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The prognostic role of programmed electrical stimulation and Holter monitoring was evaluated in 21 patients with idiopathic dilated cardiomyopathy who had no prior history of ventricular tachyarrhythmias. During a mean follow-up period of 23 months, sudden death or ventricular fibrillation occurred in four (20 percent). One patient died of complications of sepsis, and one underwent cardiac transplantation. Programmed electrical stimulation (PES) resulted in five or more beats of induced ventricular tachycardia in seven patients (33 percent), but was a poor predictor of sudden death (sensitivity = 20 percent). Thirteen patients (62 percent) had complex ventricular ectopy (Lown class 4A or 4B) by ambulatory monitoring. This was a sensitive (80 percent) but not specific (31 percent) marker for sudden death. The predictive value of a negative Holter monitor study was high (80 percent) for identifying those at low risk of sudden death. The results of this prospective study suggest that programmed ventricular stimulation and routine ambulatory monitoring are poor predictors of sudden death in this population.
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PMID:Idiopathic dilated cardiomyopathy. Role of programmed electrical stimulation and Holter monitoring in predicting those at risk of sudden death. 333 72

The clinical records of 339 consecutive patients who had received temporary transvenous pacemakers were analyzed for indications, complications and malfunctions. Of the 156 patients who had had an acute myocardial infarction (AMI), 50% had had anterior wall and 43.6% inferior wall involvement. The route of electrode insertion was the antecubital vein in 71%, subclavian vein in 24%, internal jugular vein in 4%, and a femoral vein in the remainder. The indication for pacing in the AMI group was atrioventricular (A-V) block in 55%, fascicular block in 32% and other arrhythmias in 13% of the cases. In the non-AMI group, the indication for pacing was A-V block in 46.4%, sick sinus syndrome in 25%, preparation for noncardiac surgery in 12%, and diagnostic purposes in the remainder. Ventricular fibrillation (VF) occurred only in the AMI group and appeared in 9 (5.66%) of these cases. The site of infarction did not significantly affect the incidence of VF. Ventricular premature beats (VPBs) and ventricular tachycardia (VT) appeared in 28.8 and 12.8% of the AMI group and 4.4 and 3.3% of the non-AMI group, respectively. No difference in the incidence of myocardial perforation, sepsis, and phlebitis was encountered between the AMI and non-AMI groups. Total malfunction rate was significantly higher in the AMI group (15%) vs. the non-AMI group (4%). A higher rate of pacing malfunction was found when a semifloating electrode was used through the subclavian vein (14.3%) vs. a 6 or 7 French electrode through the antecubital vein (7%). Thus, temporary pacing is safe and associated with lower incidence of complications and malfunctions in non-AMI than in AMI subjects. Moreover, a lower incidence of malfunction was encountered when a 6 or 7 French electrode was inserted through the antecubital vein.
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PMID:Temporary transvenous pacing: analysis of indications, complications and malfunctions in acute myocardial infarction versus noninfarction settings. 367 90

The results of a prospective study of ventricular electrical instability after myocardial infarction (MI) are presented. Ventricular electrical stability was assessed using a standardized protocol of programmed stimulation in 165 hemodynamically stable patients 6 to 28 days after acute MI. Ventricular electrical instability was defined as induction at programmed stimulation of ventricular fibrillation (VF) or ventricular tachycardia (VT) lasting at least 10 seconds. Of 165 MI survivors, 38 (23%) had ventricular electrical instability. No significant differences were noted between stable and unstable patients in terms of coronary prognostic index, elevation of serum creatine phosphokinase, coronary anatomy, site of MI, or frequency of VT within 48 hours of MI. The mean follow-up period was 8 months (range 0 to 12). There were 7 deaths in stable patients (5 from cardiogenic shock, 1 from septicemia, and 1 unwitnessed) and 10 deaths in unstable patients (8 instantaneous, 1 from cardiogenic shock, and 1 unwitnessed) during the subsequent year. In addition, 2 of 127 stable patients and 4 of 38 unstable patients had spontaneous VT from which they were satisfactorily resuscitated. Thus, the sensitivity of ventricular electrical instability as a predictor of instantaneous death or spontaneous VT was 86% and the specificity 83%. The predictive accuracy of the absence of ventricular electrical instability as an indicator for the absence of instantaneous death or spontaneous VT was 98%. The predictive accuracy of the presence of ventricular electrical instability as a predictor of instantaneous death or spontaneous VT was 32%. Thus, patients with ventricular electrical instability after MI have a high risk of instantaneous death within 1 year; patients without ventricular electrical instability after MI have a low risk of instantaneous death within 1 year; prospective studies of antiarrhythmic therapy and measures to prevent reinfarction and optimize left ventricular performance are required to determine whether instantaneous death can be prevented in unstable patients; and therapy to prevent reinfarction and optimize left ventricular performance may offer the best chance to improve prognosis in stable patients.
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PMID:Ventricular electrical instability: a predictor of death after myocardial infarction. 612 96

