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PubMed1984

Significance of supraventricular arrhythmias induced by electrophysiologic studies.

The clinical history and the findings on Holter monitoring of 767 patients (without evidence of ventricular pre-excitation on the ECG) were compared with the results of electrophysiological studies to assess the significance of supraventricular arrhythmias induced by intracardiac study. The studies were undertaken to determine the cause of syncope, conduction disturbances or tachycardia. In 570 patients (group 1) supraventricular arrhythmias were not induced. On Holter monitoring, 36 (6%) had evidence of supraventricular tachycardias, including atrial flutter, atrial fibrillation and paroxysmal junctional tachycardia. In 86 patients (group 2) one atrial extrastimulus induced a paroxysmal junctional tachycardia; 79 (82%) of these patients had had spontaneous supraventricular tachycardia (SVT). In 111 patients (group 3) another type of SVT was induced: The movement of the catheter induced atrial flutter or fibrillation in nine patients, eight (89%) of whom had spontaneous SVT. Atrial pacing at a rate less than 200 bpm induced atrial flutter or fibrillation in 14 patients of whom nine (64%) had SVT. Ventricular pacing induced SVT in 15 patients, of whom 14 (64%) had SVT. An atrial extrastimulus during sinus rhythm induced atrial echoes in 62 patients, 47 (76%) of whom had SVT. The atrial extrastimulus during sinus rhythm induced atrial tachycardia in 11 patients, nine (82%) of whom had SVT.

Adolescent↗
PubMed2001

Trends and outcomes in the hospitalization of older Americans for cardiac conduction disorders or arrhythmias, 1991-1998.

OBJECTIVE: To identify epidemiological trends and measure outcomes in elderly patients hospitalized for cardiac conduction disorders or arrhythmias. DESIGN: Review of the standard 5% samples of the Medicare Provider Analysis and Review Files to characterize 144,512 discharges from 1991 through 1998 in which the principal diagnosis was a conduction disorder or arrhythmia, using the corresponding Enrollment Databases for denominator data. SETTING: Short-stay hospitals in the United States. PARTICIPANTS: Medicare beneficiaries age 65 and older in the standard 5% sample. MEASUREMENTS: Diagnosis-specific trends and rates; discharges by year; cumulative age-, race-, and sex-specific discharge rates; mean length of stay in hospital and in intensive care; mean Medicare reimbursement to the hospital; case-fatality rate in hospital; discharge destinations of patients discharged alive. RESULTS: Annual hospitalizations for sinoatrial node dysfunction, atrial flutter, atrial fibrillation, or ventricular fibrillation increased more rapidly than did the elderly Medicare beneficiary population. Hospitalizations with a principal diagnosis of ventricular extrasystoles or asystole showed steep secular declines. Discharge rates for sinoatrial node dysfunction, a group of rhythms with a nonsinus pacemaker, atrial fibrillation, Mobitz I, or complete atrioventricular block all increased steeply and continuously with patient age. In contrast, discharge rates for atrial flutter or ventricular tachycardia or fibrillation peaked among 75- to 84-year-old patients. White men were at uniquely high risk of hospitalization for atrial flutter or ventricular tachycardia or fibrillation, and, among the white majority, men had higher discharge rates than women for nine of the 11 commonest rubrics. Whites, particularly white women, had the highest discharge rates for atrial fibrillation. Blacks, especially black women, were at disproportionate risk for hospitalization for the group of nonsinus pacemaker rhythms. Diagnosis-specific mean resource costs were strongly correlated with each other and with mean Medicare reimbursement but not with case-fatality rate. CONCLUSION: Medicare claims data demonstrated striking differences among and within diagnoses of heart blocks or arrhythmias in terms of the populations at greatest risk for hospitalization. This variation should be explored further to generate and test hypotheses about differential causation or delivery of care.

Black or African American↗
PubMed1988

Catheter ablation for recurrent tachyarrhythmias. Clinical experience with two different techniques of ablation in 21 patients.

