Sick Sinus Syndrome: Experience of a Cardiac Pacemaker Clinic

Out of a pacemaker clinic population of 182 patients 21 (11·5%) were found to have the sick sinus syndrome. Their ages ranged from 30 to 80 years and averaged 62. Ischaemic heart disease was more commonly an aetiological factor than in patients with chronic atrioventricular heart block. Other aetiologies were familial cardiomyopathy, postcardiac surgery, and dystrophia myotonica.Cardioversion before pacemaker insertion was a hazardous procedure. After insertion the occurrence of tachycardias and the need for drug therapy were reduced. One patient no longer required a pacemaker once atrial fibrillation became established.A high incidence of cerebral embolization was observed and the use of anticoagulant drugs therefore merits serious consideration.Failure of inhibition of demand-type pacemakers occurred in two patients. Two patients who exhibited competition with fixed-rate pacemakers died. Two patients were treated with electrodes surgically implanted on the right atrium. It is suggested that fixed-rate pacemakers may be contra-indicated and that sequential atrioventricular demand pacing is theoretically ideal.     

Catheter ablation of fascicular ventricular tachycardia

Fascicular ventricular tachycardia (VT) is an idiopathic VT with right bundle branch block morphology and left-axis deviation occuring predominantly in young males. Fascicular tachycardia has been classified into three subtypes namely, left posterior fascicular VT, left anterior fascicular VT and upper septal fascicular VT. The mechanism of this tachycardia is believed to be localized reentry close to the fascicle of the left bundle branch. The reentrant circuit is composed of a verapamil sensitive zone, activated antegradely during tachycardia and the fast conduction Purkinje fibers activated retrogradely during tachycardia recorded as the pre Purkinje and the Purkinje potentials respectively. Catheter ablation is the preferred choice of therapy in patients with fascicular VT. Ablation is carried out during tachycardia, using conventional mapping techniques in majority of the patients, while three dimensional mapping and sinus rhythm ablation is reserved for patients with nonmappable tachycardia.     

Inhibition of a Demand Pacemaker and Interference with Monitoring Equipment by Radio-frequency Transmissions

During the initial testing of Radio Leicester a swept-frequency technique for testing radio antennae was shown to affect demand pacemakers by inhibition of the pacing impulse and to interfere with physiological monitoring equipment. Adequate filtering of demand pacemakers is necessary to eliminate this interference. There is no evidence that such testing has any effect on the function of fixed-rate pacemakers. There is also a potential danger to implanted demand pacemakers by the use of similar polyscope generators used for servicing radio and television apparatus in industry.     

Idiopathic fascicular ventricular tachycardia

Idiopathic fascicular ventricular tachycardia is an important cardiac arrhythmia with specific electrocardiographic features and therapeutic options. It is characterized by relatively narrow QRS complex and right bundle branch block pattern. The QRS axis depends on which fascicle is involved in the re-entry. Left axis deviation is noted with left posterior fascicular tachycardia and right axis deviation with left anterior fascicular tachycardia. A left septal fascicular tachycardia with normal axis has also been described. Fascicular tachycardia is usually seen in individuals without structural heart disease. Response to verapamil is an important feature of fascicular tachycardia. Rare instances of termination with intravenous adenosine have also been noted. A presystolic or diastolic potential preceding the QRS, presumed to originate from the Purkinje fibers can be recorded during sinus rhythm and ventricular tachycardia in many patients with fascicular tachycardia. This potential (P potential) has been used as a guide to catheter ablation. Prompt recognition of fascicular tachycardia especially in the emergency department is very important. It is one of the eminently ablatable ventricular tachycardias. Primary ablation has been reported to have a higher success, lesser procedure time and fluoroscopy time.     

Ischemic Ventricular Tachycardia Presenting as a Narrow Complex Tachycardia

This report describes a patient presenting with a narrow complex tachycardia in the context of prior myocardial infarction and impaired ventricular function. Electrophysiological studies confirmed ventricular tachycardia and activation and entrainment mapping demonstrated a critical isthmus within an area of scar involving the His-Purkinje system accounting for the narrow QRS morphology. This very rare case shares some similarities with upper septal ventricular tachycardia seen in patients with structurally normal hearts, but to our knowledge has not been seen previously in patients with ischemic heart disease.     

