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RESUMEN El sistema Purkinje y el tracto de salida del ventrículo derecho tienen un papel trascendente en relación con las arritmias ventriculares malignas (taquicardia y fibrilación ventriculares, torsión de puntas) y con la muerte súbita cardíaca. Se discuten su fisiopatología, participación en el origen (extrasístoles desencadenantes) y mantenimiento de estas arritmias, y las posibilidades ablativas para disminuir las recurrencias y los episodios de tormenta eléctrica. Se expone el diagnóstico diferencial entre variantes benignas y malignas de la taquicardia ventricular relacionada con el tracto de salida del ventrículo derecho y la relación entre factores genéticos, estructurales, electroanatómicos y funcionales (inflamación, fibrosis), con los eventos clínicos y la vulnerabilidad a las arritmias. Se necesita reclasificar algunas de estas enfermedades, vistas ahora en su carácter orgánico-funcional (síndrome de Brugada, por ejemplo), lo cual implica cambios revolucionarios en algunos conceptos clásicos y una nueva visión en cuanto a la estratificación de riesgo y la conducta terapéutica.
ABSTRACT The Purkinje system and the right ventricular outflow tract play a pivotal role in relation to malignant ventricular arrhythmias (ventricular tachycardia and fibrillation, torsades de pointes) and sudden cardiac death. Details such as their pathophysiology, origin involvement (triggering extrasystoles) maintenance of such arrhythmias, and ablative possibilities to reduce recurrences and electrical storm events are discussed herein. The differential diagnosis between benign and malignant ventricular tachycardia related to the right ventricular outflow tract, and the relationship between genetic, structural, electroanatomical and functional factors (inflammation, fibrosis) with clinical events and vulnerability to arrhythmias are presented. Some of these diseases need to be reclassified as they are now seen in their organic-functional character (Brugada syndrome, for example), and this implies radical changes in some classical concepts as well as a new perspective on risk stratification and therapeutic management.
Subject(s)
Arrhythmias, Cardiac , Atrial Premature ComplexesABSTRACT
RESUMEN Se presenta una panorámica de la falla cardíaca ligada a las arritmias y a la muerte súbita, que pueden coexistir, agravarse, o ser causa o consecuencia una de otra. Se discuten los signos eléctricos premonitorios que permiten estratificar riesgo en pacientes con eventos previos, con posible acercamiento a la realidad, y en quienes no los han presentado (la mayoría, los no protegidos), y resulta muy difícil o imposible establecer un pronóstico. Estos signos son numerosos, esquivos, de baja especificidad y sensibilidad, ninguno es absoluto ni despreciable, para interpretarlos se requiere una visión integral. Se discuten las extrasístoles ventriculares como predictoras y desencadenantes de arritmias, de muerte súbita y de miocardiopatía, y la utilidad de los procedimientos ablativos frente a los medicamentosos. Los signos eléctricos son buenos para identificar grandes grupos de riesgo pero no lo son tanto para, dentro del gran grupo de bajo riesgo (la mayoría), identificar los individuos de alto riesgo.
ABSTRACT In this research is presented an overview of heart failure related to arrhythmias and sudden death, which can coexist, worsen, or be cause or consequence of one another. Here are discussed the premonitory electrical signs that allow to stratify risk in patients with previous events, with a possible approach to reality, and in those who have not presented them (most of them, the unprotected ones) and where a prognosis is very difficult, or impossible, to be established. These signs are numerous, elusive, with low specificity and sensitivity, none is absolute or negligible, in order to interpret them, a comprehensive vision is required. Premature ventricular contractions are discussed as predictors and triggers of arrhythmias, sudden death and cardiomyopathy, as well as the usefulness of ablative procedures versus medications. Electrical signs are good for identifying large risk groups but not for identifying high risk individuals inside the large low risk group (the majority).
