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Pacemakers in the treatment of tachyarrhythmias.
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[The recourse to electrotherapy in emergency treatment of disorders affecting rhythm and cardiac function].
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Surgical closure of atrial septal defects. Results of the circumclusion technique.
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[Rhythm disorders during intracardiac examinations in infants and young children].
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26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Task Force 6: arrhythmias.
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[Arrhythmias in the adolescent and adult with a congenital heart defect].
Rhythm disturbances may be observed in the natural history of congenital heart defects, as well as after open heart surgery. About 40-50% of adults with congenital heart defects will experience some type of arrhythmia. In the growing population of postoperative patients, the type of rhythm disturbance depends on the type of heart surgery: after operation at ventricular level, conduction disturbances and ventricular arrhythmias are quite common. After surgery at atrial level (e.g. closure of ASD, but much more after atrial correction of transposition), sick sinus syndrome and supraventricular arrhythmias are chiefly observed. Conduction disturbances may be subdivided into the very common intraventricular conduction defects (right bundle branch block, sometimes with left anterior hemiblock) and complete A-V block. Complete heart block has become less frequent in recent years since surgeons have learnt to avoid the bundle of His during VSD closure. All patients with postoperative complete heart block need a permanent pacemaker. Ventricular arrhythmias after ventricular surgery are commonly found if Holter recordings are done, particularly after correction of tetralogy. They are often asymptomatic but may be a cause of late sudden death (1-3% of patients operated on for tetralogy). Antiarrhythmic treatment is indicated if symptoms are present, or in selected asymptomatic patients with a poor hemodynamic result (severe residual pulmonary stenosis or ventricular dysfunction). Sinus node dysfunction and sick sinus syndrome are common after atrial repair of transposition (Mustard or Senning operation). The manifestations are either sinus bradycardia and sinus arrest with long pauses, or atrial reentry tachycardia (Flutter); these may combine, so that antiarrhythmic medication must be associated with permanent pacemaker implantation.(ABSTRACT TRUNCATED AT 250 WORDS)
The 1998 NASPE prospective catheter ablation registry.
The results of the NASPE Prospective Voluntary Registry are reported. A total of 3,357 patients were entered. For those undergoing atrioventricular (AV) junctional ablation (646 patients), the success rate was 97.4% and significant complications occurred in 5 patients. A total of 1,197 patients underwent AV nodal modification for AV nodal reentrant tachycardia, which was successful in 96.1% and the only significant complication was development of AV block (1%). Accessory pathway ablation was performed in 654 patients and was successful in 94%. Major complications included cardiac tamponade (7 patients), acute myocardial infarction (1 patient), femoral artery pseudoaneurysm (1 patient), AV block (1 patient), pneumothorax (1 patient), and pericarditis (2 patients). A total of 447 patients underwent atrial flutter ablation and acute success was achieved in 86% of patients. Significant complications included inadvertent AV block (3 patients), significant tricuspid regurgitation (1 patient), cardiac tamponade (1 patient), and pneumothorax (1 patient). Atrial tachycardia was attempted for 216 patients and the success rate was higher for those with right atrial (80%) or left atrial (72%) compared to those with septal foci (52%). A total of 201 patients underwent ablation for ventricular tachycardia. The success rate was higher for those with idiopathic ventricular tachycardia compared to those with ventricular tachycardia due to ischemic heart disease or cardiomyopathy. While the number of AV junction ablation were higher for those > 60 years of age, there was no significant difference in the success rate or incidence of complication comparing patients > or = 60 to those < 60 years of age. In addition, we found no differences in incidence of success or complications comparing large volume centers (> 100 ablation/year) with lower volume centers or between teaching and non-teaching hospitals.
Ibutilide: efficacy and safety in atrial fibrillation and atrial flutter in a general cardiology practice.