As precursors of permanent pacemakers, Lidwill (1929) and Hyman (1932) introduced temporary pacemakers for resuscitation. Callaghan (1950) intravenously paced the sinus nodal region for bradycardia in hypothermic dogs. Zoll (1952) used external electrodes to treat Adams-Stokes attacks, and Lillehei (1957) fixed stainless steel electrodes to the myocardium, successfully treating iatrogenic total atrioventricular block with a percutaneous pacemaker. Since 1951, by experimental and clinical use of ventricular fibrillation to obtain a functional cardiac standstill during open heart surgery, we used all known methods of stimulation to treat asystole or bradycardia after defibrillation. Since 1957, percutaneous stimulation by Adam-Stokes attacks has been performed. The most serious complication is infections along the electrodes causing death from sepsis. The solution of the problem was the implantation of the pacemaker and its energy supply. Percutaneous leads were used to study the different parameters for electric stimulation and to find the lowest frequency (to spare energy) with the best variation of cardiac output. In October 1958 in Stockholm a fixed rate pacemaker was implanted by thoracotomy. At present, the patient is living with his 23rd pacemaker. Four additional patients had pacemaker implantations until 1960. In 1961, Chardack and Greatbach successfully implanted pacemakers with mercury batteries. Johanson and Lagergren connected the pacemaker to an intravenous electrode to avoid thoracotomy. The enormous development in the electronic field made more elaborate pacemakers possible, and eliminated the risk of the fixed rate (interference, repetitive firing, and ventricular fibrillation).
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PMID:Cardiac pacing in retrospect. 634 75

An international registry was formed to collate data for patients undergoing attempted catheter ablation of the atrioventricular (AV) junction and insertion of a permanent pacemaker. Over the past 2 years, data was submitted for 127 patients who were followed for a mean of 9.9 +/- 8.2 months. The most common arrhythmia treated was chronic or paroxysmal atrial fibrillation or flutter (78 patients, 61%); the remainder had supraventricular tachycardia due to AV node reentry, ectopic atrial tachycardia, or incorporated an accessory pathway. A single shock of 150 to 400 J was effective in producing chronic third-degree AV block in 45 patients while two or more shocks were used in an additional 45 patients. There was no significant difference in the total cumulative energy used in successful and unsuccessful procedures. Immediate complications related to the shock included ventricular fibrillation (one patient), pericardial tamponade (one patient), and transient hypotension (one patient). No chronic sequelae occurred as a result of these complications. Late complications (1 day to 1 month) included ventricular tachycardia (three patients), sepsis involving the pacemaker pocket (two patients), staphylococcal sepsis from temporary pacing catheter (one patient), thrombophlebitis (one patient), thrombosis of the left subclavian vein (one patient), and hemothorax (one patient). Follow-up evaluation revealed chronic third degree AV block in 90 (71%) and AV conduction resumed but no drugs were required for arrhythmia control in eight (6.5%) and arrhythmia control was achieved with previously ineffective drugs in 16 (13%). Thirteen patients (10%) had no improvement and five of these patients underwent cardiac electrosurgery for direct His bundle ablation.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Catheter ablation of the atrioventricular junction: a report of the percutaneous mapping and ablation registry. 649 41

Eight adults with acute non-lymphocytic leukemia refractory to BH-AC.DMP therapy (N4-behenoyl-1-beta-D-arabinofuranosylcytosine, daunomycin, 6-mercaptopurine and prednisolone) were treated with a combination therapy of anthracycline antibiotics: adriamycin and aclacinomycin A (AA therapy). Four of five patients, who had received neither adriamycin nor aclacinomycin A previously, achieved complete remission after one course of AA therapy with a median time to remission of 24.5 days (ranging from 21 to 31 days). Two cases were in first remission induction phase and the other two were in first of third relapse. Three cases still maintain complete remission and the durations of remission range from 3 to over 14 months. Major side effects were loss of hair (100%) and myocardial damage (64%). T wave flattening and appearance of U wave in ECG were noted a few days after receiving chemotherapy but those changes returned to normal within 2 to 3 weeks. Ventricular fibrillation was observed in one case, which was refractory to chemotherapy and complicated by sepsis and electrolytes imbalance. Thus, this regimen deserves to be tried as a remission induction in patients with refractory acute non-lymphocytic leukemia.
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PMID:[Adriamycin-aclacinomycin therapy (AA therapy) for acute leukemia unresponsive to BH-AC-DMP therapy]. 657 27