Between 1984 and 1988, 21 patients underwent catheter ablation for drug refractory arrhythmias. Nine patients presented atrial flutter, atrial fibrillation or atrial tachycardia, nine had supraventricular tachycardia (one AV nodal reentrant tachycardia, one reciprocating tachycardia due to concealed accessory pathway and seven WPW syndrome). Three had ventricular tachycardia. Fourteen patients were treated with direct current shock ablation (DC) and seven patients with radiofrequency ablation (RF). Eight patients underwent ablation of the His bundle. In six patients permanent AV block could be induced and in two first-degree AV block. All became asymptomatic (two with additional antiarrhythmic drug therapy). In four patients with WPW syndrome DC ablation of the accessory pathway was attempted. In one patient a permanent block in the accessory pathway and in another an intermittent block were obtained. In the two remaining patients with accessory pathways the ablation failed to interrupt the retrograde conduction: in one the retrograde conduction was modified; however, in the other no change could be demonstrated. Two patients underwent ventricular foci ablation, with one partial success (arrhythmia controlled with associated drug therapy) and one failure. Three patients had RF His bundle ablation (two for atrial flutter and one for atrial fibrillation). One complete atrioventricular block, one first degree AV block and one first degree AV block associated with right bundle branch block were induced. Recurrence of tachyarrhythmias was prevented only in the patient with complete atrioventricular block. RF ablation of accessory pathway was performed in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial Fibrillation↗
PubMed2001

[Atypical flutters].

Typical atrial flutter may now be definitely treated in a single session. However, the very meaning of the term, atrial flutter, is confusing because it is a multiple entity. In fact, flutters may be classified with respect to their electrocardiographic and electrophysiological features. In addition to typical common atrial flutter with biphasic, predominantly negative F waves in the inferior leads and positive F waves in V1 due to an anticlockwise macro-reentry circuit localised to the right atrium, there are other forms which may be described as typical in that they pass through the cavo-tricuspid isthmus. They include typical flutter with inverted rotation, short loop inferior flutter and flutter with a double reentry circuit. In 2001, it would seem licit to call all flutters which do not pass through the cavotricuspid isthmus atypical, independently of their surface ECG appearances. The term flutter still refers to a continuous electrical activity with absence of an isoelectric line in at least one lead but with extremely variable ECG features. They may be classified as flutter on pre-existing lesions, with right or left atrial macro-reentry circuits. The ECG appearance is then that of very atypical flutter. More recently, flutters with circuits passing through the coronary sinus have been described. Ablation of the muscle of the coronary sinus seems to be able to treat this type of flutter, the prevalence of which is not yet known.

Arrhythmia, Sinus↗
PubMed2006

Rationale and design of a prospective study of the clinical significance of atrial arrhythmias detected by implanted device diagnostics: the TRENDS study.

BACKGROUND: Sustained atrial fibrillation (AF) is a common risk factor for stroke. While intermittent AF also appears to pose a substantial stroke risk, the quantitative relationship between the percentage of time spent in AF and stroke risk is poorly specified and "intermittent" AF is not the same as paroxysmal AF. Improved assessment of the impact of AF burden on stroke risk will allow more targeted and safer use of antithrombotic therapy. METHODS AND RESULTS: The primary objective of this study is to determine if AT/AF (all device detected atrial tachyarrhythmias, including atrial flutter, atrial fibrillation, and atrial tachycardia) burden over a 30 day period is an independent predictor of the occurrence of ischemic stroke, transient ischemic attack (TIA) and/or systemic embolism in subjects not receiving anticoagulation therapy. TRENDS is a prospective, post-market, non-randomized, multicenter study designed to enroll 3100 subjects who have an independent Class I/II indication for cardiac rhythm device implantation and who have demographic features suggestive of an increased risk for thromboembolic complications related to AT/AF. All implanted devices will have the ability to collect long-term AT/AF burden trending data and will be equivalently programmed to ensure consistent data collection. All subjects will be followed with device interrogations every 3 months and clinic visits every 6 months for 1 year. Subjects with a documented history of AT/AF prior to enrollment and those who develop AT/AF during the 12-month follow-up will be followed until the last subject enrolled in the study has completed their 24-month follow-up. CONCLUSIONS: The results of the TRENDS study should help clarify the implications of data retrieved from an implantable device with regard to the risk for thromboembolic complications from atrial arrhythmias, even in the absence of symptoms.

Anti-Arrhythmia Agents↗
PubMed1999

Atrial arrhythmia after surgical closure of atrial septal defects in adults.

