Manfred Geiger

Syncope in hypertrophic cardiomyopathy: Multivariate analysis of prognostic determinants

Twenty-nine consecutive patients with symptomatic hypertrophic cardiomyopathy and a mean age of 44.8 +/- 12.2 years (range 21 to 63) underwent complex invasive and noninvasive testing to identify a risk profile for syncope. Clinical, morphologic, electrophysiologic and hemodynamic variables at rest and at a symptom-limited pacing rate were analyzed for a significant association with syncope. Exact stepwise logistic regression analysis identified three variables as significant independent predictors of syncope in hypertrophic cardiomyopathy: 1) age less than 30 years (beta = 4.803; p = 0.0007); 2) left ventricular end-diastolic volume index less than 60 ml/m2 (beta = 3.302; p = 0.006); and 3) nonsustained ventricular tachycardia on 72 h ambulatory electrocardiographic monitoring (beta = 2.5909; p = 0.03). The combined occurrence of all three variables had a sensitivity and specificity of 100% in identifying eight patients with syncopal events. Thus, the risk for syncope in hypertrophic cardiomyopathy is high in young patients with the combination of low left ventricular filling volume and episodes of nonsustained ventricular tachycardia. This finding might also explain the mechanism of syncope in hypertrophic cardiomyopathy as low input-low output failure induced by a sudden increase in heart rate in the presence of a low filling volume.

Successful Catheter Ablation of Human Ventricular Tachycardia with Radiofrequency Current Guided by an Endocardial Map of the Area of Slow Conduction

A case is presented of a 68‐year‐old male patient with a history of myocardial infarction and recurrent ventricular tachycardia who was successfully treated with a single 20‐second transcatheter application of radiofrequency current. Prior to current application a complete endocardial map had been obtained of an area of slow conduction that extended caudo‐cranially for approximately 2 cm along the lower left ventricular septum. Stimulation techniques yielded evidence that this area was critically related to tachycardia initiation and maintenance. Its central part was subsequently chosen as the site for current delivery.

Modulation of atrioventricular nodal conduction using radiofrequency current

Abstract Transvenous catheter ablation of the atrioventricular (AV) node has become a new therapeutic alternative in the treatment of patients with drug-resistant supraventricular tachycardia. After high-energy direct current shocks are delivered to the AV junction, conducd tion block is achieved in about 80% of patients, with subsequent control of symptoms. Pacemaker implantation, however, is mandatory because no, or only slow, junctional or ventricular escape rhythms emerge after ab1ation.l Therapeutic means currently under investigation for the modification of AV nodal conduction are transcatheter application of radiofrequency current 2 or laser energy. 3 We report the successful modulation of AV nodal conduction by radiofrequency current in a patient with intermittent, medically refractory atrial fibrillation.

Pleomorphic Ventricular Tachycardia: Demonstration of Conduction Reversal Within the Reentry Circuit

A case is presented of a patient with incessant venfricular tacbycardia of left bundle branch block morphology. Endocardial mapping revealed the site of earliest activation during tachycardia to be the proximal right ventricular septum. Pacing at this site elicited the clinical tachycardia, whereas pacing at the proximal left ventricular septum induced a right bundle branch block morphology identical to that of a previously recorded spontaneous ventricuiar tachycardia. Electrophysiological evidence is given that both types of tachycardia originate from a single reentry circuit located in the proximal ventricular septum in which the reentrant wavefront may travel either orthodromically (during spontaneous tachycardia and right ventricular pacing) or antidromically (during left ventricular pacing).

Diprafenone for treatment of Wolff-Parkinson-White syndrome

SummaryThe effect of intravenous (1.5 to 2.0 mg/kg body weight) and oral (300 to 375 mg/d) diprafenone was studied in 15 patients with the Wolff-Parkinson-White syndrome and symptomatic supraventricular tachycardia. Intravenous application of diprafenone significantly increased atrioventricular nodal conduction time as well as the effective refractory periods of the right ventricle and the accessory pathway in both the antegrade and retrograde directions. Antegrade conduction block in the accessory pathway occurred in two patients after the dose was increased to 2.0 mg/kg body weight. Intravenous diprafenone suppressed the inducibility of supraventricular tachycardia in two patients, but the tachycardia cycle length was significantly increased in all other patients. Fourteen patients were treated with oral diprafenone, and 11 were asymptomatic during a 17-month follow-up, two of these after the dose had been increased to 375 mg/d. Oral therapy had to be withdrawn in two patients because of adverse gastrointestinal side effects and in one because of recurring bronchospasm.

