Willem P. Beukema

Long-Term Clinical Response of Cardiac Resynchronization After Chronic Right Ventricular Pacing

Chronic right ventricular (RV) pacing might elicit unpredictably deleterious effects on left ventricular (LV) function similar to that of native left bundle branch block (LBBB). The objective of the present study was to evaluate the clinical and echocardiographic response to cardiac resynchronization therapy after years of chronic RV pacing. In this prospective observational study of 284 consecutive patients, cardiac resynchronization therapy was performed in 194 patients (68%) with a native LBBB and in 90 patients (32%) with a pacing-induced LBBB after chronic RV pacing (upgraded group). Echocardiographic and clinical parameters were evaluated in both groups at baseline and during 2 years of follow-up. The clinical response was defined as survival with improvement of > or =1 in the New York Heart Association class without heart failure hospitalization. Reverse LV remodeling was defined as LV end-systolic volume reduction of > or =15%. At baseline, the New York Heart Association class, quality of life, and exercise capacity were comparable but the LV ejection fraction was significant greater and the LV volumes were significant smaller in the upgraded group. Changes with time in the clinical parameters, echocardiographic parameters, and clinical response were not significantly different between the 2 groups. Reverse LV remodeling was observed in 86% in the upgraded group versus 78% of the native LBBB group after 1 year (p = 0.39). Survival was not significantly different between the 2 groups. In conclusion, comparable clinical and echocardiographic improvement was seen when resynchronization therapy was applied in patients with preceding chronic RV pacing compared with patients with a native LBBB.

Multisite atrial pacing: an option for atrial fibrillation prevention? Preliminary results of the Dutch Dual-site Right Atrial Pacing for Prevention of Atrial Fibrillation study.

Multisite pacing is a novel concept for the prevention of recurrent drug-refractory atrial fibrillation (AF). Two different pacing methods have been described, biatrial pacing and dual-site right atrial stimulation. The use of multisite pacing as preventive therapy for recurrences of atrial fibrillation is still under investigation. We conducted a prospective, randomized, crossover study in patients with recurrent drug-refractory AF without or with minimal structural heart disease. After implantation of a DDD pacemaker, patients were randomized to either dual-site pacing first (Group I) or single-site (high right atrium) pacing first (Group II) and, after 6 months of treatment, the device was reprogrammed to the other pacing mode. Preliminary results of 13 patients in each group are presented. Clinical characteristics of patients in both groups with respect to age, sex, left atrial dimension, left ventricular function, and New York Heart Association (NYHA) functional class were comparable. Pacing therapy was combined with antiarrhythmic drug treatment. After completion of the study protocol, the arrhythmia-free interval was not remarkably different in either group. However, the endpoint free interval (i.e., the need for electrical cardioversion because of recurrent AF lasting >24 hours, was less during dual-site pacing in Group II. Within 6 months, 43 patients enrolled in this study will have completed the protocol.

New strategies in the surgical treatment of atrial fibrillation

In patients with longstanding atrial fibrillation surgical correction of the underlying cardiac abnormality alone will not abolish the arrhythmia. The Coxs Maze III has proven to be an effective treatment for atrial fibrillation but because of its complexity cardiac surgeons are reluctant to expose their patients to the potential risks of this procedure. Attempts have been made to simplify the Coxs Maze III procedure by using alternative energy sources and modifying the pattern of atrial lines of conduction block. In patients with atrial fibrillation without structural heart disease Maze surgery may be an option as an ultimate therapeutic alternative when atrial fibrillation is drug resistant and very symptomatic. The objective of this article is to outline the different surgical procedures that have formerly been used in the treatment of atrial fibrillation and to give an overview of new and evolving techniques.

Spontaneous disappearance of blue-gray facial pigmentation during amiodarone therapy (out of the blue)

Abstract Amiodarone hydrochloride (Cordarone ® ) was originally introduced in Europe in 1965 as an antianginal drug. In the early 1970s its antiarrhythmic potency was recognized. Currently, amiodarone is approved for use in patients with refractory malignant ventricular arrhythmia. The drug has a number of untoward effects that include adverse skin reactions. Photosensitivity occurs in 30 to 57% of patients receiving amiodarone. 1 A slate-gray or blue-gray discoloration of sun-exposed areas occurs in 2 to 24% of patients given amiodarone and is often preceded by a phototoxic skin reaction. 1,2 The pigmentation appears dose- and duration-dependent and is reported to fade gradually over many months or years after amiodarone therapy is discontinued. 3 We report the case of a patient in whom the typical amiodarone-induced pigmentation spontaneously disappeared despite continued amiodarone therapy.