BACKGROUND: Atrial flutter and atrial fibrillation are causes of morbidity in adults with an atrial septal defect. In this study, we attempted to identify risk factors for atrial flutter and fibrillation both before and after the surgical closure of an atrial septal defect. METHODS: We searched for preoperative and postoperative atrial flutter or fibrillation in 213 adult patients (82 men and 131 women) who underwent surgical closure of atrial septal defects because of symptoms, a substantial left-to-right shunt (ratio of pulmonary to systemic blood flow, >1.5:1), or both at Toronto Hospital between 1986 and 1997. RESULTS: Forty patients (19 percent) had sustained atrial flutter or fibrillation before surgery. As compared with the patients who did not have atrial flutter or fibrillation before surgery, those who did were older (59+/-11 vs. 37+/-13 years, P<0.001) and had higher mean pulmonary arterial pressures (25.0+/-9.7 vs. 19.7+/-8.2 mm Hg, P=0.001). There were no perioperative deaths. After a mean follow-up period of 3.8+/-2.5 years, 24 of the 40 patients (60 percent) continued to have atrial flutter or fibrillation. The mean age of these patients was greater than that of the 16 who converted to sinus rhythm (P=0.02). New-onset atrial flutter or atrial fibrillation was more likely to have developed at follow-up in patients who were older than 40 years at the time of surgery than in those who were 40 or younger (5 of 67 vs. 0 of 106, P=0.008). Late events (those occurring more than one month after surgery) included stroke in six patients (all but one with atrial flutter or fibrillation, one of whom died) and death from noncardiac causes in two patients. Multivariate analysis showed that older age (>40 years) at the time of surgery (P=0.001), the presence of preoperative atrial flutter or fibrillation (P<0.001), and the presence of postoperative atrial flutter or fibrillation or junctional rhythm (P=0.02) were predictive of late postoperative atrial flutter or fibrillation. CONCLUSIONS: The risk of atrial flutter or atrial fibrillation in adults with atrial septal defects is related to the age at the time of surgical repair and the pulmonary arterial pressure. To reduce the morbidity associated with atrial flutter and fibrillation, the timely closure of atrial septal defects is warranted.

Adolescent↗
PubMed1994

An approach to therapy of supraventricular tachyarrhythmias: an algorithm versus individualized therapy.

Approaches to the treatment of supraventricular arrhythmias, including atrial fibrillation, atrial flutter, atrial tachycardia, atrioventricular (AV) reentrant tachycardia, and AV nodal reentrant tachycardia, continue to evolve. Within the past two decades, many new and effective treatments have become available. These include several new antiarrhythmic agents, ablative therapies, pacing and surgical modalities, and cardioversion/defibrillation techniques. This paper provides an algorithm for the treatment of these supraventricular arrhythmias which includes therapy for the acute episode as well as the prevention of subsequent episodes of the tachyarrhythmia.

Algorithms↗
PubMed1997

Role of the surface electrocardiogram in the diagnosis of patients with supraventricular tachycardia.

In this era of interventional electrophysiology, the accuracy of the electrocardiogram in diagnosis of supraventricular tachycardia could be improved by detailed endocardial mapping and confirmed by results of radiofrequency catheter ablation. This article describes the electrocardiographic characteristics for different types of supraventricular tachycardia: atrial fibrillation, atrial flutter, atrial tachycardia, atrioventricular reciprocating tachycardia using an accessory pathway, and atrioventricular node reentrant tachycardia. Several limitations, including the identification of P wave morphologies and polarities and separation between the terminal part of T wave and P wave during tachycardia, should be resolved before an accurate algorithm of the 12-lead surface electrocardiogram is developed for the diagnosis of supraventricular tachycardia.

Atrial Fibrillation↗
PubMed1984

Automatic tachycardia recognition.

A microcomputer algorithm for tachycardia identification, suitable for use in an implanted antitachycardia pacemaker, is described. The system employs an atrial and ventricular electrogram, detects a sustained fast rate in either chamber, and awakens the main program to perform detailed analysis of the tachycardia and its immediately preceding beats. The algorithm distinguishes atrial, ventricular, and AV nodal and re-entrant tachycardia from high rates due to sinus tachycardia. For testing of the program, we used a data base of twenty-two tape-recorded and documented arrhythmias provoked during electrophysiologic studies in which atrial and ventricular bipolar electrodes were in place; twenty-one were successfully detected. These included atrial fibrillation, atrial flutter, atrial tachycardia, AV nodal re-entrant tachycardia, AV re-entrant tachycardia using an accessory pathway, and ventricular tachycardia with and without ventriculo-atrial conduction.

Atrial Fibrillation↗
PubMed2004

[Ablative strategy: a definite treatment for cardiac arrhythmias?].

