Trastorno del ritmo poscierre del foramen oval con dispositivo Amplatzer PFO® / Rhythm disorder post-closure of the foramen ovale with Amplatzer PFO® device

Presentamos el caso clínico de una paciente de 53 años que consultó con síntomas neurológicos compatibles con un ataque isquémico transitorio. Se encontró un desorden protrombótico y un foramen oval permeable, sin otra explicación para la enfermedad. Se decidió cerrarlo por vía percutánea mediante un dispositivo Amplatzer PFO® y no hubo complicaciones durante el procedimiento. A los 15 días del alta comenzó con palpitaciones rápidas y se demostró una taquicardia auricular paroxística recurrente. Se inició tratamiento farmacológico con propafenona que logró controlar la arritmia y el síntoma. A los tres meses se suspendió la medicación. Transcurridos seis meses la paciente está asintomática, con electrocardiograma normal y un Holter sin la arritmia. Revisamos la literatura disponible sobre los trastornos del ritmo luego del cierre percutáneo del foramen oval y comunicación interauricular.

Trastorno del ritmo poscierre del foramen oval con dispositivo Amplatzer PFO® / Rhythm disorder post-closure of the foramen ovale with Amplatzer PFO® device

Presentamos el caso clínico de una paciente de 53 años que consultó con síntomas neurológicos compatibles con un ataque isquémico transitorio. Se encontró un desorden protrombótico y un foramen oval permeable, sin otra explicación para la enfermedad. Se decidió cerrarlo por vía percutánea mediante un dispositivo Amplatzer PFO® y no hubo complicaciones durante el procedimiento. A los 15 días del alta comenzó con palpitaciones rápidas y se demostró una taquicardia auricular paroxística recurrente. Se inició tratamiento farmacológico con propafenona que logró controlar la arritmia y el síntoma. A los tres meses se suspendió la medicación. Transcurridos seis meses la paciente está asintomática, con electrocardiograma normal y un Holter sin la arritmia. Revisamos la literatura disponible sobre los trastornos del ritmo luego del cierre percutáneo del foramen oval y comunicación interauricular.

We report the case of a 53 years old woman who presents with neurologycal symptoms suggestive of a transient ischemic attack. A prothrombotic disorder and patent formen oval were found, with no other explantion for the disease. It was decided to closed the foramen with a percutaneously implanted Amplatzer PFO® device and there were no incidents during the procedure. Fiftheen days after hospital discharge she began to refere rapid palpitations and a paroxistic recurrent atrial tachycardia was documented. Pharmacological therapy with propafenone was initiated and it was able to control the arrhythmia and the symptoms. Three months later the drug was discontinued. After 6 months follow up the patient is asymptomatic, with a normal EKG and a Holter without arrhythmias. We review the available literature about rhythm disorders after the percutaneus closure of the foramen oval and interatrial comunication.

Arritmias en el embarazo / Arrhythmias during pregnancy

Las arritmias durante el embarazo son eventos de aparición frecuente. Desde las extrasístoles aisladas hasta las taquiarritmias, capaces de poner en riesgo las vidas materna y fetal, constituyen el amplio espectro de presentación. Muchas de ellas exigen intervenciones de urgencia, tratamientos crónicos o ambos. La comunicación de este caso nos motivó a realizar una revisión de las indicaciones y posibilidades farmacológicas de las taquicardias paroxísticas supraventriculares en este período particular de la mujer. El fármaco de elección para el manejo agudo de las taquicardias paroxísticas supraventriculares es la adenosina. Este agente debería encontrarse siempre en el área de quirófano al alcance de los anestesiólogos, para un manejo terapéutico de urgencia. La conducta obstétrica estará marcada por el estado hemodinámico de la madre y del feto.

Arrhythmias during pregnancy are frequent events. There is a wide spectrum of presentations: from isolated extrasystoles to tachyarrhythmias with risk to mother and fetal life. Many of these arrhythmias need urgent interventions and/or chronic treatment. The communication of this clinical case motivated us to realize a review of the indications and pharmacological possibilities in paroxysmal tachyarrhythmias in this particular period in women. Adrenosine is the pharmacological treatment of choice to manage paroxysmal supraventricular tachyarrhythmias. This drug should always be at hand in the operating theater, to be used by the anesthesiologists for the therapeutic managing of the emergencies. Obstetric clinical conduct will depend on the haemodynamic condition of the mother and the fetus.

