[Pre-interventional, peri-interventional and post-interventional anticoagulation in the setting of catheter ablation for atrial fibrillation : current practice and practical approach]. / Prä-, peri- und postinterventionelle Antikoagulation im Rahmen der Vorhofflimmerablation : Aktueller Stand und praktisches Vorgehen.

In addition to treatment with drugs to control the rate and rhythm, the method of catheter ablation is a cornerstone in the treatment of atrial fibrillation. Another crucial part in treating patients with atrial fibrillation is an adequate oral anticoagulation. Apart from the vitamin K antagonists (VKA) phenprocoumon and warfarin, the direct oral anticoagulants (DOAC) apixaban, dabigatran and rivaroxaban have been approved for oral anticoagulation of patients with atrial fibrillation. As a result there are different potential treatment possibilities for pre-interventional, peri-interventional and post-interventional anticoagulation in the setting of catheter ablation for atrial fibrillation. Due to increasing clinical experience with DOAC and the increasing number of atrial fibrillation ablations worldwide, peri-interventional treatment strategies are continuously changing. Therefore, the current article discusses current standards and gives practical guidance.

Radiofrequency catheter ablation using long coiled electrodes: impact of irrigation on lesion dimensions and incidence of coagulum formation.

Ablation catheters with multiple long coiled electrodes have been recently developed to induce continuous linear lesions for the treatment of atrial fibrillation. The efficacy and safety of ablation catheters with multiple long coiled electrodes has not been evaluated. The aim of the present in vivo study was to investigate the influence of saline irrigation on lesion dimensions and coagulum formation during RF current ablation using those ablation catheters. In 14 anesthetized sheep, the thigh muscle was prepared as a cradle and filled with heparinized blood (37 degrees C). The quadripolar coiled ablation catheter (electrode length 7 mm, electrode distance 2 mm) was placed parallel to the muscle with standardized 10-g contact pressure. RF current energy was delivered sequentially temperature-(70 degrees C) or power-controlled (10, 20, 30, or 40 W) with additional irrigation of the electrode (10 mL/min normal saline) for 90 seconds. Forty-two of 129 RF current lesions were induced by temperature-controlled and 87 by irrigated ablation. Except for three lesions following low energy irrigated application (10 W), all lesions were continuous. Significantly larger lesions following irrigated RF current applications were produced with a power output of 30 W (depth 0.74 +/- 0.13 cm, width 0.78 +/- 0.13 cm) and 40 W (depth 0.75 +/- 0.16 cm, width 0.92 +/- 0.28 cm) as compared to 20 W (depth 0.47 +/- 0.13 cm, width 0.82 +/- 0.22 cm). Coagulum formation adherent to the electrode was exclusively observed following 18 of 42 nonirrigated RF current ablations. In conclusion, irrigated coiled ablation electrodes induce continuous linear lesions with a power output of 20-40 W. The risk of coagulum formation at the coiled electrode can be avoided by irrigation.

Radiofrequency catheter ablation with the split-tip electrode in the temperature-controlled mode.

