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1.
Minerva Cardioangiol ; 62(4): 305-9, 2014 Aug.
Article in English | MEDLINE | ID: mdl-25012099

ABSTRACT

AIM: Clinical experience shows that about 2 out of 3 patients with indication to resynchronization therapy (CRT) may have improvements in NYHA class, echocardiographic parameters and survival. However, specific clinical or technical parameters that identify responder patients have not yet been found. Aim of the present study was to assess the efficacy of CRT and to estimate the predictive value of specific echocardiographic parameters. METHODS: All patients who underwent CRT from January 2004 till June 2009, at our Institution, were clinically examined and evaluated by echo and ECG before implant. Between January and February 2010, among a population of 55 patients (41 M, 14F, mean age 66.3±5.9), 42 patients (33 M) were considered in the final multiparametric analysis. Of the 13 excluded patients, 6 died, 2 underwent cardiac transplantation and 5 were lost to follow-up. Basal characteristics of the study population were: ischemic etiology in 15 out of 42 patients, back-up defibrillation in 39 patients. The mean follow-up period was 26.2±13.0 months. Patients had been classified as CRT responders if they showed an inverse left ventricle (LV) remodeling, defined as a 10% reduction of end-diastolic diameter (LVEDD) compared to the basal measure. RESULTS: Echo parameters significantly improved after CRT: LVEDD was significantly (P<0.05) reduced (basal vs. CRT: 76±7 mm vs. 64±10 mm, P=0.00004); basal ejection fraction (EF) was 21±5% vs. 37±14% after CRT (P=0.00001); mitral regurgitation (MR) (grading from 1 to 4) was 2.8±0.6 vs. 2.3±0.9 (P=0.00998); QRS duration was 157±25 ms vs. 135±23 ms (P=0.00036), and NYHA class 2.6±0.5 vs. 2.1±0.4, P=0.00006). Only a positive trend of the E/A ratio was observed (P=0.088). Among 42 patients, 24 (57%) had an inverse LV remodeling and were defined as CRT responders. By comparing responder with no-responder patients, the basal values of echo parameters like EF, LVEDD, MR, QRS, NYHA class were similar in the two groups; while E/A was statistically different between the two groups (P=0.02), being less severe in responder patients. CONCLUSION: Our experience confirms that about 2 out of 3 patients are responder to CRT and their clinical improvements remain stable in a long term follow-up. Patients with a less severe E/A ratio are more likely to improve their clinical condition as shown by the reverse remodeling measured through the LVEDD.


Subject(s)
Cardiac Resynchronization Therapy/methods , Echocardiography , Heart Failure/therapy , Ventricular Remodeling/physiology , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , Treatment Outcome
2.
Minerva Cardioangiol ; 62(3): 283-6, 2014 Jun.
Article in English | MEDLINE | ID: mdl-24831764

ABSTRACT

AIM: Both ablation catheters with irrigated system and 8mm tip-catheters have shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. The purpose of this prospective study was to compare the efficiency of radiofrequency catheter ablation (RFA) of the cavotricuspid isthmus using a new type of open irrigation-tip catheter versus 8 mm tip-catheters to eliminate atrial flutter (AFL). METHODS: Sixty consecutive patients, matched for age, presence of cardiopathy, atrial dimensions and comorbidity, underwent RF ablation of cavotricuspid isthmus (CTI) for the treatment of typical atrial flutter, using an open irrigated tip catheter - Surround Flow™ - (N.=30) or an 8-mm-tip catheter (N.=30). The RF pulses were applied point-by-point for 30 seconds, with power limited at 35 w for the irrigated catheter and by temperature control (60/70 w) for the 8-mm catheter. RESULTS: The CTI block was successfully performed in 100% of cases. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (608±324 vs. 556±244 s, P=0.79), number of RF applications (12±8 vs. 10±5, P=0.56), total procedure duration (86.4±23.6 vs. 78.1±22.5 min, P=0.58) and time of fluoroscopy (12±6 vs. 14±6 min, P=0.25) and periprocedural complications (1 groin hematoma in the 8 mm group). During follow-up of 11.6 months on average, one patient in the 8 mm group had recurrence of typical atrial flutter. CONCLUSION: Efficacy and safety of CTI ablation was comparable between both techniques (open irrigated catheter and 8mm tip catheter). The ablation parameters were comparable and homogeneous between the two groups.


