Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally.

Brugada syndrome is an inherited cardiac disease and is associated with a peculiar pattern on the electrocardiogram and an increased risk of sudden death. Electrical storm is a malignant but rare phenomenon in symptomatic patients with Brugada syndrome. We describe a patient who presented with repetitive ICD discharges during two episodes of recurrent VF. After the initiation of isoproterenol infusion and oral quinidine, the ventricular tachyarrhythmias were successfully suppressed. (Neth Heart J 2007;15:151-4.).

Cardioverter defibrillator implantation in a patient with absent right superior vena cava.

Left-sided superior vena cava (LSVC) is the most common venous thoracic anomaly. Absence of the right superior vena cava (RSVC) on the other hand is very rare. We describe a patient with this abnormal venous system, who was admitted to our centre for an implantation of a cardioverter defibrillator (ICD).

Recommendations for pacemaker implantation for the treatment of atrial tachyarrhythmias and resynchronisation therapy for heart failure: A report from the task force on pacemaker indications of the Dutch Working Group on Cardiac Pacing.

Today, new pacing algorithms and stimulation methods for the prevention and interruption of atrial tachyarrhythmias can be applied on patients who need bradycardia pacing for conventional reasons. In addition, biventricular pacing as additive treatment for patients with severe congestive heart failure due to ventricular systolic dysfunction and prolonged intraventricular conduction has shown to improve symptoms and reduce hospital admissions. These new pacing technologies and the optimising of the pacing programmes are complex, expensive and time-consuming. Based on many clinical studies the indications for these devices are beginning to emerge. To support the cardiologist's decision-making and to prevent waste of effort and resources, the 'ad hoc committee' has provided preliminary recommendations for implantable devices to treat atrial tachyarrhythmias and to extend the treatment of congestive heart failure respectively.

Radiofrequency modified maze in patients with atrial fibrillation undergoing concomitant cardiac surgery.

OBJECTIVE: In the majority of patients with chronic atrial fibrillation the arrhythmia will persist after correction of the underlying structural abnormality. The maze procedure is an effective surgical method to eliminate atrial fibrillation and to restore atrial contractility. METHODS: In this study we used radiofrequency energy to create lines of conduction block in both atria during cardiac surgery as a modification of the maze III procedure. One hundred twenty-two patients with atrial fibrillation for at least 1 year and structural heart disease underwent open heart operation and a radiofrequency modified maze procedure. RESULTS: In 108 (89%) of 122 patients mitral valve surgery was performed, and in this group 86 patients (80%) underwent 121 concomitant procedures. Fourteen patients (11%) underwent cardiac surgery not involving the mitral valve. The additional crossclamp time required for the left atrial part of the radiofrequency modified maze procedure was 14 +/- 3 minutes. The in-hospital mortality rate was 4.1%. The overall 39-month survival was 90%, and freedom of atrial flutter or atrial fibrillation was 78.5% +/- 5.1%. Eighty-nine survivors with sinus, atrial rhythm, or atrioventricular sequential pacemaker had Doppler echocardiography, and right atrial transport function was documented in 83% and left atrial transport function in 77% of patients. CONCLUSION: We concluded that the radiofrequency modified maze procedure as an adjunctive procedure is safe, time-sparing, and effective in eliminating atrial fibrillation and restoring atrial transport function.

A bleeding disorder caused by a cardiac tumor: case report.

A 22-year-old female developed symptomatic thrombocytopenia. On physical examination, apart from ecchymoses, a loud holosystolic murmur was heard. Echocardiography revealed a cardiac tumor. The thrombocytopenia did not respond to corticosteroids, but after surgical removal of the intracardiac tumor, a papillary fibroelastoma, the platelet count normalised. There are no similar case reports in the literature. Our case report illustrates that thrombocytopenia may be associated with a cardiac tumor and that complete physical examination is essential in every patient presenting with easy bruising.