The 7 Fr "split-tip electrode" (2.5-mm tip electrode divided longitudinally into four electrodes with an adjacent 2-mm ring electrode) improves mapping resolution due to its small recording electrodes and narrow interelectrode distances (0.1 mm). The purpose of this study was to examine the temperature-controlled ablation properties of this electrode. In seven anesthetized dogs, the thigh muscles were exposed and superfused with canine blood. A split-tip catheter electrode (with a thermocouple in each of the five electrodes) and a conventional 4-mm catheter electrode were positioned at constant pressure perpendicular or parallel to the surface of the thigh muscle. Impedance measured between each split electrode and a skin patch correlated with the degree of contact with blood and tissue. In the parallel catheter to tissue orientation, split electrodes not in contact with tissue had a low impedance (mean 210-224 ohms), and the split electrode almost entirely in contact with tissue had the highest impedance (380 +/- 56 ohms). In the perpendicular catheter to tissue orientation all split electrodes had a similar impedance (mean 279-286 ohms). A total of 75 radiofrequency (RF) lesions were produced in the temperature-controlled mode with the 4-mm electrode (target 60 degrees C) or the split-tip electrode (power limited by the hottest electrode reaching 70 degrees C) with current delivered to all five electrodes simultaneously, or only to electrodes in contact with tissue. Lesion depth was not significantly different between electrodes in the parallel orientation (5.2 +/- 0.9 vs 5.1 +/- 1.4 vs 5.3 +/- 1.1 mm), but significantly deeper with the conventional 4-mm tip electrode in the perpendicular orientation (6.7 +/- 1.2 vs 5.3 +/- 1.3 vs 5.6 +/- 0.9 mm, P < 0.05). This was due to higher power delivered to the conventional 4-mm electrode (27 +/- 9 vs 17 +/- 7 vs 15 +/- 7 W, P < 0.05) because convective cooling by the blood flow was less effective for the split-tip electrode due to a reduced heat conduction across the interelectrode space from the hottest electrode to cooler areas of the group of five electrodes (mean temperature difference between the hottest split electrodes and the ring electrode: 24 degrees C). Electrode cooling or heat conduction was not effected by the elimination of current delivery to non-contact electrodes. Steam pops occurred in 36% of applications with the conventional 4-mm electrode in the perpendicular orientation but never with the split-tip electrode in spite of the higher target temperature. Measurement of impedance from the split electrodes allow the determination of electrode tissue contact and RF lesions produced with the split-tip electrode in the temperature-controlled mode using a target of 70 degrees C were of reasonable size and not associated with steam pops.

Modification of the substrate for maintenance of idiopathic human atrial fibrillation: efficacy of radiofrequency ablation using nonfluoroscopic catheter guidance.

BACKGROUND: Catheter ablative techniques to modify the substrate to maintain atrial fibrillation (AF) require the creation of continuous radiofrequency current-induced ablation lines. This study was designed to assess the efficacy and safety of nonfluoroscopic mapping in this setting. METHODS AND RESULTS: A total of 45 consecutive patients with idiopathic AF were studied. The first 13 underwent ablation confined to the left atrium by creating a circular line isolating the pulmonary vein ostia and a second line connecting the former with the mitral annulus. Subsequently, 12 of these patients underwent a procedure confined to the right atrium (RA), where attempts were made to create an isthmus line between the inferior vena cava and the tricuspid annulus, an anterior line connecting the tricuspid annulus with the superior vena cava, and an intercaval line between the ostia of the inferior and superior venae cavae. In the last 32 patients, only the RA approach was performed. Technical difficulties prevented the creation of the intended left atrial line pattern: all patients experienced recurrences. A 100% recurrence rate was also observed after subsequent RA ablation, despite creation of a complete line pattern in 4 of 12 patients. Of the final 32 patients, AF recurred in 94%; a complete ablation line pattern had been achieved in 18 patients (56%), 16 of whom had recurrences. CONCLUSIONS: The electroanatomically-guided creation of extended radiofrequency current lesions is technically feasible only in the RA. However, procedural success in the RA does not suppress recurrences of AF in the majority of patients.

Electrical conduction between the right atrium and the left atrium via the musculature of the coronary sinus.

BACKGROUND: The purpose of this study was to determine whether the coronary sinus (CS) musculature has electrical connections to the right atrium (RA) and left atrium (LA) and forms an RA-LA connection. METHODS AND RESULTS: Six excised dog hearts were perfused in a Langendorff preparation. A 20-electrode catheter (2-4-2-mm spacing center to center) was placed along the CS. Excision of the pulmonary veins provided access to the LA, and a second 20-electrode catheter was placed along the LA endocardium opposite the CS catheter. An incision opened the CS longitudinally, and microelectrodes were inserted into the CS musculature and adjacent LA myocardium. Continuous CS musculature was visible along a 35+/-9-mm length of the CS beginning at the ostium. During lateral LA pacing, CS electrodes recorded double potentials, a rounded, low-frequency potential followed by a sharp potential. The rounded initial potential propagated in the lateral-to-septal direction and represented "far-field" LA activation (timing coincided with adjacent LA potentials and with action potentials recorded from microelectrodes in adjacent LA cells). The sharp potential represented CS activation (timing coincided with action potentials recorded from CS musculature). A distal LA-CS connection (earliest sharp potential in the CS during lateral LA pacing) was located 26+/-7 mm from the ostium. During RA pacing posterior to the CS ostium, CS electrodes recorded septal-to-lateral activation of the high-frequency potential, with slightly later activation of the rounded potential (LA activation). Incisions surrounding the CS ostium isolating the ostium from the RA had no effect on the CS musculature and LA potentials during RA pacing within the isolated segment containing the CS ostium. RA pacing outside the isolated segment delayed activation of the CS musculature until after LA activation, confirming that the RA-CS connection was located in the region of the CS ostium as well as confirming the presence of the LA-CS connection. CONCLUSIONS: In canine hearts, the CS musculature is electrically connected to the RA and the LA and forms an RA-LA connection.