Utilization of endocavitary defibrillation electrodes avoids thoracotomy used in implantable cardioverter-defibrillator procedures, reducing associated morbi-mortality. In our institution we have used this approach in 16 patients during a two years period (July 1990-July 1992). Fifteen were males, with a mean age of 56.9 +/- 10.6 (range 32-73). Nine patients suffered ischemic cardiomyopathy, 4 non ischemic cardiomyopathy and in three there was no structural heart disease. Mean ejection fraction was 44.3 +/- 18.3% (range 20-73%). Clinical arrhythmia was ventricular tachycardia in 8 cases, ventricular fibrillation in 6 cases and both types in 2. Endocavitary implantation procedure was not completed in 3 patients, thus an open trans-sternal approach was performed. In 13 patients it was completed successfully, using a total amount of 14 units (1 patient required two procedures due to sepsis in the generator pouch). Most important intraoperative incidences have been defibrillation thresholds between 20-24 J in 4 cases, displacement of defibrillation electrode from vena cava into coronary sinus in 4 cases, epicardial patch implantation via subcostal approach in 1 case and right ventricle perforation in 1 case. No operative mortality was registered. One patient suffered sudden death during follow-up. Surgical complications were few: 1 case of lead dislodgement and 1 infected wound in the generator's pouch. Non-surgical complications were also few: 1 case with superior vena cava syndrome and 1 patient with inadequate discharges. In conclusion, due to our early experience, we believe that endocavitary implantation of an implantable cardioverter-defibrillator is the procedure of choice at the present time.
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PMID:[The implantable endocavitary cardioverter-defibrillator: the initial and short-term results]. 821

This paper reviews cardiac dysrhythmias occurring in the perioperative period. Electrocardiography was the first application of electronic monitoring to anesthesia care. The detection of dysrhythmias remains the most important use of this technology today. While the description of dysrhythmias dates back to the early 1900's, the first large series was reported in 1936. Early descriptions of the kinds seen and the predisposing factors have changed little in the past 50 years. Several factors tend to emerge when one evaluates perioperative dysrhythmias. These are the anesthetic given, the site of surgery, abnormalities of blood gases or electrolytes, tracheal intubation, reflexes such as vagal slowing and the oculocardiac reflex, stimulation of the central nervous system the presence of pre-existing heart disease, and the use of intracardiac devices. In the evaluation of cardiac dysrhythmias several facts need to be determined. The most important is to determine if there is an underlying complication of anesthesia and surgery which may explain the dysrhythmia. In addition, one needs to evaluate the heart rate, the regularity, the number of P waves per QRS, and the configurations of the QRS. The anesthesiologist needs to determine whether the rhythm is dangerous to the patient and whether it requires treatment. The two major abnormalities of sinus rhythm are sinus bradycardia and the sinus tachycardia. Sinus bradycardia can be due to hypoxia, vagal stimulation, drug effects, a high sympathetic block or an acute myocardial infarction. Sinus tachycardia can be due pain, light anesthesia, hypovolemia, sepsis, hypoxia, hypercapnia and drug effects. The major atrial dysrhythmias are paroxysmal atrial tachycardia, atrial fibrillation and atrial flutter. Each require treatment if perfusion is impaired or if the heart rate is persistently elevated. The new agents esmolol and adenosine are particularly useful in managing atrial dysrhythmias. The major ventricular dysrhythmias are ventricular premature contractions, ventricular tachycardia and ventricular fibrillation. The later two demand emergency management with DC cardioversion when perfusion is impaired. The major abnormality of conduction is complete heart block which usually requires emergency treatment in the perioperative period. Prompt evaluation and management of perioperative dysrhythmias reduce anesthetic morbidity and mortality.
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PMID:Management of perioperative dysrhythmias. 828 46

