Electrophysiological relation between the superior vena cava and right superior pulmonary vein in patients with paroxysmal atrial fibrillation.

INTRODUCTION: The superior vena cava (SVC) is a main source of nonpulmonary vein (PV) ectopies initiating atrial fibrillation (AF). Empiric SVC isolation may improve rhythm outcomes after catheter ablation of AF. Because the SVC passes immediately adjacent to the right superior PV (RSPV), an electrophysiological relation could be present between the two structures. The present study aimed to estimate the interrelation between the SVC and RSPV by evaluating arrhythmogenic activities observed during catheter ablation of AF. METHODS AND RESULTS: Study subjects comprised 121 consecutive patients referred for catheter ablation of paroxysmal AF. Isoproterenol infusion was used to induce ectopies and AF. Patients were divided into two groups depending on the presence of arrhythmogenic SVC: arrhythmogenic-SVC (A-SVC) and nonarrhythmogenic SVC (Non-A-SVC) groups. The prevalence of females was higher and body surface area was smaller in the A-SVC group (N = 22) than Non-A-SVC group (N = 99). Arrhythmogenic activities were observed in 60 (49%) RSPVs, 24 (20%) right inferior PVs, 72 (59%) left superior PVs, and 31 (25%) left inferior PVs. Arrhythmogenic RSPVs were more prevalent in the A-SVC group than Non-A-SVC group (86% vs. 41%, P = 0.0001), whereas these prevalences in the other three PVs were not different between groups (P >0.3). In multivariable analysis, arrhythmogenic RSPV was the only independent predictor of arrhythmogenicity of the SVC (OR, 8.53; 95% CI 2.31-31.46; P = 0.001). CONCLUSIONS: An electrophysiological interrelation may be present between the SVC and RSPV in patients with paroxysmal AF. Semiempiric SVC isolation limited to patients with an arrhythmogenic RSPV may be a more efficient treatment strategy.

[Malignant bileaflet mitral valve prolapse syndrome in otherwise idiopathic ventricular fibrillation]. / Malignes Mitralklappenprolapssyndrom bei "idiopathischem" Kammerflimmern.

A 32-year-old, otherwise healthy woman was admitted after successful out-of-hospital resuscitation due to ventricular fibrillation. Established cardiac, pulmonary, metabolic, and toxicological causes were excluded. However, persisting (biphasic) negative T waves in the inferior ECG leads and premature ventricular contractions (PVC) were noted. PVC morphology indicated a focus alternating between the posterior papillary muscle/the left posterior fascicle and the left ventricular outflow tract region/anterior papillary muscle. Echocardiography revealed a bileaflet mitral prolapse with mild mitral valve regurgitation. This case is a typical presentation of the recently described malignant bileaflet mitral valve prolapse syndrome. The patient was discharged without overt neurological deficit after implantation of a cardioverter-defibrillator.

[The influence of electrosleep therapy on the dynamics of the parameters of biorhythmic hormonal activity in the children presenting with extrasystolic arrhythmia in the course of the spa and resort-based treatment].

UNLABELLED: Heart rhythm disorders occupy a leading place in the modern structure of cardiovascular diseases in the children. At present, the role of stress-induced reactions in the development of more than a thousand diseases has been proved. Rehabilitation of systemic manifestations of extrasystolic arrhythmia (EA) in the children is only scarcely described in the literature. AIM: The objective of the present work was to improve the effectiveness of the spa and resort-based treatment of the children presenting with extrasystolic arrhythmia taking advantage of the available information about the different biorhythmic activities of the stress-realizing and stress-limiting systems. MATERIAL AND METHODS: The study included 60 children presenting with EA, who received a standard combination of spa and resort-based therapeutic modalities in conjunction with electro-sleep therapy. RESULTS AND DISCUSSION: The study revealed desynchronization of the endocrine functions in the children with EA that manifests itself as the increased secretion of cortisol and adrenaline, suppressed melatonin and ACTH production, mismatched daytime and nocturnal hormonal levels. The daily bio-rhythmic profile influenced the formation of circadian-type extra systola in the children. The most unfavorable clinical and electrocardiographic patterns were observed in the children with the mixed and night-type arrhythmia. The complex of rehabilitation measures practiced at the Evpatoriya health resort including electro-sleep therapy made it possible to balance the activities of the stress-limiting and stress-implementing systems of the body in the form of normalization of the altered levels of adaptive hormones, ordering of biorhythmical hormonal relationships, and reduction of the number of extrasystoles. The most pronounced effect of the treatment was observed in the group of children with a rare and day-type of arrhythmia to whom electrosleep was prescribed. It is concluded that the significant decrease in the frequency of night-type and mixed-type extrasystoles under effect of electro-sleeptherapy allows to recommend the treatment modality being considered for the correction of this type of heart rhythm disorders.

Optimization of ultrasound parameters of myocardial cavitation microlesions for therapeutic application.