Premature Ventricular Contractions and Non-sustained Ventricular Tachycardia: Association with Sudden Cardiac Death,Risk Stratification,and Management Strategies

Premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia (NSVT) are frequently encountered and a marker of electrocardiomyopathy. In some instances, they increase the risk for sustained ventricular tachycardia, ventricular fibrillation, and sudden cardiac death. While often associated with a primary cardiomyopathy, they have also been known to cause tachycardia-induced cardiomyopathy in patients without preceding structural heart disease. Medical therapy including beta-blockers and class III anti-arrhythmic agents can be effective while implantable cardiac defibrillators (ICD) are indicated in certain patients. Radiofrequency ablation (RFA) is the preferred, definitive treatment in those patients that improve with anti-arrhythmic therapy, have tachycardia-induced cardiomyopathy, or have certain subtypes of PVCs/NSVT. We present a review of PVCs and NSVT coupled with case presentations on RFA of fascicular ventricular tachycardia, left-ventricular outflow tract ventricular tachycardia, and Purkinje arrhythmia leading to polymorphic ventricular tachycardia.     

Tachycardia in Post-Infarction Hearts: Insights from 3D Image-Based Ventricular Models

Ventricular tachycardia, a life-threatening regular and repetitive fast heart rhythm, frequently occurs in the setting of myocardial infarction. Recently, the peri-infarct zones surrounding the necrotic scar (termed gray zones) have been shown to correlate with ventricular tachycardia inducibility. However, it remains unknown how the latter is determined by gray zone distribution and size. The goal of this study is to examine how tachycardia circuits are maintained in the infarcted heart and to explore the relationship between the tachycardia organizing centers and the infarct gray zone size and degree of heterogeneity. To achieve the goals of the study, we employ a sophisticated high-resolution electrophysiological model of the infarcted canine ventricles reconstructed from imaging data, representing both scar and gray zone. The baseline canine ventricular model was also used to generate additional ventricular models with different gray zone sizes, as well as models in which the gray zone was represented as different heterogeneous combinations of viable tissue and necrotic scar. The results of the tachycardia induction simulations with a number of high-resolution canine ventricular models (22 altogether) demonstrated that the gray zone was the critical factor resulting in arrhythmia induction and maintenance. In all models with inducible arrhythmia, the scroll-wave filaments were contained entirely within the gray zone, regardless of its size or the level of heterogeneity of its composition. The gray zone was thus found to be the arrhythmogenic substrate that promoted wavebreak and reentry formation. We found that the scroll-wave filament locations were insensitive to the structural composition of the gray zone and were determined predominantly by the gray zone morphology and size. The findings of this study have important implications for the advancement of improved criteria for stratifying arrhythmia risk in post-infarction patients and for the development of new approaches for determining the ablation targets of infarct-related tachycardia.     

经食道心房调搏术及食道心电图在心律失常中的应用

目的:分析经食道心房调搏术(TEAP)及食道内心电图(EECG)在心律失常中的应用价值。方法:选取2018年6月至2019年12月于我院行食道心电图及经食道调搏的患者189例,其中男80例,女109例,年龄11~83岁。结果:54例为房室结折返性心动过速(AVNRT),34例为房室折返性心动过速(AVRT),8例为房性心动过速(AT),4例为心房扑动(AF),6例为心房颤动(Af),5例为室性心过速,78例为室早或其他。共105例心律失常患者拟行食道心房调搏终止心动过速,所有AVNRT和AVRT患者及17例AT患者经食道心房调搏S1S1成功转为窦律,50例AVNRT、32例AVRT、6例AT、3例AF及2例VT患者通过射频消融术成功根治。其中1例11岁AT患者因无法耐受食道调搏,未能转为窦律,患者经静推普罗帕酮后次日转为窦律。共97例患者拟行食道心房调搏诱发,共49例诱发出心动过速,1例左后分支型室速经静滴异丙肾上腺素后诱发心动过速,且仍需静滴异丙肾上腺素后经心房食道调博终止心动过速,后经射频消融术成功根治。结论:TEAP及EECG可用于复杂心律失常的诊断及治疗,是一种相对安全、临床容易掌握的技术,值得推广。     

