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PubMed1993

Evaluation of transesophageal echocardiography before cardioversion of atrial fibrillation and flutter in nonanticoagulated patients.

This study prospectively evaluated the role of transesophageal echocardiography (TEE) in screening for atrial thrombi before electrical cardioversion in 40 nonanticoagulated patients with nonvalvular atrial fibrillation (n = 33) or atrial flutter (n = 7). Transthoracic echocardiography did not detect atrial thrombus in any patient. TEE detected left atrial appendage thrombi in five patients (12%, p = 0.03), significantly associated with left ventricular systolic dysfunction (p = 0.02) and left atrial spontaneous echo contrast (p = 0.04). Cardioversion was cancelled in the five patients with thrombi and in two patients with spontaneous reversion before planned cardioversion. Cardioversion was successful in 25 (76%) of the 33 remaining patients. Cerebral embolism occurred 24 hours after successful cardioversion in one patient with atrial fibrillation and left ventricular dysfunction, who had left atrial spontaneous echo contrast, but no thrombus was detected by TEE before cardioversion. Repeat TEE after embolism showed a fresh left atrial appendage thrombus and increased left atrial spontaneous echo contrast. These results indicate that TEE improves the detection of left atrial appendage thrombi in candidates for cardioversion, in whom the procedure may be deferred. However, the exclusion by TEE of preexisting atrial thrombi before cardioversion does not eliminate the risk of embolism after cardioversion because of persistent atrial stasis and de novo thrombosis.

Anticoagulants↗
PubMed1983

Electrophysiologic testing: clinical applications.

Electrophysiologic studies can be used in evaluating a large number of arrhythmias and conduction disturbances. These tests are extremely useful in the diagnosis and treatment of sick sinus syndrome, paroxysmal supraventricular tachycardias, atrial flutter, and AV conduction abnormalities. The decision to implant a permanent pacemaker in patients with a history of syncope also may be aided by the results of electrophysiologic studies. Finally, electrophysiologic studies have been used in the diagnosis and treatment of recurrent sustained ventricular tachycardia and in the evaluation of survivors of cardiac arrest. It is in these last two areas that electrophysiologic testing may have its widest and most important applications.

Arrhythmias, Cardiac↗
PubMed1998

Emergence of bidirectional accessory pathway conduction in adulthood.

A 30-year-old woman presented with tachycardiomyopathy due to atrial flutter-fibrillation and underwent radiofrequency ablation of the AV node and VVIR pacemaker implantation. There was no evidence of any accessory pathway (AP) conduction during the AV nodal ablation or during chronic ventricular pacing. One year later, she had a transient preexcited tachycardia. A year after this, her ECG showed 1:1 AV conduction with preexcitation. Electrophysiologic study revealed a left lateral AP with anterograde and retrograde refractory periods of 280 and 240 msec, respectively. Successful radiofrequency ablation of the AP was performed. This case highlights a unique emergence of an AP in adult life.

Adult↗
PubMedDate not supplied

Use of ibutilide for cardioversion of recent-onset atrial fibrillation and flutter in elderly.

Ibutilide is a class III antiarrhythmic drug used for pharmacological cardioversion of recent-onset atrial fibrillation and flutter. The objective of the study was to assess the efficacy of ibutilide in elderly patients (age, >or=65 years). The study population consisted of 32 consecutive elderly patients (17 women, 15 men; mean age, 76 +/- 8 years; age range, 65-94 years) with recent-onset atrial fibrillation (19 patients) or flutter (13 patients). Ibutilide was administered 1-mg intravenously over 10 minutes, and a second 10-minute infusion of 1-mg was given if the arrhythmia did not terminate within 10 minutes after the end of initial infusion. Twenty-six patients received two 1-mg doses of ibutilide. The rate of successful arrhythmia termination was 59% (19 patients): 63% in patients with atrial fibrillation (12 of 19) and 54% in atrial flutter (7 of 12). The mean conversion time was 33 +/- 45 minutes. Three-fourths of the conversions occurred within 45 minutes of treatment. No clinical variables were correlated with success of cardioversion. Patients with a left atrial size of 50 mm or larger had a conversion rate of 50% compared with a conversion rate of 61% in patients with a left atrial size of less than 50 mm (P = NS). Ibutilide-induced lengthening in the QTc interval was of 17 +/- 21 milliseconds. Cardiac complications were torsade de pointes (1 patient), nonsustained ventricular tachycardia (1 patient), and transient bradycardia (1 patient). Torsade de pointes was terminated with direct current cardioversion. Ibutilide appears to be an effective drug for conversion of recent-onset atrial fibrillation and flutter in elderly patients under monitored conditions. Complications are rare and transient.

