High-resolution free-breathing automated quantitative myocardial perfusion by cardiovascular magnetic resonance for the detection of functionally significant coronary artery disease.

AIMS: Current assessment of myocardial ischaemia from stress perfusion cardiovascular magnetic resonance (SP-CMR) largely relies on visual interpretation. This study investigated the use of high-resolution free-breathing SP-CMR with automated quantitative mapping in the diagnosis of coronary artery disease (CAD). Diagnostic performance was evaluated against invasive coronary angiography (ICA) with fractional flow reserve (FFR) measurement. METHODS AND RESULTS: Seven hundred and three patients were recruited for SP-CMR using the research sequence at 3 Tesla. Of those receiving ICA within 6 months, 80 patients had either FFR measurement or identification of a chronic total occlusion (CTO) with inducible perfusion defects seen on SP-CMR. Myocardial blood flow (MBF) maps were automatically generated in-line on the scanner following image acquisition at hyperaemic stress and rest, allowing myocardial perfusion reserve (MPR) calculation. Seventy-five coronary vessels assessed by FFR and 28 vessels with CTO were evaluated at both segmental and coronary territory level. Coronary territory stress MBF and MPR were reduced in FFR-positive (≤0.80) regions [median stress MBF: 1.74 (0.90-2.17) mL/min/g; MPR: 1.67 (1.10-1.89)] compared with FFR-negative regions [stress MBF: 2.50 (2.15-2.95) mL/min/g; MPR 2.35 (2.06-2.54) P < 0.001 for both]. Stress MBF ≤ 1.94 mL/min/g and MPR ≤ 1.97 accurately detected FFR-positive CAD on a per-vessel basis (area under the curve: 0.85 and 0.96, respectively; P < 0.001 for both). CONCLUSION: A novel scanner-integrated high-resolution free-breathing SP-CMR sequence with automated in-line perfusion mapping is presented which accurately detects functionally significant CAD.

Train stimulation at the atria for prevention of atrioventricular tachycardia: dependence on accessory pathway location.

In 12 patients with accessory pathway-mediated supraventricular tachycardia, programmed electrical stimulation with a rapid train of 10 stimuli was assessed for prevention of tachycardia induction. Tachycardia was induced with one or two extrastimuli from both the right and the left atrium (by way of the coronary sinus). Preventive train stimulation, with the train delivered after the tachycardia-initiating stimulus, was attempted at the site of tachycardia induction as well as at the opposite site. Prevention at the site of tachycardia induction was successful in all patients when the length of the train (90 ms) exceeded the effective refractory period of the tachycardia-initiating stimulus to achieve single atrial capture within the "preventive zone." However, in patients with a left-sided accessory pathway, preventive stimulation at the right atrium failed when tachycardia was induced from the coronary sinus because of interatrial conduction delay. It is concluded that train stimulation is an effective mode for supraventricular tachycardia prevention, yet the site of preventive stimulation should lie as close as possible to the anatomic site of the reentrant circuit to reduce interatrial conduction delay.

Effect of encainide and flecainide on chronic ectopic atrial tachycardia.

In the treatment of chronic ectopic atrial tachycardia, standard antiarrhythmic therapy has been shown to be ineffective in the majority of patients. The intravenous and oral effects of two class IC antiarrhythmic drugs, encainide and flecainide, in five patients with chronic ectopic atrial tachycardia were studied using exercise testing, 24 hour long-term electrocardiography and programmed electrical stimulation. All patients had been treated unsuccessfully with at least four antiarrhythmic drugs. In two patients tachycardia was persistent, and in three patients tachycardia occurred intermittently for more than 12 hours/day. Intravenous encainide and flecainide at doses ranging from 0.3 to 2.0 mg/kg and from 0.5 to 1.5 mg/kg body weight, respectively, terminated atrial ectopic tachycardia in all patients. Oral encainide, 150 to 225 mg/day, completely suppressed ectopic atrial activity in four patients during a mean follow-up period of 8 +/- 3 months. In the remaining patient encainide markedly reduced the number of episodes of tachycardia. In three patients encainide had to be withdrawn because of intolerable side effects. These patients were well controlled with oral flecainide, 200 to 300 mg/day, without side effects. On the basis of these results, the efficacy of encainide and flecainide in the treatment of chronic ectopic atrial tachycardia appears to be not drug-specific but rather a general class IC property.

