Selective right ventricular angiography in apparently idiopathic ventricular fibrillation

Summary The definition of underlying heart disease in apparently idiopathic ventricular fibrillation seems to be important in regard to prognosis and choice of therapy. From October 1989, until August 1993, cardiac arrest due to the documented ventricular fibrillation occurred in eight consecutive patients with normal results on clinical examination, normal echocardiography, and normal or apparently nonspecific electrocardiogram (ECG) findings. Complete invasive investigations, including selective right ventricular angiography, were done; regional hypokinesia and segmental bulging of the right ventricle were found in seven patients (88%). Arrhythmogenic right ventricular dysplasia was suspected in these patients, although endomyocardial biopsy was not performed. After the finding of localized right precordial QRS prolongation of more than 110 ms in November 1993 in five patients, a retrospective, a more precise approach to QRS duration in standard ECG supported this diagnosis. Selective right ventricular angiography is of great help in identifying underlying heart disease in patients with apparently idiopathic ventricular fibrillation, and confirms ECG findings.     

Isolated noncompaction left ventricular myocardium and polymorphic ventricular tachycardia

A 57-year-old woman with syncope was admitted. She had a family history of sudden death: two brothers had died suddenly at the age of 47. Transesophageal echocardiography showed numerous prominent trabeculations and deep intertrabecular recesses in the anterior and lateroapical zones. Isotopic left ventricular ejection fraction was 46%. Cardiac catheterization showed coronary arteries with no angiographic lesions. A prominent trabecular zone and deep intertrabecular recesses were seen in the anterior wall on left ventriculography. Right ventriculography was normal. The diagnosis of isolated noncompaction left ventricular myocardium was established. Continuous 24-h electrocardiographic registry showed episodes of polymorphic ventricular tachycardia. Programmed ventricular stimulation performed at the right ventricular apex with up to three extrastimuli failed to induce ventricular arrhythmias. Treatment with beta blockers was initiated, but short runs of polymorphic ventricular tachycardia persisted. A dual-chamber automatic implantable defibrillator was implanted. We discuss the physiopathology of the arrhythmia. It appears that several factors could be responsible for the malignant arrhythmias in this entity.     

Contribution of each ventricular wall to ventricular interdependence

Summary The influences of presure and volume changes in one ventricle on the other ventricle may be determined from the relative compliances of the ventricular free walls and the interventricular septum. If this is correct, then disease states which alter regional compliances should influence the diastolic mechanical coupling between the ventricles. To examine this hypothesis, the hearts of 15 canine dogs were removed and placed in cool cardioplegic solution. Balloons were inserted into each ventricle and the right and left ventricular pressure (P_r, P_l) and volume (V_r, V_l) changes caused by changing the pressure and volume of the other ventricle were recorded. Acute changes in right ventricular free wall (N=5), septal (N=5), and left ventricular free wall (N=5) compliances were induced by glutaraldehyde injections. After injecting glutaraldehyde into the right coronary artery, P_l/V_r, V_l/V_r, P_r/P_l, and P_r/V_l increased significantly (P<0.05). After septal artery injection, pressure and volume transfer between the ventricles was significantly depressed. After left coronary artery injection, P_l/P_r, P_l/V_r, P_r/V_l, and V_r/V_l increased significantly (P<0.05). Thus, selective alterations in the mechanical coupling between the ventricles occurred following changes in right ventricular, septal, and left ventricular free wall compliances. Such changes may be important in diseases which primarily affect one side of the heart.This study was supported in part by NIH Grant No. HL 36068 by a grant from the American Heart Association, New Jersey Chapter.     

特发性右心室流出道室性心动过速/室性早搏的性别、年龄和临床特点

Objective The aim of this study was to clarify gender,age and clinical feature of idiopathic right ventricular outflow tract ventricular tachycardia/premature ventricular complexes(ROVT/PVC). Methods We studied 478 patients[mean age(39. 8 ± 13. 8)years]with idiopathic ROVT/PVC who were admitted to our center consecutively in past 15 years. All of them underwent catheter mapping and radiofrequency catheter ablation (RFCA), and the original sites of ventricular tachycardia/premature ventricular complexes were confirmed by catheter mapping and radiofrequency catheter ablation. Results Of 478 patients, 288 patients (60. 3% )were female, 190 patients(39. 7% )were male, female/male ratio was 1.52. The early onset of symptom was at (41.2 ± 12. 7 ) years for female, and ( 37.6 ± 15. 0) years for male ( P ＜ 0. 05 ). Almost all patients had palpitation in varying degrees. Sixty-seven of 478 patients( 14.2% ) had history of near-syncope,and 13 of 478 patients(2. 7% )had history of syncope. Two hundred and sixty-three patients( 55% )underwent unsuccessful treatment with antiarrhythmic drugs before the radiofrequency ablation. Of them, 110 patients (23%)had received one kind of antiarrhythmic drug, 104 patients (21.8%)had received two types of antiarrhythmic drugs,49 patients( 10. 3% )had received three types of antiarrhythmic drugs. Conclusion ROVT/VPC occur more in female than in male,the early onset of symptom is older for female than for male. Almost all patients have symptom in varying degrees, some of them have near-syncope or syncope.     