The development of radiofrequency catheter ablation has dramatically changed the therapeutic approach of cardiac arrhythmias. All atrial rhythm disturbances are now amenable to ablative strategy. Ablation has become the first-line therapy for atrial flutter. Atrial fibrillation, a major factor of morbidity and mortality, is now a target for this radical treatment. Ablation of pulmonary vein foci, eventually associated to atrial linear lesions, raises the possibility of suppressing atrial fibrillation. The success rate is now as high as 70 to 85%, depending on the form of atrial fibrillation. For atrioventricular reentrant tachycardia either nodal or over an accessory pathway, ablation is the reference treatment with success rates of 99%. All symptomatic Wolff-Parkinson-White syndromes can be definitely cured by this technique. At the ventricular level, the procedures are often more complexes, due to advanced cardiomyopathy. However, most of sustained ventricular tachycardias can be cured by ablation. The success rates are somewhat lower (about 80%). The challenge for the next years is ablation of premature ventricular beats initiating ventricular fibrillation. The technique is also improving from day-to-day (88% success rate) and makes rise the hope of curing sudden death.

Arrhythmias, Cardiac↗
PubMed1975

[Intra-atrial cardioversion in supraventricular tachycardial arrhythmia].

Cardioversion by rapid atrial stimulation has been carried out in 29 patients with supraventricular tachycarida and 12 patients with "coarse" atrial fibrillation. Atrial stimulation rates of 60-1200/min and electrical impulses of 6-25 mA were used. Intracardial conversion was successful in 86% of the cases presenting supraventricular tachycardia. Cardioversion was not achieved with atrial fibrillation but atrial flutter and atrial tachycardia were both found to be easily converted. Transformation of an arrhythmia into sinus rhythm or into stable atrial fibrillation with a slowed ventricular rate was the criterion for a successful conversion. Transient arrhythmias prior to an eventual stable rhythm was observed in 28% of the cases. Two mechanisms to explain the induced change in supraventricular tachycardias are discussed: (1) interruption of atrial or junctional foci (overdrive suppression) and (2) interruption of a re-entry circle by single premature beats. Cardioversion using atrial stimulation is indicated in atrial flutter, atrial tachycardias and junctional tachycardias. The method is of advantage in that it does not require anesthesia or interruption of digitalis therapy and its use involves no complications. Cardioversion using DC-shock is to be preferred in all cases of atrial fibrillation.

Adult↗
PubMed1987

Flecainide acetate for conversion of acute supraventricular tachycardia to sinus rhythm.

The efficacy of intravenous flecainide acetate (maximum 2 mg/kg or 150 mg given at a rate of 15 mg/min) was assessed in patients with acute supraventricular tachycardia (SVT) (within 24 hours). Fifty patients were studied, 46 with spontaneous SVT and 4 with induced SVT at electrophysiologic assessment. Conversion to sinus rhythm was achieved within 45 minutes in 76%: in 25 patients with atrial fibrillation (76% conversion), 15 with atrioventricular (AV) nodal or AV reentrant tachycardia (100% conversion) and 10 with atrial flutter or atrial reentrant tachycardia (40% conversion). Adverse effects were noted in 21 patients (42%): paresthesia in 9, drowsiness in 8, nausea in 2, accelerated ventricular rate in 5, ventricular tachycardia in 1, sinus bradycardia in 1 and hypotension in 5. Adverse effects were associated with larger dosage and atrial flutter or atrial reentrant tachycardia. Thus, flecainide acetate is effective in converting to sinus rhythm acute atrial fibrillation and AV nodal and AV reentrant tachycardias, but not atrial flutter or atrial reentrant tachycardia.

Acute Disease↗
PubMed1995

Computer-assisted instruction of arrhythmia for MS-windows.

