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W Saliba,
N Juratli,
M K Chung,
M J Niebauer,
O Erdogan, R Trohman,
B L Wilkoff,
R Augostini,
K A Mowrey,
G R Nadzam,
P J Tchou
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ABSTRACT: We sought to evaluate the safety and efficacy of higher energy synchronized cardioversion in patients with atrial fibrillation refractory to standard energy direct current (DC) cardioversion.
Standard external electrical cardioversion fails to restore sinus rhythm in 5% to 30% of patients with atrial fibrillation.
Patients with atrial fibrillation who failed to achieve sinus rhythm after at least two attempts at standard external cardioversion with 360 J were included in the study. Two external defibrillators, each connected to its own pair of R-2 patches in the anteroposterior position, were used to deliver a synchronized total of 720 J.
Fifty-five patients underwent cardioversion with 720 J. Mean weight was 117 +/- 23 kg (body mass index 48.3 +/- 4.1 kg/m2). Structural heart disease was present in 76% of patients. Mean left ventricular ejection fraction was 45 +/- 12%. Atrial fibrillation was present for over three months in 55% of the patients. Sinus rhythm was achieved in 46 (84%) of the 55 patients. No major complications were observed. No patient developed hemodynamic compromise and no documented cerebrovascular accident occurred within one month after cardioversion. Of the 46 successful cardioversions, 18 patients (39%) remained in sinus rhythm over a mean follow-up of 2.1 months.
External higher energy cardioversion is effective in restoring sinus rhythm in patients with atrial fibrillation refractory to standard energy DC cardioversion. This method is safe and does not result in clinical evidence of myocardial impairment. It may be a useful alternative to internal cardioversion because it could be done within the same setting of the failed standard cardioversion and obviates the need to withhold protective anticoagulation for internal cardioversion.
Journal of the American College of Cardiology 01/2000; 34(7):2031-4. · 14.16 Impact Factor
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ABSTRACT: Functional bundle branch blocks during supraventricular tachycardia have been described, and their sustainment has been attributed to concealed conduction. Such blocks frequently resolve spontaneously, but the electrophysiologic mechanism of resolution has not been well described. This report describes the resolution of functional bundle branch block through proximal migration of the site of block.
During electrophysiologic study of a patient with reentrant antidromic tachycardia via an atriofascicular accessory pathway, functional retrograde right bundle branch block could be readily induced following tachycardia initiation with right ventricular apical pacing. Resolution of this block was associated with shortening of the tachycardia cycle length. Electrogram recordings along the right bundle branch during tachycardia determined that resolution of the functional retrograde right bundle branch block was associated with migration of the site of block from the distal to the proximal right bundle. When the site of block was directly at the recording site, both anterograde and retrograde activation of the right bundle was demonstrated.
Migration of the site of block is a mechanism of resolution for functional conduction blocks maintained by concealed conduction.
Journal of Cardiovascular Electrophysiology 05/1996; 7(4):335-40. · 3.06 Impact Factor
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ABSTRACT: The hemodynamic consequences of atrioventricular (AV) synchrony during ventricular tachycardia were evaluated during cardiac electrophysiologic testing. The relationship between stroke volume and the AV interval was investigated on a beat-by-beat basis in six patients during induced monomorphic ventricular tachycardia. Stroke volume was calculated either (1) in the right ventricle using impedance catheter method (four patients) or (2) in the left ventricle using Doppler measurement of aortic blood velocity (two patients). The impedance catheter method underestimated stroke volume by a factor of 4.2 +/- 2.4 compared with the thermodilution cardiac output method. However, there was a highly linear relationship between both methods for computing stroke volume (r greater than 0.9). Five patients had complete AV dissociation during ventricular tachycardia, and different AV intervals spanned the entire tachycardia cycle lengths. Largest stroke volumes were associated with optimal AV intervals within 120 and 230 msec, resulting in a 97 +/- 59% increase in stroke volume over ventricular tachycardia cycles not associated with atrial activity. Customized atrial pacing during ventricular tachycardia may provide a valuable means for artificially establishing the hemodynamically optimal AV interval and eliminating the ventricular tachycardia cycles not preceded by atrial activity.
American Heart Journal 07/1992; 123(6):1561-8. · 4.65 Impact Factor
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ABSTRACT: Standard implantation procedure for the implantable cardioverter defibrillator (ICD) has traditionally required a thoracotomy approach. A newly revised nonthoracotomy defibrillator lead system that uses a single transvenous tripolar endocardial lead alone or in combination with a subcutaneous/submuscular patch lead was introduced into clinical trials in September, 1990. Fourteen patients requiring a cardioverter defibrillator for recurrent sustained ventricular tachycardia (eight patients) or aborted sudden cardiac death (six patients) were evaluated for implantation of this lead system. Primary successful lead system implantation was obtained in nine patients. The remaining five patients had unacceptably high defibrillation thresholds (DFTs) for implantation. One of the nine initially successful implants demonstrated unacceptable DFTs and cross-talk inhibition from a permanent pacemaker necessitating removal of the nonthoracotomy lead system and replacement with a conventional lead system via thoracotomy. All remaining primary implanted patients experienced successful conversion of induced ventricular fibrillation prior to hospital discharge. Continued follow-up and greater experience to confirm the durability and efficacy of the nonthoracotomy AICD lead system are needed.
Pacing and Clinical Electrophysiology 12/1991; 14(11 Pt 2):1865-9. · 1.35 Impact Factor
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ABSTRACT: Records of 105 patients, who received an automatic implantable cardioverter defibrillator (AICD), were studied to investigate the causes of spontaneous AICD discharges and to correlate the symptoms with the arrhythmias triggering AICD discharges. During a follow-up period of 13 +/- 8 months, 46/105 (44%) patients had 566 spontaneous AICD discharges. A total of 101 discharges were documented with Holter monitoring in 23 patients. In this study group, there were 8 (8%) AICD discharges for 5 episodes of ventricular fibrillation, and 68 (67%) discharges for 63 episodes of sustained ventricular tachycardia. Patients lost consciousness in all episodes of ventricular fibrillation, but were symptomatic prior to only 36 (53%) discharges in ventricular tachycardia. Nonsustained ventricular tachycardia persisting for a period of 7.5 +/- 2 seconds resulted in 20 AICD discharges; patients were symptomatic prior to 13 (65%) discharges. Supraventricular tachycardias triggered three discharges. One patient had two spurious discharges during sinus rhythm. In conclusion, most of the spontaneous AICD discharges were appropriate for the detected rhythms, but only clinically appropriate for the management of arrhythmias in 75% of the cases. A significant portion of the patients with sustained or nonsustained ventricular tachycardias triggering AICD discharges were asymptomatic prior to discharge, which requires further assessment of the physiology of the arrhythmia as a component of the detection algorithm.
Pacing and Clinical Electrophysiology 03/1991; 14(2 Pt 2):280-5. · 1.35 Impact Factor