Nonfluoroscopic endocardial catheter mapping of atrial fibrillation.

The treatment of drug-refractory atrial fibrillation (AF) remains one of the unsolved problems in cardiology. Surgical interventions have demonstrated that AF can be prevented by multiple incisions within both atria. Recently, this strategy has been translated into a catheter procedure. So far, the ablation approach is not based on individual electrophysiologic data, but constitutes only an anatomic approach. Further insight into the spatial and temporal distribution of the local electrograms during AF is needed. Electroanatomic maps acquired by sequential mapping over 45 seconds at each site during AF in six patients with paroxysmal AF were analyzed off-line. Electrograms were sampled at a mean of 36 +/- 12 sites in the left atrium of each patient. A total of 217 sites were sampled, of which 27.3% (59) represented type A (regular) AF, 9.7% (21) represented type B (totally irregular), and 63.1% (137) represented type C (mixture of type A and B) electrograms. The distribution was analyzed in 20 different segments of the left atrium, and a significantly higher incidence of type A electrograms was found in area 3 (upper lateral pulmonary vein) than at all other sites (P < 0.005). This observation needs further confirmation before any conclusion with regard to catheter ablation can be drawn, particularly because the analysis was based on bipolar recordings from a 4-mm tip electrode.

[High frequency current ablation of supraventricular tachyarrhythmias in congenital heart defects]. / Hochfrequenzstromablation supraventrikulärer Tachyarrhythmien bei angeborenen Herzfehlern.

Supraventricular tachycardia is a frequent cause of disease in patients with congenital heart defects and has a potentially high impact on quality of life, morbidity and mortality of this patient cohort. Conventional treatment often fails to avoid recurrences of tachycardia in a long-term perspective. Potential side effects of antiarrhythmic drugs include aggravation of heart disease related disturbances of impulse generation and conduction properties or negative inotropic effects on haemodynamically impaired ventricular chambers. For these reasons, interventional electrophysiology is increasingly used for the treatment of supraventricular tachycardias in patients with congenital heart disease. Until March 1998 a total of 83 patients with congenital heart defects underwent an attempt for radiofrequency current treatment of supraventricular tachycardias. Among these were 36 children with an age of 5 months to 15 years (8.2 +/- 4.6 years) and 4.7 grown ups with an age of 17 to 76 years (39.3 +/- 14.3 years). In a natural course or preoperative status of the congenital heart disease were 35 patients, while palliative or corrective surgery was performed in 48 patients. Supraventricular tachycardia was based on a total of 63 congenital arrhythmogenic substrates, among them were 53 accessory pathways, 4 Mahaim fibres, 5 functionally dissociated AV-nodes and an anatomically doubled specific conduction system including 2 distinct AV-nodes in one case. In the remaining patients with tachycardia based on acquired arrhythmogenic substrates there were 45 incisional atrial reentrant tachycardias, 15 atrial flutters of the common type and 6 ectopic atrial tachycardias. In a total of 105 sessions 78 of the 83 patients were successfully treated with the use of radiofrequency current ablation. There were no significant procedure related complications. Radiofrequency current ablation can be carried out safely and successfully for the treatment of supraventricular tachycardia in young and adult patients with congenital heart disease. As such therapeutic strategy meets the specific requirements of this patient cohort, early consideration for this therapy is recommended.

Evidence for multiple atrio-AV nodal inputs in the normal dog heart.

