tachycardia occurs seldom, and in this study was due to proarrhythmic drug effects.
Adult↗
Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure.
The purpose of this study was to prospectively determine the incidence of diastolic mitral and tricuspid regurgitation in atrioventricular (AV) block using Doppler echocardiography. The temporal relation between mitral and tricuspid diastolic insufficiency and the diastolic murmur recorded in patients with complete heart block was also investigated. Twenty-two consecutive patients with AV block (referred to the Echo-Doppler laboratory for routine clinical studies), aged 18 to 87 years, were enrolled in the study. Eleven patients had third degree AV block and a ventricular-inhibited (VVI) pacemaker, two patients had second degree AV block, seven patients had first degree AV block, one patient had blocked premature atrial complexes and one patient had atrial flutter with 4:1 AV block. Diastolic mitral regurgitation was detected in 20 patients, and diastolic tricuspid regurgitation in 21. A mid-diastolic murmur was detected in all patients except in the three youngest. The murmur occurred before diastolic regurgitation and coincided with peak forward flow through the AV valve after atrial contraction. M-mode mitral valve echocardiograms obtained in nine patients demonstrated near closure of some portions of the mitral valve after atrial contraction. Effective closure of the valve, however, did not occur unless ventricular systole supervened. In conclusion, diastolic mitral and tricuspid regurgitation are almost universally present in patients with AV block and are associated with a diastolic murmur. The murmur coincides with forward AV valve flow. Diastolic regurgitation is silent. Effective AV valve closure is not established until ventricular systole occurs, as demonstrated by M-mode echocardiographic recording of the mitral valve.
Adult↗
Atrial fibrillation in the pacemaker clinic.
BACKGROUND: Electrocardiographic (ECG) recognition of the underlying rhythm in patients with ventricular pacing can be difficult. Atrial fibrillation (AF) in particular may go unreported. OBJECTIVES: To compare the underlying atrial rhythm determined in the pacemaker clinic with the 12-lead ECG interpretation of the atrial rhythm in those who were continuously paced in the ventricle. It was intended to determine whether long term anticoagulation therapy was related to whether AF was diagnosed before or after pacemaker implantation. METHODS: Pacemaker clinic patients were enrolled if they had a 100% paced ventricular rhythm. The underlying rhythm was determined using pacemaker programming manoeuvres. A 12-lead ECG was recorded on all patients within 10 min of their pacemaker assessment and interpreted by one of the several geographic full-time cardiologists at the centre. All cardiologists were blinded to the results of pacemaker assessment and to the clinical history. RESULTS: Fifty-six patients were enrolled. At the pacemaker clinic, 37 were determined to be in AF and three were in atrial flutter (AFL). Of these 40 patients with AF/AFL, 28 were correctly identified as such on the 12-lead ECG interpretation. Twelve of the 40 were interpreted only as having an 'electronic ventricular pacemaker' (EVP). Sixteen of the 40 patients (40.0%) with AF or AFL were not taking warfarin. Twenty-two of 25 patients with an AF/AFL diagnosis before pacemaker implantation were taking warfarin, compared with two of 15 patients with AF/AFL diagnosis after pacemaker implantation (P<0.0001). CONCLUSION: These results show that the underlying rhythm in patients with ventricular pacing is frequently unrecognized by routine ECG interpretation. This may be of particular importance in the AF/AFL population as a potential contributor to the underuse of warfarin, especially when AF develops after pacemaker implantation. The pacemaker clinic may be in a position to play an important role in the identification of these patients.
Ambulatory Care Facilities↗
Cardiac pacing in intensive care.
Cardiac pacing techniques and equipment have developed dramatically in recent years. Bradycardias and tachycardias may be effectively treated by pacing. Bradyarrhythmias: It is generally accepted that pacing is indicated for a sustained symptomatic bradycardia. Prophylactic pacing for 'high-risk' bundle branch block in acute myocardial infarction is more controversial. A new era in cardiology has been introduced with the advent of 'physiological pacing', i.e. pacing of the heart with the maintenance of atrioventricular synchrony and varying the heart rate according to the body's metabolic leads. Modern pacing systems, which allow the atria and ventricles to contract in sequence, improve cardiac haemodynamics, result in subjective improvement and increase exercise tolerance. There are, however, pacemaker-associated and pacemaker-mediated tachyarrhythmias. Further advances in technology should overcome these problems. Tachyarrhythmias: Intracardiac electrocardiograms are often useful in the diagnosis of tachyarrhythmias, especially wide complex tachycardias. Rapid pacing of the atria in certain supraventricular tachycardias or of the ventricle in ventricular tachycardia is an alternative to cardioversion in many instances. This form of treatment is usually utilised in conjunction with drug therapy.
