阵发性室上性心动过速并发阵发性房颤危险因素的临床研究

目的:筛选阵发性室上性心动过速(PSVT)患者中并发房颤的临床危险因素。了解PSVT患者中房颤的患病率及PSVT患者房颤发生的可能机制。方法:回顾研究经电生理检查证实为PSVT的患者共630例,其中依据临床记录同时有房颤发作的患者编为房颤组,其余无临床房颤发作的患者为对照组。制订调查表格并详细记录患者人口学资料、临床疾病相关资料、心脏超声检查结果、24h动态心电图结果、电生理检查中确定的PSVT折返机制、旁道数目等资料。利用SPSS进行t检验、χ2检验及Logistic回归分析PSVT患者并发房颤的危险因素。结果:630例(年龄13~79岁,平均年龄44.2±14.3岁男性326人,女性304例)中电生理检查房室结折返性心动过速256例(均为慢-快型),房室折返性心动过速374例,单因素分析表明男性、左房内径大及术前频发房性早搏(在AVRT亚组心电图表现为显性预激)为PSVT患者并发房颤的临床危险因素,多因素分析证明性别为PSVT患者并发房颤的独立临床危险因素。结论:PSVT并发房颤的患者常有一定的临床特征:男性居多,左房内径相对较大。     

Occurrence of Atrial Fibrillation in Patients With Paroxysmal Supraventricular Tachycardia Due to Atrioventricular Nodal Reentry

The occurrence of atrial fibrillation in patients with paroxysmal supraventricular tachycardia (PSVT) has been well documented when PSVT is secondary to atrioventricular reentry, but not when PSVT is secondary to atrioventricular nodal reentry (AVNRT). Seventeen patients with AVNRT were followed using transtelephonic electrocardiogram monitoring to document symptomatic tachycardias. The median length of telephone monitor surveillance was 357 days. Fifteen of 17 patients transmitted electrocardiograms that showed PSVT. Three of 17 patients (18%) transmitted electrocardiograms that showed atrial fibrillation. A transition from PSVT into atrial fibrillation was not recorded, but all three did have PSVT recorded on other days of follow-up. We report the occurrence of atrial fibrillation in patients with AVNRT and that its incidence is higher than expected for the general population.     

Treatment of Out-of-hospital Supraventricular Tachycardia: Adenosine vs Verapamil

Objective: To compare the use of adenosine and the use of verapamil as out-of-hospital therapy for supraventricular tachycardia (SVT). Methods: A period of prospective adenosine use (March 1993 to February 1994) was compared with a historical control period of verapamil use (March 1990 to February 1991) for SVT. Data were obtained for SVT patients treated in a metropolitan, fire-department-based paramedic system serving a population of approximately 1 million persons. Standard drug protocols were used and patient outcomes (i.e., conversion rates, complications, and recurrences) were monitored. Results: During the adenosine treatment period, 105 patients had SVT; 87 (83%) received adenosine, of whom 60(69%) converted to a sinus rhythm (SR). Vagal maneuvers (VM) resulted in restoration of SR in 8 patients (7.6%). Some patients received adenosine for non-SVT rhythms: 7 sinus tachycardia, 18 atrial fibrillation, 7 wide-complex tachycardia (WCT), and 2 ventricular tachycardia; no non-SVT rhythm converted to SR and none of these patients experienced an adverse effect. Twenty-five patients were hemodynamically unstable (systolic blood pressure < 90 mm Hg), with 20 receiving drug and 13 converting to SR; 8 patients required electrical cardioversion. Four patients experienced adverse effects related to adenosine (chest pain, dyspnea, prolonged bradycardia, and ventricular tachycardia). In the verapamil period, 106 patients had SVT; 52 (49%) received verapamil (p < 0.001, compared with the adenosine period), of whom 43 (88%) converted to SR (p = 0.11). Two patients received verapamil for WCT; neither converted to SR and both experienced cardiovascular collapse. VM resulted in restoration of SR in 12 patients (11.0%) (p = 0.52). Sixteen patients were hemodynamically unstable, with 5 receiving drug (p = 0.005) and 5 converting to SR; 9 patients required electrical cardioversion (p = 0.48). Four patients experienced adverse effects related to verapamil (hypotension, ventricular tachycardia, ventricular fibrillation). Recurrence of SVT was noted in 2 adenosine patients and 2 verapamil patients in the out-of-hospital setting and in 23 adenosine patients and 15 verapamil patients after ED arrival, necessitating additional therapy (p = 0.48 and 0.88, for recurrence rates and types of additional merapies, respectively). Hospital diagnoses, outcomes, and ED dispositions were similar for the 2 groups. Conclusion: Adenosine and verapamil were equally successful in converting out-of-hospital SVT in patients with similar etiologies responsible for the SVT. Recurrence of SVT occurred at similar rates for the 2 medications. Rhythm misidentification remains a common issue in out-of-hospital cardiac care in this emergency medical services system.     