Significance of timing programmed electrical stimulation after acute myocardial infarction.

To assess the influence of time on the inducibility by programmed electrical stimulation of ventricular arrhythmias after acute myocardial infarction, 18 patients were studied on day 5 and day 24 after infarction with a stimulation protocol employing a maximum of three right ventricular extrastimuli during sinus rhythm and at three paced cycle lengths. All patients were without documented sustained ventricular arrhythmia (sustained ventricular tachycardia or ventricular fibrillation) before the investigation. Sustained ventricular arrhythmia was induced in two patients on day 5, but in nine on day 24 after infarction. This difference in incidence was statistically significant (p less than 0.05), as was the change in the distribution ratio of induced sustained ventricular arrhythmia from day 5 to day 24 (p less than 0.05). The types of arrhythmia induced on day 24 were sustained ventricular tachycardia with a mean cycle length of 207 ms in six cases (five monomorphic, one polymorphic), and ventricular fibrillation in three cases. These nine patients did not differ from the remaining nine patients in maximal serum creatine kinase, infarct site, number of stenosed coronary arteries, global left ventricular ejection fraction (47 +/- 7% versus 46 +/- 10%) and results of 24 hour ambulatory electrocardiographic (Holter) monitoring, but they had a significantly shorter right ventricular effective refractory period (223 +/- 10 ms versus 259 +/- 28 ms; p less than 0.05). During the follow-up period of 24 +/-5 months no patient died, had syncopal attacks or developed spontaneous episodes of sustained ventricular arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)

Right atrial thrombus formation after transvenous catheter ablation of the atrioventricular node.

The formation of a right atrial mass was detected in a patient by two-dimensional echocardiography 3 weeks after successful transvenous electrical ablation of the atrioventricular node had been performed. The mass was attached to the atrial septum at the site where the electrode catheter used for the ablation had supposedly been located and it exhibited no mobility. It was interpreted as a right atrial thrombus induced by the ablation procedure. Although no pulmonary embolic events have been observed during a 7 month follow-up period, right atrial thromboembolism must be considered a potentially dangerous complication of transvenous catheter ablation to control cardiac arrhythmias.

Spontaneous termination of reciprocating tachycardia owing to interaction of dual atrioventricular nodal pathways in patients with an accessory pathway.

Retrospective analysis of the electrophysiologic recordings from 125 consecutive patients with reciprocating tachycardia involving an accessory atrioventricular (AV) pathway suggested, by the mode of spontaneous termination of reciprocating tachycardia, the coexistence of dual AV nodal pathways in 7 patients. Three different modes of spontaneous tachycardia termination were observed. In 2 patients with antidromic tachycardia, termination was a result of AV nodal reentry, preceded by a decrease in retrograde AV nodal conduction. In 3 other patients with antidromic tachycardia, termination occurred after a sudden switch from a slow to a fast AV nodal pathway, leading to conduction block in either the accessory pathway or the His-Purkinje system. In 2 patients with orthodromic tachycardia, termination was caused by a sudden change of anterograde conduction from a fast to a slow AV nodal pathway, eliciting an AV nodal echo beat. The interaction of dual AV nodal pathways within the reentry circuit incorporating the accessory pathway always inhibited sustained reciprocating tachycardia.

Encainide versus flecainide for chronic atrial and junctional ectopic tachycardia.

