Anterograde conduction of a concealed accessory pathway after transvenous electric catheter ablation.

An 18-year-old woman with a concealed right midseptal accessory pathway and refractory supraventricular tachycardia with a cycle length of 280-400 ms and a wide echo zone of 280-520 ms is reported. The transvenous electric catheter ablation with two shocks of 200 and 300 J, each on a separate occasion, was followed by anterograde and retrograde atrioventricular block. The patient received an implantable pacemaker (VVI). Four weeks later we observed a stable anterograde conduction of the pathway in spite of a persisting retrograde block. It is concluded that the site of unidirectional block in this patient is at the origin of the concealed accessory pathway in the ventricular septal muscle. The necrosis after ablation changed conduction conditions at the site of unidirectional block. Presently, the patient has been free of tachycardia for 19 months. This observation is of importance for the patient because another mechanism of tachycardia might be possible after ablation.

Long QT syndrome associated with inflammatory degeneration of the stellate ganglia.

A well-studied case of intermittent long QT syndrome in a 21-year-old female is presented. Electrophysiologic investigation repeated three times revealed changing sinoatrial and atrioventricular dysfunction and nonsustained ventricular tachycardia. The patient died 29 months after first hospitalization in a stage of electromechanical dissociation after runs of torsade de pointes although she had been treated with repeated anti-inflammatory therapy as well as high doses of propranolol. Postmortem examination demonstrated active inflammation of stellate ganglia. Myocardium appeared normal.

[Clinico-electrophysiologic studies on the action of the anti-arrhythmic substance 3-carbethoxyamino-5-dimethylamino-acetyl-10,11-dihydro-5H- dibenz[b,f]azepine hydrochloride (Bonnecor, AWD 19-166, GS 015)]. / Klinisch-elektrophysiologische Untersuchungen zur Wirkung der antiarrhythmischen Substanz 3-Carbethoxyamino-5-dimethylamino-acetyl-10,11- dihydro-5H-dibenz[b,f]azepinhydrochlorid (Bonnecor, AWD 19-166, GS 015).

The effects of the new antiarrhythmic drug 3-carbethoxy-amino-5-dimethyl-amino-acetyl-iminodibenzyl-hydroc hlorid (Bonnecor) (B.) were investigated by means of clinical-electrophysiologic methods (His-bundle electrography, programmed electrical stimulation) in 11 patients with normal cardiac output and paroxysmal supraventricular tachycardias. In a maximal dosage of 0.24 mg/kg body mass. B. affects several compartments of the impulse initiation and conduction. B. has positive chronotropic actions on the sinus node automaticity, negative dromotropic effects on the sinu-atrial, intraatrial, AV nodal and intraventricular conduction and finally negative bathmotropic actions on the myocardium of the atria and ventricles. B. suppress the artificial induction of paroxysmal supraventricular tachycardias in patients with AV nodal reentry. These results help to recognize indications (supraventricular and ventricular premature beats or tachycardias) and contraindications (sick sinus syndrome, atrio-ventricular block of higher degreé and bifascicular blocks).

[Heart failure and cardiac arrhythmias]. / Herzinsuffizienz und Herzrhythmusstörugen.

Treatment of ventricular tachycardias is still a very important problem, especially in patients with malignant tachycardias and patients with heart failure and ejection fraction (EF) less than 30%. The majority of antiarrhythmic drugs have negative inotropic action and may therefore aggravate the arrhythmia or the ventricular impairment. The strategy of treatment must be directed toward suppression of arrhythmias as well as ventricular function. For this reason the treatment requires a close control of heart rhythm and parameters of ventricular function by Holter-ECG, ventricular stimulation and signal-averaged electrocardiography, as well as EF and exercise testing. In view of the risk of aggravation of both heart failure and/or arrhythmia it has been suggested that it might be better to treat patients with low EF with alternative non-medical treatment methods such as by surgical interventions, implantation of cardioverter-defibrillators or ablation techniques. Especially in cases after myocardial infarction, we need new information concerning the risk stratification and the value of the parameters of ventricular function, electrophysiological substrate, and trigger mechanisms.

[Accentuated anterior and posterior orientation--2 newly defined disorders of impulse conduction of the heart distal to the AV node]. / Die betonte anteriore und posteriore Orientierung--zwei neue definierte Störungen der Erregungsausbreitung des Herzens distal des AV-Knotens.

During a programmed atrial stimulation in 80% of the cases disturbances of the stimulus conduction could be produced distally to the atrioventricular node. In the horizontal plane of the vector cardiogram two different configurations appeared. In 45 examinations an anterior displacement and in 36 examinations a posterior displacement of the vector loop could be evoked. Issuing from this, in healthy persons in 44 cases vector cardiograms with an emphasized anterior orientation (AD) and 21 cases with an opposite configuration of an emphasized posterior orientation (PD) were compiled. The criteria for the two up to now little or not described disturbances of the stimulus conduction are presented. It is referred to the extension of the principles of the subdivision of the disturbances of the stimulus conduction.