U22, a Protocol to Quantify Symptoms Associated with Supraventricular Tachycardia

Background: The main indication for ablation of supraventricular tachyarrhythmias (SVTA) is symptomatic relief. Specific paroxysmal symptoms cannot be quantified with general measures of quality of life, such as with the SF-36 questionnaire. U22 is a new protocol which measures the effects of arrhythmia on well-being, the intensity of discomfort during an episode, the type and temporal characteristics of dominant symptoms, and the duration and frequency of episodes. Discrete 0–10 scales are used. Unlike SF-36, U22 can be used in individual patients.
Methods: U22 and SF-36 protocols were used in the symptomatic evaluation of 88 patients (mean age = 49.6 ± 16.4 years; 43 men), who underwent catheter ablation of SVTA.
Results: The U22 scores (SD) for (a) well-being (10 being best), (b) effects of arrhythmia on well-being (10 being worst), and (c) discomfort during arrhythmia (10 being worst) were 5.6 (2.7), 7.5 (2.8), and 8.0 (2.4), respectively. For comparison, the physical and mental component summaries of SF-36 were 45.3 (11.0) and 45.2 (12.1), respectively, slightly lower than the expected normal of 50. The intensity of dominant symptom scored by U22 was 9.7 (1.2), 10 being worst. In 29% of patients ≥4 symptoms were equally dominant. Multiple dominant symptoms in U22 were associated with a low general well-being in SF-36.
Conclusion: We found U22 useful to quantify symptoms associated with SVTA.     

Atrial Antitachycardia Pacing in Patients with Supraventricular Tachycardia: Clinical Experience with the Intertach Pacemaker

MCCOMB, J.M., ET AL.: Atrial Antitachycardia Pacing in Patients with Supraventricular Tachycardia: Clinical Experience with the Intertach Pacemaker. During a 3-year period, 22 patients with recurrent supraventricular tachycardia have been treated with antitachycardia pacemakers [Intermedics Intertach, 262–12, n = 17, and Intertach II, 262–16, n = 5). Eighty-two percent were female, the mean age was 44 ± 14 years; 86% had atrioventricular node reentrant tachycardia. Symptoms had occurred over 11.8 ± 7.1 years, with 3.6 hospital admissions per patient, despite 4.7 ± 2.1 antiarrhythmic drugs. Following pacemaker implantation, during a follow-up of 14.8 ± 11.5 months, only two patients have been readmitted to a hospital because of supraventricular tachycardia (mean 0.1 per patient). One patient is taking an antiarrhythmic agent, and four are taking beta adrenergic blocking agents. Thus, 23% are taking cardioactive drugs (it was anticipated that two patients would continue on drugs after pacemaker implantation). There have been no serious complications. Atrial antitachycardia is thus an effective therapy in carefully selected patients with recurrent supraventricular tachycardia, reducing hospital admissions for supraventricular tachycardia and reducing the need for antiarrhythmic drugs.     