Intermittent high intensity ultrasound scanning with contrast microbubbles can induce scattered cavitation microlesions in the myocardium, which may be of value for tissue reduction therapy. Anesthetized rats were treated in a heated water bath with 1.5 MHz focused ultrasound pulses, guided by an 8 MHz imaging transducer. The relative efficacy with 2 or 4 MPa pulses, 1:4 or 1:8 trigger intervals and 5 or 10 cycle pulses was explored in six groups. Electrocardiogram premature complexes (PCs) induced by the triggered pulse bursts were counted, and Evans blue stained cardiomyocyte scores (SCSs) were obtained. The increase from 2 to 4 MPa produced significant increases in PCs and SCSs and eliminated an anticipated decline in the rate of PC induction with time, which might hinder therapeutic efficacy. Increased intervals and pulse durations did not yield significant increases in the effects. The results suggest that cavitation microlesion production can be refined and potentially lead to a clinically robust therapeutic method.

The actual management of common arrhythmias and other ECG abnormalities in children.

Primary cardiac arrhythmias are much less common in infants and children than adults and the symptoms presented may be vague and nonspecific. Though true emergencies due to unstable arrhythmias in children are rare it is critical to identify and appropriately manage these arrhythmias, since when left untreated, arrhythmias may lead to cardiopulmonary compromise and arrest. Most children with a primary arrhythmia present to a pediatrician, cardiologists, or emergency physicians before being referred to a pediatric cardiologist for assessment and management. Thus, the pediatricians, cardiologists, and emergency physicians have to be able to recognize the arrhythmia and in some cases to provide the acute treatment. This article is intended to provide diagnostic and management guidelines of the most common types of arrhythmias seen in children with structurally normal hearts.

[Investigation and treatment of premature beats]. / Sydämen lisälyönnit--miten tutkin, miten hoidan?

If a patient has premature beats, it is essential to clarify whether they are associated with a heart disorder or some other disease. The basis for an examination for all patients is the rest-ECG. Ultrasound examination is indicated, if the symptoms are severe or findings indicating a heart disorder are present. The occurrence of severe symptoms, such as episodes of tachycardia and attacks of unconsciousness, is mapped in an interview and they are an indication for further investigations within specialized care. Atrial extrasystoles as such do not require any treatment unless they are accompanied by atrial fibrillation.

Ventricular fibrillation in loop recorder memories in a patient with early repolarization syndrome.

We report the first documentation of spontaneous ventricular fibrillation by a loop recorder in a patient with an ECG pattern of early repolarization (ER) in the inferior leads and presenting with syncope.

A His bundle extrasystole can both induce and reverse 2:1 atrioventricular block.

An 84 year-old man with history of recurrent dizziness presented with first degree atrio-ventricular block (1° AVB) and periods of 2:1 AVB. An electrophysiological study revealed a predominant 1:1 AV conduction with markedly prolonged AH interval and frequent His bundle extrasystoles (H). A properly timed H could induce periods of 2:1 AV nodal block and 1:1 AV conduction could only resume following another properly timed H. Procainamide suppressed H. However, because of persistence of the patient symptoms, a permanent pacemaker was eventually inserted. The case illustrates a hitherto not described manifestation of H.

[Practical management of common arrhythmias in children]. / Der Umgang mit Herzrhythmusstörungen beim Kind.

Premature supraventricular or ventricular beats are frequently seen in children of all age groups and are in most instances a benign condition. Intermittent and infrequent premature beats usually are not an indication for a cardiologic work-up. If ventricular or supraventricular premature beats are frequent and persist over a period of weeks or months, we usually recommend a cardiological evaluation. In those patients where ventricular or supraventricular tachycardias are found, the treatment is based on symptomatology, frequency of arrhythmias and impact on quality of life. In ventricular tachycardias, the presence of underlying cardiac disease is of prognostic importance and treatment more aggressive. Idiopathic ventricular tachycardia without structural heart disease usually shows a benign course and has a good prognosis.

[The arrhythmogenic right ventricular cardiomyopathy (ARVC)]. / Die arrhythmogene rechtsventrikuläre Cardiomyopathie (ARVC)Typische Befunde anhand eines Fallbeispieles.

The following report illustrates the case of a 40-year old patient, who was transferred to our hospital because of a symptomatic sustained ventricular tachycardia (VT). The documented VT showed typical left bundle branch block morphology with an inferior axis, which was accompanied by repolarization abnormalities in the right precordial leads, as revealed by the surface ECG. While coronary angiography allowed the exclusion of an obstructive coronary heart disease and confirmed an intact left ventricular function, the right ventricular angiography as well as the MRI demonstrated not only reduced right ventricular function but also regional abnormalities of contraction in the inferior and diaphragmal regions and typical "outpouchings" and "bulgings". The MRI also provided evidence for sporadic fatty infiltrations of the right ventricle. In the electrophysiological study, sustained VT could be reproducibly induced, while showing the typical RVOT configuration, which corresponded to the clinically apparent VT. Since these examination results matched with the criteria of McKenna et al., arrhythmogenic right ventricular cardiomyopathy was diagnosed. The patient underwent implantation of a cardioverter-defibrillator (ICD) and medical treatment with metoprolol. This particular case report was selected because it shows a typical presentation of an ARVC. Furthermore, the present example offers the possibility of demonstrating that in the case of an ARVC in the regions of the right ventricle, arrhythmogenic areals can also be found which seem morphologically inconspicuous.