Subject(s)
Atrial Flutter/surgery , Catheter Ablation/methods , Catheters , Aged , Catheter Ablation/adverse effects , Catheter Ablation/instrumentation , Equipment Design , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prospective Studies , Recurrence , Time Factors , Treatment Outcome
3.
Europace ; 5(3): 225-9, 2003 Jul.
Article in English | MEDLINE | ID: mdl-12842632

ABSTRACT

AIM: To compare clinical, electrophysiological characteristics and transcatheter ablation results between two groups of patients, one with atrioventricular reentrant tachycardia (AVRT) and the other with atrioventricular nodal reentrant tachycardia (AVNRT). METHODS: The study population consisted of 94 consecutive patients who underwent endocavitary electrophysiological study and radiofrequency (RF) ablation: 46 patients had AVRT due to an accessory pathway with only retrograde conduction while 48 patients had AVNRT. RESULTS: In relation to general and clinical characteristics, differences between the two groups emerged regarding the age of symptom onset (25+/-16 vs 37+/-17 years, p=0.001), the prevalence of heart disease (8 vs 31%, p=0.001) and the correct diagnosis on surface ECG (50 vs 79%, p=0.001). Clinical presentation was quite similar apart from a higher prevalence of fatigue and sweating in the AVNRT group. Transcatheter RF ablation therapy results were similar. CONCLUSIONS: Patients with AVRT have a lower mean age at arrhythmia symptom onset compared with those with AVNRT and have fewer associated cardiac abnormalities. Clinical presentation is quite similar as well as their outcome after ablation. A correct diagnosis by standard ECG is more frequent in AVNRT.


Subject(s)
Catheter Ablation , Tachycardia, Atrioventricular Nodal Reentry/physiopathology , Tachycardia, Atrioventricular Nodal Reentry/surgery , Tachycardia, Supraventricular/physiopathology , Tachycardia, Supraventricular/surgery , Adolescent , Adult , Age of Onset , Aged , Electrocardiography , Electrophysiology , Female , Heart Diseases/complications , Heart Diseases/physiopathology , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Tachycardia, Atrioventricular Nodal Reentry/complications , Tachycardia, Supraventricular/complications
4.
Europace ; 4(4): 357-60, 2002 Oct.
Article in English | MEDLINE | ID: mdl-12408253

ABSTRACT

BACKGROUND: The finding of bundle branch block in patients with syncope suggests that paroxysmal AV block may be the cause of syncope, even though its prevalence is unknown. METHODS: We evaluated 55 consecutive patients with syncope and bundle branch block (mean age 75 +/- 8 years; median of two syncopal episodes per patient) referred to three Syncope Units. The hierarchy and appropriateness of diagnostic tests and the definitions of the final diagnoses followed standardized predefined criteria. RESULTS: Cardiac syncope was diagnosed in 25 patients (45%): AV block in 20, sick sinus syndrome in 2, sustained ventricular tachycardia in 1, aortic stenosis in 2. Neurally mediated syncope was diagnosed in 22 (40%): carotid sinus syndrome in 5, tilt-induced syncope in 15, adenosine-sensitive syncope in 2. Syncope remained unexplained in 8 (15%). CONCLUSIONS: Less than half of the patients with bundle branch block have a final diagnosis of cardiac syncope; in these patients, paroxysmal AV block is the most frequent but not the only mechanism supposed.


Subject(s)
Bundle-Branch Block/complications , Syncope/etiology , Syncope/physiopathology , Aged , Female , Heart Function Tests , Humans , Male , Syncope/diagnosis
5.
Europace ; 4(4): 351-5, 2002 Oct.
Article in English | MEDLINE | ID: mdl-12408252

ABSTRACT

BACKGROUND: The appropriate diagnostic work-up of patients with syncope is not well defined. We applied the guidelines of Italian 'Associazione Nazionale Medici Cardiologi Ospedalieri' to a group of consecutive patients with syncope referred to three Syncope Units. The aim of the study was to evaluate the applicability of those guidelines in the 'real world' and their impact on the use of the tests. METHODS: We evaluated 308 consecutive patients with syncope (mean age 61 +/- 20 years; median of three syncopal episodes per patient). The hierarchy and appropriateness of diagnostic tests and the definitions of the final diagnosis followed standardized predefined criteria. In brief, all patients underwent initial evaluation consisting of history, physical examination, supine and upright blood pressure measurement and standard electrocardiogram (ECG) (only in patients > 45 years or with history of heart disease). Any subsequent investigations were based on the findings of the initial evaluation. Priority was given to cardiological tests (prolonged ECG monitoring, exercise test, electrophysiological study), or to neurally mediated tests (carotid sinus massage, tilt test, ATP test), or to neuro-psychiatric tests, as appropriate. FINDINGS: The initial evaluation alone was diagnostic in 72 patients (23%). One further test was necessary for diagnosis in 65 patients (21%), > or = 2 tests in 64 (21%) and > or = 3 tests in 50 (16%). The diagnostic yield was 10% for ECG, 3% for echocardiogram, 16% for Holter, 5% for exercise test, 27% for electrophysiological study, 57% for carotid sinus massage, 52% for tilt testing and 15% for ATP test. At the end of the work-up the mechanism of syncope remained unexplained in 57 patients (18%). CONCLUSIONS: When standardized criteria based on the appropriateness of indications are used, few simple tests are usually needed for diagnosis of syncope.