特发性右心室流出道室性心动过速/室性早搏的性别、年龄和临床特点

Objective The aim of this study was to clarify gender,age and clinical feature of idiopathic right ventricular outflow tract ventricular tachycardia/premature ventricular complexes(ROVT/PVC). Methods We studied 478 patients[mean age(39. 8 ± 13. 8)years]with idiopathic ROVT/PVC who were admitted to our center consecutively in past 15 years. All of them underwent catheter mapping and radiofrequency catheter ablation (RFCA), and the original sites of ventricular tachycardia/premature ventricular complexes were confirmed by catheter mapping and radiofrequency catheter ablation. Results Of 478 patients, 288 patients (60. 3% )were female, 190 patients(39. 7% )were male, female/male ratio was 1.52. The early onset of symptom was at (41.2 ± 12. 7 ) years for female, and ( 37.6 ± 15. 0) years for male ( P ＜ 0. 05 ). Almost all patients had palpitation in varying degrees. Sixty-seven of 478 patients( 14.2% ) had history of near-syncope,and 13 of 478 patients(2. 7% )had history of syncope. Two hundred and sixty-three patients( 55% )underwent unsuccessful treatment with antiarrhythmic drugs before the radiofrequency ablation. Of them, 110 patients (23%)had received one kind of antiarrhythmic drug, 104 patients (21.8%)had received two types of antiarrhythmic drugs,49 patients( 10. 3% )had received three types of antiarrhythmic drugs. Conclusion ROVT/VPC occur more in female than in male,the early onset of symptom is older for female than for male. Almost all patients have symptom in varying degrees, some of them have near-syncope or syncope.     

Cryosurgery for ventricular bigeminy using a transaortic closed ventricular approach

Disabling monomorphic ventricular bigeminy has not been describedas an indication for surgery. Three young patients with thisarrhythmia sometimes deteriorating into ventricular tachyarrhythmiasand in whom drug therapy failed completely were accepted forsurgical ablation of the arrhythmogenic area. The earliest endocardialsite of origin was located preoperatively by catheter mappingof the spontaneously occuring ventricular bigeminy in the leftand right ventricles. For maximum preservation of myocardialmuscle and function, the peroperative mapping and surgical procedurewere preformed through the aortic root; mapping by transaorticmultipolar balloon was done during normothermic coronary perfusionand cryocoagulation was done during cardioplegic arrest. Cryocoagulationof the endocardial site was performed using the transaorticapproach and epicardial cryocoagulation at the opposite sitewas done afterwards. In the two patients in whom the peroperativemapping results were consistent with those of preoperative cathetermapping, the arrhythmia could be abolished, as documented duringlong-term follow-up. In the only patient in whom the mappingresults were not in agreement, the ventricular arrhythmia reoccurredand was the cause of death at five months after surgery. Postoperativewall-motion studies performed in the two surviving patientsshowed limited scars in the area of cryocogulation and minordamage to the coronary arteries in that area. The transaorticapproach can be considered as a new and important surgical optionfor endocardial mapping and cryocoagulation which prevents thedamaging effects of a left ventriculotomy.     

A case of arrhythmogenic right ventricular dysplasia with ventricular fibrillation

A case of repeated attacks of ventricular fibrillation is described. The patient suffered from an arrhythmogenic right ventricular dysplasia (ARVD) documented by right and left ventriculograms and myocardial biopsies obtained during surgical treatment of the arrhythmia. The histological changes were interpreted as being signs of fresh myocardial damage of unknown origin in addition to a replacement of the normal myocardium by adipose and fibrotic tissue. The repeated attacks of ventricular fibrillation in this patient contrast to the arrhythmia spectrum noted in the available literature on ARVD, mostly stable chronic ventricular tachycardias.     

