Howard Frumin

Amiodarone versus implantable cardioverter-defibrillator:randomized trial in patients with nonischemicdilated cardiomyopathy and asymptomaticnonsustained ventricular tachycardia—AMIOVIRT

OBJECTIVES The purpose of this multicenter randomized trial was to compare total mortality during therapy with amiodarone or an implantable cardioverter-defibrillator (ICD) in patients with nonischemic dilated cardiomyopathy (NIDCM) and nonsustained ventricular tachycardia (NSVT). BACKGROUND Whether an ICD reduces mortality more than amiodarone in patients with NIDCM and NSVT is unknown. METHODS One hundred three patients with NIDCM, left ventricular ejection fraction < or =0.35, and asymptomatic NSVT were randomized to receive either amiodarone or an ICD. The primary end point was total mortality. Secondary end points included arrhythmia-free survival, quality of life, and costs. RESULTS The study was stopped when the prospective stopping rule for futility was reached. The percent of patients surviving at one year (90% vs. 96%) and three years (88% vs. 87%) in the amiodarone and ICD groups, respectively, were not statistically different (p = 0.8). Quality of life was also similar with each therapy (p = NS). There was a trend with amiodarone, as compared to the ICD, towards improved arrhythmia-free survival (p = 0.1) and lower costs during the first year of therapy (

Two-dimensional echocardiographic detection and diagnostic features of tricuspid papillary fibroelastoma

8,879 US dollars vs.

Long‐term Efficacy and Toxicity of High‐ and Low‐Dose Amiodarone Regimens

22,039 US dollars, p = 0.1). CONCLUSIONS Mortality and quality of life in patients with NIDCM and NSVT treated with amiodarone or an ICD are not statistically different. There is a trend towards a more beneficial cost profile and improved arrhythmia-free survival with amiodarone therapy.

Intravenous and oral loading versus oral loading alone with amiodarone for chronic refractory ventricular arrhythmias

Cardiac papillary fibroelastomas are rare and benign primary tumors in the cardiac valves or occasionally the mural endocardium. Before 1977, these tumors were diagnosed exclusively at postmortem examination. Over the last few years, a handful of cases have been diagnosed in vivo by echocardiography. In this report, we describe the first tricuspid valve papillary fibroelastoma detected by echocardiography in an adult. Clinical and echocardiographic features are discussed.

Late thrombolysis of an occluded aortocoronary saphenous vein graft

Amiodarone is an effective antiarrhythmic drug for the control of potentially lethal and lethal ventricular arrhythmias (VA). In the United States, a high‐dose regimen has been used at the expense of a high toxicity profile for the control of lethal VAs. Significant antiarrhythmic efficacy has also been established with low‐dose regimens, which carry a low rate of intolerable side effects (5.4%) when compared with the high‐dose regimen (16.7%). The high incidence of tolerable and intolerable adverse side effects is probably related to high amiodarone loading (31.92 g) and maintenance doses (520 mg/d). In contrast, the low‐dose regimen uses much lower loading (7.2 g) and maintenance (280 mg/d) doses.

Prolonged Asystole During Head‐Up Tilt Table Testing After Beta Blockade

To determine whether combined intravenous (i.v.) and oral loading with amiodarone can shorten its onset of action, a comparative study was conducted. Twenty patients with refractory ventricular arrhythmias were treated with amiodarone. All patients had frequent (greater than or equal to 30/hour) and complex (repetitive) ventricular premature beats on a 48-hour baseline Holter recording. Ten patients (group A) received oral loading alone: 800 mg/day for 7 days, 600 mg/day for 3 days, then a maintenance dose 200 to 400 mg/day. Ten patients (group B) received i.v. and oral loading: 5 mg/kg i.v., and then the same regimen as for group A. Follow-up 24-hour Holter recordings were obtained daily for 7 days, weekly for 1 month, and then monthly. Arrhythmia control was defined as at least a 70% reduction in ventricular premature beats, a 90% or greater reduction in couplets and abolition of ventricular tachycardia. The time to optimal ventricular arrhythmia control was shorter for group B (20 +/- 18 vs 105 +/- 83 days, p less than 0.05) and the cumulative amiodarone dose at the time of control was smaller for group B (10 +/- 8 vs 48 +/- 39 g, p less than 0.05). No complications were encountered with i.v. amiodarone. Thus, initial loading with i.v. amiodarone can shorten the time to optimal ventricular arrhythmia control and lower the cumulative dose required.