As arritmias durante a gravidez são eventos de ocorrência freqüente. Desde as extrassístoles isoladas até as taquiarritmias, que podem pôr em risco as vidas materna e fetal, constituem o amplo espectro de apresentação. Muitas delas exigem intervenções de urgência, tratamentos crônicos ou ambos. Este caso nos estimulou a fazer uma revisão das indicações e possibilidades farmacológicas das taquicardias paroxísticas supraventriculares nesse período da mulher. O fármaco de escolha para o manejo agudo das taquicardias paroxísticas supraventriculares é a adenosina. Este agente deveria estar sempre disponível na sala de operações, ao alcance da mão dos anestesiologistas, para um manejo terapêutico de urgência. A conduta obstétrica estará marcada pelo estado hemodinâmico da mãe e do feto.

Isolated noncompaction of the myocardium.

Noncompaction of the myocardium (NCM) is a rare congenital heart defect. It was first described 15 years ago, and few cases are published. The purpose of this study is to describe a NCM case. Clinical findings and imaging test results of a 37-year-old female patient with isolated NCM are presented. The patient complained of palpitations; her physical examination revealed extrasystoles, and her 12-lead electrocardiogram showed ventricular bigeminy. Three-dimensional Doppler echocardiography revealed numerous prominent trabeculations with deep intertrabecular recesses with blood flow which communicated with the ventricular cavity, which were more intense in the septal apical region. Cardiac magnetic resonance imaging corroborated the echocardiographic findings. The clinical presentation and the patients laboratory test results confirmed the diagnosis of isolated NCM. The knowledge of the echocardiographic findings of this disease enables an early diagnosis and a more adequate treatment.

Forma isolada do miocárdio não-compactado / Isolated noncompaction of the myocardium

Miocárdio não-compactado (MNC) é uma cardiopatia congênita com incidência rara, sendo o seu primeiro relato feito há 15 anos e com poucos casos publicados. O objetivo deste artigo é descrever um caso de MNC. É apresentada descrição dos achados clínicos e dos exames complementares de imagem de uma paciente com 37 anos, portadora de MNC de forma isolada. A paciente queixava-se de palpitações, apresentava extra-sístoles no exame clínico e, no eletrocardiograma de 12 derivações, bigeminismo ventricular. Realizou ecocardiograma Doppler tridimensional que revelou a presença de numerosas e proeminentes trabéculas com recessos intertrabeculares profundos com fluxo de sangue que se comunicavam com a cavidade ventricular e que se acentuavam na região septo-apical. A ressonância nuclear magnética de coração corroborou os achados do ecocardiograma. A clínica e os resultados dos exames complementares dessa paciente confirmaram o diagnóstico de MNC de forma isolada. O conhecimento de achados ecocardiográficos dessa doença permite um diagnóstico precoce e tratamento mais adequado.

Noncompacted myocardium (NCM) is a rare congenital heart disease, first reported 15 years ago and with only a few published cases. In this paper, we report the main clinical findings and the complementary exams that suports NCM diagnostic. Discretion of anamnesis and physical examination, together with characteristic image complementary exams findings of symptomatic NCM. (Case report). The clinical assessment and the electrocardiogram at the admission found bigeminism ventricular. A tridimensional Doppler echocardiogram was performed and showed numerous and prominent myocardium trabeculations and deep intertrabecular recess filled with blood that communicate with the ventricular cavity, more present in the septal-apical area. Magnetic resonance imaging supported the echocardiographic findings and ruled out the presence of others cardiac malformations. The clinical and imaging complementary exams filled out the touchstones that support isolated NCM diagnose. Is important to know that suggestive NCM findings permits an earlier diagnostic and treatment.

Uso de adenosina en taquicardia paroxística supraventricular en emergencia / Use of adenosine in paroxysmal supraventricular tachycardia in emergency

Se conoce la eficacia de la adenosina en el tratamiento de la taquicardia paroxística supraventricular sin compromiso hemodinámico. Objetivo: se propone analizar la respuesta al uso de esta droga en todos los niños que consultaron por esta causa en una emergencia pediátrica, independientemente de su estado hemodinámico. Material y método: se revisaron retrospectivamente 19 historias clínicas de niños entre 21 días y 14 años, que presentaron un total de 25 episodios de taquicardia paroxística supraventricular, en un período de 5 años y 7 meses. Se consideraron dos grupos de pacientes: uno sin repercusión hemodinámica (40 por ciento) y otro con repercusión hemodinámica (60 por ciento).Se consideró como respuesta positiva a la adenosina la reversión electrocardiográfica de la arritmia a ritmo sinusal, luego de un máximo de 3 dosis en el mismo episodio. Resultados: en el grupo sin repercusión hemodinámica de los 10 episodios tratados (siete niños), revirtió el 70 por ciento, luego de una a tres dosis de adenosina. En el grupo con repercusión hemodinámica, de los 15 episodios tratados (13 pacientes), revirtió el 93 por ciento luego de una a dos dosis de adenosina. Respuesta global positiva: 84 por ciento. No hubo muertes y no se observaron complicaciones ni efectos secundarios. Conclusiones: el tratamiento con adenosina en las taquicardias paroxísticas supraventriculares en la emergencia es efectivo en los dos grupos considerados y surge como una alternativa terapéutica aun en pacientes con compromiso hemodinámico (AU)