Since January 1985, the date of the first dynamic cardiomyoplasty, until April 1992, 52 patients with end-stage heart disease were operated on in our institution. Mean preoperative New York Heart Association functional class was 3.3 and ventricular ejection fraction 16% +/- 3%. Associated procedures in 23 patients comprised ventricular aneurysm resection (10), valve surgery (9), coronary artery bypass (8), and tumor resection (3). Thirty-eight patients had a ventricular reinforcement, 13 a ventricular substitution, and 1 an atrial reinforcement using the left latissimus dorsi muscle. Preassist mortality rate before full latissimus dorsi muscle stimulation was 7 of 13 patients (54%) in the 1985 to 1987 period and 5 of 39 (12%) in the 1988 to 1992 period. The causes of death were heart failure (4), multiorgan failure (4), septicemia (2), ventricular fibrillation (1), and sudden death (1). Multivariate analysis of factors influencing hospital mortality showed that age, cardiac suture technique, associated surgical procedures, biventricular heart failure, and hemodynamic instability plus inotropic drug support were predictors of unfavorable outcome. All patients were followed up for from 2 months to 7 years (mean 21 months). Postassist mortality rate was 8 of 40 (20%). Causes of death included heart failure (5), ventricular fibrillation (1), myocardial infarction (1), and gastric bleeding (1). Preoperative risk factors influencing long-term mortality were permanent New York Heart Association functional class IV, biventricular heart failure, atrial fibrillation, cardiothoracic ratio greater than 60%, and ejection fraction less than 15%. Actuarial survival at 7 years was 70.4% (preassist mortality excluded). Surviving patients were in a mean New York Heart Association functional class of 1.8 (preoperatively 3.3, p < 0.05). The average ejection fractions (rest/stress) were 25%/28% at 1 year, 26%/30% at 2 years, and 23%/28% at 3 years. Average cardiothoracic ratios were 57% +/- 3% at 1 year, 56% +/- 2% at 2 years, and 57% +/- 2.5% at 3 years. Catheterization obtained in 20 patients showed no significant changes at rest in capillary wedge pressure, pulmonary artery pressure, and diastolic left ventricular pressure when compared with preoperative pressures. Average ejection fractions increased from 24% to 30.6%. Maximal oxygen consumption increased from 12.8 +/- 3.5 to 18.6 +/- 4 ml/min per kilogram. The number of rehospitalizations resulting from congestive heart failure was reduced to 0.4 hospitalizations per patient per year (preoperatively 2.4, p < 0.05). In 62% of the patients, pharmacologic therapy was diminished after the operation. Three patients required orthotopic heart transplantation 6 months, 4 years, and 5 years after cardiomyoplasty.
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PMID:Dynamic cardiomyoplasty at seven years. 832 Oct 4

The most important technical improvements of implantable cardioverter-defibrillators (ICD) of the latest generation comprise more sophisticated antitachycardia pacing options, stored intracardiac electrograms and biphasic shock capabilities which virtually always allow ICD implantation without thoracotomy. The present study summarizes the first clinical experience with these new devices. In 37 consecutive symptomatic (near sudden death 17, syncope 16, pre-syncope 4) patients aged 56 +/- 10 years with refractory ventricular arrhythmias (presenting arrhythmia: ventricular fibrillation 14, ventricular tachycardia 22, not documented 1), an ICD (Jewel PCD 7219, Medtronic) was implanted. Coronary artery disease was present in 21, dilated cardiomyopathy in 5, valvular heart disease in 2 and various conditions in 8 patients; the mean left ventricular ejection fraction was 43 +/- 18%. In 29 patients (78%), the ICD was inserted in a pectoral and in 8 (22%) in an abdominal position. A non-thoracotomy lead (NTL) configuration was successfully implanted in 36/37 patients (97%) (purely transvenous systems in 30, in combination with subcutaneous patch electrode in 6). Surgical complications comprised one pneumothorax, one hemorrhage and one death due to sepsis; during a mean follow-up of 5 +/- 3 months, another patient died of heart failure and 2 revisions (5.4%) for lead problems (1 connector, 1 SQ-patch) became necessary. In 23/37 patients (62%), the ICD was activated after 74 +/- 89 days post implant. 22 of these 23 patients (96%) received one or more appropriate shocks (9 +/- 22 shocks per patient). The actuarial survival was 95% at 6 months. In the present study, an ICD of the newest generation was successfully implanted without thoracotomy in > or = 97% and with purely transvenous systems in > or = 84%. Compared to older systems, this has made the implantation procedure remarkably easier and will most likely lead to a further reduction in mortality and morbidity. Despite the relatively short follow-up, the high incidence of appropriate ICD utilization underscores the high recurrence rate of arrhythmias in this population and suggests that the ICD may be very effective in preventing unnecessary rehospitalizations.
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PMID:[Initial clinical results with a novel implantable cardioverter-defibrillator: a prospective evaluation in 3 Swiss university hospitals]. 855 30


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