BACKGROUND: Published experience with ibutilide (IB) in randomized clinical trials reveals that conversion to sinus rhythm (SR) occurs in 31% of patients with atrial fibrillation (AF) and in 63% of patients with atrial flutter. HYPOTHESIS: The study was undertaken to test the efficacy and safety of IB in patients with AF and with atrial flutter and to compare them with those reported in previous studies. METHODS: In a general cardiology practice, 54 consecutive patients with AF or atrial flutter, no contraindication to IB, and a normal QTc interval, were treated with intravenous IB (0.4-2.0 mg). Duration of arrhythmia, left atrial (LA) size, ejection fraction (EF), time to conversion, QTc interval, and adverse drug events were determined. Patients were observed for a minimum of 6 h. Successful cardioversion was defined as arrhythmia termination within 6 h. RESULTS: Twenty-four of 34 (70.6%) patients with AF and 15 of 20 (75%) patients with atrial flutter converted to SR. Conversion of AF to SR was more likely to occur if duration of AF was approximately 96 h compared with > 96 h (81 vs. 17%, respectively; p = 0.006). The mean time to arrhythmia termination was 68.8 min. Left atrial size, determined by echocardiogram, was 44 +/- 13 mm in 43 patients. Patients with LA size approximately 45 mm had a conversion rate of 55% in both AF and flutter, compared with a conversion rate of 72% in patients with LA size < 45 mm. Ejection fraction was not a predictor of drug success. The QTc intervals were significantly prolonged after IB administration, with a mean change of 47.1 ms for successfully treated patients. Sustained polymorphic ventricular tachycardia occurred in one patient within 1 min of IB infusion, requiring electrical cardioversion to SR. This patient's serum electrolytes and QTc interval were normal prior to IB infusion; however, the QTc increased by 160 ms (from 387 to 547 ms) during drug infusion. No systemic or pulmonary emboli occurred. CONCLUSION: The efficacy of IB for conversion of AF to SR in this prospective observational study was considerably better than previously reported. Duration of AF remains an important predictor of conversion to SR. Complications are rare and without long-term adverse effects.
Cardioversion and defibrillation.
The use of electrical energy for the immediate treatment of atrial and ventricular arrhythmias is practical and easily applied. The method, though simple, is the most effective method for terminating cardiac arrhythmias and is associated with only a low risk if properly employed. In symptomatic patients, the utilization of cardioversion reduces patient discomfort and complications which may occur while awaiting pharmacologic reversion of arrhythmia. At present, transthoracic defibrillation is the only practical method for terminating VF. Despite the safety of electrical reversion, proper precautions are necessary to prevent complications. In particular, the discharge of excessive energies, especially in the presence of digitalis toxicity, promises grave and life-threatening consequences. The use of antiarrhythmic medications is not supplanted by cardioversion and defibrillation. Rather, ongoing drug therapy is frequently necessary to prevent recurrence of arrhythmia.
Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation.
The safety and efficacy of amiodarone and propafenone in converting atrial fibrillation or flutter after cardiac surgery were compared in a randomized double-blind trial. Eighty-four patients with sustained atrial tachyarrhythmias of more than 30 min' duration, stable hemodynamic status and neither preoperative atrial arrhythmias nor treatment with other antiarrhythmis drugs, were randomized to receive amiodarone (46 patients: 5 mg/kg over 15 min and then 15 mg/kg over the subsequent 24 h for non-converting) or propafenone (38 patients: 2 mg/kg over 15 in and then 10 mg/kg over the subsequent 24 h for non-converting). Nine of the 46 patients (19.5%) receiving amiodarone converted to sinus rhythm within 1 h following bolus injection compared with 17 of 38 patients (44.7%) treated with propafenone (P < 0.05). Within the 24 h study, 38 of 46 patients (82.6%) given amiodarone and 26 of 38 patients (68.4%) given propafenone were converted to sinus rhythm (P = NS). A significantly progressive reduction in ventricular response, already evident at 10th min from the start of treatment, was achieved in both groups of patients. Side effects occurred in six patients given propafenone (15.7%) and in five given amiodarone (10.8%) (P = NS). The two drugs were equally effective in converting postoperative atrial fibrillation and/or flutter after 24 h although propafenone was superior within the first hour.
Curative therapy of cardiac tachyarrhythmias with catheter ablation--a review of the experience with the first 1000 patients.