Abnormalities in pituitary thyroid axis function tests in patients with paroxysmal supraventricular arrhythmias

The study was carried out on 60 consecutive patients (23 males and 37 females) aged between 20 and 83 years (means +/- SD, 40.7 +/- 16) who arrived at our Cardiologic Unit with paroxysmal supraventricular arrhythmias (PSVA) including junctional paroxysmal tachycardia (n = 32), atrial fibrillation (n = 13), atrial flutter (n = 1), premature beats (n = 13) and with no obvious cardiovascular causes. Serum thyroxine and triiodothyronine were normal in all patients and thyroid scintiscan revealed normal shape and size thyroids without autonomously functioning nodule(s). Thyrotropin (TSH) response to thyrotropin releasing hormone (TRH) was normal in 44 subjects in whom normal serum free T4 (FT4) and free T3 (FT3) levels were measured. Six patients with normal FT4 and FT3 levels did not respond to TRH. Abnormalities in thyrotropin response to TRH were observed in 10 patients all exhibiting increased FT4 or also FT3 levels. Among these, 5 patients did not respond to TRH, whereas the remaining 5 exhibited a blunted TSH response to TRH. These results suggest that only in a small proportion (5/60) of consecutive patients with PSVA it is possible to recognize a status of "occult thyrotoxicosis" on the basis of the combined evaluation of free thyroid hormones and TSH response to TRH.     

Parallel import and pacemakers: who pays the ferryman?

Fifty years after its introduction in clinical cardiology, artificial pacing for patients with bradyarrhythmias has made a huge leap forward.1 The development from bulky, simple fixed-rate pacemakers to small, complex, multi-programmable devices paralleled the vast technological achievements of the second half of the 20th century. In the late 1990s hope emerged even for patients with severe heart failure, with the introduction of biventricular pacing which resulted in an additional class I indication according to the recent guideline of the European Society of Cardiology.2 Consequently, the number of implantations has steadily increased, resulting in more than 10,000 implantations (both first implants and replacements) in the Netherlands in 2007.     

Artificial Cardiac Pacemakers

Nine patients with complete heart block and Stokes-Adams disease were treated with subcutaneously implanted, fixed-rate, artificial cardiac pacemakers. All of these patients were refractory to medical treatment and confined to bed by the frequency of their attacks. One patient died in uremia one month after operation; in the remaining eight, the implanted pacemakers are providing adequate stimulation at present. These patients are free of seizures and show an improvement in the amount of their physical activity. A fixed rate of 60 to 65 per minute was adequate in all cases. The results of our clinical experience with cardiac pacemakers is satisfactory, but the possibility of mechanical failure limits their use to situations in which the patient is incapacitated despite medical treatment.     

Ventricular arrhythmias.

Sudden cardiac death claims thousands of Canadians annually. Ventricular tachycardia and fibrillation account for up to 85% of these deaths. Identifying the patients at risk remains a major challenge. Those who have recurrent ventricular tachycardia or have been resuscitated from ventricular fibrillation are generally considered to be at highest risk. Although ventricular premature beats in the absence of previous ventricular tachycardia or fibrillation are not helpful in identifying such patients in most cases, they can indicate increased risk for sudden cardiac death in the presence of a structural cardiac abnormality, particularly recent myocardial infarction; however, the need for treatment in such cases is speculative and is being investigated. Treatment is mandatory for survivors of an episode of ventricular fibrillation and those with recurrent sustained ventricular tachycardia or torsade de pointes ventricular tachycardia. The approach to management is either invasive or noninvasive. Selection of an antiarrhythmic agent is facilitated by knowledge of some basic electrophysiologic features of the heart and of the classification of antiarrhythmic drugs. However, drug therapy has to be individualized on the basis of efficacy, left ventricular function and adverse effects or potential adverse effects of the drug. Amiodarone therapy or nonpharmacologic therapy should be considered if a suitable antiarrhythmic agent cannot be found.     

