[Biatrial pacing--new possibility in the non-pharmacologic treatment of drug-resistant paroxysmal atrial fibrillation]. / Biatrialis ingerlés--a gyógyszerrezisztens paroxizmális pitvarfibrilláció nonfarmakológiás kezelésének újabb lehetósége.

Biatrial pacing seems to be a possible non-pharmacological therapeutic choice in the prevention of drug-refractory, paroxysmal atrial fibrillation. Biatrial pacing using standard right atrial and coronary sinus left atrial pacing shows an antiarrhythmic effect, which mechanism is not well understood. Biatrial pacemaker was implanted in three patients suffering from drug refractory, symptomatic paroxysmal atrial fibrillation (lone and nonvalvular in 2 and in one case, respectively). Interatrial conduction disturbance (P > 120 ms) was found in three case. Bradycardia dependent arrhythmia development was not observed. Left atrial and right atrial premature beats dominated in 2 and in one case, respectively. P-wave duration was decreased by biatrial pacing in every patients. Atrial fibrillation has not been detected in two patients 1 day and 4 weeks after pacemaker implantation (follow up period: 9 and 5 months), however antiarrhythmic drugs has been withdrawn. In the number of left atrial premature beats a marked decrease was observed. Neither biatrial nor standard right atrial pacing nor combined medical and atrial pacing antiarrhythmic therapy were proven to be effective. In Hungary we were the first to implant and apply effectively biatrial pacemaker in the prevention of paroxysmal drug-refractory atrial fibrillation. However better identification the responding patients subgroup with atrial fibrillation is needed.

[Control of tachycardia with intravenous amiodarone in acute left heart failure]. / Intravénás amiodaronnal szerzett tapasztalatok akut bal szívfél elégtelenséghez társult tachyarrhythmiában.

The treatment of atrial tachycardia in critically ill patients can be difficult. Nine cases were presented with atrial tachyarrhythmias (mean heart rate > 130 beats/min) and left heart failure. Congestive heart failure was diagnosed in 6 patients (ejection fraction < 25%) and hypertensive heart failure in 3 patients (ejection infarction > 55%). The infusion of amiodarone (450 mg over 10 min and 0.5 mg/min after the bolus administration) was associated with a decrease in heart rate 31 beats/min and an increase in systolic blood pressure of 13 mm Hg after one hour. There was only one adverse effect secondary to amiodarone therapy. In this case the sinus rhythm converted within 24 hours but T-waves alternans and short running torsade de pointes ventricular tachycardia was observed and amiodarone therapy was discontinued.

Early proarrhythmia during intravenous amiodarone treatment.

We present a case of early (within the first 24 hours) development of malignant torsades de pointes (TdP) associated with intravenous amiodarone therapy. After correction of predisposing factors (heart failure, hypokalemia, digoxin) amiodarone again resulted in torsades. This observation suggests that in patients who have experienced amiodarone-induced proarrhythmia, amiodarone administration under different, more stable clinical conditions may still be hazardous.

Gauze swabs left intrapericardially following cardiac surgery.

The occurrence of surgical gauze swabs left in the body following operations is not as rare as one would suspect, however the actual incidence is difficult to estimate. This accident seems to be occurring most frequently in general and gastro-intestinal surgery followed by operations in gynaecology and obstetrics and orthopaedics. There have been only a few papers in the literature dealing with the topic of foreign bodies left in place after cardiac surgical procedures. In this paper two cases of gauze swabs left intrapericardially following cardiac surgery are presented. The issue goes far beyond professional significance alone, but raises important and critical questions of medical ethics let alone legal implications.

[Ventricular tachycardia masquerading as supraventricular tachycardia]. / Supraventricularis tachycardiát utánzó kamrai tachycardia.

To distinguish supraventricular tachycardia with aberrancy from ventricular tachycardia is sometimes difficult. It seems to be easy to distinguish the two forms in patients with preexisting bundle branch block: if the QRS morphology during tachycardia is identical to those during at rest the tachycardia is supraventricular, if different, ventricular. We present two cases with preexisting bundle branch block and wide complex tachycardia whose QRS morphologies were almost same to those during normal rest rhythm. The atrioventricular dissociation and the response to adenosine and lidocaine strongly suggests ventricular tachycardia. In these cases ventricular tachycardia masqueraded as supraventricular tachycardia and the identical QRS morphology with the preexisting bundle branch block may suggest a misdiagnosis of supraventricular tachycardia.

Urgent coronary artery revascularization with different arteries.

Authors present the case report of a young man with advanced coronary artery disease of the left main trunk, and the large tributaries of the left coronary system, leading to sudden onset of many ventricular fibrillation, associated with unconsciousness requiring several reanimation. The condition was treated with coronary artery surgery with the use of three different arterial conduits (right radial artery, right gastroepiploic artery as free grafts and the left internal mammary artery in situ) with an additional saphenous vein bypass graft. Details of surgical activity as well as the documents of the early postoperative course and of the 1 month follow-up are described.

[Transient Q-waves in coronary disease]. / Tranziens Q-hullámok coronariabetegségben.