Aged↗
PubMed2000

[Fetal arrhythmias: diagnosis, prognosis, treatment; apropos of 33 cases].

From October 1993 to February 1998, 33 cases of fetal cardiac arrhythmia were investigated by doppler-echocardiography at the Lille infantile and congenital cardiology department. Extrasystolic arrhythmias were the most frequently encountered disorder (25 fetuses, i.e., 76% of cases: 24 instances of extrasystolic auricular arrhythmia and one case of extrasystolic ventricular arrhythmia). They were invariably benign, and apart from one case only required standard monitoring. Tachycardia was observed in 15% of cases (three cases of supraventricular tachycardia [SVT] and two cases of auricular flutter [AF]). In no instance was a cardiopathic syndrome noted. A number of efficient treatments have been described, but the prognosis is often poor in the presence of hydrops fetalis. Direct fetal treatments (cordocentesis) are currently under evaluation, and at present can only be used as a last resort. In our series, one fetus died 15 minutes after transplacental Flecaine (flecainide) administration. Two of the three SVT and the two AF cases were successfully treated. Bradycardia, which was unassociated with extrasystolic arrhythmia, was found in 9% of cases. It is concluded that Flecaine is probably the treatment of choice for supraventricular and ventricular fetal tachycardia, as it has no teratogenic effect and crosses the placenta at a fetal concentration that is 80% of the maternal level. However, the administration of this drug is not without risk. It is known to possess certain negative side effects, and its pharmacological profile and maternal and fetal health risks have not yet been fully investigated. At present, no entirely safe and efficient treatment for fetal cardiac arrhythmia has been found.

Anti-Arrhythmia Agents↗
PubMed1975

Properties of acebutolol in twenty patients with cardiac arrhythmias.

Acebutolol (M & B 17,803 A), a new cardioselective beta-adrenergic blocking agent, was given intravenously to 20 selected patients with various cardiac arrhythmias. Cumulative doses ranging from 12.5 to 50 mg were moderately or highly effective in 4 out of 4 patients with sinus tachycardia, 2 out of 3 patients with premature atrial beats, 3 out of 4 patients with premature ventricular beats, 3 out of 5 patients with atrial fibrillation (one was converted to sinus rhythm) and in 2 out of 3 patients with atrial flutter. The drug was ineffective in one patient with atrial tachycardia. Mild systolic hypotension occured in two patients with recent myocardial infarction and there was some aggravation of a preexisting bronchospasm in a patient with congestive heart failure secondary to hyper-thyroidism. It was concluded that acebutolol is a cardioselective beta-blocker which by intravenous route may be useful in the treatment of selected cardiac arrhythmias.

Acebutolol↗
PubMed1991

Closed heart cryoablation of the His bundle using an anterior septal approach.

His bundle cryosurgical ablation using a closed heart anterior septal approach was used in 6 patients. There were 3 men and 3 women, aged 24 to 73 years. Three patients had atrial fibrillation and 2 patients had atrial flutter (2 with combined episodes of atrial tachycardia). One patient had atrial tachycardia. Five patients had no structural heart disease and 1 patient had left ventricular dilatation (ejection fraction, 0.35). All patients undergoing His bundle cryosurgical ablation had permanent heart block without intraoperative complications (mean follow-up, 25 months). Closed heart anteroseptal cryoablation of the His bundle is effective and is an alternative to attempted catheter ablation.

Adult↗
PubMed1985

Prevention by acebutolol of rhythm disorders following coronary bypass surgery.