Subject(s)
Syncope/diagnosis , Adult , Aged , Aged, 80 and over , Algorithms , Electrocardiography, Ambulatory , Female , Humans , Male , Middle Aged , Physical Examination , Practice Guidelines as Topic
6.
Ital Heart J Suppl ; 2(8): 888-93, 2001 Aug.
Article in Italian | MEDLINE | ID: mdl-11582721

ABSTRACT

BACKGROUND: It is current opinion that concealed and manifest accessory pathways (APs) are indistinguishable with respect to their location and contribution to orthodromic reciprocating tachycardias. The aim of this study was to compare clinical and electrophysiological characteristics of two groups of patients. METHODS: Between January 1999 and June 2000, 42 consecutive patients underwent radiofrequency catheter ablation for paroxysmal atrioventricular reciprocating tachycardia attributable to a concealed AP. Their clinical and electrophysiological characteristics were compared with a group of 48 consecutive patients with manifest AP and supraventricular tachyarrhythmias. RESULTS: There were no differences regarding gender, the prevalence of heart disease and the age of onset of symptomatic tachycardias between the two groups. Compared to those with a manifest AP, the patients presenting with a tachyarrhythmia due to a concealed AP were older (48 +/- 15 vs 40 +/- 16 years, p < 0.05) and had a longer history of tachyarrhythmias (22 +/- 16 vs 13 +/- 13 years, p < 0.05). Atrial fibrillation was more frequent in patients with a manifest AP than in patients with a concealed AP (50 vs 9.5% respectively, p = 0.02). Atrioventricular reciprocating tachycardia was a cause of more hospitalizations (76 vs 35%, p = 0.01) and episodes of pre-syncope (47 vs 22%, p < 0.05) in the group of patients with a concealed AP. The anatomical site of concealed and manifest APs was significantly different: concealed APs were more frequently localized in the left side (93% left, 7% right), while manifest APs were seen in the left side in 64% of cases, in the right side in 29% and in the posteroseptal left + right region in 7% of cases. The retrograde electrophysiological properties and the inducibility of other types of reentrant arrhythmias were similar. Catheter ablation was similarly successful regardless of whether the AP was concealed or manifest, the rates of success being 91 and 88% respectively at the first attempt and with a similar number of energy applications (7 +/- 7 vs 10 +/- 9, p = NS). At a second attempt, the procedure was successful in 100 and 98% of cases respectively. Periprocedural complications occurred in 5% of patients with a concealed (1 ventricular fibrillation, 1 cerebral transient ischemic attack) and in 8% of patients with a manifest AP (2 pericardial effusion, 1 transient atrioventricular block, 1 anginal attack with spontaneous recovery) (p = NS). Complications occurred only for left-sided APs and were independent of the approach (transseptal or retrograde). Relapse of AP conduction was more frequent in the group of patients with a manifest than in those with a concealed AP (12 vs 5%), though not significantly. There were no late complications. CONCLUSIONS: Those patients presenting with a tachyarrhythmia due to a concealed AP, compared to those with a manifest AP, were older and had a longer history of tachyarrhythmia. Atrial fibrillation was more frequent in patients with manifest AP. Atrioventricular reciprocating tachycardia episodes were longer-lasting and caused more hospitalizations and more frequently pre-syncope in the group of patients with a concealed AP. Almost all concealed APs were localized in the left side. The retrograde electrophysiological properties were similar. The results of radiofrequency catheter ablation were comparable in both groups.


Subject(s)
Atrial Fibrillation/physiopathology , Tachycardia, Supraventricular/physiopathology , Wolff-Parkinson-White Syndrome/physiopathology , Adult , Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Catheter Ablation , Electrophysiology , Female , Humans , Male , Middle Aged , Tachycardia, Supraventricular/diagnosis , Tachycardia, Supraventricular/surgery , Wolff-Parkinson-White Syndrome/diagnosis , Wolff-Parkinson-White Syndrome/surgery
7.
Circulation ; 104(17): 2045-50, 2001 Oct 23.
Article in English | MEDLINE | ID: mdl-11673344

ABSTRACT

BACKGROUND: In patients with syncope and bundle branch block (BBB), syncope is suspected to be attributable to a paroxysmal atrioventricular (AV) block, but little is known of its mechanism when electrophysiological study is negative. METHODS AND RESULTS: We applied an implantable loop recorder in 52 patients with BBB and negative conventional workup. During a follow-up of 3 to 15 months, syncope recurred in 22 patients (42%), the event being documented in 19 patients after a median of 48 days. The most frequent finding, recorded in 17 patients, was one or more prolonged asystolic pause mainly attributable to AV block; the remaining 2 patients had normal sinus rhythm or sinus tachycardia. The onset of the bradycardic episodes was always sudden but was sometimes preceded by ventricular premature beats. The median duration of the arrhythmic event was 47 seconds. An additional 3 patients developed nonsyncopal persistent III-degree AV block, and 2 patients had presyncope attributable to AV block with asystole. No patients suffered injury attributable to syncopal relapse. CONCLUSIONS: In patients with BBB and negative electrophysiological study, most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses, mainly attributable to sudden-onset paroxysmal AV block.


