Evaluation of pacemaker dependence in patients on ablate and pace therapy for atrial fibrillation.

AIMS: In patients with atrial fibrillation (AF) and uncontrolled ventricular rate, radiofrequency (RF) ablation of the atrioventricular (AV) node and pacemaker (PM) implantation (ablate and pace) is a valid therapeutic approach, especially in elderly patients. The aim of our study was to evaluate the PM dependence and the incidence of correlated clinical phenomena in a patients population with AV block induced by RF ablation of the AV junction. METHODS AND RESULTS: One-hundred and sixty-three patients (71 men; mean age 71 +/- 8 years) who had undergone ablate and pace therapy were evaluated. The patients underwent assessment of quality of life, impairment of consciousness, stroke/transient ischaemic attack (TIA), hospitalizations for heart failure, episodes of palpitations, and instrumental evaluation of PM dependence during PM inhibition (absence of escape rhythm; asystolic pause >5 s; escape rhythm <30 bpm after rhythm stabilization). Correlation between instrumentally evaluated PM dependence and clinical history was analysed. Hundred and thirty-two patients were evaluated after a mean follow-up period of 36 months [31 subjects (19%) died before the evaluation]; 55 patients (42%) were classified as PM-dependent: 38 (69%) complained of disturbances (19 dizziness, 15 pre-syncope, 4 syncope); 77 patients (58%) were considered non-PM-dependent: symptoms (dizziness, flush) were reported by only 3 (4%). No significant differences emerged between PM-dependent and non-PM-dependent patients with regard to episodes of pre-syncope, syncope, stroke/TIA, hospitalizations for heart failure, and quality of life. CONCLUSION: This study confirms that ablate and pace is an effective and safe approach in subjects with chronic or recurrent AF and uncontrolled ventricular rate.

Severe ventricular dysrhythmias and silent ischemia during infusion of the antimetabolite 5-fluorouracil and cis-platin.

The antimetabolite 5-fluorouracil is frequently used in the therapy of various malignancies. Cardiotoxicity has frequently been described during treatment, but there is no common agreement on the need to perform cardiovascular monitoring of patients during 5-fluorouracil administration. We report the case of a young patient with an head-neck cancer on whom a continuous electrocardiogram recording was performed, documenting serious ventricular dysrhythmias in the presence of myocardial ischemia during 5-fluorouracil and cis-platin infusion.

Cardiac resynchronization therapy as an 'alternative' approach to a non-operable severe aortic stenosis with left ventricular dysfunction.

Severe symptomatic aortic stenosis (AS) is an indication for surgical replacement of the aortic valve in adults. Patients are often affected by comorbidities, and the surgical indication is sometimes problematic. Non-surgical techniques have been developed during the past few years, though their roles have not yet been established. Cardiac resynchronization therapy has been shown to be effective in selected patients, but no data yet exist on the role of this therapy in AS patients. The case is presented of a patient with non-operable severe symptomatic AS and cardiac dissynchrony who showed significant improvement following the implantation of a biventricular pacemaker.

[Long QT and torsade de pointes in a patient with acquired human immunodeficiency virus infection in multitherapy with drugs affecting cytochrome P450]. / Allungamento del QT e torsione di punta in un paziente con immunodeficienza virale acquisita in multiterapia con farmaci utilizzatori del citocromo P450.

In acquired human immunodeficiency virus (HIV) infection, a long depolarization period at ECG may be the consequence of cardiac complications due to viral myocarditis or cardiomyopathy or indirectly due to autonomic neuropathy, or sometimes resulting from pharmacological treatments. Several drugs administered for direct treatment of HIV disease or its complications, such as antiretrovirus, fluconazole, and antibiotics, may induce ventricular arrhythmias due to long QT prolonged depolarization period. Also methadone, frequently associated with HIV therapy to treat patients with opiate addiction, is described in the literature to have cardiac inotropic effects. It has also the potential to increase the QT period and to develop ventricular torsade de pointes, primarily through interference with the rapid component of the delayed rectifier potassium ion current. Moreover, the use of methadone associated with other inhibitors of cytochrome P450 might increase plasma concentrations and contribute to methadone cardiac toxicity. We report the case of an HIV patient receiving antiretroviral treatment, fluconazole and high-dose methadone, who suddenly complained of vertigo, dizziness, pre-syncope and syncope due to severe ventricular arrhythmias that disappeared after discontinuation of all treatments.

Transient platypnea-orthodeoxia-like syndrome induced by propafenone overdose in a young woman with Ebstein's anomaly.