For treatment of chronic atrial and junctional ectopic tachycardia, standard antiarrhythmic therapy has been shown to be ineffective in most patients. Both the intravenous efficacy and the oral efficacy of 2 class IC antiarrhythmic drugs, encainide and flecainide, were studied in 16 patients with atrial ectopic tachycardia and in 3 patients with junctional ectopic tachycardia, using exercise testing, 24-hour long-term electrocardiography and programmed electrical stimulation. All patients had been previously treated unsuccessfully with several antiarrhythmic drugs. In 5 patients, tachycardia was persistent; in the remaining patients, it occurred intermittently for more than 12 hours/day. Intravenous encainide, in doses ranging from 0.3 to 2.0 mg/kg body weight, was given to 5 patients with atrial ectopic tachycardia, and it terminated atrial ectopic tachycardia in all patients. Intravenous flecainide was given to 9 patients, and it terminated atrial tachycardia in 4 and slowed the tachycardia rate in 2. It terminated junctional tachycardia in 2 patients and slowed tachycardia rate in 1. During a follow-up period of 10 +/- 5 months, oral encainide, in dosages between 150 and 225 mg/day, completely suppressed atrial ectopic activity in 4 patients. In the remaining patient, encainide reduced the number of tachycardia episodes markedly but had to be withdrawn because of intolerable side effects. During a 12 +/- 11-month (median 6) follow-up, oral flecainide at dosages between 200 and 300 mg/day, completely suppressed ectopic activity in 7 patients and improved symptoms in 5. Only 1 patient failed to respond to oral flecainide. The results of this study indicate that both encainide and flecainide are effective in the treatment of chronic ectopic atrial and junctional tachycardia.

Tachycardia prevention by programmed stimulation.

Ten patients with an atrioventricular accessory pathway were studied by standard electrophysiologic techniques to determine if reentrant tachycardia can be prevented in these patients by delivery of a single extrastimulus, applied at a critical time after the tachycardia-initiating stimulus (or stimuli). In all 10 patients, reentrant tachycardia was reproducibly induced from the high right atrium with a single premature beat, and initiation of tachycardia could be prevented from the same site by a second premature beat. This second extrastimulus was effective if delivered within a zone that began 10 ms outside of the effective refractory period of the tachycardia-initiating stimulus and averaged 50 ms in width. This zone was termed the "preventive zone." The width of the preventive zone was independent of the initial tachycardia interval and the tachycardia cycle length. Prevention of reentrant tachycardia was always possible with a single atrial extrastimulus, whereas termination of the ongoing tachycardia required at least 2 atrial extrastimuli or stimulation from the right ventricle.

Recanalization of chronic coronary artery occlusions using laser followed by balloon angioplasty.

Excimer laser angioplasty with adjunctive percutaneous transluminal coronary angioplasty of chronic coronary artery occlusions was performed using the Litvack 1.3 Z laser catheter in 80 patients in whom the occlusion could be passed by a guidewire; success rate was 89%. Angiographic follow-up revealed a restenosis rate of 33% and a reocclusion rate of 20%, and clinical follow-up showed a significant symptomatic improvement. It is concluded that laser angioplasty is a promising method for the treatment of chronic coronary artery occlusions.

Electrophysiologic and clinical effects of intravenous and oral encainide in accessory atrioventricular pathway.

The effect of intravenous and oral encainide was studied in 12 patients with an accessory atrioventricular pathway (AP). Eight patients had Wolff-Parkinson-White syndrome and 4 had a concealed AP. Electrophysiologic studies were performed before and after intravenous encainide, 1.0 to 1.5 mg/kg, and 4 weeks after oral encainide, 75 to 200 mg/day. Mean follow-up was 19 +/- 6 months. During sinus rhythm, intravenous and oral encainide significantly prolonged the AH and HV intervals. In patients with Wolff-Parkinson-White syndrome, after intravenous encainide, anterograde conduction over the AP was blocked in 3 patients, and the anterograde effective refractory period (ERP) of the AP was markedly increased in 3. Five of these 6 patients had a control value of the anterograde AP ERP of less than 270 ms. Anterograde AP block was maintained in 2 patients after oral encainide therapy. Retrograde AP block or marked increase of retrograde AP ERP was seen in 4 of 9 patients after intravenous encainide and in 2 of 7 after oral therapy. Encainide either prevented induction of circus movement tachycardia (intravenous, 4 of 11 patients; oral, 2 of 7 patients) or significantly prolonged tachycardia cycle length (intravenous, 7 of 11 patients; oral, 5 of 7 patients). During long-term follow-up of 9 patients, 6 patients had no recurrences of tachyarrhythmia after individual adjustment of encainide dosage. One patient had worsening of supraventricular tachycardia after intravenous encainide therapy and 4 patients complained of visual blurring; in 1 patient it was so severe that it required withdrawal of the drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Preexcitation in hypertrophic cardiomyopathy: a case of a fasciculoventricular Mahaim fiber.

