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PubMed1987

[Therapeutic trials of aclarubicin in previously treated acute leukemias and hematosarcomas].

In a phase I-II trial, 38 patients with acute myeloid leukemia (AML) were given single drug induction therapy with aclarubicin (ACM) according to two dosing schedules: treatment 1: 10 to 30 mg/m2/d to a maximum total dose of 300 mg/m2 or until development of unacceptable toxicity: treatment 2: 15 mg/m2/d in ten-day courses separated by ten-day intervals. Response rates were 15% with treatment 1 and 44% with treatment 2 (overall response rate 34%). Complete remission (CR) was achieved in 6 patients who had previously failed to respond to adriamycin (ADM). Toxicity was more frequent and more severe in those patients given more than 150 mg/m2 ACM per course. The main side effects were oropharyngeal mucositis and diarrhea. Three patients exhibited T wave inversion and one had an episode of auricular flutter. In a separate trial in 16 patients with AML we used cyclic chemotherapy combining ACM (20 mg/m2/d) and ARA-C (200 mg/m2/d) for seven consecutive days. Complete remission rate was 50%. Severe ventricular rhythm disorders were seen in two patients. In a phase I-II study, 19 patients with acute lymphoid leukemia (ALL) and 8 patients with non-Hodgkin lymphoma (NHL) were given ACM alone according to the regimen designated treatment 1 described above. Response rates were 11% (2/19) in ALL and 25% (2/8) in NHL. A review of the literature is presented in the discussion of the original trials reported herein.

Aclarubicin↗
PubMed1982

[Intravenously disopyramide phosphate administration for treatment of arrhythmias].

Disopyramide phosphate (DF) was administered intravenously to 50 patients during 55 episodes of arrhythmias. The mean dosage employed was 2 +/- 1.4 mg/kg over a period of 3 minutes to 60 minutes (mean 16 +/- 6'), followed by an infusion at a dose of 0.4 mg/kg/hr in 9 cases. Atrial premature beats were suppressed in 3 of 4 treated cases (75%). Conversion to sinus rhythm was achieved in 4 of 5 (80%) cases of paroxysmal supraventricular tachycardia, unresponsive to vagal maneuvers in 7 of 10 cases (70%) of atrial flutter of recent onset (less than 48 hours) and in 13 of 17 (76%) cases of atrial fibrillation (less than one week in duration). In 9 of 11 cases (81%) with frequent, multiform, repetitive ventricular premature beats and in 7 of 8 cases (87%) of ventricular tachycardia, DF completely suppressed the arrhythmia. The drug increased sinus rate, PR and QRS intervals, but the difference was not statistically significant: the QRS of patients with complete bundle branch block and the QTc interval were significantly prolonged. Severe hypotension was observed in 10 patients after DF i.v., in 5 of whom withdrawal of therapy was deemed to be necessary. Nine other patients had anticholinergic side effects. Our study shows that DF administered i.v. can be used successfully in 75% of supraventricular arrhythmias and in 82% of ventricular arrhythmias.

Adult↗
PubMed1990

[Clinical electrophysiologic effects of lorcainide in patients and its effect on the conduction of accessory pathway in Wolff-Parkinson-White syndrome].

The electrophysiologic effects of the intravenous administration of a new antiarrhythmic drug, lorcainide, were evaluated by programmed electrical stimulation of the heart in 20 patients with and without Wolff-Parkinson-White (WPW) syndromes. Lorcainide shortened the sinus cycle length from 721.0 +/- 125.9 to 649.5 +/- 100.1 ms (P less than 0.001), but did not influence sinus node function and AV node conduction and refractoriness, slightly increased atrial effective period (ERP) (P less than 0.02) and did not change ventricular ERP (P less than 0.2), obviously lengthened atrial conduction time, H, H-V interval and the width of V wave. Lorcainide caused complete antegrade block of the accessory pathway (AP) in six of 9 WPW patients and resulted in exclusive conduction over the AV nodal. His conduction in two patients with atrial flutter. It also prolonged the retrograde conduction time and refractoriness of AP, and prevented initiation of orthodromic atrioventricular tachycardia (O-AVRT) in six of 12 patients by blocking of the retrograde conduction of the AP, increased the cycle length of tachycardia from 321.7 +/- 43.6 to 361.7 +/- 54.9 ms (P less than 0.005) by marked prolongation of retrograde AP conduction time in 6 patients in whom O-AVRT could still be induced. It is concluded that intravenous lorcainide does not affect sinus node and AV node function, slightly influences atrial and ventricular refractoriness, obviously suppresses atrial, His bundle and intraventricular conduction, and is an effective antiarrhythmic drug for patients with WPW by blocking both the antegrade and retrograde conduction of the AP.