Surgery for Atrial Tachycardia

GUIRAUDON, G.M., ET AL.: Surgery for Atrial Tachycardia. Atrial flutter is associated with a macro-reentrant loop including an area of slow conduction cryoablation of which prevents atrial flutter to occur. Three patients underwent such intervention. Atrial fibrillation is associated with multiple reentrant circuits (leading circle of Allessie) that requires a critical surface area to perpetuate. We have designed an operation, the corridor operation, which isolate the sinus node and the AV node within a small segment of atrial tissue, to restore the chronotropic function of the sinus node. Nine patients underwent the corridor operation at our institution. There were eight men and one woman. Five had incessant atrial fibrillation and four paroxysmal. One patient had associated mitral valve stenosis and one cardiomyopathy. There were no perioperative complications. Six patients had normal sinus node function postoperatively including all the four patients with documented normal sinus node function preoperatively. Three patients required implantation of an AAI pacemaker. Two patients had recurrence of atrial fibrillation within the corridor. Our experience suggests that the corridor operation should be restricted to patients with documented good sinus node function and without structural heart disease. Our experience with five patients with paroxysmal sinus node tachycardia has been disappointing. Only one patient had long-term success although better series have been published.     

Long-Term Antitachycardia Pacing Experience for Supraventricular Tachycardia

A pacemaker was used to control drug-resistant reentrant supraventricular tachycardia (SVT) in 40 patients. An antitachycardia pacemaker was implanted in 37 for SVT; in one for ventricular tachycardia that could also be used to terminate SVT; in one SVT could be terminated with an activity rate variable pacemaker; and in one a DDD pacemaker was used for prevention and termination of SVT. Twenty patients had AV nodal reentrant tachycardias, eight had tachycardias due to a concealed accessory pathway, eight had a Wolff-Parkinson-White syndrome, three had reentrant atrial tachycardias, and one had atrial flutter. Twenty-two patients were paced from the right atrium, five from the coronary sinus, ten from the right ventricle, and three had a DDD pacemaker. During a total follow-up period of 1,503 (mean 38) months an estimated 16,240 episodes of tachycardia were terminated promptly at home, 58 required several attempts, 57 episodes lasted longer than 30 minutes but did not require medical attention, and 11 required hospital admission. Hospital admission for SVT decreased from one per patient-month (in the 3 months before implantation) to 1 per 137 patient-months after implantation. Additional reentrant tachycardias occurred in 13 patients. Antiarrhythmic drug therapy in combination with a conservative antitachycardia pacing mode was required in four patients paced from the atrium to avoid pacing induced atrial fibrillation. Antiarrhythmic drug therapy was used in 42% of patients to help control SVT. Conclusions: (1) Drug-resistant SVTs can be safely and effectively managed on the long-term with antitachycardia pacemakers. (2) Rapid termination of SVT improved the quality-of-life significantly by avoiding prolonged episodes of tachycardia and repetitive hospital admissions.     

国产艾司洛尔治疗阵发性室上性心动过速的临床观察

目的:评价国产艾司洛尔治疗阵发性室上性心动过速的疗效和安全性。方法:用国产艾司洛尔治疗阵发性室上性心动过速42例,观察其转复窦性心律和控制心室率的情况,并记录用药前后的血压变化。结果:静脉注射国产艾司洛尔起效时间为4.2±1.5分钟,治疗有效率为78.6％;副作用较少,静脉注射后仅轻度影响收缩压,共有4例出现低血压,给予快速补液后好转。结论:国产艾司洛尔不仅能有效地转复阵发性室上性心动过速,而且使用安全。     

Studies on the Prevalence of Complicated Atrial Arrhythmias, Flutter, and Fibrillation in Patients with Reciprocating Supraventricular Tachycardia Before and After Successful Catheter Ablation