A patient with hypertrophic cardiomyopathy (HCM) who presented with preexcitation pattern on the surface ECG suggestive of the Wolff-Parkinson-White (WPW) syndrome is described. Intracardiac electrophysiological study revealed a fixed anomalous QRS complex and a short-fixed His-ventricular interval indicating a fasciculoventricular Mahaim fiber. As this specific form of accessory connection does not cause reentrant tachycardias, no treatment was required. It is important to distinguish this entity from atriofascicular or nodoventricular Mahaim fibers or the WPW syndrome in patients with HCM showing a preexcitation pattern in the surface ECG, as these may cause life-threatening arrhythmias in this patient population.

[Successful high-frequency catheter ablation of an accessory atrioventricular conduction pathway in atrial fibrillation]. / Erfolgreiche Hochfrequenzstrom-Katheterablation einer akzessorischen atrioventrikulären Leitungsbahn bei Vorhofflimmern.

This report describes the case of a 41-year-old patient with Wolff-Parkinson-White syndrome and recurrent, highly symptomatic episodes of atrial fibrillation (with rapid heart rates of a mean of 250 beats/min) in whom transvenous catheter ablation of the accessory pathway was successfully performed in a relatively short time during the arrhythmia. The feasibility of an abbreviated approach to the relatively time-consuming ablation procedure in Wolff-Parkinson-White syndrome is discussed.

[Ambulatory catheter ablation. Indications, results and risks]. / Ambulante Katheterablation. Indikationen, Ergebnisse, Risiken.

The purpose of this study was to test the efficacy, feasibility, and safety of outpatient radiofrequency catheter ablation in 162 consecutive patients. There were 83 men and 79 women at a mean age of 47 + 15 years; 13 patients underwent 2 and 1 patient 3 ablation procedures. In 167 cases patients suffered from highly symptomatic paroxysmal tachycardia associated with presyncope or syncope in 74. Severe palpitations were present in 7 cases and recurrent syncope in 1 case. One patient had an asymptomatic Wolff-Parkinson-White syndrome with a shortest RR-interval during atrial fibrillation of 150 ms. The mechanism of tachycardia was found to be atrioventricular nodal reentry in 78 cases, atrioventricular reentry involving an accessory atrioventricular pathway in 56, atrial fibrillation in 16, atrial flutter of the common type in 15, ectopic atrial tachycardia in 8, and idiopathic ventricular tachycardia in 3. Catheter ablation was performed in these 176 cases at an overall success rate of 86%. In 148 cases patients could be treated on an outpatient basis and were discharged after a maximal observation time of 3 hours in 28, and 24 hours in another 120 cases. Short-term follow-up was uneventful in these patients. After 28 ablation procedures patients had to be admitted to the hospital, because of pain at the puncture sites or after pacemaker implantation in 15 cases, because of minor complications in 12, and because of pericardial tamponade in 1 case. Another severe complication occurred in 1 patient after successful ablation of right atrial tachycardia. Three days after discharge the patient suffered from pulmonary embolism originating from a thrombus at the ablation site. After hospital admission the patient recovered completely. In general, complication rate was 2.27%. This study shows that catheter ablation can be performed effectively and safety on an outpatient basis.

[High-frequency stimulation in the prevention of atrioventricular tachycardias: relation to stimulation site and location of the accessory conduction pathway]. / Hochfrequenzstimulation zur Prävention atrioventrikulärer Tachykardien: Abhängigkeit vom Stimulationsort und von der Lage des akzessorischen Leitungsbündels.

