[Difficult intradural puncture for urgent cesarean section in a morbidly obese patient].
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Adult↗
Biomedical subjects
M Metge
Publications and source records attributed to M Metge.
[Intravenous and oral propafenone in the treatment and prevention of paroxysmal atrial fibrillation].
The efficacy of propafenone in the treatment of paroxysmal atrial fibrillation was investigated in 16 patients presenting with frequent and/or poorly tolerated paroxysmal atrial fibrillation despite prophylactic treatment in 13 patients. Prolonged atrial fibrillation (> 10 minutes) was triggered in 16 patients following a standard atrial stimulation protocol. Intravenous injection of propafenone (2 mg/kg over 5 minutes) restored sinus rhythm in 12 patients (75%) within 15 minutes after the end of the injection. In five of the 10 patients in whom this was possible, propafenone prevented the induction of atrial fibrillation in response to programmed stimulation by the same protocol. Oral propafenone (900 mg/24 hours) was indicated in 11 patients. The treatment was discontinued in 1 patient due to severe dizziness. Atrial fibrillation recurred in 4 patients 10 to 91 days after treatment began. With a mean follow-up time of 8 months, 4 patients had been brought under control and 2 had relapsed despite a generally beneficial effect. Three patients suffered side effects which did not make it necessary to stop treatment. This study suggests that intravenous propafenone is effective against persistent atrial fibrillation induced by stimulation. Oral propafenone may be useful for the prevention of attacks of recalcitrant paroxysmal atrial fibrillation.
Administration, Oral↗
[Comparative effects of anti-arrhythmia agents on ventricular refractory period and prevention of ventricular tachycardia induced by stimulation].
The efficacy of antiarrhythmic drugs is attributed to their actions on the refractory periods or conduction velocity in the reentry circuit. The aim of this study was to determine the relationship between these factors and the prevention of electrically inducible ventricular tachycardia (VT). Twenty-seven patients with sustained monomorphic postinfarction VT underwent programmed stimulation under basal conditions and after administration of oral Class I antiarrhythmic drugs. The protocol of stimulation consisted of delivering one to three extrastimuli to the right ventricular apex on two basic cycle lengths. Sustained VT was induced in all patients. After the same protocol under antiarrhythmic therapy (1 to 5 tests, average 2.9 +/- 1) sustained VT could not be induced in 12 patients (44%). The effective right ventricular refractory period was significantly increased in patients without inducible VT under treatment (247 +/- 18 versus 302 +/- 26 ms). The increase in the right ventricular effective refractory period in patients with persistence of inducible VT was much less (from 270 +/- 28 to 287 +/- 30 ms). In all patients in whom several antiarrhythmic drugs were tested the right ventricular effective refractory period was higher when the treatment was judged to be effective (299 +/- 27 ms) than ineffective (272 +/- 27, p < 0.02). The prevention of inducible VT by class I antiarrhythmic agents seems therefore to be related to their effect on the ventricular refractory period.
Anti-Arrhythmia Agents↗
[Value of systematic preventive antibiotherapy in cardiac pacemaker implantation].
The aim of this study was to assess the usefulness of prophylactic antibiotics during insertion of a cardiac pacemaker, in order to avoid infection of exteriorisation of infectious origin. The study involved two groups. One hundred and eight patients made up group I, a control group without the use of prophylactic antibiotics. Group II consisted of 101 patients who were given an intravenous injection of 1 or 2 g of oxacillin before surgery, followed up by four days of oral oxacillin (3 g per day). Serum oxacillin levels at the end of the procedure were 0.37 +/- 0.09 mcg/ml, falling within the range of minimum inhibitory concentrations of methicillin-sensitive staphylococci. In the patients of the control group, followed up for 1 to 36 months (mean 12 +/- 11 months), during the first 2 months there were 2 infections, 4 exteriorisations and one cutaneous erosion over the pacemaker. In addition, one exteriorisation and one infection occurred at 17 and 29 months respectively. In patients with exteriorisation of their pacemaker device, there was nothing to suggest an infection and bacteriological specimens were sterile. No obvious infections nor any cutaneous complications occurred in the patients of group II, with prophylactic antibiotics, followed up for 1 to 21 months (mean 6 +/- 5 months). In conclusion, anti-staphylococcal antibiotic treatment appears not only to be capable of avoiding cardiac pacemaker infections but also of preventing exteriorisation of the pacemaker device, which may be linked to hidden infections. A randomised study is nevertheless necessary to confirm this hypothesis.
