[Surgery of refractory ischemic arrhythmia]

Since June 1980, 138 patients have undergone surgical treatment for refractory ventricular tachycardia due to ischemic heart disease. Electrically guided surgical ablation (EGSA) of the focus was performed in 117 patients, while 14 patients underwent application of automatic implantable cardioverter-defibrillator (AICD), and 8 patients underwent heart transplantation. During the whole period considered, among the EGSA patients an operative mortality of 13 patients was observed (11.4%), with a late mortality of another 14 patients (13.4%). Two early and six late recurrences were described, and 4 cases of sudden or unexplained death, with 2 cases clearly due to an arrhythmic event. Multivariate analysis showed preoperative ejection fraction lower than 25% as a powerful predictor of early mortality (32% vs 0%). Actuarial survival rate of patients with LVEF lower than 25% was 67 +/- 12% vs 95 +/- 2% at one year and 37 +/- 25% vs 94 +/- 8% at 8 years. A high operative mortality was then observed in patients who underwent aneurysmectomy alone or visually guided procedures as compared to electrically guided procedures (75% or 3 deaths out of 4 patients vs 8.5% or 10 out of 113 patients, respectively). Patients who received an AICD with or without associated procedures showed 1 case of in-hospital mortality and no late mortality; in 6 patients at least one shock was delivered; in two patients the AICD was implanted during an EGSA procedure, due to multiple or difficult origins of the arrhythmias. Of patients who underwent heart transplantation one case of later mortality was observed due to malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Transient cardiac pacing is insufficiently used to treat arrhythmia associated with thioridazine

All cases of arrhythmias associated with thioridazine were reviewed (177 cases). No case of severe ventricular arrhythmia was reported in children. In adults, at therapeutic doses, ventricular tachycardia or fibrillation (VT/VF) or torsade de pointes was observed mainly in patients with concomitant risk factors. At doses higher than 800 mg, atrioventricular (A-V) and bundle branch blocks were associated with VT/VF. Mortality was higher in patients with A-V blocks. Although transient cardiac pacing is known to be efficacious to control phenothiazine-induced arrhythmias, it was rarely used.

Prospective community evaluation of the signal-averaged electrocardiogram in predicting malignant ventricular arrhythmias: beneficial outcome with electrophysiology guided therapy

The role of the signal-averaged ECG was prospectively assessed in 517 patients in whom there was a suspicion for malignant ventricular arrhythmias. Patients were divided into Group I with a normal surface QRS width less than 120 ms (426 patients) and Group II with a prolonged QRS duration greater than or equal to 120 ms (91 patients). Late potentials were present in 42 (10%) Group I patients and in 24 (26%) Group II patients. Programmed ventricular stimulation was performed for standard indications in 55 patients without late potentials and in 42 patients with late potentials, combining both groups. The sudden death or recurrent sustained ventricular tachycardia rate in follow-up was evaluated based on the presence or absence of late potentials and whether programmed ventricular stimulation was performed. In the patients without late potentials, these rates were 4 patients (1.0%) in the no EP group and 3 patients (5.5%) in the EP group (p less than .05), respectively (overall 1.6%). In the patients with late potentials, these rates were 7 patients (29%) in the no EP group and 7 patients (17%) in the EP group (p = .19), respectively (overall 21%). In addition, appropriate automatic defibrillator shocks were present in 1 patient without late potentials and in 8 patients with late potentials which were not included in the recurrent sudden death or sustained ventricular tachycardia statistics. The signal-averaged ECG accurately defines patients at a higher risk for malignant ventricular arrhythmias regardless of unfiltered QRS duration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Problem analysis. Evaluation of therapeutic means and objectives]

There is an inadequacy between the increasingly effective antiarrhythmia drugs at our disposal for the treatment of ventricular arrhythmias, their increasingly accurate and standardised evaluation by different invasive and non-invasive methods, and the pertinence of their clinical usage, especially in terms of patient safety. The reason why this situation has occurred are analysed in order to review a number of beliefs which have been too easily adopted without sufficient discussion.

[Polymorphous ventricular tachycardia: the implant of a permanent atrial pacemaker and long-term follow-up in a case]

Polymorphous ventricular tachycardia is a malignant arrhythmia associated to reversible conditions such as electrolyte imbalance, drug action, ischemia or Q-T prolongation. It is usually self limited ending with the correction of the triggering factor. We report a 70-year-old woman with a myocardial infarction who developed polymorphous ventricular tachycardia which persisted after several days. A temporary atrial pacing electrode was used effectively to control the arrhythmia, and permanent implantation was finally required. Eighteen months after discharge, the pacemaker function is normal and the arrhythmia has not recurred.