The radiofrequency modified maze procedure. A less invasive surgical approach to atrial fibrillation during open-heart surgery.

OBJECTIVE: Patients with mitral valve disease and suffering of atrial fibrillation of more than 1 year's duration have a low probability of remaining in sinus rhythm after valve surgery alone. Intraoperative radiofrequency ablation was used as an alternative to simplify the surgical maze procedure. METHODS: Seventy-two patients with mitral valve disease, aged 63+/-11 years ranging from 31 to 80 years, underwent valve surgery and radiofrequency energy applied endocardially, based on the maze III procedure to eliminate the arrhythmia. The right-sided maze was performed on the beating heart and the left-sided maze during aorta cross-clamping. RESULTS: Surgical procedures included mitral valve repair (n=38) or replacement (n=34) and in addition tricuspid valve repair (n=42), closure of an atrial septal defect (n=2) and correction of cor triatriatum (n=1). The left-sided maze needed 14+/-3 min extra ischemic time. There were two in-hospital deaths (2.7%) and three patients (4.2%) died during follow-up of 20+/-15 months. Among 67 surviving patients, 51 patients (76%) were in sinus rhythm, two patients (3%) had an atrial rhythm and eight patients (12%) had persistent atrial fibrillation or atrial flutter. Four patients had a pacemaker implanted, in one patient because of sinus node dysfunction. Doppler echocardiography in 64 patients demonstrated right atrial contractility in 89% and left atrial transport in 91% of patients. CONCLUSIONS: Intraoperative radiofrequency ablation of atrial fibrillation is an effective and less invasive alternative for the original maze procedure to eliminate atrial fibrillation.

Multisite atrial pacing: an option for atrial fibrillation prevention? Preliminary results of the Dutch Dual-site Right Atrial Pacing for Prevention of Atrial Fibrillation study.

Multisite pacing is a novel concept for the prevention of recurrent drug-refractory atrial fibrillation (AF). Two different pacing methods have been described, biatrial pacing and dual-site right atrial stimulation. The use of multisite pacing as preventive therapy for recurrences of atrial fibrillation is still under investigation. We conducted a prospective, randomized, crossover study in patients with recurrent drug-refractory AF without or with minimal structural heart disease. After implantation of a DDD pacemaker, patients were randomized to either dual-site pacing first (Group I) or single-site (high right atrium) pacing first (Group II) and, after 6 months of treatment, the device was reprogrammed to the other pacing mode. Preliminary results of 13 patients in each group are presented. Clinical characteristics of patients in both groups with respect to age, sex, left atrial dimension, left ventricular function, and New York Heart Association (NYHA) functional class were comparable. Pacing therapy was combined with antiarrhythmic drug treatment. After completion of the study protocol, the arrhythmia-free interval was not remarkably different in either group. However, the endpoint free interval (i.e., the need for electrical cardioversion because of recurrent AF lasting >24 hours, was less during dual-site pacing in Group II. Within 6 months, 43 patients enrolled in this study will have completed the protocol.

Multisite or alternate site pacing for the prevention of atrial fibrillation.

The role of permanent pacing in preventing atrial fibrillation in patients at risk for this arrhythmia is a relatively new concept. Existing retrospective studies support the superiority of atrial-based pacing over ventricular stimulation with respect to lowering the incidence of atrial fibrillation. Constant rate overdrive pacing has been shown to reverse abnormalities in conduction or refractoriness that are dependent on bradycardia and suppress atrial ectopic complexes. Multisite (biatrial and dual right atrial) pacing is a promising concept. The antiarrhythmic mechanism is not well understood, but atrial resynchronization and reduction of site-dependent conduction delay of atrial premature complexes may be relevant. The cardiology community awaits additional data from prospective trials that are currently underway.

Surgical treatment of atrial fibrillation.