Subject(s)
Heart Failure , Arrhythmias, Cardiac , Ventricular Premature Complexes , Death, SuddenABSTRACT
Objective To explore the validity of lead aVL in combination with lead V1 for identifying idiopathic outflow tract premature ventricular contractions(PVCs)originating from aortic sinus cusp(ASC).Methods This study consecutively enrolled 102 idiopathic outflow tract PVCs patients who underwent radiofrequency catheter ablation at the Second Xiangya Hospital,Central South University between January 2015 and August 2017.We compared the QRS wave amplitudes in the surface twelve leads electrocardiography between PVCs originating from ASC and right ventricular outflow tract(RVOT).Results(1)The origin sites of PVCs were ASC(n=28,27.5％)and RVOT(n=74,72.5％).The lead V1R/S wave amplitude ratio and lead aVL S wave amplitude were significantly higher in the ASC group than in the RVOT group[(1.14±1.32)vs.(0.16±0.18),P＜0.001;(0.99±0.36)mV vs.(0.56±0.26)mV,P＜0.001].The areas under the receiver operating characteristic curve(AUCs)and 95％confidence intervals of V1R/S wave amplitude ratio and aVL S wave amplitude had relatively larger AUCs which were 0.894(0.824-0.964)and 0.831(0.749-0.912),with the cut-offs of 0.25 and 0.80 respectively.(2)The sensitivity,specificity and accuracy of the lead V1R/S wave amplitude ratio＞0.25 to identify ASC originating PVCs were 78.9％,83.7％and 82.4％,respectively.The sensitivity,specificity and accuracy of the lead aVL S wave amplitude＞0.80 mV were 78.6％,85.1％and 83.3％,respectively.The lead aVL S wave amplitude＞0.80 mV in combination with the lead V1R/S wave amplitude ratio＞0.25 was applied to developed a new diagnostic approach and the sensitivity,specificity and accuracy were 60.7％,93.2％and 84.3％,respectively.Conclusions Lead aVL in combination with lead V1 could be applied to develop a more accurate method for identifying ASC originating PVCs.
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Objective To investigate the clinical characteristics, electrocardiography, electrophysiological features and the eff ectiveness of catheter ablation of ventricular arrhythmias originating from left ventricle posterior papillary muscles. Methods Clinical features and electrocardiography of 16 patients with ventricular arrhythmias arising from left ventricular posterior papillary muscles underwent catheter ablation were retrospectively analyzed. Activation mapping and/or pace mapping were performed to identify the site of origin and transthoracic echocardiography were used to demonstrate ablation catheter position and contact. The immediate success and recurrence rates were evaluated. Results During arrhythmias, QRS wave duration of 16 patients [5 men, mean age (45.0±18.2) years] was (155.1±9.0)ms. The prevalence of R>r' and r<R' of V1QRS morphology was 6/16 and 9/16, respectively. Earliest local ventricular electrogram preceded QRS wave by (30.8±8.4)ms at successful ablation site. Immediate success were achieved in 14 patients (14/16) ,11 patients(11/16) had full clinical follow-up and recurrences occurred in 5 patients (5/11). Conclusions Electrocardiography of ventricular arrhythmias originating from left ventricular posterior papillary muscles has its specifi c features. Earliest focal electrogram indicates successful ablation site and transthoracic echocardiography can demonstrate ablation catheter position and increase success rate but recurrence rate is still high.
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Premature ventricular contraction(PVC)is one of the most common types of arrhythmias in children.PVC in children usually disappears with age gradually and doesn't affect cardiac function and has a fa-vorable prognosis.Some PVC patients may have malignant arrhythmias or cardiomyopathy,which cause the de-creased ventricular systolic function,and even cardiac arrest,leading to poor prognosis.PVC can be classified to functional and structural type,and can also be classified according to the origin site.Until now,there are still no well-accepted standards to assess the prognosis and treatments of PVC in children.The PVC therapy in children mainly depends on the PVC frequency,type and the presence of congenital heart disease.Currently,propafenone, β-blocker and amiodarone are the nost commonly used drugs in PVC.Radiofrequency ablation(RFA)is another way of treating refractory cases. In this paper,we reviewed the prognosis of different types and therapies of PVC,and hope it could guide the clinical treatments of PVC in children.
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Aconiti Lateralis Radix (Fuzi) is a toxic traditional Chinese medicine with definite efficacy. In order to improve the quality control of its different prepared products and ensure the security in clinic, it is significant to establish a method of quality evaluation related to clinic adverse effects. Aiming at the important biological marker of early cardiac toxicity reaction, there was no method to detect it. In this manuscript, a novel approach for measuring the minimal toxic dose (MTD) of premature ventricular contractions (PVC) poisoning of rats was established. Then, the determination methodology and conditions were optimized to meet the needs of the quality and biological assessment, including animal sex, weight, stability of standards and test solutions. Using this method, the MTD value of different Fuzi products were determined, such as Heishunpian, Baifupian, Zhengfupian, Baofupian, and Paotianxiong. The results showed that the MTD of Fuzi was significantly decreased after detoxification processed (P<0.05) and the MTD of Heishunpian, Zhengfupian, Baofupian and Baifupian was as much as 15.76, 22.36, 19.65 and 20.97 times to that of unprocessed Shengfuzi. In addition, Paotianxiong could not induce PVC in rats, which indicated that Paotianxiong was nontoxic and safe.This method could appropriately reflects the cardiotoxity of Fuzi and its prepared samples. Together with the chemical composition analysis, the contents of diester alkaloids were explored including aconitine, mesaconitine and hypaconitine as well as monoester alkaloids in Fuzi and its prepared products were significantly associated with PVC. Furthermore, there may be some components undetermined facilitating arrhythmia to be worth exploring. This research provides an overall and comprehensive approach to diagnose early clinical cardiotoxity and control the quality of Fuzi, which could not only be a complementary solution for the chemical evaluation, but a new method to ensure its efficacy and security of clinical application.