Subject(s)
Bundle-Branch Block/complications , Electrocardiography, Ambulatory , Syncope/diagnosis , Syncope/etiology , Aged , Bundle-Branch Block/physiopathology , Defibrillators, Implantable , Disease-Free Survival , Electrocardiography, Ambulatory/instrumentation , Electrophysiologic Techniques, Cardiac , Female , Follow-Up Studies , Heart Block/complications , Heart Block/diagnosis , Heart Conduction System/physiopathology , Humans , Male , Predictive Value of Tests , Prospective Studies , Syncope/physiopathology , Tilt-Table Test
8.
J Am Coll Cardiol ; 37(7): 1921-8, 2001 Jun 01.
Article in English | MEDLINE | ID: mdl-11401133

ABSTRACT

OBJECTIVES: We sought to establish what historical findings are predictive of the cause of syncope. BACKGROUND: The clinical features of the various types of syncope have not been systematically investigated. METHODS: Three hundred forty-one patients with syncope were prospectively evaluated. Each patient was interviewed using a standard questionnaire. A cause of syncope was assigned using standardized diagnostic criteria. RESULTS: A cardiac cause of syncope was established in 23% of the patients, a neurally mediated cause in 58% and a neurologic or psychiatric cause in 1%, and in the remaining 18%, the cause of syncope remained unexplained. In a preliminary analysis including age, gender and the presence of suspected or certain heart disease after the initial evaluation, only heart disease was an independent predictor of a cardiac cause of syncope (odds ratio 16, p = 0.00001), with a sensitivity of 95% and a specificity of 45%. In contrast, the absence of heart disease allowed us to exclude a cardiac cause of syncope in 97% of the patients. In patients with certain or suspected heart disease, the most specific predictors of a cardiac cause were syncope in the supine position or during effort, blurred vision and convulsive syncope. Significant and specific predictors of a neurally mediated cause were time between the first and last syncopal episode >4 years, abdominal discomfort before the loss of consciousness and nausea and diaphoresis during the recovery phase. In the patients without heart disease, palpitation was the only significant predictor of a cardiac cause. CONCLUSIONS: The presence of suspected or certain heart disease after the initial evaluation is a strong predictor of a cardiac cause of syncope. A few historical findings are useful to predict cardiac and neurally mediated syncope in patients with and without heart disease.


Subject(s)
Heart Diseases/complications , Syncope/diagnosis , Syncope/etiology , Algorithms , Female , Humans , Male , Medical History Taking , Middle Aged , Predictive Value of Tests , Prospective Studies , Surveys and Questionnaires
9.
J Am Coll Cardiol ; 37(2): 548-53, 2001 Feb.
Article in English | MEDLINE | ID: mdl-11216977

ABSTRACT

OBJECTIVES: We tested the efficacy of two drug treatments, flecainide (F) and the combination ofdiltiazem and propranolol (D/P), administered as a single oral dose for termination of the arrhythmic episodes. BACKGROUND: Both prophylactic drug therapy and catheter ablation are questionable as first-line treatments in patients with infrequent and well-tolerated episodes of paroxysmal supraventricular tachycardia (SVT). METHODS: Among 42 eligible patients (13% of all screened for SVT) with infrequent (< or =5/year), well-tolerated and long-lasting episodes, 37 were enrolled and 33 had SVT inducible during electrophysiological study. In the latter, three treatments (placebo, F, and D/P) were administered in a random order 5 min after SVT induction on three different days. RESULTS: Conversion to sinus rhythm occurred within 2 h in 52%, 61%, and 94% of patients on placebo, F and D/P, respectively (p < 0.001). The conversion time was shorter after D/P (32 +/- 22 min) than after placebo (77 +/- 42 min, p < 0.001) or F (74 +/- 37 min, p < 0.001). Four patients (1 placebo, 1 D/P, and 2 F) had hypotension and four (3 D/P and 1 F) a sinus rate <50 beats/min following SVT interruption. Patients were discharged on a single oral dose of the most effective drug treatment (F or D/P) at time of acute testing. Twenty-six patients were discharged on D/P and five on F. During 17 +/- 12 months follow-up, the treatment was successful in 81% of D/P patients and in 80% of F patients, as all the arrhythmic episodes were interrupted out-of-hospital within 2 h. In the remaining patients, a failure occurred during one or more episodes because of drug ineffectiveness or drug unavailability. One patient had syncope after D/P ingestion. During follow-up, the percentage of patients calling for emergency room assistance was significantly reduced as compared to the year before enrollment (9% vs. 100%, p < 0.0001). CONCLUSIONS: The episodic treatment with oral D/P and F, as assessed during acute testing, appears effective in the management of selected patients with SVT. This therapeutic strategy minimizes the need for emergency room admissions during tachycardia recurrences.