射频消融治疗室性早搏触发特发性室性心动过速／心室颤动的病例分析

目的探讨射频消融治疗在室性早搏（室早）触发特发性室性心动过速／心室颤动（室速／室颤）中的作用。方法总结3例由室早触发室速／室颤的治疗经验,1例对室早进行射频消融（RF—CA）并植入心律转复除颤器（ICD）,另1例经射频消融未完全消除室早而选择植入ICD,第3例经射频消融成功消除室早,未再发室颤。结果随访2年,3例患者均存活,ICD未再记录到室速／室颤。结论在室早触发室速／室颤病例中,应分析室早与室速／室颤的相关性,给予个体化治疗,射频消融室早可以消除／减少晕厥和室颤的发作。     

Delayed ventricular depolarization -- correlation with ventricular activation and relevance to ventricular fibrillation in acute myocardial infarction

Signal averaging to detect abnormalities in the terminal phaseof ventricular depolarization has been performed in severalgroups of patients with various manifestations of ischaemicheart disease. Late potentials were common in patients withVT and in a group of patients having cardiac surgery. Findingsin the surgical group highlighted the close correlation of latepotentials with delayed, fragmented epicardial activation supportingthe hypothesis that late potentials reflect a myocardial substratewhich would support re-entrant VT. The findings in the surgicalgroup allowed a definition of late potentials which could beapplied to other patients in the study, and also demonstrateda spectrum of late depolarization abnormalities. Signal averaging is technically feasible in the noisy CCU environmentbut late potentials were detected in few patients early in AMI.Late potentials were also rarely seen in patients with VF andtherefore cannot be construed as a predictive index of thisarrhythmia.     

Hoffmayer心电图积分识别ARVC室早／室速

目的探讨应用Hoffmayer心电图积分鉴别致心律失常性右室心肌病（arrhvthmogenic right ventricular cardiomyopathy,ARVC）和特发f生右室流出道室早／室速的临床意义。方法收集2009年9月至2013年5月就诊于北京大学人民医院患者中,心电图表现为右室流出道起源室早／室速患者57例。其中明确诊断为ARVC患者4例,经电生理检查及射频消融治疗成功的特发性右室流出道室早／室速患者53例。由两位电生理医生在不知道确切诊断的情况下,依据Hoffmayer心电图积分对上述患者的心电图进行分析,计算总积分≥5分,各单项积分诊断ARVC伴发的室早／室速的敏感度、特异度、阳性预测值、阴性预测值及诊断符合率。结果Hoffmayer心电图积分≥5分诊断ARVC伴发室早／室速的敏感度75％,特异度96．23％,阳性预测值60％,阴性预测值98％、诊断符合率94．7％。结论Hoffmayer积分≥5可有效鉴别右室流出道室早／室速是ARVC伴发的还是特发性的。应用此项积分具有简单、快速、敏感度及特异度均较高的优点,具较高的临床应用价值。     

左心室质量及几何模式对左心室功能的影响

目的 探讨左心室质量(LVM)及几何模式对左心室功能的影响。方法 根据相对室壁厚度(RWT)>0.43和≤0.43将170例高血压患者分为向心性模式组和离心性模式组,分别作超声心动图检测。结果 向心性模式组的EF明显高于离心性模式组,而前者E、E/A明显低于后者。单变量及多变量回归分析均显示EF与LVM及RWT相关,E/A在单变量分析时与RWT呈非常显著负相关,但在多变量分析时被剔出。结论 LVM及几何模式的改变均对左心室收缩功能产生明显的损害,几何模式的变化可能对左心室舒张功能也会产生不利影响。     

Isolated right ventricular noncompaction caused ventricular tachycardia and pulmonary embolism

Isolated ventricular noncompaction is an unclassified cardiomyopathy due to intrauterine arrest of compaction of the loose interwoven meshwork. Its mortality and morbidity are high, including heart failure, thromboembolic events, and ventricular arrhythmias. Isolated right ventricular noncompaction was reported rarely, especially that causes pulmonary embolism and ventricular tachycardia. We describe a case of isolated noncompaction of the right ventricular causing pulmonary embolism and ventricular tachycardia.     