Adult↗
[Complex ventricular extrasystole. Value of programmed electric stimulation for evaluating the risk of sudden death].
A prospective study was carried out from May 1984 to July 1987 to determine the prognostic value of the results of programmed electrical stimulation (PES) in patients with complex ventricular ectopy. The study population comprised 118 patients, 80 with and 38 without apparent underlying cardiac disease. The PES consisted in at most 3 extrastimuli delivered to the right ventricular apex during 2 imposed basal rhythms. Two groups of patients were identified: Group I (n = 35; 29.6%) in which a significant ventricular arrhythmia was induced (sustained ventricular tachycardia (11 cases), non-sustained VT (21 cases) and ventricular fibrillation (3 cases); and Group II (n = 83; 70.3%) in which no significant arrhythmia could be induced. During follow-up (average 28.7 +/- 11.7 months, range 6 to 48 months) there were 10 cardiac deaths, 8 of which occurred suddenly. Sudden death only occurred in patients with cardiac disease and usually with LV ejection fraction of less than 0.40; the prevalence of sudden death in Group I (11.5%) was higher than in Group II (4.8%) but the difference was not statistically significant. The prognosis of patients in Group II was the same as that of the general population. The results of this study suggest that PES enables identification of a subgroup of patients with complex ventricular ectopy in which ventricular tachyarrhythmias cannot be induced and the risk of sudden death is low; the management of patients with inducible ventricular tachyarrhythmias and normal LV function has to be determined case by case.
Adolescent↗
[Post-traumatic fistula of the left anterior descending coronary artery and left ventricle. Apropos of a new case].
The authors report the case of a 23 year old man who presented with a continuous murmur five years after closed chest trauma. The electrocardiographic and echocardiographic findings indicated previous apical myocardial infarction. The underlying diagnosis was first suggested by continuous wave Doppler which showed systolo-diastolic flow in the septo-apical region directed towards the left ventricle (LV) in diastole. Color Doppler flow studies showed a mosaic pattern opposite a dilated left anterior descending (LAD) artery. These signs of LAD-LV fistula with a single orific were confirmed at coronary arteriography. The patient's previous history was in favour of a traumatic etiology. In the absence of left ventricular failure and myocardial ischaemia by coronary steal, surgery was deferred; Doppler echocardiography would seem to be a good method of following up the fistula and its consequences on left ventricular function. A traumatic left coronary to left ventricular fistula is an extremely rare condition and merits publication. The authors review the literature and describe the physiopathology, diagnosis and therapeutic indications of these fistulae.
Adult↗
[Electrophysiologic evaluation and follow-up of patients with a syncopal episode of unknown origin].
The etiology of syncope of presumed cardiac origin can be determined by clinical and electrocardiographic examination with Holter monitoring in about 50 per cent of cases. The aim of this study was to review the data of electrophysiological investigation and the outcome of the patients in whom a cardiac pacemaker was eventually implanted, in those cases in whom the initial work-up had been negative. Ninety four patients, all of whom underwent standardised electrophysiological investigation, were included. The results of the investigations enabled us to identify three groups of patients: Group I: patients in whom the criteria did not suggest a cardiac origin of syncope; Group II: with criteria possibly suggesting a cardiac origin and Group III in which the criteria were strongly suggestive of a cardiac origin. A cardiac pacemaker was implanted systematically for AV block in Group III; on the other hand, this was very rare (only 1 patient) in Group I, and the indication in Group II depended on age and the history of recurrent syncope. Ninety patients (96%) were followed up for an average of 39.3 +/- 15.3 months. There was a very low incidence of recurrent syncope irrespective of the original classification, so confirming the value of electrophysiological investigations for cardiac pacemaker implantation in this type of patients. In addition, negative electrophysiological investigations allowed identification of a group of patients with a low mortality and low risk of recurrent syncope.