Seventy-one patients submitted routinely to coronary artery bypass surgery were randomized into 2 groups. Group A (32 patients) received 24 hr after initiation of surgery an intravenous perfusion of 100 mg of acebutolol given over 24 hr (22 cases) or 600 mg administered orally (10 cases). On subsequent days, they received 1200 mg of acebutolol/day orally. Group B (39 patients) was used as control. The groups were comparable in terms of age, sex, severity of coronary disease, preoperative therapy, duration of extracorporeal circulation, aortic clamping time, and immediate postoperative haemodynamic findings. No patient received digitalis. During hospital stay (10 days), 1 group A patient (3%) and 13 group B patients (33%; P less than 0.001) developed a sustained episode of atrial arrhythmia (fibrillation, flutter or atrial ectopic tachycardia). The majority of these rhythm disorders developed between days 2 and 4. On Holter monitoring on days 7-10, malignant ventricular extrasystoles (grades IV and V of Lown's classification) were more frequent in group B (65.2%) than in group A (19.3%; P less than 0.001). Haemodynamic measurements taken at rest performed in 27 patients on days 7-10 (16 patients of group A; 11 of group B). No difference was observed between the two groups. Acebutolol is a safe and efficacious drug for the prevention of arrhythmias following coronary surgery.

Acebutolol↗
PubMed2002

How to test mode switching in pacemakers implanted in patients: the MOST study.

Optimal management of atrial arrhythmias with dual chamber pacemakers requires proper performance of automatic mode switching (AMS). The aim of this study was to develop a reliable technique to test the AMS function by using an external electronic device capable of mimicking the occurrence of supraventricular arrhythmias (Supraventricular Arrhythmia Simulator [SAS]). The SAS delivers low voltage pulse trains (200 mV, 20 ms) through two skin electrodes. Each pulse train lasts 15 seconds and starts synchronously with a pacing pulse of the implanted pacemaker to avoid interference from the operator. The pulse train rate is set at 350, 250, and 160 beats/min to simulate AF, atrial flutter, and atrial tachycardia (AT), respectively. Thirty-five patients implanted with Vitatron pacemakers, whose AMS system has been previously validated, were enrolled. Atrial and ventricular sensing were programmed in unipolar mode at 0.5 mV and in bipolar mode at > 2 mV, respectively. All pulses from the SAS were detected by the atrial channel at an amplitude ranging from 1 to 3 mV. The test proved to be safe and reliable at rest and during exercise. AMS occurred immediately at onset or at offset of atrial arrhythmias, and no adverse interference on pacemaker function was seen from the SAS. In conclusion, the described technique and the SAS are safe and reliable for patient and pacemaker function and can be proposed as a useful method to verify proper performance of AMS function irrespective of the type of implanted devices.

Aged↗
PubMed1989

Efficacy and safety of adenosine in the treatment of supraventricular tachycardia in infants and children.

One hundred and seventeen episodes of supraventricular tachycardia in 50 children, including 28 infants, were treated with intravenous adenosine. Adenosine was prepared in a sterile solution of 0.9% saline (1 mg/ml) and given in incremental doses of 0.05 mg/kg every two minutes to a maximum of 0.25 mg/kg. Ninety of the 117 episodes were terminated. This included 88 of the 102 episodes of junctional tachycardia (79 of the 92 episodes of atrioventricular reentry tachycardia, seven of the eight episodes of atrioventricular nodal reentry tachycardia, and both of the episodes of long R-P' tachycardia). Only one of four episodes of His bundle tachycardia and one of the eight episodes of ectopic atrial tachycardia were terminated. None of the three episodes of atrial flutter were terminated. Side effects were frequent but mild and included transient complete atrioventricular block (less than 6 s), sinus bradycardia (less than 40 s), ventricular extrasystoles, flushing, nausea, headache, and respiratory disturbance. Reinitiation (within 5 s) of supraventricular tachycardia occurred in 13 of the terminated episodes. Although reinitiation limited its clinical efficacy in some patients, intravenous adenosine offered a safe and efficient method of rapid termination of most episodes of supraventricular tachycardia and in some cases facilitated diagnosis of the mechanism.

