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PubMed1997

[The use of adenosine in the diagnosis and treatment of cardiac arrhythmias].

The authors investigated the effect of adenosine or ATP on narrow QRS tachycardia in 56 pts, 3 pts with wide QRS tachycardia 9 pts with suspected latent preexcitation and 10 pts with PVC suspected to be ventricular parasystole. After the bolus iv. administration of adenosine or ATP every SVT was stopped related to AV node (44 pts), but in the rest twelve related to atrial origin of SVT only one automatic atrial tachycardia could be stopped. From the 9 patient suspected to have concealed WPW 2 pts had delta wave during the effect of adenosine, and in four pts parasystole was demonstrated among the pts had varying coupling interval PVC. None of the pts who had wide QRS tachycardia was the tachycardia stopped, but in two cases the supraventricular origin--atrial flutter and tachycardia--was discovered. The authors emphasize the favourable effect of adenosine in narrow complex tachycardia and suggest that it can given safely in wide QRS tachycardia of unknown origin either. The diagnostic effect of adenosine can be used in sinus rhythm too if latent preexcitation or ventricular parasystole is suspected.

Adenosine Triphosphate↗
PubMed1991

Efficacy of cardioselective beta-adrenergic blockade with intravenously administered metoprolol in the treatment of supraventricular tachyarrhythmias.

The efficacy of intravenously administered metoprolol, a cardioselective beta-adrenergic blocking agent, was evaluated in the treatment of supraventricular tachyarrhythmias in 16 patients. The arrhythmias that were treated were atrial fibrillation (11 patients), atrial flutter (2 patients), supraventricular tachycardia (2 patients), and multifocal atrial tachycardia (1 patient). Mean dose of metoprolol was 9.5 mg (range: 2-15 mg) administered in one or two separate infusions of up to 7.5 mg each over a cumulative maximum interval of 25 minutes. In the 13 responders (81%), mean ventricular rate decreased from 134 +/- 6 to 106 +/- 7 beats/min 10 minutes after metoprolol administration and was controlled for 40 to 320 minutes without further therapy. Minimum ventricular rate (98 +/- 6 beats/min) was reached 48 minutes after initiation of metoprolol. Metoprolol reduced ventricular rate by greater than 15% (decrease of 26-60 beats/min) in 11 (69%) of 16 patients, including 9 (82%) of 11 patients with atrial fibrillation. In two other patients, one with atrial fibrillation and one with supraventricular tachycardia, ventricular rate was reduced by greater than 12%. Hypotension, occurring in five patients, was the most frequent side effect but was transient and readily managed. Cardioselective beta-adrenergic blockade by metoprolol was rapidly effective in controlling ventricular rate in a majority of patients with supraventricular tachyarrhythmias and may be of particular use in selected patients with chronic obstructive pulmonary disease in whom intravenous beta-adrenergic blockade is indicated. Hypotension is an important potential side effect.

Adult↗
PubMed2005

Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease.

BACKGROUND: Diabetes mellitus (DM) is a major risk factor for atherosclerosis. There is a controversy in literature about correlation between DM and atrial fibrillation. The goal of this study was to evaluate DM as a risk factor for atrial fibrillation or flutter using a very large database. METHOD: Patient treatment files (PTF) containing discharge diagnoses were utilized using ICD-9 codes of inpatient treatment from Veterans Health Administration Hospitals (VAH). Patients with type II DM (ICD-9 code 250.0) (293,124) discharged from the VAH between 1990 and 2000. Non-matched controls without DM but with hypertension (552,624) were selected from the same PTF. By using multi-variate logistic regressions, the occurrence of atrial fibrillation, atrial flutter, CHF, CAD and LVH was compared. RESULTS: Atrial fibrillations occurred in 43,674 (14.9%) DM patients vs. 57,077 (10.3%) in the control group (p<0.0001). Atrial flutter occurred in 11,852 (4%) of DM patients vs. 13,554 (2.5%) of the control group (p<0.0001). Using multi-variant analysis, DM remained independently associated with atrial fibrillation with an OR of 2.13, (95% CI: 2.10 to 2.16; p<0.0001) and flutter (OR 2.20, CI: 2.15 to 2.26; p<0.0001). Furthermore, CHF (OR 3.12, CI: 3.09 to 3.16; p<0.0001), LVH (OR 1.85, CI: 1.77 to 1.92; p<0.0001) and CAD (OR 2.39, CI: 2.34 to 2.44; p<0.0001) were also independently associated with DM. CONCLUSION: This is the first large-scale study finding DM as a strong, independent risk for the occurrence of atrial fibrillation and flutter and other cardiovascular disease.

Aged↗
PubMed1999

Pharmacologic versus direct-current electrical cardioversion of atrial flutter and fibrillation.