Ambulante Katheterablation@@@Outpatient radiofrequency catheter ablation: Indications, results, risks: Indikationen, Ergebnisse, Risiken

ZusammenfassungBei 162 Patienten wurden 176 Katheterablationen ambulant durchgeführt. Die Indikation bestand aus anfallsweisem Herzrasen bei 167 Prozeduren, 74mal mit Präsynkope oder Synkope. Siebenmal bestanden hochsymptomatische Palpitationen, einmal rezidivierende Synkopen und einmal ein bisher asymptomatisches Wolff-Parkinson-White-Syndrom. Durch die Ablation wurde 78mal eine AV-Knoten-Reentry-Tachykardie, 56mal eine akzessorische Leitungsbahn, 15mal Vorhofflattern, 16mal Vorhofflimmern, achtmal eine atriale Tachykardie und dreimal eine idiopathische ventrikuläre Tachykardie behandelt. Die Erfolgsrate betrug 86%. Nach 148 Ablationen wurden die Patienten innerhalb von 24 Stunden entlassen, davon 28mal nach drei Stunden, jeweils mit unkompliziertem Verlauf. In 28 Fällen erfolgte eine stationäre Einweisung, 15mal aufgrund von Wundschmerzen, zwölfmal wegen geringfügiger, ablationsbedingter Komplikationen, einmal wegen Perikardtamponade, die operativ versorgt werden mußte. Bei einem Patienten trat drei Tage nach Ablation einer atrialen Tachykardie und Entlassung am selben Tag ein rechtsatrialer Thrombus mit konsekutiver Lungenembolie auf. Insgesamt betrug die Inzidenz schwerwiegender Komplikationen 2,27%.Die Katheterablation kann auch ambulant effektiv und sicher durchgeführt werden.SummaryThe 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 safely on an outpatient basis.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.

Wert der programmierten Elektrostimulation bei Patienten mit hypertropher Kardiomyopathie

Der plotzliche Herztod ist eine bekannte Komplikation bei Patienten mit hypertropher Kardiomyopathie (10, 12, 20). In mehreren Studien wurde der Nachweis einer nichtbestandigen Kammertachykardie im Langzeit-Elektrokardiogramm mit einem spateren plotzlichen Herztod oder einem Herzstillstand in einen kausalen Zusammenhang gebracht (21, 23, 25, 26), jedoch ist der Befund bei dieser Art der Herzerkrankung unspezifisch. Eine nichtbestandige Kammertachykardie ist haufig langsam und asymptomatisch, so das man keinen ursachlichen Bezug zwischen dem Auftreten von Kammerarrhythmien und symptomatischen Episoden folgern kann. Dennoch basiert die Therapie zur Vermeidung eines plotzlichen Herztodes hauptsachlich auf Befunden aus Langzeit-Elektrokardiogramm. Die programmierte Elektrostimulation wurde bei verschiedenen kardialen Grunderkrankungen in der Diagnostik und Therapie von Patienten mit einem Risiko zu Synkopen oder dem plotzlichen Herztod eingesetzt (9, 22, 28). Bei Patienten mit hypertropher Kardiomyopathie beschrankt sich der Einsatz dieser Methode jedoch auf wenige Fallberichte an ausgewahlten Patienten (2, 14, 29). Wir begannen daher eine prospektive Studie an konsekutiven Patienten mit hypertropher Kardiomyopathie, die entweder in der Anamnese einen Herzstillstand oder eine Synkope aufwiesen oder bei denen symptomatische Kammerarrhythmien weder dokumentiert waren noch vermutet wurden. Alle Patienten unterzogen sich einer programmierten Elektrostimulation. Dieser Bericht stellt die Stimulationsergebnisse der Patienten zum Zeitpunkt der Aufnahme in die Studie vor.