INTRODUCTION: Cardiac tachyarrhythmias present as supraventricular or ventricular tachycardia. Catheter ablation has completely revolutionised the treatment of patients with these arrhythmias. METHOD: We reviewed the experience of radiofrequency catheter ablation in a single centre. RESULTS: A total of 1,022 patients underwent radiofrequency catheter ablation from October 1991-December 1997. There were 480 patients who had AV nodal re-entrant tachycardia, 429 patients with accessory pathways, 7 patients with both AV nodal re-entrant tachycardia and accessory pathways, 4 patients with both AV nodal re-entrant tachycardia and atrial tachycardia. Twenty-seven patients had atrial tachycardia ablation, 28 had atrial flutter ablation and 11 patients had AV node ablation for atrial fibrillation. The mean age of the supraventricular tachycardia patients was 41 +/- 15 years (10-80 years). The mean duration of procedure was 108 +/- 60 minutes (15 to 480 minutes) and the mean fluoroscopy time was 19 +/- 17 minutes (3-122 minutes). Another 14 patients had ablation for right ventricular outflow tract ventricular tachycardia and 22 patients had ablation for idiopathic left ventricular tachycardia. The mean age of the ventricular tachycardia patients was 35 +/- 14 years (19-65 years). The mean duration of the ventricular tachycardia ablation procedure was 185 +/- 63 minutes (110-285 minutes) and the duration of fluoroscopy was 33 +/- 16 minutes (range 14-68 minutes). Of the 1,022 patients, 1,002 (98%) of the patients were successfully ablated. There were significant complications in less than 1% of the patients and no mortality associated with the procedure. The recurrence rate was 5% and could be successfully reablated when the procedure was repeated. CONCLUSION: Radiofrequency catheter ablation is thus an extremely safe and successful procedure and has replaced drug therapy as the treatment of choice for patients with supraventricular tachycardia and non-ischaemic ventricular tachycardia. It provides curative therapy without the need for life-long drug therapy.
The use of radiofrequency energy in pediatric cardiology.
The use of radiofrequency energy for the treatment of supraventricular tachycardia in pediatric patients has gained widespread acceptance, especially for tachyarrhythmias associated with palpitations, dizziness, presyncope or syncope, cardiomyopathy, and cardiac arrest. Ablation of the substrate supporting atrioventricular reentry, atrioventricular node reentry, and automatic atrial tachycardia yields a 90%-98% success rate with low incidence (< 1%) of complications and adverse side-effects. Ablation of intra-atrial reentry, including atrial flutter and fibrillation, appears to be promising and would be a significant advance in the management of patients following extensive atrial surgery for congenital heart disease. Radiofrequency energy is also used to treat various forms of idiopathic ventricular tachycardia. Finally, radiofrequency energy has been extended to control the ventricular rate associated with malignant atrial tachycardia by either modification or ablation of the atrioventricular node, and subsequent pacemaker implant. Long-term outcome of radiofrequency ablation is unknown, but the short-to-intermediate (1-5 yrs) outcome is excellent, with low recurrence rate of the tachycardia, no proarrhythmic effect, and excellent clinical state.
Oral loading with propafenone for conversion of recent-onset atrial fibrillation: a review on in-hospital treatment.
Atrial fibrillation (AF) is a very common arrhythmia. In order to treat acute AF rapidly, effective drug regimens are required. Propafenone is a class IC antiarrhythmic agent that is suitable for oral loading as it reaches peak plasma concentrations within 2 to 4 hours of administration. The use of propafenone loading in patients with AF must be based on appropriate patient selection in view of the negative inotropic effect and the potential proarrhythmic effects of the drug. A series of controlled trials in patients with recent-onset AF without heart failure who were hospitalised with enforced bed rest has shown that orally loaded propafenone (450 to 600 mg as single dose) exerts a relatively quick effect (within 3 to 4 hours) and a high rate of efficacy (72 to 78% within 8 hours). A potentially harmful effect of class IC agents is the risk of transforming AF into atrial flutter (3.5 to 5% of patients). However, atrial flutter with 1 : 1 atrioventricular response was observed in only two of 709 patients receiving propafenone (0.3% incidence). Nevertheless, the potential negative inotropic effect of propafenone demands careful patient selection, with systematic exclusion of patients with left ventricular dysfunction or congestive heart failure. Oral loading with propafenone can be considered as an episodic treatment in patients with AF recurrences, as has been proposed for other drugs in the past. However, the safety of oral loading with propafenone as an outpatient treatment in appropriately selected patients has to be assessed by appropriately designed prospective studies.
[Heart failure in acute myocardial infarct and the importance of hemodynamic monitoring].