Adenosine↗
PubMed1999

Sotalol: Current Status and Expanding Indications.

BACKGROUND: The role of antiarrhythmic drug therapy continues to undergo major changes. The change is necessitated by the advent of invasive interventional procedures, such as catheter ablation of arrhythmias and the use of implantable devices for sensing and terminating life-threatening ventricular arrhythmias and symptomatically traublesome supraventricular arrhythmias. Many conventional and time-honored drugs, such as sodium channel blockers, have been found either to be ineffective or to have the potential to produce serious proarrhythmic reactions. Attention is therefore focused on compounds that prolong repolarization and reduce sympathetic stimulation. Two compounds, amiodarone and sotalol, have emerged as prototypes of drugs of the future. METHODS AND RESULTS: This review focuses on sotalol for controlling supraventricular and ventricular tachyarrhythmias. Sotalol is a major antiarrhythmic agent that combines potent class III action with nonselective beta-blocking properties. The drug's pharmacokinetics is simple. Its elimination half-life is 10-15 hours, the drug being excreted almost exclusively by the kidneys. Sotalol's pharmacokinetics allows development of optimal dosing for initiation of therapy relative to changes in creatinine clearance with further dose adjustment by monitoring the QT interval on the surface electrocardiogram. The compound exerts broad-spectrum antiarrhythmic actions in supraventricular and ventricular arrhythmias. It prevents inducible ventricular tachycardia (VT) and ventricular fibrillation (VF) in approximately 30% of patients with a higher figure for the suppression of spontaneously occurring arrhythmias documented on Holter recordings. CONCLUSIONS: The major role of sotalol is in the management of VT/VF often in conjunction with an implantable cardioverter/defibrillator, in which context it lowere the defibrillation threshold. Sotalol is superior to class I agents, especially in VT/VF and in survivors of cardiac arrest. Sotalol has emerged as a major antifibrillatory compound for the control of life-threatening ventricular arrhythmias as the main indication. Data have indicated its potential for the maintenance of stability of sinus rhythm in patients with atrial fibrillation and flutter after electrical conversion and in preventing their occurrence in a variety of clinical settings.

Journal Article↗
PubMed1981

Aortic regurgitation with dove-coo murmur with special references to the mechanism of its generation using dual echocardiography.

Triphasic dove-coo murmur in a patient with aortic regurgitation was studied as to the mechanism of its generation using simultaneous recording phonocardiography and dual echocardiography. The murmur arose coincident with the coarse regular fluttering of aortic posterior wall during the opening of mitral valve and decreased coincident with the protrusion of mitral valve anterior leaflet into the left ventricular outflow tract. Thus the murmur might occur, provided that normal mitral valve opening and closure was maintained. It may well explain why the murmur hardly occurs in aortic regurgitation of rheumatic origin in which rheumatic lesion often is thought to involve mitral valve, restricting mitral opening during diastole and thereby inhibits aortic root vibrations.

Adult↗
PubMed1977

Clinical experience with lorcainide (R 15 889), a new anti-arrhythmic drug.

The anti-arrhythmic properties of a new drug, lorcainide, have been evaluated. Lorcainide is highly efficient for the treatment of ventricular arrhythmias, especially ventricular extrasystoles and recurrent ventricular tachycardia. It is also efficient in the treatment of supraventricular extrasystoles and repetitive auricular tachycardia. It is ineffective in cases of auricular fibrillation and flutter. The drug also has effective anti-arrhythmic properties when administered orally. It has a small negative inotropic effect which was not clinically relevant in the patient group studied. Side effects were within acceptable limits and essentially consist of dizziness, tremor and blurring of vision, occurring only during rapid i.v. injection and depending upon the speed of injection.

Acetamides↗
PubMed1989

[A case of atrial paralysis during the use of intravenous flecainide acetate].