[Cardiac arrhythmias during pregnancy--what to do?]. / Rhythmusstörungen während der Schwangerschaft--was tun?

METHODS: Atrial premature beats are frequently diagnosed during pregnancy, supraventricular tachycardia (atrial tachycardia, AV nodal reentrant tachycardia, circus movement tachycardia) less frequently. For acute therapy, electrical cardioversion with 50-100 J is indicated in all unstable patients. In stable supraventricular tachycardia, initial therapy includes vagal maneuvers to terminate breakthrough tachycardias. For short-term management, when vagal maneuvers fail, intravenous adenosine is the drug of first choice and may safely terminate the arrhythmia. For long-term therapy, beta-blocking agents with beta(1) selectivity are first-line drugs; class Ic agents or the class III drug sotalol represent effective and therapeutic alternatives. Ventricular premature beats are also frequently present during pregnancy and benign in most of the unstable patients; however, malignant ventricular tachyarrhythmias (sustained ventricular tachycardia, ventricular flutter, ventricular fibrillation) are less frequently observed. Electrical cardioversion is necessary in all patients with hemodynamically unstable situation and life-threatening ventricular tachyarrhythmias; in hemodynamically stable patients, initial therapy with ajmaline, procainamide or lidocaine is indicated. If prophylactic therapy is needed, beta-blocking agents with beta(1) selectivity are regarded as drugs of first choice. If this therapy proves ineffective, class Ic agents or sotalol can be considered. In patients with syncopal ventricular tachycardia, ventricular fibrillation, ventricular flutter or aborted sudden death, an implantable cardioverter-defibrillator is indicated. In patients with symptomatic bradycardia, a pacemaker can be implanted using echocardiography at any stage of pregnancy. CONCLUSIONS: The treatment of the pregnant patient with cardiac arrhythmias requires important modifications of the standard practice of arrhythmia management. The goal of therapy is to protect the patient and fetus through delivery, after which chronic or definitive therapy can be administered.

[Use of plasmapheresis in the treatment of drug-resistant cardiac arrhythmias]. / Ispol'zovanie plazmafereza pri lechenii narushenii ritma serdtsa, rezistentnykh k lekarstvennoi terapii.

AIM: To study the therapeutical efficiency of plasmapheresis (PA) in patients with drug-resistant cardiac arrhythmias (CA) and its mechanisms. MATERIALS AND METHODS: Discrete PA sessions were carried out in 56 patients with drug-resistant CA: paroxysmal atrial arrhythmia (AA), ventricular and supraventricular premature contractions, supraventricular tachycardia of various etiology. Biochemical blood values, coagulographic parameters, lipid peroxidation (LPO), the spectrum of nonesterified fatty acids (NEFA), the level of medium-sized molecules were determined, ECG monitoring, EchoCG, and left ventricular radioisotope computed tomography were performed before and after a PA session. RESULTS: PA was effective in 50% of cases. The duration of its effect averaged 3.0 (1.25-5.0) months. PA was more beneficial for patients with IHD, AA with normal left atrial dimensions, and hyperlipidemia. The duration of the effect was significantly higher when antiarrhythmic drug therapy was continued after PA. Due to PA, there were significant decreases in the blood concentrations of cholesterol, medium-sized molecules, malonic dialdehyde (MDA) and in the proportion of polyunsaturated NEFA. The antiarrhythmic effect was associated with the decreases in MDA and NEFA, with a tendency for a reduction in the rate of chemiluminescence. CONCLUSION: PA may be used in the treatment of drug-resistant CA. The most significant mechanism of its antiarrhythmic activity is to recover sensitivity to antiarrhythmics. The intrinsic antiarrhythmic activity may be associated with its effect on NEFA metabolism and LPO; however, its mechanisms await further studies.

[Determination of coronary-myocardial reserve by stress echocardiography in patients with programmed pacemaker]. / Opredelenie koronarno-miokardial'nogo rezerva metodom nagruzochnoi ékhokardiografii u bol'nykh s programiruemym élektrostimuliaorom.

AIM: To study coronary-myocardial reserve in patients with a programmed pacemaker. MATERIALS AND METHODS: Stress-echocardiography was performed in 64 patients with coronary heart disease (CHD). The stress was induced by a gradual increase in the frequency of electrostimulation (ES) by 10 imp/min from initial 90 imp/min to threshold value which was defined as the frequency threshold of myocardial ischemia induction (FT). RESULTS: Registration of defects in local left ventricular contractility and cardiodynamics in frequent heart ES identified patients with predominant coronary and myocardial failure. Low FT (100-110 imp/min) indicates poor coronary reserve while a considerable rise of the end diastolic pressure in the left ventricle indicates limited myocardial reserve. Positive results of the test in isolated ventricular ES were obtained in 90.9%, in atrial ES in 72.7% of patients. CONCLUSION: As a highly informative and reproducible method, stress echocardiography can be employed for optimization of antianginal therapy in CHD patients with a pacemaker.