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Objective To assess the efficacy of radiofrequency catheter ablation ( RFCA) in premature ven-tricular contractions ( PVCs) by electrophysiological mapping.Methods 60 patients with symptomatic PVCs original from the right ventricular outflow tract underwent RFCA guided by pace mapping and activation mapping,ablation was performed by a catheter with temperature control.The patients were divided into 3 groups,20 cases in each group.The first group ( the combination group ) was the combination with pacing mapping and activation mapping underwent RFCA.The second group ( the activation mapping group) was guided by activation mapping underwent RFCA.The third group( the pacing mapping group) was guided by pacing mapping underwent RFCA.Successful ablation immedi-ate end was that PVCs disappeared and could not be induced by isoproterenol.The success rate,time and composition ratio of the three groups were observed.Results The immediate success rate of ablation of either the combination group or the activation mapping group was higher than that of the pacing mapping group.But the ablation time of the combination group was the shortest.There was no statistical difference between the baseline results of each test group. The cardiac arrhythmia originated from the septum was usual (45/60,75.0%),and the arrhythmia originated from the free wall (15/60,25.0%) was less.The success rate of PVCs ablation of right ventricle was high,and the total success rate was 91.7%(55/60).There was no significant difference in the success rate of the combined mapping and the activation mapping (χ2 =0.084,P>0.05),but were significantly higher than those in the pacing mapping group (χ2 =0.032,0.047,all P<0.05).The ablation time of the pacing mapping group and the combination group were significantly lower than that of the activation mapping group(all P<0.05).Conclusion The effect of the com-bination with pacing mapping and activation mapping is the best.Pacing mapping is better than activation mapping during RFCA of PVCs.
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Se presenta el caso de un hombre de 54 años de edad con historia de un infarto del miocardio inferior antiguo y función ventricular izquierda normal, cuya atención en la consulta externa de nuestra institución se inició por palpitaciones frecuentes. El electrocardiograma mostró extrasístoles ventriculares de una morfología y en el monitoreo Holter se documentó extrasístoles ventriculares frecuentes de una morfología con periodos de acoplamiento variable y con latidos de fusión. Se concluyó la presencia de un foco parasistólico ventricular.
We present a case of a 54 years old male who had had an inferior myocardial infarction previously, with normal ejection fraction of the left ventricle whose care in the autopatient clinic of our institution started by frequent palpitations. The electrocardiogram showed premature ventricular contractions and Holter monitoring documented frequent premature ventricular contractions with periods of variable coupling and fusion beats. It was concluded the presence of ventricular parasystole.
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Objective To investigate the quality of life (QOL) of patients with frequent premature ventricular contractions (PVCs) and the effects of radiofrequency catheter ablation (RFCA) on them.Methods 120 patients with frequent PVCs,100 cases with frequent APCs and 60 healthy persons were assessed by 36-Health survey questionnaire (SF-36) originally.Three months later,the QOL of 48 cases received RFCA and 72 cases with drug therapy were evaluated again by SF-36.Meanwhile,decrease of PVCs were also calculated between these two groups.Results The scores of physiological function and mental health in patients with PVCs were lower than that of cases with APCs,while the score of bodily pain in patients with PVCs was higher (P value:0.0002-0.0380).In addition,the quality of life in patients with frequent PVCs were worse than healthy control(P value:0.0001-0.0915).Three months later,PVCs in 48 cases with frequent PVCs received RFCA were much fewer than that of 72 cases with drug therapy (t=18.8682,P＜0.01),and the quality of life in the former was much better than the latter (F=15.329-39.274,P＜0.01).Conclusion Frequent PVCs can deteriorate the patients' quality of life.RFCA can control or eliminate PVCs in these patients and markedly improve the quality of life of them.
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Premature ventricular contractions (PVCs) in children are a common arrhythmia in clinical work.Assessment and treatment of PVCs have been remarkably changed in the past 10 years.By the explanation of etiology,pathogenesis,and diagnosis as well as treatment progress of PVCs,the aim of the thesis is to enrich the knowledges of clinician about the diagnosis and treatment of PVCs.
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Objective To analyze premature ventricular contractions by dynamic electrocardiogram.Method 186 cases of premature ventricualr contractions were divided into two groups:patho-group(organic heart disease group) 106 cases,and the control group(non-organic heart disease group) 80 cases,both were examined by 24 hours dynamic electrocardiogram,the correlation between PVC shape and T-waves and the heart rate variation were analyzed.Result The variability of Lawn's degrees between the two groups was significant,the indexes of premature ventricualr contractions of patho-group were significantly different compared to the control group(P