Adolescent↗
PubMed1998

Interventional electrophysiology and its role in the treatment of cardiac arrhythmia.

Cardiac arrhythmias can present as benign ectopics or as life-threatening arrhythmias and sudden cardiac death. Clinical cardiac electrophysiology is the study of the electrophysiology of the heart and all aspects of management of cardiac arrhythmias. The invasive electrophysiological study was initially purely diagnostic, but recent advances in technology has allowed us to intervene and hence the term interventional electrophysiology. The interventional therapies include permanent pacing for bradyarrhythmias, arrhythmia surgery for arrhythmias, percutaneous catheter ablation and implantable devices for tachyarrhythmias. The treatment of bradyarrhythmias with permanent pacemaker implantation represents the first interventional therapy for patients with cardiac arrhythmias. From 1973 to June 1996, a total of 791 pacemakers have been implanted at the Singapore General Hospital. Previously, patients with tachyarrhythmias could only be cured by open heart surgery utilising intraoperative map guided surgery and ablation of the arrhythmia. Only 17 patients with supraventricular tachycardia (SVT) and 3 patients with VT have undergone this procedure. Catheter ablation has completely revolutionised the treatment of these patients. From October 1991 until December 1996, 860 patients have undergone radiofrequency (RF) catheter ablation for SVT and non-ischaemic VT. Ninety-eight per cent of the patients with SVT have been successfully ablated and 94% of the patients with VT were successfully ablated. RF ablation has become the technique of choice to cure patients with recurrent paroxysmal SVT due to AV re-entrant tachycardia using an accessory pathway, AV nodal re-entrant tachycardia, atrial tachycardia and atrial flutter. It is also used for AV nodal ablation followed by pacemaker insertion or AV nodal modification in patients with poorly controlled atrial fibrillation. Patients with idiopathic non-ischaemic VT arising from the left ventricle or right ventricular outflow tract can similarly be cured. For all these patients, RF ablation offers curative therapy, thus eliminating recurrent symptoms, life-threatening attacks, tachycardia cardiomyopathy and need for life-long drug therapy. For patients with resuscitated sudden cardiac death or at high risk for sudden death, the implantable cardioverter defibrillator (ICD) is the only technique that has significantly improved survival from sudden cardiac death. Since August 1992, 11 patients have had the ICD implanted, with 9 surviving. The 2 deaths were due to cardiac failure and not to sudden death. Thus the ICD can prevent sudden death, but the main limitation is the cost of the device and it is not suitable in patients who have severe heart failure. In conclusion, interventional electrophysiology represents a tremendous leap forward in the management of cardiac arrhythmias. With catheter ablation, it offers a safe curative therapy for patients with recurrent SVTs and VTs and with the ICD, prevents sudden cardiac death in patients who have been resuscitated from it or who are at risk for it. The future will see us improving our success in ablating patients with monomorphic ischaemic VT and even atrial fibrillation, and the role of prophylactic ICDs in high risk patients will be better defined.

Arrhythmias, Cardiac↗
PubMed2006

Cardiac arrhythmias in the intensive care unit.

Cardiac arrhythmias are a common problem encountered in the intensive care unit (ICU) and represent a major source of morbidity. Arrhythmias are most likely to occur in patients with structural heart disease. The inciting factor for an arrhythmia in a given patient may be an insult such as hypoxia, infection, cardiac ischemia, catecholamine excess (endogenous or exogenous), or an electrolyte abnormality. Management includes correction of these imbalances as well as medical therapy directed at the arrhythmia itself. The physiological impact of arrhythmias depends on ventricular response rate and duration, and the impact of a given arrhythmia in a given situation depends on the patient's cardiac physiology and function. Similarly, urgency and type of treatment are determined by the physiological impact of the arrhythmia as well as by underlying cardiac status. The purpose of this review is to provide an update regarding current concepts of diagnosis and acute management of arrhythmias in the ICU. A systematic approach to diagnosis and evaluation will be presented, followed by consideration of specific arrhythmias.

Anti-Arrhythmia Agents↗
PubMed1998

Risk of thromboembolic events in patients with atrial flutter.