To assess the validity of train stimulation for the prevention of accessory pathway mediated atrioventricular tachycardia, thirteen patients were studied. Tachycardia was induced from high right atrium and coronary sinus by means of single extrastimuli; preventive stimulation at high right atrium and coronary sinus consisted of the delivery of a train of ten or eleven stimuli 10 ms apart, following the tachycardia initiating stimulus. Preventive train stimulation at the site of tachycardia induction was successful in all patients when the train exceeded the atrial effective refractory period of the initiating stimulus to achieve single atrial capture within the "preventive zone". In patients with a left-sided accessory pathway in whom tachycardia was induced from the coronary sinus, preventive stimulation at high right atrium failed because of interatrial conduction delay. It is concluded that train stimulation is an effective mode of prevention of atrioventricular reentrant tachycardia, yet preventive stimulation should be performed as close as possible to the reentry circuit to reduce interatrial conduction delay.

[Value and safety of ambulatory electrophysiologic study]. / Stellenwert und Sicherheit der ambulanten elektrophysiologischen Untersuchung.

One-hundred-thirty patients underwent 53 electrophysiological studies including programmed atrial and ventricular stimulation and 96 atrial overdrive stimulations on an outpatient basis. The indications for electrophysiological study were disabling palpitation, syncope, or presyncope, intracardiac conduction disturbance, and bradyarrhythmia. In one patient the efficacy of oral antiarrhythmic drug therapy was evaluated by repeat electrophysiological study. Atrial overdrive stimulation was performed in patients with atrial flutter or atrial tachycardia. On the basis of the result of electrophysiological testing, 25 patients were believed not to require any treatment, 16 patients received new drug therapy, 7 patients underwent catheter ablation in a second session, 2 patients had either a pacemaker or an ICD implanted, and 1 patient continued to receive the drug therapy that had been tested. Atrial overdrive stimulation resulted in a regular sinus rhythm in 66 patients (69%). Except for one patient in whom atrial flutter could not be terminated, atrial fibrillation was induced in the remaining 30 patients. After the procedure, patients were monitored for 30 min in case of overdrive stimulation, and for approximately 3 h after electrophysiological study or 6 h if additional coronary angiography had been performed. Severe complications were not observed. In 10 cases minor hematoma occurred at the puncture site without serious sequelae.--Outpatient electrophysiological study as well as atrial overdrive stimulation are feasible and safe in a selected group of patients.

Sotalol in patients with Wolff-Parkinson-White syndrome.

We evaluated the effects of intravenous and long-term oral sotalol treatment in 17 patients with an accessory atrioventricular (AV) pathway. All patients had a history of symptomatic supraventricular tachycardia. During electrophysiologic study intravenous (1.5 mg/kg body weight) and oral (240 to 320 mg/day) sotalol caused significant increases of sinus cycle length, AV nodal conduction time, and refractory periods of atrial and ventricular myocardium and accessory pathway. AV reciprocating tachycardia, which was inducible and sustained in 15 patients at control, was still inducible after intravenous sotalol in 14 patients, including one in whom it was not inducible at control. However, tachycardia became nonsustained in 10 patients. In seven patients who underwent repeat drug testing while on oral sotalol, results were the same as after intravenous sotalol. Sixteen patients were followed-up for 36 months (median value). Fifteen of them were clinically free of symptoms or experienced marked improvement, despite recurrences of tachycardia in two. In a third patient sotalol had to be withdrawn because of recurrent supraventricular tachycardia. Orthostatic hypotension occurred in five patients and required withdrawal of sotalol in one. To predict the long-term clinical outcome of patients, exercise testing and Holter monitoring were of little or no value. Programmed electrical stimulation predicted clinical outcome in 63% after intravenous and in 86% after oral sotalol. This study shows that long-term treatment with sotalol is highly effective in patients with the Wolff-Parkinson-White syndrome and regular supraventricular tachycardia.

[Morphology of aortic isthmus stenosis--invasive study using intravascular ultrasound]. / Morphologie einer Aortenisthmusstenose--Invasive Untersuchung mittels intravaskulärem Ultraschall.