INTRODUCTION: Complete AV block after combined fast pathway (FP) and slow pathway (SP) ablation is uncommon. The purpose of this study was to interrupt activation of these and additional inputs by placing a radiofrequency lesion across the interatrial septum between the FP and SP ablation sites. METHODS AND RESULTS: In eight anesthetized open chest dogs, FP ablation induced significant A-H prolongation (deltaA-H: 51 +/- 14 msec; P < 0.001) and a shift of earliest retrograde atrial activation from the anterior septum to the region of the coronary sinus (CS) os. Subsequently, ablation of the interatrial septum across the fossa ovalis was successful in 5 of 8 dogs, changing the sequence of atrial activation (A) so that A at the His-bundle electrogram, which initially preceded A at the CS os (18 +/- 4 msec vs 46 +/- 7 msec, P < 0.01), now followed CS os A (81 +/- 31 msec vs 59 +/- 20 msec, P < 0.05). Additional ablation of the SP caused a type II Mobitz AV block or complete AV block in 5 of 8 dogs. The four dogs with complete AV block showed a stable, high junctional escape rhythm at a rate of 64 +/- 16 beats/min. Pacing between the ablation lesions and the AV node in one dog showed 1:1 AV conduction and Wenckebach-type AV block indicating preserved AV nodal function. Histology showed necrotic changes in the FP and SP transitional cell zones and in the atrial tissue of the interatrial septum. However, the compact AV node, His bundle, and adjacent atria and transitional cells were undamaged. CONCLUSION: There are additional AV nodal inputs in the interatrial septum in addition to the anterior FP and posterior SP inputs. Ablation of all of these may be required, if the aim is production of complete AV block proximal to the AV node with a high junctional escape rhythm.

Why a large tip electrode makes a deeper radiofrequency lesion: effects of increase in electrode cooling and electrode-tissue interface area.

INTRODUCTION: Increasing electrode size allows an increase in radiofrequency lesion depth. The purpose of this study was to examine the roles of added electrode cooling and electrode-tissue interface area in producing deeper lesions. METHODS AND RESULTS: In 10 dogs, the thigh muscle was exposed and superfused with heparinized blood. An 8-French catheter with 4- or 8-mm tip electrode was positioned against the muscle with a blood flow of 350 mL/min directed around the electrode. Radiofrequency current was delivered using four methods: (1) electrode perpendicular to the muscle, using variable voltage to maintain the electrode-tissue interface temperature at 60 degrees C; (2) same except the surrounding blood was stationary; (3) perpendicular electrode position, maintaining tissue temperature (3.5-mm depth) at 90 degrees C; and (4) electrode parallel to the muscle, maintaining tissue temperature at 90 degrees C. Electrode-tissue interface temperature, tissue temperature (3.5- and 7.0-mm depths), and lesion size were compared between the 4- and 8-mm electrodes in each method. In Methods 1 and 2, the tissue temperatures and lesion depth were greater with the 8-mm electrode. These differences were smaller without blood flow, suggesting the improved convective cooling of the larger electrode resulted in greater power delivered to the tissue at the same electrode-tissue interface temperature. In Method 3 (same tissue current density), the electrode-tissue interface temperature was significantly lower with the 8-mm electrode. With parallel orientation and same tissue temperature at 3.5-mm depth (Method 4), the tissue temperature at 7.0-mm depth and lesion depth were greater with the 8-mm electrode, suggesting increased conductive heating due to larger volume of resistive heating because of the larger electrode-tissue interface area. CONCLUSION: With a larger electrode, both increased cooling and increased electrode-tissue interface area increase volume of resistive heating and lesion depth.

Critical atrial site for ablation of pacing-induced atrial fibrillation in the normal dog heart.