Uso de adenosina en taquicardia paroxística supraventricular en emergencia / Use of adenosine in paroxysmal supraventricular tachycardia in emergency

Se conoce la eficacia de la adenosina en el tratamiento de la taquicardia paroxística supraventricular sin compromiso hemodinámico. Objetivo: se propone analizar la respuesta al uso de esta droga en todos los niños que consultaron por esta causa en una emergencia pediátrica, independientemente de su estado hemodinámico. Material y método: se revisaron retrospectivamente 19 historias clínicas de niños entre 21 días y 14 años, que presentaron un total de 25 episodios de taquicardia paroxística supraventricular, en un período de 5 años y 7 meses. Se consideraron dos grupos de pacientes: uno sin repercusión hemodinámica (40 por ciento) y otro con repercusión hemodinámica (60 por ciento).Se consideró como respuesta positiva a la adenosina la reversión electrocardiográfica de la arritmia a ritmo sinusal, luego de un máximo de 3 dosis en el mismo episodio. Resultados: en el grupo sin repercusión hemodinámica de los 10 episodios tratados (siete niños), revirtió el 70 por ciento, luego de una a tres dosis de adenosina. En el grupo con repercusión hemodinámica, de los 15 episodios tratados (13 pacientes), revirtió el 93 por ciento luego de una a dos dosis de adenosina. Respuesta global positiva: 84 por ciento. No hubo muertes y no se observaron complicaciones ni efectos secundarios. Conclusiones: el tratamiento con adenosina en las taquicardias paroxísticas supraventriculares en la emergencia es efectivo en los dos grupos considerados y surge como una alternativa terapéutica aun en pacientes con compromiso hemodinámico

[Amiodarone induced retrobulbar neuritis. Clinical case]. / Neuritis retrobulbar inducida por amiodarona. Caso clínico.

We report a 66 years old male, with an ophtalmologic history of long sightedness, admitted to the hospital due to paroxysmal atrial fibrillation crises in the context of a coronary heart disease. He was treated with i.v. amiodarone, receiving a total dose of 6 g in 72 hours. After the third day of treatment, the patient noticed a correction of his long sightedness and 24 h later, he complained of hlurred vision and orbital frontal headache. Visual field examination revealed a concentric retraction of visual field and a centrocecal scotoma in both eyes. Amiodarone was withdrawn and dexametasone treatment was begun. Three days after amiodarone discontinuation, sight improved and visual field returned to normal. Although retrobulbar neuritis has been associated to various drugs, amiodarone has not been considered as a possible agent.

[Intravenous diltiazem in the reversion to sinus rhythm in supraventricular tachyarrhythmias]. / Diltiazem pro vía intravenosa en la conversión a ritmo sinusal de taquiarritmias supraventriculares.

UNLABELLED: The safety and therapeutic efficacy (sinus rythm recovery) of intravenous diltiazem vs verapamil in paroxysmal supraventricular tachycardias (PSVT), and diltiazem vs the Sokolow protocol (i.v. digital and oral quinidine) in recent onset atrial fibrillation (AF) were compared. Sixty patients with PSVT were randomized to have a bolus of 0.3 mg/Kg of diltiazem or 75 micrograms/Kg of verapamil. If after 15 minutes the PSVT persisted, a 6 hours i.v. infusion of diltiazem was started (0.0028 mg/Kg/min) or a second dose of verapamil was repeated. In 100 patients with PAF the alternative to diltiazem was i.v. digital plus oral quinidine (400 to 1,200 mg). Ninety per cent of the PSVT and 64% of de AF, recovered sinus rythm with diltiazem. The same results were obtained with verapamil in PSVT. With the Sokolow protocol 90% of the AF recovered sinus rythm. In 83% of AF who did not revert to sinus rythm, diltiazem was effective for slowing the ventricular response. In relation with the drug safety, only 5 patients showed hypotension, without clinical relevance, in the diltiazem group. With verapamil one patient had a transitory ischemic attack after recover sinus rythm. In the Sokolow group 26% had minor gastrointestinal disorders. CONCLUSIONS: In this clinical trial (n = 160): 1) Diltiazem and verapamil were highly and equally effective (90%) in reverting PSVT to sinus rythm. 2) The Sokolow protocol was more effective than diltiazem for reversing PAF to sinus rythm (90% vs 64%, p < 0.01). 3) Diltiazem was effective for slowing the ventricular rate in 83% of the patients with AF who did not revert to sinus rythm. 4) There was a low incidence of side effects with diltiazem and verapamil. 5) Diltiazem is a first choice therapeutic agent in reverting PSVT to sinus rythm and for slowing the ventricular rate in AF.