Conversion of atrial flutter and atrial fibrillation (AF) can be achieved by either pharmacologic or direct-current (DC) electrical cardioversion. DC electrical cardioversion is more effective and restores sinus rhythm instantaneously; however, general anesthesia is necessary, which can cause severe complications. On the other hand, pharmacologic cardioversion is less effective. First, time to conversion is unpredictable and may be relatively long, especially with oral drug therapy. Also, the rate of conversion is lower and depends on duration of AF. In addition, safety is an important issue. Adverse drug reactions include bradycardia, paradoxical tachycardia due to enhanced atrioventricular conduction, ventricular proarrhythmia, and acute heart failure. In paroxysmal AF, drug therapy is usually aimed at an acute conversion. Class IA and IC drugs are more efficacious than the class III drugs sotalol, amiodarone, and ibutilide. By contrast, class III drugs are more effective for the conversion of atrial flutter. Acute conversion out-of-hospital ("pill in the pocket approach") should be done only if the drug used appeared effective and safe after a few in-hospital trials. In persistent AF, DC conversion is preferred because drugs are particularly ineffective if the arrhythmia has lasted >24-48 hours. The latter probably relates to electrical and anatomical remodeling of the atria during ongoing atrial fibrillation and flutter. Nevertheless, a wait-and-see approach using, for example, oral amiodarone may be adopted with late DC conversion if the drug fails to convert persistent AF. However, the consequences of remodeling seem to dictate an early conversion. In this respect, echocardiography-guided DC cardioversion may become increasingly important in AF. It will prevent treatment resistance and potentially reduces embolic complications. In a hybrid approach, antiarrhythmic drugs may be used to enhance DC conversion and prevent (sub)acute recurrences of AF. However, it may increase the defibrillation threshold, especially if class IC drugs are used. New treatment options such as automatic defibrillation (implantable atrioverter) are still investigational.

Ambulatory Care↗
PubMed1999

Noncontact mapping of cardiac arrhythmias.

The development of new mapping systems is beginning to overcome some of the limitations of conventional techniques by offering percutaneous deployment, simultaneous acquisitions of data, high-resolution maps, and correlation of anatomy and electrophysiology, in addition to a catheter location system. The noncontact mapping system continues to undergo development and does not completely address all requirements for an ideal mapping system. The limitations of the system include deterioration in the quality of electrogram reconstruction with increasing distance between the MEA and the endocardium, the inability of the noncontact system to identify subendocardial activation, and problems with distinguishing noise from low-amplitude diastolic electrograms.

Arrhythmias, Cardiac↗
PubMed2006

Transvenous pacing leads and systemic thromboemboli in patients with intracardiac shunts: a multicenter study.

BACKGROUND: The risk of systemic thromboemboli associated with transvenous leads in the presence of an intracardiac shunt is currently unknown. METHODS AND RESULTS: To define this risk, we conducted a multicenter, retrospective cohort study of 202 patients with intracardiac shunts: Sixty-four had transvenous leads (group 1), 56 had epicardial leads (group 2), and 82 had right-to-left shunts but no pacemaker or implantable cardioverter defibrillator leads (group 3). Patient-years were accrued until the occurrence of systemic thromboemboli or study termination. Censoring occurred in the event of complete shunt closure, death, or loss to follow-up. Mean ages for groups 1, 2, and 3 were 33.9+/-18.0, 22.2+/-12.6, and 22.9+/-15.0 years, respectively. Respective oxygen saturations were 91.2+/-9.1%, 88.1+/-8.1%, and 79.7+/-6.7%. During respective median follow-ups of 7.3, 9.3, and 17.0 years, 24 patients had at least 1 systemic thromboembolus: 10 (15.6%), 5 (8.9%), and 9 (11.0%) in groups 1, 2, and 3, respectively. Univariate risk factors were older age (hazard ratio [HR], 1.05; P=0.0001), ongoing phlebotomy (HR, 3.1; P=0.0415), and an transvenous lead (HR, 2.4; P=0.0421). In multivariate, stepwise regression analyses, transvenous leads remained an independent predictor of systemic thromboemboli (HR, 2.6; P=0.0265). In patients with transvenous leads, independent risk factors were older age (HR, 1.05; P=0.0080), atrial fibrillation or flutter (HR, 6.7; P=0.0214), and ongoing phlebotomy (HR, 14.4; P=0.0349). Having had aspirin or warfarin prescribed was not protective. Epicardial leads were, however, associated with higher atrial (P=0.0407) and ventricular (P=0.0270) thresholds and shorter generator longevity (HR, 1.9; P=0.0176). CONCLUSIONS: Transvenous leads incur a >2-fold increased risk of systemic thromboemboli in patients with intracardiac shunts.

Arteriovenous Shunt, Surgical↗
PubMed2006

Dronedarone: a new antiarrhythmic agent.

Dronedarone (SR 33589; N,N-dibutyl-3-[4-([2-butyl-5-methylsulphonamido] benzofuran-3-yl-carbonyl) phenoxy]propylamine) is a new synthetic noniodinated derivative of amiodarone that is currently undergoing phase III clinical trials. It demonstrates electrophysiologic patterns similar to amiodarone and shows equivalent efficacy in preventing or converting various ventricular and atrial arrhythmias in laboratory animals. Two phase III trials demonstrated that dronedarone is safe and effective for the maintenance of normal sinus rhythm in patients with atrial fibrillation or atrial flutter. Dronedarone at the dose of 400 mg twice daily was effective in preventing both symptomatic and asymptomatic recurrences of atrial fibrillation or atrial flutter and had a safety profile similar to that of placebo. Further studies are needed to determine the long-term effectiveness and safety of dronedarone in various groups of patients with atrial fibrillation. Other clinical applications of this novel antiarrhythmic drug need to be determined in future clinical trials.