In his study the author deals with etiopathogenesis, diagnosis and therapy of heart failure in acute infarction of myocardium (AMI) with special attention paid to haemodynamic monitoring. The therapy of AMI is based especially on thrombolysis, or urgent revascularisation. In therapy of left ventricular failure we prefer nitrates, diuretics, and ACE-inhibitors. A severe heart failure requires haemodynamic monitoring and administration of positive inotropic substances (dopamine, dobutamine, amrinone) and sodium nitroprusside. Digoxin is indicated only in atrial fibrillation and flutter with fast response of ventricles. In cardiogenic shock it is necessary to introduce an intraaortic balloon contrapulsation and urgent revascularisation (coronary angioplasty, or aortocoronary bypass). Special attention has to be paid to the diagnosis and therapy of AMI of the right ventricle. We avoid the administration of diuretics, nitrates, or morphine which cause hypotension. The therapy is based on thrombolysis, hypotension requires volume expansion, sustained hypotension needs administration of dobutamine, and haemodynamic monitoring. In case of complete AV block, sequence atrioventricular cardiostimulation is recommended. (Ref. 11.).
Effects of radiofrequency catheter ablation on quality of life in patients with atrial flutter.
The long-term effects of radiofrequency catheter ablation on quality of life in patients with typical atrial flutter are still unknown. This study included 100 consecutive patients with clinically documented typical atrial flutter. Subjective perception of quality of life was assessed by a semiquantitative questionnaire before, and 1 and 6 months after ablation. Ablation of typical atrial flutter was associated with a significant improvement in the general quality of life, frequency of significant symptoms, and symptoms during attacks. The frequency of hospital admission and emergency room visits, and number of antiarrhythmic drugs significantly decreased after ablation. Activity capacity significantly improved after ablation in patients with depressed left ventricular function. All improvements after ablation were maintained over 6-month follow-up. However, patients with atrial fibrillation compared with those without atrial fibrillation before ablation had less improvement in the general quality of life, frequency of significant symptoms, and symptoms during attacks (including palpitation, asthenia, effort, dyspnea, rest dyspnea, and dizziness). Furthermore, patients with atrial fibrillation before ablation needed more antiarrhythmic drugs, and had a higher frequency of hospital admission and emergent room visits at 6-month follow-up (all variables p <0.01). Multivariate analysis demonstrated that only the presence of atrial fibrillation before ablation could independently predict improvement in general quality of life (p = 0.03), frequency of significant symptoms (p = 0.03), symptoms during attacks (p = 0.04), and decrease in the consumption of health care resources including antiarrhythmic drugs (p = 0.01), hospital admission (p = 0.02), and emergency room visits (p = 0.02). Ablation of typical atrial flutter could significantly improve quality of life, but patients who had atrial flutter associated with atrial fibrillation before ablation had less improvement than those without atrial fibrillation.
[Ablation of atrio-ventricular conduction by fulguration of the His bundle. Proposal for a simplified technic. Apropos of 70 cases].
Between 1982 and 1987, 70 patients (32 men, 38 women, aged from 45 to 93 years) underwent catheter ablation of His bundle and were followed up for more than 3 months. The disorders treated were atrial fibrillation, flutter of tachycardia (62 cases), junctional tachycardia (7 cases) and refractory atrial extrasystoles (1 case). The overall results were: early failure in 1 case, late death in 3 cases, persistent high degree AV block in 53 cases (75 p. 100), 1st degree AV block in 9 cases (12 p. 100) and failure in 8 cases (13 p. 100). Two techniques were used. In the first 30 patients ablation was performed by tri- or quadripolar catheters with electrodes 10 mm apart (USCI 2943/2854) and localization by an unipolar electrode connected to the negative pole of the defibrillator. The mid-term results in this series were: complete AV block in 20 cases (66 p. 100), partial AV block in 5 cases (17 p. 100) and failure in 17 cases (17 p. 100). In the last 40 patients localization was bipolar and ablation was obtained with simultaneous bipolar leads taken from a Josephson catheter with electrodes 5 mm apart (USCI 8567); the two electrodes recording the highest His bundle potential were connected to the negative pole of the defibrillator. The results in these series were: complete AV block in 33 cases (82 p. 100), partial AV block in 4 cases (11 p. 100) and failure in 3 cases (7 p. 100). Although the two series were not exactly similar, it seems permissible to recommend the second, more convenient technique.