Endless loop tachycardia started by an atrial premature complex in a patient with a dual chamber pacemaker.

Reprint requests: Mark J. Goldberg, M.D., Dept. of Medicine, Section of Cardiovascular Diseases, Sinai Hospital of Detroit, 6767 West Outer Dr., Detroit, MI 48235. vein graft. Thrombolysis was “late,” both in the sense that graft occlusion occurred several weeks after surgery, and that treatment was administered several days after the onset of symptoms. We believe this represents a promising new application for streptokinase therapy. JP, a 53-year-old male with unstabie angina and a history of previous myocardial infarction, underwent coronary angiography on July 27, 1982. The study revealed a 70 % stenotic lesion in the proximal left anterior descending artery, a 90 % stenotic lesion in the proximal portion of a relatively large intermediate branch, and total proximal occlusion of the right coronary artery. Left ventriculography showed normal segmental wall motion, with the left ventricular ejection fraction being 58%. Coronary artery bypass graft surgery was performed on August 4, 1982. Saphenous vein grafts were fashioned for the left anterior descending artery, the intermediate branch, and the posterior descending branch of the right coronary artery. The early postoperative course was uneventful. The patient was discharged in excellent condition 7 days after surgery.

Arrhythmia control and other factors related to sudden death in coronary disease patients at intermediate risk

Neurally mediated vasodepressor syncope is a common clinical problem. The diagnosis is generally associated with a benign prognosis, however, a less common “malignant” form has been identified. Head‐up tilt table testing is helpful in the confirmation of the diagnosis of neurally mediated vasodepressor syncope and may be useful in the selection of therapy. One form of therapy commonly used is beta blockade. In this case report we describe a patient with neurally mediated vasodepressor syncope who developed asystole during head‐up tilt table testing after treatment with a beta blacker.

ICD Implantation via Thoracoscopy without the Need for Sternotomy or Thoracotomy

In a patient with a dual chamber pacemaker that senses in both the atrium and ventricle (VDD, DDD), a ventricular depolarization temporally displaced from a P wave can cause retrograde atrial activation and initiate an endless loop pacemaker-mediated tachycardia. A case in which an endless loop tachycardia was initiated by an end-diastolic atrial premature complex is reviewed. Retrograde conduction occurred because of the change in the temporal relation of atrial sensing and atrioventricular (AV) node depolarization. The implanted pacemaker did not have the capability of atrial refractory programmability. Atrial refractory interval extension, which occurs in this model after a ventricular premature complex to protect against a retrograde P wave, was not invoked since the tachycardia was begun by an atrial rather than a ventricular premature complex. The tachycardia was controlled by shortening the programmable AV delay. The mechanism of tachycardia induction and its management are outlined. Atrial refractory programmability is required in all VDD or DDD pacemakers.

Survival of Patients with Nonsustained Ventricular Tachycardia and Impaired Left Ventricular Function Treated with Low‐Dose Amiodarone

Thirty-three patients with coronary artery disease and frequent, complex ventricular arrhythmias (VA) were followed long-term to evaluate factors related to sudden death (SD). Patients with malignant VA (sustained ventricular tachycardia (VT), resuscitated SD, or acute myocardial infarction) were excluded. Baseline data included angiographic ejection fraction (EF), segmental wall motion, and Holter evidence of frequent (greater than 30/hr) and complex (repetitive) ventricular premature beats (VPBs). Control of VA was attempted with conventional or experimental agents and was defined as greater than or equal to 70% reduction in VPBs, greater than or equal to 90% reduction in couplets, and abolition of nonsustained VT on two consecutive Holter tapes. After 24 +/- 15 months of follow-up on the single most effective agent, 18 patients survived while 15 patients died suddenly. There was no difference between these groups with respect to age, sex, or baseline VA. Survivors had a higher EF (51% vs 34%, p less than 0.001), fewer dyskinetic segments (0.05 vs 1.0, p less than 0.01), and better VA control (83% vs 40%, p less than 0.01) than nonsurvivors. By analysis of variance, VA control was not independent of EF (F = 6.98, p less than 0.01). The 1-, 2-, and 3-year survival rates were 90%, 90%, and 82% for patients with EF greater than or equal to 40% and 22%, 11%, and 11%, for those with EF less than 40% and uncontrolled VA.(ABSTRACT TRUNCATED AT 250 WORDS)