Subject(s)
Anti-Arrhythmia Agents/administration & dosage , Diltiazem/administration & dosage , Electrocardiography/drug effects , Flecainide/administration & dosage , Propranolol/administration & dosage , Self Care , Tachycardia, Paroxysmal/drug therapy , Tachycardia, Supraventricular/drug therapy , Administration, Oral , Adolescent , Adult , Aged , Ambulatory Care , Anti-Arrhythmia Agents/adverse effects , Diltiazem/adverse effects , Drug Therapy, Combination , Female , Flecainide/adverse effects , Humans , Male , Middle Aged , Patient Readmission , Propranolol/adverse effects , Self Administration , Treatment Outcome
10.
Am J Cardiol ; 86(11): 1267-70, A9, 2000 Dec 01.
Article in English | MEDLINE | ID: mdl-11090807

ABSTRACT

We assessed the effects of left ventricular pacing on echocardiographic and clinical parameters in 13 consecutive patients with heart failure and bundle branch block by means of a controlled acute and medium-term evaluation. Left ventricular pacing induced a significant improvement in left ventricular ejection fraction, Minnesota Living with Heart Failure Questionnaire score, New York Heart Association class, and 6-minute walking test compared with sinus rhythm or right ventricular pacing.


Subject(s)
Cardiac Pacing, Artificial , Cardiotonic Agents/therapeutic use , Heart Failure/therapy , Quality of Life , Ventricular Function, Left/physiology , Aged , Cross-Over Studies , Double-Blind Method , Drug Tolerance , Echocardiography , Electrocardiography , Female , Heart Failure/physiopathology , Heart Failure/psychology , Heart Ventricles/diagnostic imaging , Heart Ventricles/physiopathology , Humans , Male , Prognosis , Surveys and Questionnaires
11.
Heart ; 83(1): 24-8, 2000 Jan.
Article in English | MEDLINE | ID: mdl-10618330

ABSTRACT

AIM: To evaluate the possible relation between adenosine sensitive syncope and tilt induced vasovagal syncope. METHODS: An ATP test and a head up tilt test were performed in 175 consecutive patients with syncope of uncertain origin. The ATP test consisted of the rapid intravenous injection of 20 mg of ATP; a positive response was defined as the induction of a ventricular pause (maximum RR interval) >/= 6000 ms. The head up tilt test was performed at 60 degrees for 45 minutes; if negative, 0.4 mg oral glyceryl trinitrate spray was given and the test continued for a further 20 minutes; a positive response was defined as induction of syncope in the presence of bradycardia, hypotension, or both. RESULTS: Of the 121 patients with a positive response, 77 (64%) had a positive head up tilt alone, 18 (15%) had a positive ATP test alone, and in 26 (21%) both ATP and head up tilt were positive. Compared with the patients with isolated positive head up tilt, those with isolated positive ATP were older (mean (SD) age, 68 (10) v 45 (20) years), had a lower median number of syncopal episodes (2 v 3), a shorter median duration of syncopal episodes (4 v 36 months), a lower prevalence of situational, vasovagal, or triggering factors (11% v 64%), a lower prevalence of warning symptoms (44% v 71%), and a higher prevalence of systemic hypertension (22% v 5%) and ECG abnormalities (28% v 9%). The patients with a positive response to both tests had intermediate features. Of the 44 positive responses to the ATP test, atrioventricular block was the cause of the ventricular pause in 43; of the 29 positive cardioinhibitory responses to head up tilt, sinus arrest was present in 23 cases and atrioventricular block in six. CONCLUSIONS: ATP and head up tilt tests identify different populations of patients affected by syncope; these have different general clinical features, different histories of syncopal episodes, and different mechanism sites of action. Therefore, adenosine sensitive syncope and tilt induced vasovagal syncope are two distinct clinical entities.


Subject(s)
Adenosine Triphosphate , Syncope, Vasovagal/diagnosis , Syncope/diagnosis , Tilt-Table Test , Female , Humans , Male , Middle Aged , Prospective Studies , Syncope/chemically induced , Syncope/physiopathology , Syncope, Vasovagal/physiopathology
12.
Europace ; 2(1): 66-76, 2000 Jan.
Article in English | MEDLINE | ID: mdl-11225598

ABSTRACT

We believe that the pattern of blood pressure response to tilt during the time preceding the development of the vasovagal reaction may provide adjunctive diagnostic information. A group of 101 consecutive patients affected by syncope of uncertain origin underwent passive tilt testing for 45 min at 60 degrees followed, if negative, by oral (sublingual) trinitroglycerin (TNG) 0.4 microg with continuation of the test for 20 min. Three main patterns were observed: the classic (vasovagal) syncope pattern was observed in 36 patients who, during the preparatory phase, had a rapid and full compensatory reflex adaptation to upright position, resulting in stabilization of their blood pressure values until abrupt onset of the vasovagal reaction; the dysautonomic (vasovagal) syncope pattern was observed in 47 patients in whom steady-state adaptation to upright position was not possible. There was thus a progressive fall in their blood pressure until the occurrence of a typical vasovagal reaction; the orthostatic intolerance pattern was observed in 18 patients in whom there was a progressive fall in blood pressure, similar to that of the dysautonomic group, but this was not followed by a clear vasovagal reaction. Compared with the classic, the dysautonomic patients were older, had a higher prevalence of co-morbidities, a very much shorter history of syncopal episodes, and a prevalence of mixed and vasodepressor forms of the VASIS classification. The patients with orthostatic intolerance had clinical characteristics similar to the dysautonmic group but they could not be classified according to the VASIS classification. In conclusion, in patients with syncope, a variety of abnormal responses is observed during tilt testing, suggesting that different syndromes can be diagnosed by the test. A more detailed, although still arbitrary, classification may form the basis of a number of future drug and pacemaker trials, as well as help towards a greater understanding of the different mechanisms of tilt-induced syncope.