Figure-8 tachycardia confined to the anterior wall of the left atrium

Incisional atrial tachycardias have been described most frequently in patients with previous corrective surgery for congenital heart defects and mitral valve disease. Less information is available on atrial tachycardias appearing late after isolated aortic valve surgery. We report the case of a patient who developed a left figure-8 tachycardia after undergoing aortic valve replacement. During electrophysiologic study the entire cycle length of the tachycardia was mapped within a low voltage area confined to the left anterior atrial wall. However, during ablation a transmural lesion could not be attained. The mapping and ablation strategy along with the mechanism of the tachycardia are discussed.     

The nature of the hypermetabolism and tachycardia in cold adaptation and experimental hyperthyroidism

The cross circulation method has been used to study contribution of humoral and nonhumoral components to the origin of hypermetabolism (increased level of basal metabolism) and tachycardia under adaptation to cold and experimental hyperthyroidism. Consumption of oxygen, heart rate and rectal temperature have been studied in periods prior to and during the cross circulation. It is shown that under experimental hyperthyroidism contribution of humoral and nonhumoral factors to the origin of hypermetabolism equals 22 and 78%, while that to genesis of tachycardia--44 and 56%, respectively. Under cold adaptation an increase of the basal metabolism level depends on humoral agents by 77% and on changes of the stationary character only by 23%. The nature of adaptation tachycardia is mainly, of the humoral origin (65%).     

Ventricular tachycardia due to cardiac ischaemia: assessment by exercise electrocardiography

Although ventricular tachycardia is a well-known complication of myocardial ischaemia and may be provoked by exercise, many patients may appreciate only the angina and be unaware of the unduly rapid heart rate that precipitates it. Exercise testing is needed to show this arrhythmia and to enable treatment to be started.Twenty-three patients were found to have chronic ischaemic heart disease complicated by ventricular tachycardia. Six patients with old myocardial infarction had ventricular tachycardia at rest which required conversion to sinus rhythm; 17 patients developed ventricular tachycardia only when they exercised. In 12 of these 17 patients coronary angiography showed disease of the anterior descending branch of the left coronary artery; other vessels were usually also affected. Although beta-adrenergic blocking drugs increased exercise tolerance, ventricular tachycardia still occurred when the heart rate on exercise reached a level similar to that before treatment. In five patients coronary artery bypass surgery was performed because of angina and exercise-induced ventricular tachycardia. Exercise tolerance was increased in all three patients who underwent exercise tests after operation, and in two of these patients, both of whom were known to have patent grafts, ventricular tachycardia was abolished.If part of the beneficial effect of coronary bypass surgery is preventing life-threatening ventricular arrhythmias it is essential to detect these, and ambulatory monitoring and stress testing have a complementary role.     

Confounding factors leading to misdiagnosing ventricular tachycardia as supraventricular in the emergency room

Studies conducted during the last 50 years have proposed electrocardiographic criteria and algorithms to determine if a wide QRS tachycardia is ventricular or supraventricular in origin. Sustained ventricular tachycardia is an uncommon reason for consultation in the emergency room. The latter and the complexity of available electrocardiographic diagnostic criteria and algorithms result in frequent misdiagnoses. Good hemodynamic tolerance of tachycardia in the supine position does not exclude its ventricular origin. Although rare, ventricular tachycardia in patients with and without structural heart disease may show a QRS duration <120 ms. Interruption of tachycardia by coughing, carotid sinus massage, Valsalva maneuver, or following the infusion of adenosine or verapamil should not discard the ventricular origin of the arrhythmia. In patients with regular, uniform, sustained broad QRS tachycardia, the presence of structural heart disease or A-V dissociation strongly suggest its ventricular origin. Occasionally, ventricular tachycardia can present with AV dissociation without this being evident on the 12-lead ECG. Cardiac auscultation, examination of the jugular venous pulse, and arterial pulse palpation provide additional clues for identifying A-V dissociation during tachycardia. This paper does not review the electrocardiographic criteria for categorizing tachycardia as ventricular but rather why emergency physicians misdiagnose these patients.     