The authors discuss the transient ischemic Q waves in various situations. Five cases are presented. Two patients had exercise-induced Q waves, one patient had right bundle branche block-dependent Q waves, one patient had transient Q waves after thrombolytic therapy and one patient had transient Q waves caused by Prinzmetal angina. Profound ischemia may not result in necrosis but may cause myocardial stunning. Myocardial stunning may be accompanied by deranged electrophysiologic activity with transient loss of electromotive forces.

[Headache as a symptom of angina]. / A fejfájás mint anginatünet.

The authors report two cases where headaches was the only manifestation of severe myocardial ischemia. They had high degree coronaria sclerosis which was demonstrated by angiocardiography in one patient and at autopsy in the second patient. These findings suggest that in the mechanism of headache angina rather the pain perception than generalized vasospasm plays an important role.

[The use of adenosine in the diagnosis and treatment of cardiac arrhythmias]. / Adenozin alkalmazása a szívritmuszavarok diagnosztikájában és kezelésében.

The authors investigated the effect of adenosine or ATP on narrow QRS tachycardia in 56 pts, 3 pts with wide QRS tachycardia 9 pts with suspected latent preexcitation and 10 pts with PVC suspected to be ventricular parasystole. After the bolus iv. administration of adenosine or ATP every SVT was stopped related to AV node (44 pts), but in the rest twelve related to atrial origin of SVT only one automatic atrial tachycardia could be stopped. From the 9 patient suspected to have concealed WPW 2 pts had delta wave during the effect of adenosine, and in four pts parasystole was demonstrated among the pts had varying coupling interval PVC. None of the pts who had wide QRS tachycardia was the tachycardia stopped, but in two cases the supraventricular origin--atrial flutter and tachycardia--was discovered. The authors emphasize the favourable effect of adenosine in narrow complex tachycardia and suggest that it can given safely in wide QRS tachycardia of unknown origin either. The diagnostic effect of adenosine can be used in sinus rhythm too if latent preexcitation or ventricular parasystole is suspected.

[Adenosine-sensitive atrial tachycardia]. / Adenozin szenzitív pitvari tachycardia.

The authors describe a case of a 71 year old man who suffered from chronic lung disease and had atrial tachycardias. 18 mg adenosine terminated his paroxysmal supraventricular tachycardia. The Holter monitoring showed that the tachycardia began at the late diastole with normal PQ interval, suggesting that an ectopic atrial tachycardia was terminated. They propose that adenosine is a "new" drug for termination of some form of atrial tachycardia.

[Emergency coronary revascularization using various arteries]. / Sürgösségi coronaria revascularisatio különbözö arteriákkal.

Authors present the case report of a young man with advanced coronary artery disease of the left main trunk and the big branches of the left coronary system leading to sudden onset of many ventricular fibrillations associated with unconsciousness requiring several reanimations. The condition was treated with coronary artery surgery with the usage of three different arterial conduits (right radial artery, right gastroepiploic artery as free grafts and the left internal mammary artery in situ) with an additional saphenous vein bypass graft. Details of surgical procedures as well as the documents of the early postoperative course and of the 1 month follow up are given.

[Intermittent Romano-Ward syndrome]. / Intermittáló Romano-Ward-syndroma.

Two cases are described to have intermittent long QT syndrome. This type of long QT syndrome is not easy to recognize and the result could be fatal in case taking I/A type antiarrhythmic drugs. The first patient who was investigated had got "chinidin syncope" two years earlier, the second one had symptoms of syncope and dizziness for 3 months. The long QT syndrome was diagnosed in both cases by Holter monitoring. For these reason this paper underline the value of Holter monitoring as a diagnostic tool to establish the diagnosis of long QT syndrome. The monophasic action potential showed early after depolarisations in both cases.

[Clinical importance of monophasic action potential registration in long QT syndrome]. / Monofázisos akciós potenciál regisztrálás klinikai jelentösége hosszú QT-szindrómában.

For more than 30 years, the monophasic action potential has been used as an experimental tool for the study of myocardial repolarisation. With recent improvements in catheter design, the utility of the tool as a means to identify the bases for ventricular arrhythmias in humans has been greatly improved. Abnormalities of repolarisation leading to ventricular arrhythmia formation can be identified and specific pharmacological therapies may be evaluated. The pathomechanism of major arrhythmias (ventricular tachycardia, ventricular fibrillation) occurring in long QT syndrome (LQTS) is not yet fully elucidated. The authors have recorded the monophasic action potentials (MAP) of the right ventricle in three patients with LQTS and with previous episodes of major ventricular arrhythmias. The changes in MAP duration and after depolarisation in response to spontaneous arrhythmias, programmed electrostimulation, atrial pacing and isoproterenol treatment were studied. In all of the three patients the early afterdepolarisation was present, which in two cases exhibited pause-dependent features. Thus in these patients dual chamber pacemaker implantatious were performed. These were the first permanent recordings of MAP during electrophysiological examination in Hungary and also the first evidences that the early afterdepolarisation does play a pathogenic role in the development of idiopathic LQTS. Further evaluation of the technique by cardiac electro-physiologists may improve both the diagnosis and the treatment of ventricular arrhythmias dependent upon afterdepolarisation formation.