INTRODUCTION: Radiofrequency catheter ablation (RFA) has been used recently to treat atrial fibrillation (AF). The purpose of this study was to investigate a new approach to preventing AF by RFA. METHODS AND RESULTS: In open chest, anesthetized dogs, AF (lasting > 30 sec) was induced after burst stimulation, and electrophysiologic parameters were recorded before and after RFA. In group 1 (9 dogs) we performed selective and combined slow and fast pathway RFA, whereas in group 2 (11 dogs) RFA was applied as a linear lesion at the mid-atrial septum between the inferior vena cava and the fossa ovalis. After ablation, the Wenckebach cycle length was significantly prolonged only in group 1 (194 +/- 23 vs 282 +/- 35 msec, P = 0.002), whereas the interval between the stimulus (S) artifact applied at the high right atrium to the His bundle (H) (SH interval) prolonged to the same extent in both groups (162 +/- 14 vs 146 +/- 45 msec, P = NS); group 1 due to an A-H prolongation whereas in group 2 it was due to an intra-atrial conduction delay. In group 1 AF still remained inducible, although with a longer mean R-R interval (215 +/- 16 vs 433 +/- 88 msec, P < 0.05). No instance of complete AV block developed. In group 2, sustained AF was noninducible in 10 dogs and its duration was markedly shorter in the remaining one (8 sec). Gross anatomy and histology did not reveal any damage inside of Koch's triangle, and particularly to the compact AV node. CONCLUSION: These findings suggest that RFA at the mid-atrial septum prevents AF in the normal dog heart. This approach might also be successful in those clinical settings in which the atrial septum plays a critical role in the maintenance of sustained AF.

Electrophysiology of the atrio-AV nodal inputs and exits in the normal dog heart: radiofrequency ablation using an epicardial approach.

INTRODUCTION: We studied the effects of selective and combined ablation of the fast (FP) and slow pathway (SP) on AV and VA conduction in the normal dog heart using a novel epicardial ablation technique. METHODS AND RESULTS: For FP ablation, radiofrequency current (RFC) was applied to a catheter tip that was held epicardially against the base of the right atrial wall. SP ablation was performed epicardially at the crux the heart. Twenty-three dogs were assigned to two ablation protocols: FP/SP ablation group (n = 17) and SP/FP ablation group (n = 6). In 12 of 17 dogs, FP ablation prolonged the PR interval (97 +/- 10 to 149 +/- 22 msec, P < 0.005) with no significant change in anterograde Wenckebach cycle length (WBCL). Subsequent SP ablation performed in 8 dogs further prolonged the PR interval and the anterograde WBCL (117 +/- 22 to 193 +/- 27, P < 0.005). Complete AV block was seen in 1 of 8 dogs, whereas complete or high-grade VA block was seen in 6 of 8 dogs. In the SP/FP ablation group, SP ablation significantly increased WBCL with no PR changes. Combined SP/FP ablation in 6 dogs prolonged the PR interval significantly, but no instance of complete AV block was seen. VA block was found in 50% of these cases. Histologic studies revealed that RFC ablation affected the anterior and posterior atrium adjacent to the undamaged AV node and His bundle. CONCLUSION: Using an epicardial approach, combined ablation of the FP and SP AV nodal inputs can be achieved with an unexpectedly low incidence of complete AV block, although retrograde VA conduction was significantly compromised.

Electrophysiology of the right anterior approach to the atrioventricular node: studies in vivo and in the isolated perfused dog heart.