Aged↗
[Septal rupture repaired in the acute stage of myocardial infarction. Clinical, hemodynamic and angio-coronarography findings in the evaluation of surgical risk].
Between 1977 and 1987, 27 consecutive patients (16 men, 11 women, mean age 66 years, range 54 to 75 years) with ventricular septal rupture complicating acute myocardial infarction underwent surgical repair. The purpose of this retrospective study was to analyse the post-operative mortality factors from clinical, haemodynamic and operative data in all patients and also from coronary angiographic data in 23/27 patients whose haemodynamic status allowed this type of exploration. Seventeen patients (63 p. 100) died during the first post-operative month, 10 survived and were discharged. Factors that influenced the prognosis were: (1) inferiorly-located necrosis associated with a 75 p. 100 mortality rate (9 out of 12 patients), as opposed to 53 p. 100 (8 out of 15 patients) with anterior necrosis; (2) right ventricular dysfunction, observed in 83 p. 100 of patients with inferior necrosis and 53 p. 100 with anterior necrosis, which was responsible for 7 out of 9 deaths in the inferior necrosis subgroup and contributed to 3 out of 8 deaths in the anterior necrosis subgroup; this established a cause-effect relationship between right ventricular function and the overmortality of patients with inferior necrosis; (3) independently of the haemodynamic status, two- and three-vessel lesions (56 p. 100 of all lesions) which had an 84 p. 100 mortality rate as opposed to 40 p. 100 with one-vessel lesions; (4) the presence of a state of shock which was associated with a 78 p. 100 mortality rate as opposed to 55 p. 100 in patients without shock. We conclude that when permitted by the patient's haemodynamic status coronary angiography should be part of the pre-operative evaluation to assess the operative risk and guide the surgical procedure.
Acute Disease↗
[Cardioversion by internal electric shock of permanent atrial fibrillation].
A new technique for cardioversion of chronic atrial fibrillation was used in 17 patients whose arrhythmia had resisted all attempts at electrical and pharmacologycal cardioversion. Atrial fibrillation was badly tolerated by all patients despite digitalis administered alone (8 patients) or combined with amiodarone (9 patients). Twelve patients had left atrial dilatation at echocardiography. The 200, 300 or 400 joule electrical shock was delivered between the proximal pole of a quadripolar catheter (cathode) and a back plate (anode). The catheter was positioned at the His bundle recording site then withdrawn into the right atrium. The internal shock restored sinus rhythm in 15 patients (88 p. 100). Transient atrioventricular block (3-315 sec) was observed in 8 patients. Eleven patients were discharged in sinus rhythm. In 4 patients, the atrial fibrillation recurred on day 8 and after 2, 4 and 9 months. A second shock was attempted in two patients and succeeded in one. After a mean follow-up period of 14.8 +/- 8 months (range 2 to 25 months), 8 of the 11 patients successfully cardioverted (72 p. 100) or of the attempted reductions (47 p. 100) were in sinus rhythm. The remaining 9 patients were treated with antiarrhythmic drugs (n = 5) or by his bundle catheter ablation (n = 4). High energy internal shock therefore seems to be an interesting treatment in patients with permanent atrial fibrillation after failure of external electric shock. It enabled 13 of the 17 patients in this series to avoid His bundle catheter ablation indicated by the quasi-impossibility to control the atrial rate and associated symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Electrocardiographic characteristics of the escape rhythm in transient complete atrioventricular block induced by transcatheter electrical ablation of the atrioventricular junction.