Subject(s)
Hemodynamics , Nitroglycerin , Syncope, Vasovagal/classification , Tilt-Table Test/methods , Vasodilator Agents/administration & dosage , Autonomic Nervous System/physiopathology , Echocardiography , Electrocardiography, Ambulatory , Humans , Prospective Studies , Severity of Illness Index , Syncope, Vasovagal/diagnosis , Syncope, Vasovagal/physiopathology
13.
Europace ; 1(1): 35-9, 1999 Jan.
Article in English | MEDLINE | ID: mdl-11220537

ABSTRACT

We evaluated the rate of progression of permanent atrial fibrillation (AF) and identified clinical factors that predict this event in 63 consecutive patients who had undergone AV junctional ablation and DDDR pacemaker implantation for drug-refractory paroxysmal atrial fibrillation/ flutter. Immediately after ablation, anti-arrhythmic drugs were discontinued in all cases. Permanent AF was considered to have developed if AF was present on two consecutive 6-monthly examinations with no interim documented sinus rhythm. During a mean follow-up of 23 +/- 16 months, 22 (35%) of the 63 patients developed permanent AF. The actuarial estimate of progression of permanent AF was 22%, 40% and 56%, respectively, 1, 2 and 3 years after ablation. Age and underlying heart disease were independent predictors of progression of permanent AF. Only one (6%) of 16 patients with idiopathic AF had permanent AF (low risk group). Among the 47 patients with structural heart disease, permanent AF developed in 18 (62%) of the 29 who were aged >75 years or had >12 arrhythmic episodes per year and a symptom duration >4 years (high risk group), but only in three (17%) of the remaining 18 patients who did not (intermediate risk group). In conclusion, during a 3-year follow-up period, about half of the patients with a history of drug-refractory paroxysmal AF did not develop permanent AF after AV junctional ablation and dual-chamber pacemaker implantation, even in the absence of anti-arrhythmic drug therapy. Moreover, subgroups of patients whose risk of permanent AF progression differed were identified on the basis of simple baseline clinical variables. The results of this study form the necessary background for the correct management of patients after AV junction ablation and for the planning of future trials in this field.


Subject(s)
Atrial Fibrillation/physiopathology , Atrial Fibrillation/therapy , Actuarial Analysis , Aged , Atrioventricular Node/surgery , Catheter Ablation , Chronic Disease , Combined Modality Therapy , Disease Progression , Female , Humans , Male , Pacemaker, Artificial , Risk Factors
14.
Europace ; 1(3): 183-6, 1999 Jul.
Article in English | MEDLINE | ID: mdl-11225795

ABSTRACT

BACKGROUND: Since the pharmacological challenge with nitroglycerin (NTG) follows the initial drug-free phase in current tilt testing protocols, the effects of nitroglycerin alone and the appropriate duration of the basal phase are unknown. METHODS: To optimize the test, a randomized intra-patient comparison of two protocols was undertaken: a conventional nitroglycerin test (cHUT) consisting of passive upright posture at 60 degrees for 45 min followed, if negative, by sublingual NTG 0.4 mg spray, with the test continued for 20 min; and, accelerated nitroglycerin test (aHUT) consisting of passive upright posture at 60 degrees for 5 min--to rule out orthostatic hypotension--followed by sublingual NTG 0.4 mg spray, with the test continued for 20 min. Eighty-four consecutive patients (33 males; mean age 55+/-22) with unexplained syncope underwent both cHUT and aHUT in a randomized sequence with a 24-72 h interval between them. Additionally, 25 age-matched control subjects underwent aHUT. RESULTS: In the drug-free phase, cHUT was positive in 15/84 patients (18%) and aHUT in 1/84 patients (1%). After NTG, cHUT and aHUT showed the same positivity rate of 33% (28/84 patients). The overall positivity rate was therefore higher with cHUT than with aHUT (51% vs 35%, P=0.04). Times to syncope were 29+/-12 min, (range 2-44) for cHUT drug-free phase, 5+/-2 min (range 2-9) for cHUT NTG phase, and 5+/-2 min (range 2-9) for aHUT. Only one (4%) of the control subjects had a positive response to aHUT. CONCLUSIONS: The contribution of NTG to the diagnosis is independent of the presence of an unmedicated phase. The appropriate duration of the NTG phase is 10 min. aHUT has good specificity, but a positivity rate lower than cHUT; thus a drug-free phase is necessary to increase the sensitivity of the test.