[Mechanism of the effect of electrostimulation during the interruption of tachycardial arrhythmias]. / Zum Wirkungsmechanismus der Elektrostimulation bei der Unterbrechung tachykarder Rhythmusstörungen

With the help of three individual electrocariograpic observations which were collected at the end of tachycardiac disturbances of rhythm by electrostimulation, the author enters the mechanism of action of this form of the cardiac electrotherapy. From this its indication and the most rational practical approach are derived.

[Importance of PQ time in the evaluation of bifascicular block]. / Zur Bedeutung der PQ-Zeit bei der Beurteilung bifaszikulärer Blockbilder.

In 103 patients with bifascicular block was tested by means of the His bundle electrography, whether with the help of the PQ-time an indirect estimation of the conduction capacity of the still conducting fascicle (HV-interval) is possible. In 70% of the cases with bifascicular blocking and AV-block of first degree the HV-interval was prolonged. However, also 45% of the patients with bifascicular block showed a prolonged HV-interval despite normal PQ-time. Of 21 patients with syncopes due to an intermitting trifascicular block 10 had a normal PQ-time in phases of the transduction. Thus a normal PQ-time in patients with bifascicular block is no guarantee for a good transduction via the still conducting fascicle. If in patients with bifascicular block additionally an AV-block of first degree is existing, the place of the primary retardation of the conduction should more exactly be analysed. For this purpose offer themselves an atropine test or the His bundle electrography.

[Differential therapeutic problems in sinus node syndrome--drug or electrical therapy?]. / Differentialtherapeutische Probleme beim Sinusknotensyndrom--medikamentöse oder elektrische Therapie?

121 hospitalised patients with electrophysiologically ascertained sick sinus syndrome were ambulatorily observed for two and a half years. The knowledge of the electrophysiological parameters allowed in every case an exact estimation of the degree of severity. Patients with preponderantly isolated disturbance of the sino-atrial node automatism, the sino-atrial conduction and the nervous regulation (patients with carotid sinus syndrome) as well as the majority of patients with bradycardia-tachycardia-syndrome were conservatively treated. Patients with high-degree combined disturbances of the sinus node partial functions were electrically treated. Every cardiac syncope in the medicamentously treated sick sinus node syndrome is the absolute indication for a pacemaker implantation. The further observation in the outpatient department showed that in many patients with symptomatic sick sinus node syndrome an attempt of conservative treatment is justified.

[Transvascular intracardiac ablation--on the current status of the method in the treatment of tachyarrhythmias]. / Transvasale intrakardiale Ablation--zum gegenwärtigen Stand der Methode in der Behandlung von Tachyarrhythmien.

A survey is given on the method of the transvasal intracardiac ablation in the treatment of atrial and ventricular tachyarrhythmias. Experimental fundaments, indication, method and possible complications are reported. Own results on five patients with His bundle ablation are described. A possible further development of the method is the enlargement of the His bundle ablation to the ablation of focal arrhythmias, Kent's fibres and ventricular tachycardias without evocation of a total atrioventricular block. Alternative techniques of the cauterization, the laser ablation and the high frequency coagulation are described.

[Arrhythmogenic effects of anti-arrhythmia agents]. / Arrhythmogene Effekte von Antiarrhythmika.

Arrhythmogenic effects appear in 5-22% of all patients. On the basis of a literary investigation on 11,547 patients with 1,114 proarrhythmic effects and of 21 own observations mechanisms, risks and diagnostics of this dangerous side effect are demonstrated. In most cases patients with severe functional disturbances of the heart and known ventricular tachyarrhythmias are affected. Not infrequently a prolonged QT-internal is found. An accumulation of the known arrhythmias or an appearance of new disturbed rhythms, frequently Torsade de pointes, may occur. Holter-ECG and programmed stimulation are suited for recognition, which are together to be applied in malignant tachyarrhythmias. The prophylaxis deals with a careful indication, aimed selection of the antiarrhythmic drugs and a subtile control of therapy in the first days after the beginning of the therapy and after every increase of dosage.

[Estimation for bugeting and evaluation of surgical procedures within the scope of comparative hospital administration. Value of LKA, PPR and DRG systems]. / Schätzverfahren zur Budgetfindung und Bewertung chirurgischer Leistungen im Rahmen eines Krankenhausbetriebsvergleiches. Wertigkeit von LKA-, PPR- und DRG-Systemen.

Comparison of costing and performances of individual departments or hospitals are required by the statute book of social affairs (Sozialgesetzbuch V; SGB V), but have not been fully introduced in Germany. LBK Hamburg, a trust of 8 hospitals with 17 surgical departments, evaluated the significance of performance and cost-accounting systems such as performance and cost-accounting (LKA), nursing staff regulation (PPR), and the diagnosis-related group system in order to distribute a three-year budget (1996-1998) and to compare, e.g., performance of surgical departments. The DRG system seems to be the best choice, since it weights all cases by means in 640 groups according to the degree of difficulty. With a given closed budget, the DRG system may compare the actual cost with the target figures.