Effects of long-term pretreatment with isoproterenol on bromocriptine-induced tachycardia in conscious rats

It has been shown that bromocriptine-induced tachycardia, which persisted after adrenalectomy, is (i) mediated by central dopamine D2 receptor activation and (ii) reduced by 5-day isoproterenol pretreatment, supporting therefore the hypothesis that this effect is dependent on sympathetic outflow to the heart. This study was conducted to examine whether prolonged pretreatment with isoproterenol could abolish bromocriptine-induced tachycardia in conscious rats. Isoproterenol pretreatment for 15 days caused cardiac hypertrophy without affecting baseline blood pressure and heart rate. In control rats, intravenous bromocriptine (150 microg/kg) induced significant hypotension and tachycardia. Bromocriptine-induced hypotension was unaffected by isoproterenol pretreatment, while tachycardia was reversed to significant bradycardia, an effect that was partly reduced by i.v. domperidone (0.5 mg/kg). Neither cardiac vagal nor sympathetic tone was altered by isoproterenol pretreatment. In isolated perfused heart preparations from isoproterenol-pretreated rats, the isoproterenol-induced maximal increase in left ventricular systolic pressure was significantly reduced, compared with saline-pretreated rats (the EC50 of the isoproterenol-induced increase in left ventricular systolic pressure was enhanced approximately 22-fold). These results show that 15-day isoproterenol pretreatment not only abolished but reversed bromocriptine-induced tachycardia to bradycardia, an effect that is mainly related to further cardiac beta-adrenoceptor desensitization rather than to impairment of autonomic regulation of the heart. They suggest that, in normal conscious rats, the central tachycardia of bromocriptine appears to predominate and to mask the bradycardia of this agonist at peripheral dopamine D2 receptors.     

RNA editing signatures identify melanoma patients who respond to Pembrolizumab or Nivolumab treatment

Immunotherapy has improved the prognosis for many melanoma patients; however, our capacity to predict patient responses and to understand the biological differences between patients who will or will not respond is limited. Gene expression profiling of tumors from patients who respond to immunotherapy has focused on deriving primarily immune-related signatures; however, these have shown limited predictive power. Recent studies have highlighted the role of RNA editing in modulating resistance to immunotherapy. To evaluate the utility of RNA editing activity as a discriminative tool in predicting immunotherapy response, we conducted a retrospective analysis of RNA-sequencing data from melanoma patients treated with Pembrolizumab or Nivolumab. Here, we developed RNA editing signatures that can identify patients who will respond to immunotherapy with very high accuracy and confidence. Our analysis demonstrates that RNA editing is a strong discriminative tool for examining sensitivity of melanoma patients to immunotherapy.     

Pacemaker lead-related macroreentrant atrial tachycardia

Macroreentrant atrial circuits are frequently associated with scarring. Previous reports have shown the possible development of scar tissue that is adjacent to pacemaker (PM) leads. However, reports of PM lead-related reentrant tachycardia are scarce. We report the case of a 63-year-old woman who presented with macroreentrant atrial tachycardia (MAT), related to the atrial trajectory of an old single-lead ventricular PM, that was successfully treated with radiofrequency ablation after a conventional electrophysiological study ruled out isthmus-dependent atrial flutter and provided sufficient data to confirm this diagnosis. This report presents a case of MAT originating around the trajectory of a PM lead, probably because of scar tissue that developed adjacent to the lead. Experimental studies have already shown that interstitial atrial fibrosis may develop adjacent to a ventricular single-lead. This finding suggests that MAT develops in patients with this specific condition. Recognizing this condition is important for managing these arrhythmias and performing safe ablation with the preservation of PM lead integrity.     

Patient-initiated transtelephone transmission of electrocardiographic signals in the diagnosis of arrhythmias.

Thirty-one patients who had complained of recurrent palpitations were given transtelephone transmitters of electrocardiographic signals and instructed to use the transmitters while they were having symptoms. From the transcribed electrocardiograms sinus tachycardia was documented in 12 patients, paroxysmal atrial tachycardia in 7, atrial fibrillation in 4, atrial flutter in 3, frequent ventricular premature beats in 4 and ventricular tachycardia in 1. Patient-initiated transtelephone transmission of electrocardiographic signals was found to be an effective means of documenting the nature of symptomatic paroxysmal tachycardia.