INTRODUCTION: Previous reports have described electrophysiologic properties and rate-dependent responses in the transitional cell zone of the posterior AV nodal input (slow pathway). The purpose of this study was to investigate the electrophysiology of the anterior transitional cell zone (fast pathway) in vivo and in a Langendorff preparation perfused with a nonblood solution containing butanedionemonoxime to inhibit contraction. METHODS AND RESULTS: In five anesthetized dogs, the His-bundle electrogram recorded from the aortic root included atrial activity in close proximity to the anterior limbus of the fossa ovalis. During decremental atrial pacing, the atrial potential exhibited amplitude alternans at a pacing cycle length (CL) of 135 +/- 14 msec. In ten isolated perfused canine hearts, a bipolar electrode catheter was positioned with its tip against the right anterior interatrial septum just superior to the tendon of Todaro. The AV Wenckebach CL (WCL) averaged 262 +/- 21 msec. During further decreases in pacing CL, the bipolar atrial potential developed a 2:1 amplitude alternans (9/10 dogs) at CL = 168 +/- 15 msec and then split into two components with subsequent 2:1 block between these components (10/10 dogs) at CL = 152 +/- 19 msec. Radiofrequency ablation at this site in six dogs prolonged the stimulus to HB interval from 113 +/- 19 to 151 +/- 30 msec (P < 0.01) without changing the WCL, consistent with ablation of the fast AV nodal pathway. In six other isolated perfused canine hearts, an octapolar catheter (2-mm spacing) was positioned along the anterior limbus of the fossa ovalis with the tip electrode located over the anterior portion (apex) of the triangle of Koch. The aforementioned 2:1 amplitude alternans occurred at a longer CL in the distal electrodes located at the tendon of Todaro than in the proximal electrodes at farther distances from the tendon of Todaro (185 +/- 25 vs 171 +/- 20 msec, P < 0.05), as did the 2:1 block between the two components (161 +/- 18 vs 150 +/- 18 msec, P < 0.05). Microelectrode recordings obtained adjacent to the catheter demonstrated 2:1 alternans and block patterns in the action potentials of transitional cells but not in atrial cells, which exhibited 1:1 conduction at all CL. CONCLUSIONS: The transitional cell zone in the anterior interatrial septum exhibits a specific rate-dependent, spatial gradient of conduction block, which can be recorded in bipolar electrograms as well as microelectrode recordings. Electrophysiologic changes induced by radiofrequency ablation of this anterior atrial/transitional cell zone (corroborated by histology) provide strong presumptive evidence that this area constitutes all or a major part of the fast AV nodal pathway.

Clinical recurrences after successful accessory pathway ablation: the role of "dormant" accessory pathways.

INTRODUCTION: Recurrence of clinical symptoms after radiofrequency catheter ablation of an accessory atrioventricular pathway (AP) may be due to the late manifestation of an additional AP that was not detected during the initial ablation session. It was the purpose of this study to elucidate the phenomenon of these "dormant" APs. METHODS AND RESULTS: Of 1280 consecutive patients who underwent radiofrequency catheter ablation of an AP, 54 patients (4.2%) developed clinical symptoms postablation, necessitating a repeat ablation session. Recurrence of conduction over the AP targeted at the initial ablation session was found in 45 patients, whereas in the other 9 patients (0.7%) the manifestation of a previously unnoticed AP had caused symptom recurrence. Retrospective analysis of the data from these patients' ablation sessions revealed that the late manifesting AP was ablated at a site clearly different from that of the initially targeted AP, and that the manifestation of conduction over a previously "dormant" AP occurred significantly later than the recovery of a presumably ablated AP. Seven (78%) of the 9 "dormant" APs were concealed, and none exhibited decremental conduction properties. CONCLUSION: The incidence of clinical recurrences mediated by the late manifestation of conduction over a previously "dormant" AP is low. The lack of an anatomic vicinity of these predominantly concealed APs with the initially targeted AP and the lack of evidence for their presence during the initial ablation session suggest intermittent conduction as the most likely explanation for their late manifestation.

Radiofrequency current catheter ablation of accessory atrioventricular pathways in Ebstein's anomaly.

BACKGROUND: In patients with Ebstein's anomaly, localization of accessory pathways (APs) may be impeded by abnormal local electrograms recorded along the atrialized right ventricle and by the presence of multiple APs. The impact of these factors on radiofrequency (RF) current catheter ablation of APs has not been evaluated yet. METHODS AND RESULTS: Twenty-one patients with Ebstein's anomaly and reentrant atrioventricular tachycardias underwent electrophysiological evaluation and subsequent attempts at RF catheter ablation. Thirty-four right-sided APs were found, with 30 located along the atrialized ventricle. Local electrograms in this region were normal in 10 patients but fragmented in 11. Fragmented electrograms prevented the clear distinction between atrial and ventricular activation potentials as well as the identification of AP potentials. Right coronary artery mapping was performed in 7 patients. Abolition of all 26 APs was achieved in the 10 patients with normal local electrograms and in 6 of 11 patients with abnormal electrograms. Right coronary artery mapping allowed AP localization and ablation in 5 patients. In the 5 patients with abnormal electrograms and a total of 8 APs, 6 APs could not be ablated. Unsuccessfully treated patients received antiarrhythmic drugs. During 22 +/- 12 months of follow-up, 5 patients had clinical recurrences, including 4 who had undergone a successful RF procedure. CONCLUSIONS: In patients with Ebstein's anomaly and reentrant atrioventricular tachycardias, factors likely to account for failure of RF catheter ablation include an AP located along the atrialized right ventricle and the abnormal morphology of endocardial activation potentials generated in this region.