Arrhythmias, Cardiac↗
Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation.
OBJECTIVES: This multicenter study compared the efficacy and safety of ibutilide versus procainamide for conversion of recent-onset atrial flutter or fibrillation. BACKGROUND: Ibutilide fumarate is an intravenous (IV) class III antiarrhythmic agent that has been shown to be significantly more effective than placebo in the pharmacologic conversion of atrial flutter and fibrillation to sinus rhythm. Procainamide is commonly used for conversion of recent-onset atrial fibrillation to normal sinus rhythm. METHODS: One hundred twenty-seven patients (age range 22 to 92 years) with atrial flutter or fibrillation of 3 h to 90 days' (mean 21 days) duration were randomized to receive either two 10-min IV infusions of 1 mg of ibutilide fumarate, separated by a 10-min infusion of 5% dextrose in sterile water, or three successive 10-min IV infusions of 400 mg of procainamide hydrochloride. RESULTS: Of the 127 patients, 120 were evaluated for efficacy: 35 (58.3%) of 60 in the ibutilide group compared with 11 (18.3%) of 60 in the procainamide group had successful termination within 1.5 h of treatment (p < 0.0001). Seven patients were found to have violated the protocol and were not included in the final evaluation. In the patients with atrial flutter, ibutilide had a significantly higher success rate than procainamide (76% [13 of 17] vs. 14% [3 of 22], p=0.001). Similarly, in the atrial fibrillation group, ibutilide had a significantly higher success rate than procainamide (51% [22 of 43] vs. 21% [8 of 38], p=0.005). One patient who received ibutilide, which was found to be a protocol violation, had sustained polymorphic ventricular tachycardia requiring direct current cardioversion. Seven patients who received procainamide became hypotensive. CONCLUSIONS: This study establishes the superior efficacy of ibutilide over procainamide when administered to patients to convert either atrial fibrillation or atrial flutter to sinus rhythm. Hypotension was the major adverse effect seen with procainamide. A low incidence of serious proarrhythmia was seen with the administration of ibutilide occurring at the end of infusion.
Aged↗
[Endocavitary electric exploration in the study of auricular dysrhythmias].
His bundle recording combined with atrial pacing permit to evaluate atrio-ventricular conduction and the function of the sinus node by measuring the corrected sinus recovering time (CSRT). Three groups of 10 patients are included in this study: -- Group I is composed of control patients; the CSRT varies between 30 and 450 msec (mean value : 320 msec +/- 123.3). Neither atrio-ventricular nor intraventricular block was observed during His bundle recording combined with atrial pacing. -- Group II, composed of patients with atrial dysrhythmia has a CSRT varying from 720 to 5.900 msec (mean value: 2.750 msec +/- 184.5). Six of these patients have atrio-ventricular conduction disturbances. -- In group III all patients had atrio-ventricular or intraventricular conduction defects without atrial dysrhythmia. CSRT varies between 205 and 510 msec (mean value: 310 +/- 88.6). The authors conclude that atrial dysrhythmia is probably an original degenerative disease which is different from the "Lenègre" disease, by his incidence, the location of the lesions and the clinical issue. This conclusion is made by comparing the results of the authors with the analysis by James of the embryogenesis of the sinus node and of atrial and atrio-ventricular pathways.
Adult↗
Conversion of atrial flutter: rapid atrial pacing as a bedside technique.
Eleven patients with atrial flutter underwent intracardiac right atrial pacing at bedside in an attempt to terminate this dysrhythmia. Nine of the eleven patients were converted to sinus rhythm; the remaining two patients were converted to atrial fibrillation with a slower ventricular rate. There were no complications. The potential hazards of direct current cardioversion (anesthesia, fractures, muscle strain, myocardial injury, etc.) were avoided. In contrast to rapid atrial pacing in the electrophysiology laboratory, the bedside technique did not require a special laboratory setting, electronic or x-ray equipment, or technical personnel. Transportation of critically ill patients was obviated. Atrial flutter can be converted at the bedside to a more favorable rhythm; the expediency, safety, and low cost of this bedside cardioversion technique not only makes it feasible, but also it is often the procedure of choice.