1. INTRODUCTION. Training in the diagnosis of arrhythmias is an important part of the curriculum for medical students, postgraduates, and paramedical staff. Although several CAI for arrhythmia have been developed [1-3], we could not get CAI software for arrhythmia for the MS-Windows environment. In this report, we present a newly-developed computer-assisted reference system for arrhythmia that functions in the Windows environment. 2. DESCRIPTION OF THE SYSTEM. The system consists of a program and two data files. An MS-Windows program (ECG9405.EXE, 180kB) was compiled using Borland's C++ v.3.1. A binary file (ECPAT.BAS 33kB) includes data of normal and abnormal wave segments of ECG: P wave, PQ interval segment, and QRs complex with/without T wave. A mother file (ECG9405.sys, 57kB) includes 85 data sets to generate ECG waveforms of arrhythmia. Each data set contains a sequence of wave form numbers, the text for questions and answers, and the commands strings. There are five major commands: 1) to create a new window as "wave window"; 2) to make electrocardiogram data; 3) to plot the data on the window; 4) to create a "dialog box" for questions and explanations; and 5) to check the answers. he program gets a data set from the data according to the user's choice. The program then interprets the data set and executes the commands. The wave segment data are plotted in a "wave window" at every 10 milliseconds; this is controlled by the MS-Windows' timer. The timer interval can be changed by selecting the speed button. The ECG waveforms are displayed on a window just like an ordinary ECG monitor with beat sound. Many windows can be created by the user and many ECG waves simultaneously plotted on CRT. 3. USAGE OF THE SYSTEM. The "main window" has a menu that has three items corresponding to the training course: BASIC, TRY, and TEST. Thirty-five types of arrythmias are listed in the "list box" of the windows in BASIC course e.g., sinus arrhythmia, atrial flutter, atrial premature contraction, ventricular extrasystole, ventricular flutter, etc. If the user selects one of them on the list by double clicking, some textual explanations of the wave are described in a dialog box. Ten multiple choice questions are displayed in the dialog box in course of learning TRY and TEST; the answers to these are requested. In the TEST course, the system offers random access to each arrhythmia. he user can send the pictorial ECG data in the window to other graphics programs through a clip board. 4. DISCUSSION. It was successfully used in a lecture of electrocardiogram for medical students. They seem to be interested in this system because of its simple usage and the dynamic drawing of ECG waves on CRT. Multiple computer-based medical resources can be run on MS-Windows. The system is able to run simultaneously with other programs, such as an electronic reference system [4]. The system may be obtained from the authors upon request.

Arrhythmias, Cardiac↗
PubMed1998

Atrial macroreentry involving the myocardium of the coronary sinus: a unique mechanism for atypical flutter.

Atrial flutter involving either clockwise or counterclockwise rotation around the tricuspid annulus utilizing the subeustachian isthmus has been well described. However, macroreentrant atrial circuits in atypical atrial flutter in patients who have not undergone previous surgery or without atrial disease are not well defined. We describe a patient without structural heart disease who presented with an atrial macroreentrant rhythm. Entrainment mapping demonstrated a critical isthmus within the coronary sinus. Activation mapping demonstrated double potential throughout the length of the coronary sinus with disparate activation sequences. A circuit involving the myocardium of the coronary sinus, exiting in the lateral left atrium, down the interatrial septum, and reentering into the coronary sinus was identified. Successful ablation of the rhythm was accomplished by a circumferential radiofrequency application within the coronary sinus.

Atrial Flutter↗
PubMed1985

Amplitude of atrial electrical activity during sinus rhythm and during atrial flutter-fibrillation.

The onset of atrial flutter or fibrillation in a patient with a DDD pacemaker may result in sensing of the atrial arrhythmia and an inappropriate ventricular pacing response. In order to assess the potential of this problem, we evaluated the amplitude of atrial electrograms recorded from the right atrial appendage during sinus rhythm and during atrial flutter or fibrillation during 19 episodes in 18 patients. In 11 episodes of fibrillation and eight episodes of flutter, there was no difference in amplitude of either unipolar or bipolar atrial electrograms compared to that recorded during sinus rhythm (p greater than 0.05). In 14 of 19 episodes, the direction of depolarization of the bipolar electrogram did not change appreciably between sinus rhythm and the atrial arrhythmia. In summary, there is insufficient difference between amplitude of atrial depolarizations recorded during sinus rhythm and atrial flutter or fibrillation to be differentiated reliably by DDD pacemakers.

Adult↗
PubMed1994

[A case report of the maze procedure with mitral valve replacement].

The maze procedure was performed simultaneously with mitral valve replacement for atrial fibrillation and mitral stenosis in a 66-year-old female. On the first postoperative day, the cardiac status deteriorated suddenly due to a very rapid heartbeat which was later diagnosed as a 1:1 AV conduction of atrial flutter. The atrial flutter responded to an injection of verapamil and changed to a 2:1 conduction. Although atrial flutter had continued until the thirteenth postoperative day, the heart achieved sinus rhythm on that day. Since then it has continued without any antiarrhythmic drugs except digitalis. It was difficult to make a diagnosis of the rapid heartbeat on the 12-lead ECG because P waves could not be seen clearly on the ECG. Recording the electrical cardiac status by using the temporal atrial pacing leads, which were placed during the operation, was helpful in diagnosing the heartbeat as atrial flutter. The electrophysiological examination eight weeks after the operation revealed that the sinus node function was normal and atrial flutter or atrial fibrillation could not be induced. The patient is well and in sinus rhythm 12 months after the operation.

Aged↗