Metoprolol versus sotalol in the treatment of sustained ventricular tachycardia.

The efficacy of sotalol in the treatment of sustained ventricular arrhythmias has been proved; however, whether its antiarrhythmic effect is due to a beta-blocking activity, a class III antiarrhythmic activity, or a combination of both is not known. We conducted a prospective randomized study to compare the effects of metoprolol, a "pure" beta-blocking agent, and of sotalol, a beta-blocking agent with additional class III antiarrhythmic properties, in 34 consecutive patients with documented sustained monomorphic ventricular tachycardia (VT) unrelated to transient causes. After undergoing baseline programmed electrical stimulation (PES-1) to assess arrhythmia inducibility, the patients were randomly assigned to a (double-blind) treatment of either metoprolol (16 patients) or sotalol (18 patients). Before the chronic regimen was initiated, arrhythmia inducibility was reassessed after the intravenous administration of either 0.15 mg/kg metoprolol or 1.5 mg/kg sotalol (PES-2), according to drug assignment. During the chronic oral regimen, a third PES (PES-3) was performed after a median follow-up of 72 days. Resting and exercise ECG, Holter monitoring and echocardiography were performed at baseline and during follow-up. During a 2-year follow-up, a non-fatal arrhythmia recurred in 1 patient of the metoprolol arm and in 5 patients of the sotalol arm; 1 patient in the latter group died suddenly 2 months after the recurrence, while receiving amiodarone therapy. Intention-to-treat analysis showed no difference in the incidence of arrhythmia recurrence, sudden death, or total mortality between the two groups. During PES-1, a sustained ventricular arrhythmia was inducible in 18 of 34 patients (53%), 8 in the metoprolol and 10 in the sotalol arm.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial inputs as determinants of atrioventricular nodal conduction: re-evaluation and new concepts.

Radiofrequency ablation was combined with standard recording and pacing procedures to determine the role of the perinodal fast pathway (FP) and slow pathway (SP) in atrioventricular (A-V) conduction in normal dog hearts. In 16 anesthetized, open-chest dogs, we recorded atrial (A) electrograms from the high right atrium (HRA), His bundle (Hb) region and coronary sinus (CS) ostium. In 8 dogs, during HRA pacing at a cycle length of 400 ms, FP ablation induced a significant change in A-H interval (61 +/- 12 to 107 +/- 9 ms, p < 0.001) but no change in Wenckebach cycle length (185 +/- 14 to 190 +/- 12 ms, NS). During ventricular pacing (400 ms cycle length) there was a shift in retrograde atrial activation so that Hb (A) delayed more than CS (A). Subsequent SP ablation in this same group of 8 dogs, produced a significant prolongation of antegrade Wenckebach cycle length (190 +/- 10 to 277 +/- 36 ms, p < 0.002) but only one instance of complete A-V block even though both FP and SP were ablated in accordance with clinical criteria. In another group of 8 dogs, a specially designed ablation electrode was inserted into the right atrium and positioned at the level of the fossa ovalis, 10-12 mm superior to the perinodal area. A radiofrequency linear lesion across the interatrial system induced a marked PR interval prolongation due to an intra-atrial rather than A-V nodal delay. The A-H interval was unchanged, and there was no change in antegrade or retrograde Wenckebach cycle length. In contrast, to the findings in both these groups direct damage to the A-V node showed immediate change in the A-H interval and at the same time progression to second degree and complete heart block. Taken together these results suggest that the perinodal FP and SP are composed of transitional cells which possess distinct electrophysiological properties not shared by adjacent atrial tissues or the compact A-V node itself. We conclude that the persistence of A-V conduction, albeit modified, after FP and SP ablation, suggests the existence of multiple atrio A-V nodal inputs whereas retrograde conduction relies mainly on dual exits from the A-V node to the atria.