Based on multiple studies, clear, guided anticoagulation therapy is recommended for patients with atrial fibrillation. The value of anticoagulation therapy in patients with atrial flutter, however, is less well established. Little is known about the incidence of thromboembolism in patients with atrial flutter. We evaluated the risk of thromboembolism in 191 consecutive unselected patients referred for treatment of atrial flutter. A history of embolic events was noted in 11 patients. Acute embolism (<48 hours) occurred in 4 patients (3 after direct current cardioversion, 1 after catheter ablation). During follow-up of 26+/-18 months, 9 patients experienced thromboembolic events. During the follow-up, the overall embolic event rate (including acute embolism and thromboembolic events during follow-up) was 7 % in this patient population. Risk indicators for an embolic event in an univariate analysis were organic heart disease (p = 0.037), depressed left ventricular function (p = 0.02), history of systemic hypertension (p = 0.004), and diabetes mellitus (p = 0.0038). Using multivariate analysis, a history of hypertension was the only independent predictor for elevated embolic risk in this patient population (odds ratio = 6.5; 95% confidence intervals 1.5 to 45). Thus, the thromboembolic risk is higher than previously recognized for patients with atrial flutter. Anticoagulation therapy may decrease this risk.

Aged↗
PubMed2005

[Predictive factors of maintenance of sinus rhythm after direct current (DC) cardioversion of atrial fibrillation/atrial flutter].

INTRODUCTION: Our aim was to determine the immediate and long-term outcome of direct current (DC) electrical cardioversion in patients with atrial fibrillation or flutter, and to determine factors predicting clinical outcome. MATERIALS AND METHODS: A retrospective one-year follow-up study of 220 patients with atrial fibrillation or flutter undergoing electrical cardioversion between September 1998 and April 2001 was done. RESULTS: Electrical cardioversion was successful in 82% of the patients. Multivariate analysis revealed that female gender was associated with successful cardioversion (p=0.008). Only 29% remained in sinus rhythm after the one-year follow-up. Maintenance of sinus rhythm was associated with anti-arrhythmic drug treatment (p=0.042). Relapse of atrial fibrillation was associated with reduced left ventricular ejection fraction (p=0.002). Complications occurred in 7.7% of the electrical cardioversions; of these, 1.2% were thromboembolic events. DISCUSSION: Less than one third of the patients remained in sinus rhythm after the one-year follow-up despite the use of anti-arrhythmic drugs. Electrical cardioversion is not without risk. Thorough consideration of choice of treatment in patients with atrial fibrillation or flutter is therefore important. According to Danish and international guidelines, electrical cardioversion should be considered primarily when symptoms of AF are unacceptable despite optimal frequency regulation or in patients with AF detected for the first time.

Adult↗
PubMed1996

Pharmacologic therapy of atrial flutter.

Atrial flutter is a relatively rare but nonetheless important arrhythmia. Its mechanism and anatomy have been defined as right atrial macroreentry. It responds to treatment with a variety of antiarrhythmic agents but, in general, drug efficacy for acute termination is low. The addition of pacing to drug therapy markedly improves the success rate for restoration of sinus rhythm. Useful antiarrhythmic agents include amiodarone, sotalol, disopyramide, flecainide, and propafenone, but definitive efficacy studies have not been performed. The risk of provoking 1:1 AV conduction and a marked increase in ventricular response rate is always present. AV nodal blocking drugs (digoxin and verapamil) probably offer protection from this unwanted effect, but the prevalence of 1:1 conduction and the efficacy of AV nodal blockade remain to be established. When drug management fails, there is a place for radiofrequency ablation. Little is known about the thromboembolic risk of atrial flutter. As a consequence, the role of prophylactic anticoagulation is uncertain. Current interest in atrial flutter will ensure that these and other clinical questions are answered in the near future.

Animals↗
PubMed2001

Interactions between pacing and arrhythmia detection algorithms in the dual chamber implantable cardioverter defibrillator.

Dual chamber implantable cardioverter defibrillator (ICD) combines the possibility to detect and treat ventricular and atrial arrhythmias with the possibility of modern heart stimulation techniques. Advanced pacing algorithms together with extended arrhythmia detection capabilities can give rise to new types of device-device interactions. Some of the possible interactions are illustrated by four cases documented in four models of dual chamber ICDs. Functioning of new features in dual chamber devices is influenced by the fact that the pacemaker is not a separate device but a part of the ICD system and that both are being used in a patient with arrhythmia. Programming measures are suggested to optimize use of new pacing algorithms while maintaining correct arrhythmia detection.

Adult↗
PubMed1989

Comparison of adenosine and verapamil for termination of paroxysmal junctional tachycardia.