Adult↗
Definitive palliation with cavopulmonary or aortopulmonary shunts for adults with single ventricle physiology.
OBJECTIVE: To compare the relative merits of cavopulmonary or aortopulmonary shunts, or both, as definitive non-Fontan palliations for patients with single ventricle physiology. DESIGN: Clinical data, ECG, echocardiographic data, surgical records, and available postmortem material were reviewed in all patients with single ventricle physiology identified from the University of Toronto Congenital Cardiac Centre for Adults (UTCCCA) database who had not undergone a Fontan operation. Current status of patients was assessed from clinic reviews and patient contact. Two groups of patients were identified: those with cavopulmonary shunt (group 1, n = 35); and those with aortopulmonary shunt(s) only (group 2, n = 15). RESULTS: 50 adults (21 male/29 female) who underwent the last palliation at a median age of 11 years (range 1 day to 53 years) were identified. During a mean (SD) follow up of 13.0 (6.2) years at the UTCCCA, 19 patients died. Survival is 89.4% and 51.9% at 10 and 20 years, respectively, from the time patients were first seen at UTCCCA, with no differences between the groups. Most recent New York Heart Association (NYHA) classification was I-II in 21 patients, III in 25, and IV in four patients; mean haemoglobin was 190 (28) g/l, and oxygen saturation was 82 (4)%, with no group differences. Arrhythmia developed in 25 patients (atrial flutter/fibrillation in 20 and/or sustained ventricular tachycardia in 11). Atrial flutter/fibrillation was more common in patients in group 2, who also showed a greater decline in ventricular function with time. Age at last palliation, cardiothoracic ratio, and inclusion in group 2 were predictive of atrial flutter/fibrillation, poor ventricular function predictive of ventricular tachycardia, NYHA class > III, and prior ventricular tachycardia predictive of death. CONCLUSIONS: Cavopulmonary or aortopulmonary shunts, or both, provide sustained palliation for selected patients with single ventricle physiology. Survival for both compares favourably with published Fontan series. Compared to aortopulmonary shunts, cavopulmonary shunts convey a beneficial long term effect on ventricular function. Arrhythmia is a major cause of late morbidity in these patients, relating to both ventricular dysfunction and death. Onset of sustained ventricular tachycardia is an ominous sign.
Adult↗
Mechanism of flutter and fibrillation.
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Arrhythmias, Cardiac↗
Effectiveness of intravenous propafenone for conversion of atrial fibrillation and flutter of recent onset.
The efficacy of intravenous propafenone (2 mg/kg) was assessed in 83 consecutive patients: 68 with atrial fibrillation (AF) and 15 with atrial flutter lasting less than 15 days. Conversion to sinus rhythm occurred in 47 patients (57%), including 42 (62%) of those with AF and 5 (33%) of those with atrial flutter (p less than 0.05). The mean time to conversion was 29 +/- 24 minutes. The success rate was strongly affected by arrhythmia duration. Thus, conversion occurred in 40 patients (71%) among the 56 with arrhythmia lasting less than 48 hours but in 7 patients (26%) among the 27 with a longer lasting arrhythmia (p less than 0.0005). Left atrial size (determined echocardiographically in 56 patients) was significantly larger in nonconverters (49 +/- 12 vs 39 +/- 7 mm, p less than 0.0005). In nonconverters the mean ventricular rate decreased from 141 +/- 26 to 104 +/- 22 beats/min (p less than 0.0005). Except for reversible low output state in 3 patients already hemodynamically compromised, no significant side effects were observed. In conclusion, (1) intravenous propafenone allows a quick restoration of sinus rhythm in the majority of patients with AF of recent onset, whereas it seems less effective in atrial flutter; (2) its efficacy is influenced by the duration of the arrhythmia and by left atrial dimensions; (3) the drug allows control of ventricular rate; and (4) its use seems to be safe except in patients with severe cardiac failure.
Adult↗