Surgical therapy has been applied in the treatment of atrial fibrillation for almost two decades. At present, the most commonly used approach is the maze operation developed by Cox. In this operation, atrial fibrillation is prevented by critically located incisional lines. Currently, these lines also are drawn during operation using cryoablation or radiofrequency current. To document the value of the maze operation, randomized studies, not only on arrhythmia prevention but also on atrial transport function and thromboembolic complications, should be performed.

Randomized comparison of primary coronary angioplasty with thrombolytic therapy in low risk patients with acute myocardial infarction.

OBJECTIVES: We sought to compare primary coronary angioplasty and thrombolysis as treatment for low risk patients with an acute myocardial infarction. BACKGROUND: Primary coronary angioplasty is the most effective reperfusion therapy for patients with acute myocardial infarction; however, intravenous thrombolysis is easier to apply, more widely available and possibly more appropriate in low risk patients. METHODS: We stratified 240 patients with acute myocardial infarction at admission according to risk. Low risk patients (n = 95) were randomized to primary angioplasty or thrombolytic therapy. The primary end point was death, nonfatal stroke or reinfarction during 6 months of follow-up. Left ventricular ejection fraction and medical charges were secondary end points. High risk patients (n = 145) were treated with primary angioplasty. RESULTS: In low risk patients, the incidence of the primary clinical end point (4% vs. 20%, p < 0.02) was lower in the group with primary coronary angioplasty than in the group with thrombolysis, because of a higher rate of reinfarction in the latter group. Mortality and stroke rates were low in both treatment groups. There were no differences in left ventricular ejection fraction or total medical charges. High risk patients had a 14% incidence rate of the primary clinical end point. CONCLUSIONS: Simple clinical data can be used to risk-stratify patients during the initial admission for myocardial infarction. Even in low risk patients, primary coronary angioplasty results in a better clinical outcome at 6 months than does thrombolysis and does not increase total medical charges.

Continuation of antiarrhythmic drugs, or arrhythmia surgery after multiple drug failures. A randomized trial in the treatment of postinfarction ventricular tachycardia.

BACKGROUND: In patients with postinfarction sustained ventricular tachycardia showing one or more antiarrhythmic drug failures, the question is how long to proceed with new drug trials before deciding to perform map-guided arrhythmia surgery. Although the techniques of this surgery developed rapidly in the early 1980s, this therapy may be offset by damage to residual left ventricular function. However, surgery has been shown to be very effective in selected groups of patients. METHODS: A randomized study was carried out in patients with postinfarction ventricular tachycardia and eligible for arrhythmia surgery based on residual left ventricular function. Therapy failure was defined by the occurrence of the following events: spontaneous recurrence of ventricular tachycardia or ventricular fibrillation, sudden cardiac death, inducibility of sustained ventricular tachycardia or ventricular fibrillation with programmed stimulation of the heart, symptomatic non-sustained ventricular tachycardia requiring therapy or side-effects of antiarrhythmic drugs requiring withdrawal. In the drug limb, failure of the first antiarrhythmic drug was accepted but failure of a second and different drug was regarded as true therapy failure. RESULTS: After randomization, antiarrhythmic drug therapy was administered in 33 patients, and 30 patients underwent surgery. Neither group differed in baseline characteristics, and the mean number of drug failures before randomization was 2.7. The Kaplan-Meier therapeutic failure of antiarrhythmic drugs was 39 +/- 11%, 42 +/- 11% and 51 +/- 18% at 0.5-, 1- and 4-year follow-up, respectively, whereas the therapeutic failure of cardiac surgery was 37 +/- 11%, 37 +/- 11% and 50 +/- 20% at 0.5, 1 and 4 years, respectively, showing no statistical difference. The 1- and 4-year Kaplan-Meier survival of the antiarrhythmic drug-treated group was 91 +/- 6% and 78 +/- 15%, respectively, and of the surgical group 92 +/- 6% and 59 +/- 20%, respectively, and did not differ between either group. However, the relative risk for total cardiac death was higher in the surgical limb than in the drug limb (relative risk 2.2, CI 0.68-7.48). CONCLUSION: This study demonstrated no difference between the therapeutic result of continuation of two different antiarrhythmic drugs and that of arrhythmia surgery. Despite the small number of patients studied, it is recommended that drug therapy should continue as long as this regimen is tolerated by the patient. When true drug refractoriness or side-effects of drugs arise, arrhythmia surgery offers a valuable alternative. However, when additional reasons for cardiac surgery exist, arrhythmia surgery should be undertaken earlier and may become the first choice of treatment of postinfarction ventricular tachycardia.