Subject(s)
Nitroglycerin , Syncope, Vasovagal/diagnosis , Tilt-Table Test , Administration, Oral , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Nitroglycerin/administration & dosage
15.
Circulation ; 98(10): 953-60, 1998 Sep 08.
Article in English | MEDLINE | ID: mdl-9737514

ABSTRACT

BACKGROUND: Uncontrolled studies have suggested that atrioventricular junction ablation and pacemaker implantation have beneficial effects on quality of life in patients with chronic atrial fibrillation (AF). METHODS AND RESULTS: We performed a multicenter, controlled, randomized, 12-month evaluation of the clinical effects of atrioventricular junction ablation and VVIR pacemaker (Abl+Pm) versus pharmacological (drug) treatment in 66 patients with chronic (lasting >6 months) AF who had clinically manifest heart failure and heart rate >90 bpm on 3 standard ECGs recorded at rest during stable clinical conditions on different days. Before completion of the study, withdrawals occurred in 8 patients of the drug group and in 4 patients of the Abl+Pm group. At the end of the 12 months, the 28 Abl+Pm patients who completed the study showed lower scores in palpitations (-78%; P=0.000) and effort dyspnea (-22%; P=0.05) than the 26 of the drug group. Lower scores, although not significant, were also observed for exercise intolerance (-20%), easy fatigue (-17%), chest discomfort (-50%), Living with Heart Failure Questionnaire (-14%), New York Heart Association functional classification (-4%), and Activity scale (-12%). The intrapatient comparison between enrollment and month 12 showed that in the Abl+Pm group, all variables except easy fatigue improved significantly from 14% to 82%. However, because an improvement was also observed in the drug group, the difference between the 2 groups was significant only for palpitations (P=0.000), effort dyspnea (P=0.01), exercise intolerance (P=0.005), easy fatigue (P=0.02), and chest discomfort (P=0.02). Cardiac performance, evaluated by means of standard echocardiogram and exercise test, did not differ significantly between the 2 groups and remained stable over time. CONCLUSIONS: In patients with heart failure and chronic AF, Abl+Pm treatment is effective and superior to drug therapy in controlling symptoms, although its efficacy appears to be less than that observed in uncontrolled studies because some improvement can also be expected in medically treated patients. Cardiac performance is not modified by the treatment.


Subject(s)
Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/therapy , Atrioventricular Node/surgery , Catheter Ablation , Heart Failure/therapy , Pacemaker, Artificial , Aged , Anti-Arrhythmia Agents/classification , Atrial Fibrillation/complications , Atrial Fibrillation/drug therapy , Atrial Fibrillation/surgery , Chest Pain , Dyspnea/prevention & control , Electrocardiography, Ambulatory , Exercise Tolerance , Female , Heart Failure/complications , Heart Failure/drug therapy , Heart Failure/surgery , Heart Rate , Humans , Male , Patient Selection , Quality of Life
16.
Am Heart J ; 136(2): 264-8, 1998 Aug.
Article in English | MEDLINE | ID: mdl-9704688

ABSTRACT

BACKGROUND: In patients affected by carotid sinus hypersensitivity, long-term vasodilator therapy might increase the risk of syncopal episodes by reducing systolic blood pressure and venous return to the heart. METHODS AND RESULTS: Thirty-two patients (mean age 73 +/- 9 years; 20 men) who met all the following criteria were included: (1) one or more episodes of syncope occurring during long-term (>6 months) treatment with angiotensin-converting enzyme inhibitors, long-acting nitrates, calcium antagonists, or a combination of these; (2) a positive response to carotid sinus massage, defined as the reproduction of spontaneous syncope in the presence of ventricular asystole > or =3 seconds or a fall in systolic blood pressure > or =50 mm Hg; (3) negative workup for other causes of syncope. The patients were randomly assigned to continue or to discontinue use of vasodilators; carotid sinus massage was repeated 2 weeks after randomization. By the end of the study period, the baseline values of systolic blood pressure were significantly different between the 2 groups of patients both in supine (P=.01) and upright (P=.03) positions. Syncope had been induced by carotid sinus massage in 81% of patients in the "on-vasodilator" group and in 62% of patients in the "off-vasodilator" group (P=.21). The cardioinhibitory reflex was of similar magnitude in the 2 groups, being found in 50% of the patients in each group, with a maximum ventricular pause of 7.1 +/- 2.7 and 6.7 +/- 1.8 seconds, respectively. The percentage decrease of blood pressure did not differ between the 2 groups, even if, in absolute values, the baseline difference of blood pressure roughly persisted for the duration of the test. In consequence of that, the rise of blood pressure to similar values was delayed approximately 30 seconds in the "on-vasodilator" group and took more than 2 minutes to return to baseline values. CONCLUSIONS: In patients affected by carotid sinus hypersensitivity, chronic vasodilator therapy does not have a direct effect on carotid sinus reflexivity, although the delayed recovery of pretest blood pressure values could indirectly potentiate the severity of the clinical manifestations of the syndrome. The persistence of hypotension for a longer time after the end of the massage suggests that vasodilators cause an impairment of compensatory mechanisms.