Atrial flutter and AF are complications in approximately 30% of cases of paroxysmal supraventricular tachycardia (PSVT)-indicated catheter ablation, and it is of interest to determine if therapeutic modification for PSVT would eliminate combined atrial tachyarrhythmia like atrial flutter and AF. The aim of this study was to determine the incidence and the risk of atrial tachyarrhythmias after catheter ablation of PSVT. A total of 152 patients (age range 12-74, mean 41 +/- 17 years) with accessory pathway (n = 106) and/or dual atrioventricular nodal conduction (n = 46) were enrolled in a 2-year follow-up program after successful catheter ablation. Possible risks on clinical background (age, sex, PSVT duration, hemodynamic instability during attacks), premature atrial contraction (PACs) on Holter monitoring, echocardiographic left atrial size, and electrophysiological property (insertion site, conduction type, effective refractory period) were evaluated. Atrial flutter and AF were complications in 53 (35%) of the subjects, who were elderly and had a longer PSVT history with a larger left atrial dimension and frequent PACs; however, the electrophysiological properties were similar. After a 2-year follow-up period 36 (24%) of the patients still exhibited PAC runs, including 13 (9%) with atrial flutter and AF, each one of whom were complicated with nonlethal cerebral thromboembolism and congestive heart failure. Multiplelogistic-regression analysis revealed that advanced age (> or = 41 years, P = 0.0152) and frequent PACs (> or = 1% of total daily QRS counts, P = 0.0426) on Holter monitoring are the risk factors of PAC runs and/or atrial flutter and AF. In conclusion, successful ablation for PSVT is thought to be beneficial for preventing atrial flutter and AF. However, careful follow-up to monitor for the recurrence and atrial flutter and AF related complications, especially in patients of solitary atrial flutter and AF without reciprocating tachycardia and with frequent PAC.     

Atrial Tachycardia Mimicking Atrioventricular Nodal Reentry Tachycardia

Background

The term supraventricular tachycardia (SVT) is used to describe tachydysrhythmias that require atrial or atrioventricular nodal tissue for their initiation and maintenance. SVT can be used to describe atrioventricular nodal reentry tachycardia, atrioventricular reentry tachycardia, and atrial tachycardia (AT). AT is the least common of these SVT subtypes, accounting for only 10% of cases. Although the suggested initial management of each SVT subtype is different, they all can present with similar symptoms and electrocardiographic findings.

Objective

Discuss the pathophysiology, diagnosis, and treatment of AT as compared with other types of SVT.

Case Report

We report a 56-year-old woman with symptoms and electrocardiographic findings consistent with SVT. Although standard treatment with intravenous adenosine failed to convert the SVT, it revealed AT as the cause of the tachydysrhythmia. The AT was successfully terminated with beta-blockade and the patient eventually underwent successful radioablation of three separate AT foci.

Conclusions

AT frequently mimics other more common forms of SVT. AT might be recognized only when standard treatment of SVT has failed. Identification of AT in this setting is crucial to allow for more definitive therapy.     

静脉注射倍他乐克治疗室上性心动过速的临床观察

目的:评价倍他乐克治疗室上性心动过速的疗效和安全性。方法:室上性心动过速患者46例静脉注射倍他乐克,观察其转复窦性心律和控制心室率的情况,并记录用药前后的血压变化。结果:静脉注射倍他乐克起效时间为3.4±1.5min,治疗有效率为91%,副作用较少,静脉注射后对血压无明显影响。结论:倍他乐克不仅能有效地转复室上性心动过速,而且使用安全。     

Nonreentrant Supraventricular Tachycardia Misdiagnosed as Inappropriate Sinus Tachycardia

We report a case of a woman with incessant palpitations initially misdiagnosed as inappropriate sinus tachycardia that proved refractory to β‐blockers. At the time of electrophysiologic testing, a sustained narrow‐complex tachycardia with a 1:2 atrioventricular relationship was repeatedly initiated by a posterior fascicle depolarization induced by means of a timed ventricular extrastimulus. The tachycardia was repeatedly terminated with a timed atrial extrastimulus, which excluded junctional bigeminy and confirmed the diagnosis of nonreentrant supraventricular tachycardia. Catheter ablation of the slow pathway eliminated dual‐pathway conduction and tachycardia. (PACE 2011; 34:e70–e73)     