Mortality, reinfarction, left ventricular ejection fraction and costs following reperfusion therapies for acute myocardial infarction.

The comparative efficacy of thrombolytic drugs and primary angioplasty for acute myocardial infarction have recently been studied, but long-term follow-up data have not yet been reported. We conducted a randomized trial involving 301 patients with acute myocardial infarction; 152 patients were randomized to primary angioplasty and 149 to intravenous streptokinase. Left ventricular function was assessed with a radionuclide technique both at hospital discharge and at the end of the follow-up period. Follow-up data were collected after a mean (+/-SD) of 31 +/- 9 months. Total medical costs were calculated. At the end of the follow-up period, 5% of the angioplasty patients had died from a cardiac cause compared to 11% of the patients randomized to intravenous streptokinase, P = 0.031. Cardiac death or a non-fatal reinfarction occurred in 7% of angioplasty patients compared to 28% of streptokinase patients, P < 0.001. There was a sustained benefit of angioplasty compared to streptokinase on left ventricular function. The total medical costs in the two groups were similar. Coronary anatomy (patency and single or multivessel disease), infarct location and previous myocardial infarction were important determinants of clinical outcome and costs. After 31 +/- 9 months of follow-up, primary angioplasty compared to intravenous streptokinase results in a lower rate of cardiac death and reinfarction, a better left ventricular ejection fraction, and no increase in total medical costs.

Radiofrequency catheter ablation of accessory pathways associated with a coronary sinus diverticulum.

In two patients with a symptomatic posteroseptally localized accessory atrioventricular pathway, but with distinct electrocardiographic patterns, a coronary sinus diverticulum appeared to be the site of this connection. Radiofrequency catheter ablation in the diverticulum was implemented to interrupt the pathway in both cases. This study demonstrates the necessity to perform coronary sinus angiography when ablation attempts in the posteroseptal region are not immediately successful, or optimal signals are not detected.

Left ventricular dilatation and high-grade ventricular arrhythmias in the first year after myocardial infarction. CATS Investigators. Captopril and Thrombolysis Study.

Progressive left ventricular dilatation is an important determinant of prognosis after myocardial infarction. The association of this process with the occurrence of ventricular arrhythmias is less well established. Of 153 patients with a first anterior myocardial infarction treated with thrombolytic therapy, 34 (22%) had high-grade ventricular arrhythmias (Lown 4A and B) during Holter monitoring after 1 year. Patients with high-grade ventricular arrhythmias had a larger end-systolic volume (38 +/- 12 vs 25 +/- 11 mL/m2; P < .001) at hospital discharge and more left ventricular dilatation (10 +/- 18 vs 1 +/- 9 mL/m2; P = .011) during the follow-up period. Increased end-systolic volume at discharge and subsequent dilatation proved to be independent predictors of high-grade ventricular arrhythmias. Six patients died suddenly during the first 12 months after myocardial infarction. Four of these patients had an enlarged end-systolic volume (> 22 mL/m2) at discharge, and the three patients who died suddenly after 3 months showed a significant increase in end-systolic volume from discharge to 3 months compared to survivors (16 +/- 6 vs 2 +/- 9; P = .008). Left ventricular remodeling after myocardial infarction is an independent predictor of the occurrence of ventricular arrhythmias late after myocardial infarction.