Amiodarone↗
PubMed1976

[Echocardiography as a method for the determination of the severity of aortic insufficiency].

4 groups of patients with different degrees of aortic regurgitation (mild n = 7, moderate n = 3, severe n = 21, and aortic regurgitation combined with organic mitral stenosis n = 5) were examined by means of echocardiography and compared with a control group of 10 healthy subjects. The purpose was to determine what information echocardiography may provide in regard to the severity of aortic regurgitation and whether patients with organic mitral stenosis can be distinguished from patients with Austin Flint murmur. Patients with mild or moderate aortic regurgitation could not be clearly distinguished by echocardiographic features from subjects with normal cardiac findings. However, patients with severe aortic regurgitation were likely to show the following characteristic changes: (1) early mitral valve closure, (2) diastolic flutter, (3) absence of the a-wave. If a premature mitral valve closure, i.e. a negative QC time or a diastolic flutter or absent a-wave are found, the aortic regurgitation is likely to be of severe degree. This finding will be particularly useful in patients with acute aortic regurgitation, no left ventricular enlargement and no left ventricular hypertrophy in the ECG. Being a noninvasive method, echocardiography may also be used in follow-up examinations. Furthermore, organic mitral stenosis can be distinguished from Austin Flint murmur.

Aortic Valve Insufficiency↗
PubMed2002

Transesophageal atrial pacing in the management of re-entry supraventricular tachyarrhythmias occurring during general anesthesia.

BACKGROUND: Supraventricular tachyarrhythmias (SVTs) represent an intraoperative risk factor that should be always prevented/managed. The commonly used anti-arrhythmic drugs are accompanied by intrinsic hazards, such as pro-arrhythmic and toxic effects or unpredictable onset and duration of action. We underline the therapeutic use of transesophageal atrial pacing (TAP) for the interruption of particular re-entry SVTs occurred during surgical procedures in general anaesthesia. METHODS: Our study was carried out in 25 patients characterized by a personal clinical history of transient tachyarrhythmic episodes, subjected to general anaesthesia obtained by midazolam, propofol, N2O e O2, sevoflurane, fentanil and vecuronium bromide. We used TAP bursts of 3-5 sec, their minimal pacing rate being equivalent to the tachyarrhythmia cycle length, with an impulse intensity ranging from 18 to 25 mA. In such conditions, the re-entry was interrupted by the induction of refractoriness of the wave-front that sustained the underlying arrhythmogenic circuit. RESULTS: During the study, the following arrhythmias occurred in 7 out of all patients: 1 type I atrial flutter, 3 nodal tachycardias, 1 antidromic and 2 orthodromic atrioventricular tachycardias, respectively. TAP assured either atrial capture or prompt suppression of arrhythmias in all cases. Low intensity impulses did not ever allow ventricular capture. CONCLUSIONS: TAP can be considered as a valid therapeutic device for the management of re-entry SVTs occurred during general anaesthesia, resulting it effective, safe and easy-practicable.

Anesthesia, General↗
PubMed1985

[Traumatic mitral insufficiency: a case report].

A 25-year-old man was admitted to Juntendo University Hospital with chief complaints of nocturnal dyspnea and shortness of breath on Sept. 22, 1983. He had no history of rheumatic fever or bacterial endocarditis. He was violently kicked in the chest while practicing Shorinji-Kempo (Karate) in July 1977. His heart murmur was first noticed in April 1978, but he was asymptomatic for six years after the accident until transient nocturnal dyspnea developed January 1983. Physical examination on admission revealed a grade 4/6 apical holosystolic murmur, a markedly accentuated third sound, and hepatomegaly of two finger breadth in the right midclavicular line. An electrocardiogram revealed sinus tachycardia (100/min), left atrial overload and left ventricular hypertrophy. Chest radiography showed slight cardiac enlargement with a cardiothoracic ratio of 55%, and slightly increased pulmonary vascular markings. Two-dimensional echocardiography showed a markedly prolapsed posterior mitral leaflet and fluttering in diastole. Cardiac catheterization showed elevated pressure of pulmonary capillaries (a: 16, v: 30, mean: 19 mmHg), the pulmonary artery and the right ventricle. Left ventriculography revealed grade four (Sellers) mitral regurgitation. Mitral valve replacement was performed on October 13, 1983. A chorda tendinae supporting the posterior leaflet of the mitral valve was found to be ruptured just above its origin from the posterior papillary muscle. Histological examination of the resected valve showed increased spongiosa tissue which mimicked so-called myxomatous changes, but it seemed preferable to interpret this as a "secondary change due to increased hemodynamic stress" rather than the "primary change".

Adult↗