The effects of intravenous adenosine and intravenous verapamil on paroxysmal junctional tachycardia were compared in 20 patients undergoing invasive cardiac electrophysiologic study. In 13 patients the diagnosis was of a reentrant tachycardia using an extranodal accessory connection (atrioventricular [AV] reentrant tachycardia); 5 of these patients had overt preexcitation in sinus rhythm, 4 had concealed accessory connections and 4 had latent or intermittent preexcitation. In 7 patients the diagnosis was of an AV nodal reentrant tachycardia. Administration of adenosine resulted in termination of tachycardia in all 20 patients at a mean dose of 0.125 mg/kg (range 0.05 to 0.20). Although termination of tachycardia was frequently accompanied by atrial and ventricular premature complexes, no significant arrhythmias were observed after conversion. Administration of verapamil (0.145 mg/kg) resulted in termination of tachycardia in 19 of 20 patients but was followed by symptomatic arrhythmias in 2: preexcited atrial flutter in 1 patient and preexcited atrial tachycardia in another. Latent or intermittent preexcitation was unmasked in 4 of 4 patients immediately after termination of tachycardia by adenosine. Termination of tachycardia by verapamil revealed preexcitation in only 1 of these 4 patients. Analysis of results in terms of successful termination of tachycardia, absence of significant arrhythmias after conversion and unmasking of latent or intermittent preexcitation reveals that adenosine therapy was satisfactory in all 20 patients, whereas verapamil was satisfactory in only 14 of the 20 patients (p less than 0.05). All 6 of the patients with unsatisfactory responses to verapamil had AV reentrant tachycardia. These results suggest that adenosine has particular advantages over verapamil as acute treatment for patients presenting with an AV reentrant tachycardia.

Adenosine↗
PubMed1995

Expanding indications for the use of Class III agents in patients at high risk for sudden death.

The evidence that antiarrhythmic compounds that act by slowing conduction velocity increase mortality in patients with cardiac disease is now compelling. Emphasis is now shifting to agents that act by lengthening repolarization and have additional antiadrenergic properties. There is preliminary evidence that pure Class III agents devoid of antisympathetic activity may also increase rather than decrease mortality in certain patients. Thus, in recent years, sotalol and amiodarone have emerged as the preferred agents for the control of most ventricular arrhythmias occurring in the setting of significant heart disease. Sotalol has not been widely studied in postinfarct patients; one trial indicated that the drug did reduce total mortality but the difference did not reach statistical significance. A number of studies with amiodarone in the postmyocardial infarction patients have revealed benefit, but these were from nonblinded studies. Two blinded, placebo-controlled studies are currently ongoing. A potential new indication of amiodarone is in patients with arrhythmias in heart failure in whom amiodarone markedly increased left ventricular ejection fraction, with a pronounced suppressant effect on premature ventricular complexes and nonsustained ventricular tachycardia and a trend for a decrease in mortality in patients with nonischemic cardiomyopathy. The most promising indication of amiodarone in low doses is in the maintenance of sinus rhythm in patients with atrial flutter and fibrillation. For the present, amiodarone appears to be the best prototype of a desirable complex antiarrhythmic compound, if its variegated side effect profile can be favorably modified from knowledge of structure-activity relationships.

Amiodarone↗
PubMed1977

Significance of abnormal echoes in left ventricular outflow tract.

We have observed abnormal echoes in the left ventricular outflow tract in 4 patients: 3 of the subjects had bacterial endocarditis and the fourth patient had myxomatous degeneration of the aortic valve (floppy aortic valve). A single diastolic echo with fine high frequency fluttering was seen in the patient with the floppy aortic valve, whereas the patients with endocarditis had associated infection of the mitral valve and an aneurysm of the anterior mitral leaflet, which was represented by dense systolic echoes on the proximal part of the mitral valve...

Adult↗
PubMed2003

A case of sick sinus syndrome that developed torsades de pointes, pacing failure and sensing failure during administration of bepridil.

A 65-year-old Japanese woman was admitted to hospital because of palpitations and faintness. She was diagnosed as having sick sinus syndrome and a permanent pacemaker was therefore implanted. Administration of bepridil (200 mg daily) was started for prevention of atrial flutter and fibrillation after PM implantation. On the twenty-fifth day of Bpd therapy, she developed recurrent syncope, ECG showed QT prolongation. torsades de pointes, and sensing failure. Electrical defibrillation (DF) was performed for ventricular fibrillation or ventricular tachycardia. It was presumed that Bpd had caused not only proarrhythmia but also a transient decrease in the amplitude of ventricular activation at the site of the pacing lead, as the sensing level was gradually restored after the drug was ceased and her plasma concentrations of Bpd decreased. It is also believed that DF had caused a sustained increase in pacing threshold because she developed pacing failure after DF and her pacing threshold had not returned to its prior level although the blood levels of Bpd had been below the minimum detectable level. Although it is well known that torsades de pointes occasionally develops in association with Bpd therapy, it is less evident that pacing and sensing failure may develop in association with Bpd therapy. This case report suggests that we should be aware of this possible outcome when employing Bpd and pacemaker implantation as combination therapy.

Aged↗
PubMed2004

Pacemaker lead endocarditis caused by Achromobacter xylosoxidans.

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

Achromobacter denitrificans↗