Clinical Experience with the Intertach 262-12 Pulse Generator in Patients with Recurrent Supraventricular and Ventricular Tachycardia

FROMER, M., ET AL.: Clinical Experience with the Intertach 262-12 Pulse Generator in Patients with Recurrent Supraventricular and Ventricular Tachycardia. An antitachycardia pulse generator, the Intermedics Intertach 262-12 was implanted in 16 patients (14 patients with supraventricular tachycardia of various origins and two patients with recurrent ventricular tachycardia), who were not responsive to various antiarrhythmic drug regimens. The follow-up was from 6–49 months (mean 30.9 ± 13.8). Five patients had a follow-up of over 3 years. The device was used in all patients. One patient with ventricular tachycardia died from a nonarrhythmic cause. Loss of responsiveness to burst pacing was observed in 1/14 patients with supraventricular tachycardia and nontolerance of antitachycardia pacing in one patient. Overall clinical success of pacing was observed in 13/16 patients = 81%. The pacemaker proved to be a versatile system with reliable tachycardia detection and termination functions.     

''Long-Term Results of Antitachycardia Pacing in Patients with Supraventricular Tachycardia

Between 1979 and 1984 the Cybertach-60, (Intermedics, Inc. Model 262-01), a programmable, automatic antitachycardia pacemaker was implanted in 11 patients who had drug-refractory supraventricular tachycardia (SVT). The patients have been followed for a total of 64-108 (mean 84 months). All patients were symptomatic and had failed two or more drugs and six patients had required prior DC cardioversion. The mechanism of supraventricular tachycardia was atrioventricular (AV) nodal reentry in six patients, AV reentry in four patients, and atrial tachycardia in one patient. Preoperatively all patients had reliable termination of the tachycardia without induction of atrial fibrillation by pacing methods available to Cybertach-60. Postimplant, Cybertach-60 reliably terminated all episodes of tachycardia without ancillary drug therapy. Nevertheless, at long-term follow-up antitachycardia pacing was effective and safe in the minority (36%), with only four patients out of eleven still using a pacemaker for supraventricular tachycardia. One of these four patients required additional drug therapy. In one of the patients, the Cybertach-60 was replaced after 78 months by a more advanced device, (Intertach, Intermedics, Inc.) because of a depleted Cybertach-60 battery. In seven patients who no longer use antitachycardia pacing for termination of tachycardia, one patient developed atrial fibrillation during tachycardia termination (at 58 months postimplant). Three patients experienced induction of tachycardia or atrial fibrillation by the pacemaker due to undersensing of sinus P waves (at 36, 48, and 51 months).(ABSTRACT TRUNCATED AT 250 WORDS)     

新生儿阵发性室上性心动过速的治疗

目的：探讨新生儿阵发性窒上性心动过速（PSVT）的治疗方法。方法：对15例阵发性室上性心动过速患儿的临床资料进行分析。结果：15例患儿中，除1例无效自动出院外。其余患儿均恢复窦性节律。心衰纠正、血清心肌酶恢复正常、肌钙蛋白转阴，于终止发作后4～10d出院．出院后继续服地高辛酏剂3-6个月。结论：（1）PSVT首先采用地高辛静脉注射治疗，若无效则按序分别加用“ATP、心律平、盐酸胺碘酮”；（2）该治疗方法列序安全可靠，值得临床应用。     

Repetitive Supraventricular Tachycardia: Clinical Manifestations and Response to Therapy with Amiodarone

Repetitive supraventricular tachycardia is an uncommon arrhythmia which usually occurs in patients free of structural heart disease. It is characterized by incessant short salvos of supraventricular tachycardia separated by only one or two normal sinus beats. Therapy with conventional antiarrhythmic drugs is usually ineffective. This report describes three patients with repetitive supraventricular tachycardia in whom evidence for associated sinus node dysfunction was observed. Amiodarone therapy, with ventricular pacing in two patients, has provided effective control of this arrhythmia in all three patients.     

