The Influence of Gender on Heart Rhythm Disease

This paper deals with cardiac arrhythmias, focusing on differences between genders. We sought to examine the potential effect of gonadal hormones on heart rhythm disorders, and sex‐related differences in incidence and clinical course of arrhythmias—differences that may require specific approaches to detection and management of heart rhythm disease.     

An Unusual Cause of Carotid Sinus Syndrome: Multiple Symmetric Lipomatosis

A 45-year-old man with multiple symmetric lipomatosis suffered recurrent syncope attributed to carotid sinus syndrome caused by extrinsic compression of the carotid body by the lipomatous masses. Surgical removal reduced but did not stop syncope, which was then controlled by implantation of a DDD pacemaker.     

Flecainide Test in Brugada Syndrome: A Reproducible but Risky Tool

GASPARINI, M., et al .: Flecainide Test in Brugada Syndrome: A Reproducible but Risky Tool. The flecainide test is widely used in Brugada syndrome. However, its reproducibility and safety remain ill-defined. This study included 22 patients (18 men, mean age 34 years). Mutations in the SCN5A gene were found in eight patients. Two patients had aborted sudden cardiac death, 8 had syncope/presyncope, and 12 were asymptomatic. The ECG was diagnostic in 19 patients and suggestive in 3. At baseline, 21 of 22 patients underwent a flecainide test (2 mg/kg IV bolus over 10 minutes). In 21 of 21 patients the test was diagnostic or amplified the typical ECG pattern. At the end of drug infusion, sustained VT lasting 7–10 minutes developed in two patients. A second flecainide test was performed within 2 months in 20 patients. The test was not repeated in the two patients with prior development of VT. The flecainide test was diagnostic in 20 of 20 patients. Sustained VT occurred in one patient and recurrent VF in another. The reproducibility of the flecainide test was 100%. In 4 (18%) of 22 patients major VAs were documented after the end of flecainide infusion. VA occurred in 3 (43%) of 7 patients with, versus 1 (7%) 15 without SCN5A gene mutation (P < 0.05). No diagnostic ECG changes or arrhythmias developed in 25 control patients without structural heart disease who underwent the same study protocol. This study shows a high flecainide reproducibility, supporting its diagnostic value in Brugada syndrome. However, the occurrence of major VA, significantly higher in patients with documented SCN5A gene mutation, including in asymptomatic patients, mandates the performance under appropriate medical supervision. Whether a slower rate of drug infusion can lower the risk of VA induction, while maintaining the sensitivity of the test should be explored. (PACE 2003; 26[Pt. II]:338–341)     

Continuous epidural block for pain control in bladder exstrophy: report of a case and description of technique

We describe in a neonate an unusual epidural technique for pain control after the surgical correction of bladder exstrophy.     

Improvement of Quality of Life by Means of Antitachy Pacing: From PainFREE to the ADVANCE-D Trial

Background: Implantable cardioverter-defibrillators (ICD) can terminate ventricular tachyarrhythmias with shocks (painful) or antitachycardia pacing (painless). According to the results of the Pacing Fast VT Reduces Shock ThErapies Trials, antitachycardia pacing (ATP) can avoid painful shocks and also increase device longevity. The purpose of the ADVANCE-D (Atp DeliVery for PAiNless ICD ThErapy) study is to determine the most appropriate ventricular tachycardia (VT) therapy, so as to optimize painless therapy for life-threatening arrhythmias.
Methods and Results: The ADVANCE-D is a prospective, multicenter, parallel, two-arm randomized study designed to evaluate the efficacy of two different sequences of ATP therapies (burst 15 pulses, 88%, vs burst 8 pulses, 88%), during an episode of spontaneous arrhythmia classified as fast VT (FVT) in patients with a Class I or IIA indication for ICD implantation (single and dual chamber devices). The primary endpoint is to compare the efficacy of two ATP therapies for FVT episodes. The study will enroll a minimum of 900 patients within 2 years, followed-up for 12 months. The investigation is expected to be completed in 2007.
Conclusions: The ADVANCE-D trial is the first large randomized clinical investigation aimed to evaluate optimal programming and efficacy of ATP.     

Nitrate‐Potentiated Head‐Up Tilt Testing in Older Patients: Outcomes,Hemodynamic Responses and Prodrome Recognition

Background: To compare head‐up tilt testing (HUT) outcomes and hemodynamic responses, and the prevalence and correlates of prodromes, in elderly and younger patients with suspected vasovagal syncope (VVS). Methods: Consecutive outpatients with a history of recurrent unexplained syncope underwent HUT by being tilted to 70°; the test was potentiated by the administration of 300 μg of nitroglycerine after 20 minutes. Occurrence of VVS and hemodynamic responses during passive and nitroglycerine phases of HUT were evaluated; symptoms preceding HUT‐induced syncope were recorded, together with heart rate and arterial blood pressure values. Results: Four hundred and sixty of the 743 patients were HUT positive: 156 fainted during the unmedicated phase and 304 after nitroglycerine administration. The patients aged ≥65 years (n = 102) experienced VVS more frequently during the pharmacological stage of HUT; the overall rate of positive results was similar to that observed in the patients aged 36–64 years (n = 329) and only slightly lower than that observed in those aged ≤35 years (n = 312). In the older patients, who experienced fewer and mainly prodrome‐free spontaneous syncopal episodes, HUT increased the number of premonitory symptoms, and there were no significant age‐related differences in symptom prevalence or timing or the patients’ hemodynamic characteristics. Conclusions: The rate of VVS induced by nitroglycerine‐potentiated HUT is similar in elderly and younger patients. In the former, nitroglycerine‐potentiated HUT significantly increases the prevalence of prodromes in comparison with spontaneous episodes, which suggests that it may be useful not only for diagnosis but also for patient counseling. (PACE 2010; 33:1210–1216)