In this report we describe the case of a 37-year-old white woman with Ebstein's anomaly, who developed a rare syndrome called platypnea-orthodeoxia, characterized by massive right-to-left interatrial shunting with transient profound hypoxia and cyanosis. This shunt of blood via a patent foramen ovale occurred in the presence of a normal pulmonary artery pressure, and was probably precipitated by a propafenone overdose. This drug caused biventricular dysfunction, due to its negative inotropic effect, and hypotension, due to its peripheral vasodilatory effect. These effects gave rise to an increase in the right atrial pressure and a decrease in the left one with a consequent stretching of the foramen ovale and the creation of massive right-to-left shunting. In our case this interatrial shunt was very accurately detected at bubble contrast echocardiography.

[Safety and effectiveness of dual chamber pacing in patients over 80 years of age with previous episodes of paroxysmal atrial fibrillation]. / Utilità ed appropriatezza della stimolazione bicamerale nell'ultraottantenne con storia di fibrillazione atriale parossistica.

BACKGROUND: Dual chamber pacing (DDD) in the elderly is still a controversial issue because of its short life expectancy and the risk of atrial fibrillation. The aim of the study was 1) to evaluate the cumulative survival and the events capable of modifying it, 2) to evaluate the stability of sinus rhythm, and 3) to try to identify patients who are at a higher risk of developing permanent atrial fibrillation after DDD implantation. We evaluated clinical, electrophysiological and pacing parameters at the time of implantation. METHODS: We examined retrospectively a group of 135 consecutive patients who were > 80 years old and who were treated with DDD in the last decade. RESULTS: At the time of evaluation (mean 33.51 +/- 27.10 months, range 4-148 months) after DDD implantation, 72% of patients were still alive. Sinus rhythm was documented in 96 (71%) patients (group A). Thirty-nine (29%) patients (group B) developed atrial fibrillation after a mean period of 28.56 +/- 30.9 months (range 1-125 months). The right atrial endocavitary signal amplitude was lower in group B compared to that observed in group A (2.6 +/- 1.16 vs 3.27 +/- 1.91 mV). The pacing and sensing atrioventricular delay were not statistically different in both groups. The minimum heart rate was higher in patients who developed atrial fibrillation (64.53 +/- 7.7 vs 67.7 +/- 5.72 b/min respectively in group A and in group B, p = 0.02). Group B patients had a higher rate of atrial fibrillation pre-implantation episodes. The incidences of sick sinus disease and of atrioventricular nodal disease were similar in both groups. CONCLUSIONS: In elderly patients the benefits of DDD are maintained for a long period of time before the development of atrial fibrillation. Episodes of atrial fibrillation prior to DDD, apart from sinus dysfunction alone, are predictive of the development of a permanent atrial fibrillation. Permanent atrial fibrillation does not seem to reduce life expectancy. A higher minimum heart rate does not seem to prevent atrial fibrillation. The capability of recording a right atrial signal amplitude > 3 mV seems to identify those patients with a lower risk of developing atrial fibrillation.

[Proarrhythmic effects of propafenone in a woman with hepatopathy: is it always a simple drug in clinical practice?]. / Effetto proaritmico del propafenone in donna con epatopatia: è sempre un farmaco di semplice utilizzo nella pratica clinica?

A 65-year-old woman with a history of alcoholic liver disease and presenting with fever and vomiting was admitted to an internal medicine unit. In view of recent atrial fibrillation with inadequate heart rate control, digoxin and propafenone were included in the therapeutic regimen. After a few days sinus rhythm was restored but suddenly ventricular arrhythmias with the characteristics of a non-responsive electrical storm arose shortly following the appearance of clinical symptoms of drug intoxication.

Management of patients with low-risk chest pain at the time of admission: a prospective study on a non-selected population from the Emergency Department.

BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge from the epidemiological, clinical, organizational and malpractice points of view. Our purpose was to test and implement a simple clinical protocol for the management of patients with acute chest pain and at low-risk for an acute coronary syndrome (ACS) at the time of admission to the Emergency Department (ED). METHODS: During a 5-month study period, 570 consecutive patients were admitted to the ED with acute chest pain: 224 patients were excluded owing to the presence of a clear diagnosis of an ACS or of high-risk factors. The remaining 346 were considered, at the time of admission, as being at low risk for an ACS and constituted the study group (208 males, 138 females, mean age 65 years). These 346 patients were evaluated in the ED area by means of multiple ECGs and multiple blood sampling for the creatine kinase-MB mass and troponin I serum levels at the time of admission and 6 and 12 hours later. In selected cases a treadmill stress test was requested in order to further clarify the diagnosis. RESULTS: The ECG at the time of admission was normal or nearly normal in 79% of the patients. Stress testing was performed in 79 patients (25%). Sixty-six/346 low-risk patients (19%) were admitted to the coronary care unit during ED observation: 38 patients because of positive markers, 10 because of a positive ECG, 13 because of positive markers and ECG, and 5 because of a positive stress test. Two hundred and eighty low-risk patients without evidence of acute ischemia were definitively discharged and classified as having non-ischemic chest pain. At 1 month of follow-up, 1 patient underwent coronary artery bypass grafting, 1 patient was again admitted to the ED for acute pulmonary edema, and 2 patients had acute extracardiac events. Within 1 year of follow-up 4 deaths occurred: 2 were cancer-related and 2 were sudden deaths. CONCLUSIONS: The tested strategy, based on integrated clinical, ECG and multimarker data, and on a short "test of time" period of low-risk patient observation, can allow the identification of patients having an ACS on the one hand and of those for whom a safe, rapid and early discharge is possible on the other, in a low-cost environment.