Role of Invasive Electrophysiologic Studies in the Evaluation and Treatment of Supraventricular Tachycardia

Electrophysiologic studies have provided new insights into the mechanisms responsible for supraventricular arrhythmias and have enabled investigators to evaluate with precision the acute effects of pharmacologic, physiologic, electrical, and surgical interventions. Not all patients with supraventricular arrhythmias require invasive studies, however, since empiric drug trials will often be adequate for management. At present, the clinical indications for study include the following: (1) for diagnosis of tachycardia mechanism when scalar ECG analysis is uncertain; (2) for assessment of risk of future life-threatening arrhythmia; and (3) as a rapid means of assessing future therapy when sporadic arrhythmias are likely to be poorly tolerated. Innovations that include surgical and catheter ablations of tachycardia pathways and antitachycardia pacing devices hold great promise and in the future, will provide nonpharmacologic options for patients poorly controlled by or intolerant of drug therapy.     

Differentiation of Sinus Rhythms from Supraventricular Tachydysrhythmias by Activation Sequence and Timing

WALSH, C.A., ET AL.: Differentiation of Sinus Rhythms from Supraventricular Tachydysrhythmias by Activation Sequence and Timing. Implantable device detection of tachydysrhythmias remains unreliable and inexact. False responses may occur because of misinterpretation of sinus tachycardia (ST) as a supraventricular tachydysrhythmia (SVTD). Timing of atrioventricular (AV) activation and ventricular dispersion identified and discriminated between ST and SVTDs in 11 dogs. Three bipolar epicardial electrodes recorded left atrial and left and right ventricular depolarizations simultaneously during normal sinus rhythm (NSRJ (mean of 5 beats in 11/11 dogs), ST produced by phlebotomy (50 beats in 10 episodes in 6/11) or isoproterenol infusion (105 beats in 21 episodes in 10/11), sinus bradycardia (SB) produced by vagal stimulation (140 beats in 29 episodes in 10/11), and during atrial flutter (AFL) (15 beats in 3 episodes in 3/11) and atrial fibrillation (AF) (152 beats in 31 episodes in 9/11) induced by programmed electrical stimulation. During lidocaine infusion, NSR (55 beats in 11 episodes in 10/11 dogs), SB (84 beats in 17 episodes in 7/11), AFL (10 beats in 2 episodes in 1/11], and AF (103 beats in 21 episodes in 7/11) were recorded. During isoproterenol infusion, SB (45 beats in 9 episodes in 5/11), AFL (15 beats in 3 episodes in 2/11), and AF (64 beats in 13 episodes in 5/11) were recorded in addition to ST. The interval between the left atrial and left ventricular intrinsic deflections (A-V₁) and between the left and right ventricular intrinsic deflections (V₁-V₂) of each beat was measured. The mean value (msec) of A-V₁ and V₁-V₂ in each episode was compared to NSR in the same dog. A difference of ≥ 16 ms was used for differentiation. In all cases except SB with first-degree AV block, V₁-V₂ in each episode was insignificant (0-14msec), categorizing the rhythms as supraventricular. During NSR, ST and SB without AV block, Δ A-V₁ was small (0–15 msec). In contrast Δ A-V₁ was ≥ 16 ms in 6/8 episodes of AFL. The remaining two episodes could be differentiated by the greater number of atrial versus ventricular beats. AF could be detected by the variability of A-V₁. An algorithm using the relative number of atrial vs ventricular beats and A-V₁ and V₁-V₂ timing can provide automated dysrhythmia detection, without effect from lidocaine or isoproterenol infusion.