[Comparative study between verapamil and adenosine triphosphate in the treatment of paroxysmal supraventricular tachycardia]. / Estudo comparativo entre verapamil e adenosina-trifosfato no tratamento das taquicardias paroxísticas supraventriculares.

PURPOSE: To evaluate the efficacy and safety of intravenous (IV) adenosine-triphosphate (ATP) and verapamil to convert acute episodes of paroxysmal supraventricular tachycardia (PSVT) to sinus rhythm. METHODS: Fifty patients with PSVT were randomized in two groups: A) 25 treated with IV bolus of ATP (10 or 20mg), and V) 25 treated with IV verapamil, up to 15mg, during 3min. We evaluated the time delay necessary to convert the arrhytmia, doses, and side-effects. Patients with acute ischemic syndromes (< 3 weeks), severe congestive heart failure, and treatment with dipyridamole or methylxanthine were excluded. RESULTS: There were no differences between the two groups regarding to age, sex, and success rate. The average time till reversal were respectively, 30s and 248s for ATP and verapamil. Ventricular ectopy and general discomfort were observed in 33% of patients receiving ATP, whereas no side-effects occurred in group V. CONCLUSION: ATP is a good option to convert rapidly PSVT to sinus rhythm and, probably, could be the first choice to treat PSVT patients with ventricular dysfunction.

[Adenosine for suppression of paroxysmal supraventricular tachycardia in a newborn infant. First case in Mexico]. / Adenosina para la supresión de taquicardia supraventricular paroxística en un recién nacido. Primer caso en México.

We present the case of a 20-day old baby who was admitted with orthodromic supraventricular reentry tachycardia with a heart-rate of 300/minute. Suppression of the arrhythmia was tried with vagal maneuvers and digoxin. On failure to control the heart rate, a 0.05 mg/kg intravenous bolus of adenosine was given, with immediate response and subsequent normal heart rate and rhythm. In the following year he has been adequately controlled with oral digoxin. This is the first pediatric patient treated with adenosine in Mexico. Even though experience elsewhere in this age group is also limited, the properties of adenosine make it a valuable first-choice drug for the control of paroxysmal supraventricular tachycardia.

[Wolff-Parkinson-White syndrome with orthodromic supraventricular tachycardia associated with a "hyper-conductor" atrio-ventricular node. A therapeutic challenge]. / Síndrome de Wolff-Parkinson-White con taquicardia supraventricular ortodrómica asociado a un nodo auriculo-ventricular "hiperconductor". Un reto terapéutico.

One case of Wolff-Parkinson-White Syndrome with paroxysmal supraventricular tachycardia related to orthodromic atrioventricular reentry using an accessory pathway for retrograde conduction an a rapidly conducting AV node for anterograde conduction is present. The pharmacological therapy with Digoxin, Propranolol, Quinidine, Disopyramide and Propafenone was not effective. An electrophysiologic study showed a reciprocating tachycardia induced by spontaneous ventricular beats. Both the effective refractory period of the AV node and the anterograde effective refractory period of the accessory pathway were minor or equal to 220 msec which made the control of the arrhythmia difficult. Amiodarone was able to suppress the premature ventricular beats, depress conduction and prolong refractoriness in both, the AV node and accessory pathway to prevent recurrences of atrioventricular reentry. In this patient a false positive test with ajmaline was documented. The electrophysiologic study showed the association of Wolff-Parkinson-White Syndrome with an enhanced atrioventricular nodal-conduction and allowed the selection of an appropriate antiarrhythmic agent.

Supraventricular tachycardia: diagnosis and treatment.

Specific mechanisms of supraventricular tachycardia include sinoatrial, intra-atrial, atrioventricular (AV) nodal as well as concealed and manifest bypass tract reentry. In dual pathway reentry, at least one of the pathways involves the AV node, usually the slow pathway and the other pathway, perinodal fibers within the atria. Localization of the perinodal fibers is critical for ablative procedures to eliminate AV nodal tachycardias. Other mechanisms of supraventricular tachycardia include chaotic atrial tachycardia and automatic atrial tachycardia with and without AV block. However, drug therapy includes intravenous adenosine 6 mg, as well as the older standbys of digoxin, calcium and beta-blocking agents, and type 1a and 1c antiarrhythmias. In resistance cases, amiodarone is usually effective. However, for incessant supraventricular mechanisms, catheter or surgical ablative techniques are recommended to eliminate long-term drug administration.