Transesophageal electrical cardioversion of persistent atrial fibrillation: a new approach for an old technology.

BACKGROUND: Low energy intracardiac cardioversion may be considered the elective, alternative method for the acute restoration of sinus rhythm when direct current cardioversion fails or is contraindicated. Transesophageal cardioversion is a further alternative method for the recovery of sinus rhythm and obviates the potential complications of the low energy intracardiac cardioversion venous approach. METHODS: The present prospective study including 30 patients (21 males, 9 females, mean age 65.1 years, range 52-76 years), with persistent atrial fibrillation (mean duration 4.3 months), was undertaken in order to further evaluate, with regard to transesophageal cardioversion: 1) the acute efficacy, 2) the patient acceptance of the procedure, 3) the preferable choice among direct current cardioversion, low energy intracardiac cardioversion and transesophageal cardioversion, 4) the time required to perform the procedure, 5) the incidence of complications, and 6) the persistence of sinus rhythm after 1 month. RESULTS: Sinus rhythm was acutely restored in 29 patients (96.7%). Discomfort induced by the electrical shock was minimal or mild in most patients (75.8%). Transesophageal cardioversion was usually preferred by patients who had been previously submitted to direct current cardioversion or low energy intracardiac cardioversion. The mean total time required to perform the procedure was 107.9 min. No complications related to the procedure occurred. In spite of adequate pharmacological prophylaxis of atrial fibrillation only 41.4% of patients were in sinus rhythm 1 month after successful transesophageal cardioversion. CONCLUSIONS: Transesophageal cardioversion may be considered a very effective, well accepted and non-time consuming procedure for the short-term restoration of sinus rhythm. The incidence of complications is low.

Reliability of new and old Doppler echocardiographic indexes of the severity of aortic stenosis in patients with a low cardiac output.

BACKGROUND: In addition to the conventional "flow-corrected" parameters (continuity equation and aortic valve resistance), new and simpler Doppler echocardiographic indexes of the severity of aortic stenosis have recently been introduced. These measures can be classified as "function-corrected" indexes (fractional shortening-velocity ratio and ejection fraction-velocity ratio) and "pressure-corrected" indexes (percent stroke work loss). Little information however is available about the diagnostic accuracy of each of these parameters in identifying patients with severe aortic stenosis in low-flow states, in which the diagnosis and clinical decision-making are more difficult and challenging. METHODS: We analyzed 161 patients with aortic stenosis (96 males, 65 females, mean age 68 +/- 9 years) and a low cardiac output (thermodilution cardiac index < or = 2.5 l/min/m2). All patients underwent both cardiac catheterization and echocardiography within 48 hours one of the other. The invasive Gorlin valve area was used as gold standard (severe aortic stenosis = Gorlin < or = 0.8 cm2). Echocardiographic indexes were assessed by an investigator who was unaware of the hemodynamic findings. RESULTS: The mean Gorlin aortic valve area was 0.7 +/- 0.3 cm2; cardiac catheterization allowed the identification of 129 patients with severe aortic stenosis and of 32 with mild-to-moderate aortic stenosis. The diagnostic accuracy of the Doppler gradient alone was low (sensitivity 55%). The best linear correlation with the Gorlin value was found using the "function-corrected" ejection fraction-velocity ratio (r = 0.85). Similarly, the best combination of sensitivity and specificity in identifying patients with severe aortic stenosis, as assessed by cardiac catheterization, was observed using the ejection fraction-velocity ratio (sensitivity 87%, specificity 88%). CONCLUSIONS: In patients with aortic stenosis and a low cardiac output, the "function-corrected" ejection fraction-velocity ratio offers the better diagnostic accuracy, as compared with the cardiac catheterization valve area calculation.

Centro de diagnóstico de lesöes bucais: potencial impacto na epidemiologia do câncer de boca em Curitiba / Oral cavity lesions diagnostic center: potential impact in oral cancer epidemiology in Curitiba

Devido à importância do câncer de boca na regiäo de Curitiba, correspondendo ao sexto tumor de maior freqüência nos homens e oitavo nas mulheres, associado ao fato de que 60 por cento de todos os casos säo diagnosticados em estágios avançacos, foi criado o Centro de Diagnóstico de Lesöes Bucais - CDLB pela Secretaria Municipal da Saúde (SMS) de Curitiba. Este estudo apresenta os resultados iniciais das atividades deste centro