The aim of the present study is to describe a case of complete temporary atrial standstill, following iv administration of flecainide during the course of an endocavitary electrophysiologic study (EES). The patient, 79 years old, with frequent anamnestic periods of flutter and atrial fibrillation, which was followed by heart failure and with conductory disturbances to the surface ECG (first degree A-V block and left axis deviation), underwent EES in order to evaluate the functional reserve of cardiac eccito-conduction. With electric programmed stimulation, during EES, we induced atrial flutter, with a cycle length of about 300 ms. The administration of flecainide, dosage 1.5 mg/Kg in 15 min, determined the complete disappearance of every atrial electric activity, confirmed by right and left (coronary sinus) atrial mapping, also after electrical stimulation, and the emergency of substitutional ventricular rhythm, to a frequency of about 30-40/min. After atropine, dosage 0.02 mg/Kg iv, we noted an increase in the frequency of added focus up to the value of about 110 b/min, without any evidence of atrial electric activity. With sulfate isoprenaline in venous infusion, dosing 2 gamma/min, we noted firstly a ventricular-atrial back-leading 1:1; and after an ectopic atrial rhythm, with a frequency of about 130 b/min. After 5 hours a sinusal rhythm appeared.

Aged↗
PubMed1997

Neonatal atrial flutter: significant early morbidity and excellent long-term prognosis.

Twenty-five neonates (16 boys and 9 girls) who had atrial flutter were identified. Diagnosis was made on or before the first day of life in 18 (72%). Heart failure were present in 9 patients, and hydrops fetalis was present in another 5. Atrial and ventricular rates did not differ between symptomatic and asymptomatic patients. Atrioventricular conduction was variable in 16 patients, and documented 1:1 conduction occurred in 5. Digoxin was the initial drug therapy given to 21 patients, with 7 reverting to sinus rhythm. Electrical cardioversion (pacing or synchronized shock) was attempted in 13 of the 14 cases in which digoxin was not successful and was attempted as the first treatment in 3 cases. Sustained sinus rhythm was achieved in 9. Two infants died of complications from prematurity but without having been successfully converted to sinus rhythm. No patient had atrial flutter during long-term follow-up (median 23 months). Neonatal atrial flutter has significant morbidity but an excellent long-term prognosis.

Anti-Arrhythmia Agents↗
PubMedDate not supplied

Ibutilide for pharmacological cardioversion of atrial fibrillation and flutter: impact of race on efficacy and safety.

OBJECTIVE: To evaluate the racial differences in the efficacy and safety of ibutilide in patients with recent-onset (<2 weeks) atrial fibrillation and atrial flutter. METHODS: This study included 58 consecutive patients with recent-onset atrial fibrillation (n = 34) and atrial flutter (n = 24). The mean age was 65.7 +/- 14.6 years (range, 37-86 years), 47% were women (n = 27) and 34% (n = 20) were African Americans. The duration of arrhythmia ranged from 3 hours to 2 weeks. All patients had echocardiography, were on therapeutic anticoagulation, had a fairly well controlled ventricular rate, normal QTc interval on 12-lead electrocardiography, and normal serum electrolytes. Ibutilide was administered as an intravenous infusion with a maximal dose of 2 mg. RESULTS: The overall conversion rate to sinus rhythm was 66% (n = 38), with 62% (n = 21) with atrial fibrillation and 71% (n = 17) of atrial flutter. Most conversions (84%) occurred within 45 minutes of ibutilide infusion. The mean time to arrhythmia conversion was 37.4 +/- 59.8 minutes. Race had a significant impact on efficacy, with increased conversions seen in African Americans (P = 0.004) and increased nonconversion seen in whites (P = 0.02). Successful conversion was not affected by the left atrial size or the presence of valvular heart disease, hypertension, heart failure, coronary heart disease, and diabetes mellitus. QTc intervals were prolonged after drug administration, with a mean change of 24.6 milliseconds for all patients. The QTc prolongation after drug administration was greater in African Americans than in whites (27.4 vs. 23.3 milliseconds). Torsade de pointes occurred in 4 patients (3 African Americans) and was treated with intravenous magnesium sulfate and electrical cardioversion. CONCLUSION: Ibutilide used for pharmacological cardioversion of atrial fibrillation and atrial flutter is more effective in African Americans but carries a higher risk of torsade de pointes.

Adult↗