In patients with coarctation of the aorta, intravascular ultrasound can yield important additional diagnostic information concerning stenosis morphology and aortic wall structure that, thus far cannot be obtained with conventional angiography. For the first time, we were able to visualize, in vivo, the eccentric thickening of the posterior aortic wall, which is the typical morphological finding in patients with coarctation of the aorta, known from post mortem or intraoperative specimens. The additional information about stenosis morphology and aortic wall structure, obtained with intravascular ultrasound, is especially valuable for the newer interventional therapy of balloon angioplasty. With intravascular ultrasound, not only the direct quantitative assessment of the aortic cross-sectional luminal area, but also the immediate visualization of local dissections and aneurysms is possible. Using special angioplasty catheters with integrated ultrasonic crystals (which are currently under manufacturing development), a step-wise dilation with immediate evaluation of the therapeutical success may improve the short- and long-term results of balloon angioplasty. At present, intravascular ultrasound is still only an additional diagnostic tool. If it is combined with interventional balloon angioplasty, however, it could gain increasing clinical importance for the treatment of aortic coarctation in the near future.

[A iatrogenic arteriovenous fistula following laminectomy. A rare differential diagnosis of heart failure]. / Iatrogene arteriovenöse Fistel nach Laminektomie. Eine seltene Differentialdiagnose der Herzinsuffizienz.

An abdominal murmur was first heard in a now 46-year-old man four years after laminectomy at the age of 21. Signs of right heart failure and, ultimately, of global heart failure developed progressively and increasingly 20 years later. Echocardiography demonstrated enlargement of the right heart cavities, and atrial fibrillation was diagnosed. Cardiac catheterization revealed the typical picture of high output failure (cardiac output 13.9 l/min). Intra-arterial subtraction angiography demonstrated a fistula between the left iliac artery and vein. After operative closure of the fistula the signs of heart failure disappeared. Six months later a residual but insignificant fistula was still present, as well as persistent atrial fibrillation. Medical treatment having failed cardioversion successfully re-established sinus rhythm and the patient became symptom-free. Arteriovenous fistula after laminectomy is a rare cause of heart failure and often diagnosed very late. The prognosis is good once the fistula has been closed.

Intravenous dantrolene does not exhibit calcium channel blocking effects on the cardiac conduction system in humans.

In malignant hyperthermia, dantrolene, a drug assumed to possess calcium channel blocking properties, effectively suppresses supraventricular and ventricular arrhythmias. To investigate antiarrhythmic properties of dantrolene, six patients (three women and three men, age 42 +/- 18 yr) with symptomatic atrioventricular (AV)-nodal reentry tachycardia were studied. Electrocardiographic measurements included sinus cycle length, PQ-interval, width of the QRS-complex, and QT- and rate-corrected QT-interval. During the electrophysiologic study, effective refractory periods of the right atrium, AV node, right ventricle, and AV-nodal conduction intervals were determined, and AV-nodal reentry tachycardia was induced in all patients. Dantrolene was administered intravenously over a period of 15 min at doses of 1.0, 1.5, or 3.0 mg/kg in two patients each. The dosage was not further increased because of side effects at the dose of 3.0 mg/kg. After the infusion of dantrolene, the electrocardiographic measurements and electrophysiologic study were repeated. The plasma concentrations of dantrolene ranged from 1.69 to 6.61 micrograms/ml at the time of the electrophysiologic study. After dantrolene administration, the sinus cycle length shortened from 686 +/- 80 to 622 +/- 55 ms (P less than 0.05). No significant changes of any other parameter could be demonstrated after intravenous dantrolene. AV-nodal reentry tachycardia remained inducible in all patients without change of the tachycardia cycle length and without change in coupling intervals of tachycardia-inducing extrastimuli. Antiarrhythmic properties of dantrolene could not be demonstrated in patients with AV-nodal reentry tachycardia at therapeutic doses.(ABSTRACT TRUNCATED AT 250 WORDS)