Subject(s)
Carotid Sinus/innervation , Pressoreceptors/drug effects , Syncope/chemically induced , Vasodilator Agents/adverse effects , Aged , Aged, 80 and over , Blood Pressure/drug effects , Female , Heart Arrest/chemically induced , Homeostasis/drug effects , Humans , Long-Term Care , Male , Massage , Middle Aged , Reflex, Abnormal/drug effects , Risk Factors , Syndrome , Vasodilator Agents/administration & dosage , Venous Pressure/drug effects
17.
Am J Cardiol ; 81(3): 351-4, 1998 Feb 01.
Article in English | MEDLINE | ID: mdl-9468083

ABSTRACT

Among 63 patients affected by symptomatic drug refractory paroxysmal atrial fibrillation who had undergone atrioventricular junction ablation and dual-chamber pacemaker implantation, the actuarial estimate of progression of permanent atrial fibrillation was 22%, 40%, and 56% respectively, 1, 2, and 3 years after ablation. A stratification of the risk of development of permanent atrial fibrillation was obtained on the basis of several clinical variables.


Subject(s)
Atrial Fibrillation/diagnosis , Atrial Fibrillation/surgery , Atrioventricular Node/surgery , Cardiac Pacing, Artificial , Tachycardia, Paroxysmal/therapy , Aged , Disease Progression , Female , Humans , Male , Middle Aged , Risk Assessment , Tachycardia, Paroxysmal/surgery , Time Factors
18.
Circulation ; 96(11): 3921-7, 1997 Dec 02.
Article in English | MEDLINE | ID: mdl-9403616

ABSTRACT

BACKGROUND: ATP and its related nucleoside, adenosine, are ubiquitous biological compounds with potent depressant activity on the atrioventricular node. We hypothesized that an increased susceptibility of the atrioventricular node to adenosine may, in some cases, play a role in the genesis of syncope. METHODS AND RESULTS: The study was performed in two parts. In part 1, we evaluated the effects of a bolus injection of 20 mg ATP in a group of 60 patients (57+/-19 years, 31 men) with syncope of unexplained origin and in 90 control subjects without syncope (55+/-17 years, 46 men). In control subjects, the upper 95th percentile of the maximum RR interval distribution, during ATP-induced atrioventricular block (AVB), was 6000 ms. In the syncope group, 28% of patients had a maximum RR interval above this limit (P=.000). The distribution of the maximum RR interval below the 95th percentile was similar in the two groups. In part 2, we validated the ATP test in 24 patients who had the fortuitous ECG recording of a spontaneous syncope caused by a transient asystolic pause (AVB in 15 and sinus arrest in 9). The ATP test caused AVB with an asystolic pause of > or = 6000 ms in 53% of the patients with documented AVB but in none (0%) of the patients with documented sinus arrest (P=.01). Among the patients with spontaneous AVB, the ATP test was abnormal in 6 of the 7 patients (86%) in whom all conventional investigations for syncope had been negative and in 2 of the 8 patients (25%) who had shown positivity (P=.03). CONCLUSIONS: An increased susceptibility to ATP testing is present in patients with SUO and patients with syncope due to paroxysmal AVB. Thus, a logical inference is that ATP testing can be used to identify patients with syncope due to paroxysmal AVB. The results of this study form the necessary background for future prospective studies with an aim to validate this assumption.


Subject(s)
Adenosine Triphosphate , Adenosine/adverse effects , Cardiovascular Agents/adverse effects , Heart Block/diagnosis , Syncope/etiology , Adult , Aged , Atrioventricular Node/drug effects , Case-Control Studies , Diagnosis, Differential , Electrocardiography , Female , Heart Block/chemically induced , Heart Block/complications , Humans , Male , Middle Aged , Predictive Value of Tests
19.
Am J Cardiol ; 80(8): 1092-4, 1997 Oct 15.
Article in English | MEDLINE | ID: mdl-9352988

ABSTRACT

To evaluate the effect of chronic vasodilator therapy on susceptibility to vasovagal syncope, 45 patients with syncope and a positive response to tilt testing were randomly assigned to continue or to discontinue vasodilators. The study result demonstrated that chronic vasodilator therapy enhances susceptibility to vasovagal reaction during upright tilt testing.


Subject(s)
Syncope, Vasovagal/chemically induced , Vasodilation/physiology , Vasodilator Agents/adverse effects , Aged , Case-Control Studies , Female , Humans , Male , Middle Aged , Nitroglycerin/pharmacology , Tilt-Table Test
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