Left ventricular aneurysm associated with isolated noncompaction of the ventricular myocardium

A 66-year-old woman was admitted to our hospital because of left ventricular failure and nonsustained ventricular tachycardia. Two-dimensional echocardiography demonstrated prominent trabeculations and deep intertrabecular recesses, findings consistent with noncompaction of the ventricular myocardium. Myocardial perfusion scintigraphy demonstrated a defect in the anterobasal left ventricular segment. Coronary angiogram was normal, but the left ventriculogram showed an aneurysm in the anterior myocardial segments. This is the first reported case with isolated noncompaction of the ventricular myocardium associated with left ventricular aneurysm.     

Regression of established ventricular remodeling: A therapeutic goal in ventricular dysfunction?

Ventricular remodeling refers to the development of structural changes in the myocardium following injury. Attenuation of this process has become a focus of therapy in ventricular dysfunction in an effort to improve the prognosis in this condition. To date, however, little is known about the potential to induce regression of established venticular remodeling or, if possible, whether such an approach is beneficial. This review focuses on what is known regarding regression of remodeling and what needs to be clarified about this process.     

右室间隔起搏与心尖部起搏对左室功能中远期影响的Meta分析

目的系统评价右室间隔起搏与心尖部起搏对左室功能中远期影响。方法计算机检索PubMed、EMbase及Cochrane图书馆，同时检索中国生物医学文献数据库、中国期刊全文数据库、万方数据库和中文科技期刊数据库，检索时间截至2012年12月，收集右室间隔起搏与右室心尖起搏对左室心功能影响的随机对照试验，并用Cochrane协作网推荐的质量评价体系对纳入研究进行质量评价、资料提取，采用RevMan5.1进行Meta分析。结果最终纳入20项研究，1642例患者。Meta分析结果显示，在术后12个月左室射血分数（LVEF，MD=4.00，95%CI：1.87～6.12）、术后12个月以上LVEF （MD=5.28，95%CI：2.53～8.03）、术后12个月血N末端脑钠肽前体（NT-proBNP，SMD=-0.89，95%CI：-1.56～-0.22）、术后12月左室收缩末体积（MD=-5.24，95%CI：-9.53～-0.96）、术后12月Tei指数（MD=-0.42，95%CI：-0.18～-0.05）、术后QRS时限（SMD=-1.16，95%CI：-1.64～-0.68）方面右室间隔起搏均优于右室心尖部起搏；而在术后12个月左室舒张末内径（MD=-0.52，95%CI：-1.91～0.87）、术后12个月左室舒张末体积（MD=-1.43，95%CI：-3.72～0.87）方面两者差异无统计学意义。结论相对于心尖部起搏，右室间隔起搏对左室功能影响较小；但受纳入研究质量及样本量的限制，上述结论仍需进行更多多中心、大样本、前瞻性研究进一步证实。     

Arrhythmogenic right ventricular dysplasia presenting as right ventricular outflow tract tachycardia.

A case of a 51-year old male is presented. A left bundle branch block inferior axis tachycardia was manifest. At electrophysiological study this tachycardia was inducible and was ablated in the septal right ventricular outflow tract (RVOT). Two other tachycardias were identified both with right bundle branch block (RBBB) morphology raising the suspicion of diffuse pathology. Arrythmogenic right ventricular dysplasia (ARVD) was confirmed by right ventricular angiography and magnetic resonance imaging (MRI). An implantable cardioverter defibrillator (ICD) was implanted and an appropriate shock was later delivered.     

Right ventricular dysfunction and surgical outcome in postinfarction ventricular septal defect

The data of 50 consecutive patients treated for postinfarctionventricular septal defect were reviewed. Cardiac catheterizationwas carried out in all patients and surgical repair was undertakenin 32 patients. The main factors affecting surgical outcome were the site ofinfarction and the extent of right ventricular damage. Anteriormyocardial infarction carried a better hospital survival ratethan inferior infarction (67 and 31%, respectively). Poor rightventricular free wall contraction, present in 44% of anteriorinfarctions and 71% of inferior infarctions carried a high mortality.Eighty per cent (12/15) of patients with good right ventricularcontraction survived operation compared to only 24% (4/17) ofpatients with poor right ventricular contraction. Surgery within 24 h to 14 days of infarction carried a survivalrate of 50% (7/14), similar to that in patients operated onmore than two weeks following infarction (9/18). Seventeen out of 18 patients who did not undergo surgery eitherdied suddenly before scheduled operation or were consideredtoo poor a surgical risk. Of these, 12 patients died withinone week of infarction and five patients survived between twoweeks and three months. Early surgical repair should therefore be considered in allpatients with postinfarction ventricular septal defect, theprognosis in patients with good right ventricular contractionbeing excellent.