The electrocardiographic characteristics of spontaneous escape rhythm during complete heart block induced by transcatheter ablation of the atrioventricular junction was prospectively studied in 21 patients by periodically interrupting temporary pacing. The data derived from 13 of these 21 patients, in whom conduction recurred after the procedure, were analyzed. An escape rhythm was present in 12 patients 8.2 +/- 5.8 minutes after shock delivery at a cycle length of 1985 +/- 974 ms. The escape QRS had a configuration of right bundle branch block with left axis deviation in 9 patients, of right bundle branch block with normal axis in 1, of left bundle branch block with left axis deviation in 1, and 2 distinct morphologies in the remaining patient. After resumption of conduction, the conducted complexes were identical to the escape complexes in six patients, different only in axis in four patients, and different in morphology in two patients. This suggests that in the majority of patients the escape rhythm seen during transient heart block, induced by transcatheter ablation of the atrioventricular junction, presents a right bundle branch morphology with or without a left axis deviation, and most likely originates from an area above, or close to, the site of the anatomical damage.
Adult↗
[Wolff-Parkinson-White syndrome. Outcome of patients treated with anti-arrhythmia agents from data of electrophysiological examinations].
Seventy-two consecutive patients with electrocardiographic evidence of Wolff-Parkinson-White syndrome underwent electrophysiological study (EPS). Fifty-five of these patients (76 p. 100) had episodes of tachycardia, 11 experienced palpitations or syncopes and 6 were asymptomatic. The decision to prescribe an antiarrhythmic agent was reached on the basis of the patients' symptoms and EPS data. One patient was treated by surgery before the medical treatment was tried; 17 patients were discharged without treatment, 4 were discharged with an episodic and 50 with a preventive antiarrhythmic treatment. Among these 50 patients, 46 (92 p. 100) could be followed up for a mean period of 45.7 +/- 28 months. One died of lung cancer; 43 presented with spontaneous episodes of tachycardia, 4 were able to discontinue treatment at the end of the follow-up period since they had very few symptoms and 2 were lost sight of. Among the 37 patients under antiarrhythmic treatment followed up, 29 (78 p. 100) are well controlled, while 8 (22 p. 100) still present with episodes of tachycardia. A tachycardia-reducing pacemaker was implanted in 5 of these 8 patients. It therefore appears that 78 p. 100 of patients presenting with spontaneous episodes of tachycardia associated with WPW syndrome can be controlled with an antiarrhythmic treatment. This result was obtained after trying at least two types of antiarrhythmic agents in 86 p. 100 of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Post-traumatic myocardial infarction caused by dissection of the anterior interventricular artery. A case].
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Adult↗
[Internal electric shock: a new possibility for the reduction of permanent auricular fibrillation].
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Atrial Fibrillation↗
Remote occurrence of high degree heart block following failure of transcatheter AV junctional ablation: incidence and clinical significance.
We report on two patients out of a series of 22 who underwent transcatheter ablation of the atrioventricular (AV) junction. The procedure failed to induce permanent complete heart block in 15 patients, 12 of whom were in sinus rhythm with 1:1 AV conduction before hospital discharge. Of the 12 patients, two (16.6%) were found to be in high degree heart block, one month later. We discuss the mechanism of late occurrence of high degree heart block and we emphasize the need for systematic implantation of permanent ventricular or dual chamber pacemakers, despite failure of transcatheter ablation of the AV junction.
Adult↗
[Complex ventricular extrasystole. Value of technics of programmed electric stimulation].
The incidence and significance of ventricular arrhythmia induced by programmed electrical stimulation in subjects with complex ventricular ectopy were studied in 46 consecutive subjects: 34 with heart disease, 12 with an apparently normal heart. The procedure consisted of delivering on one spontaneous and 2 imposed rhythms one, two, then three extrastimuli. Significant arrhythmia with more than 6 ventricular complexes was induced in 17 patients (37%), including 6 (13%) with sustained ventricular tachycardia and 11 with unsustained ventricular tachycardia. Induction of ventricular arrhythmia was observed in 12 of the 14 patients with a history of myocardial infarction. At the end of a mean follow-up period of 12 +/- 4 months, there were 2 sudden deaths, and 3 patients had clinically sustained ventricular tachycardia. Clinical ventricular tachycardia occurred in the group of 17 patients inducible during programmed electrical stimulation. The patients who died suddenly belonged to the group of 29 patients without induced ventricular arrhythmia. This study shows a high proportion of significant stimulation-induced arrhythmia in patients who had suffered from myocardial infarction more than 3 months previously and who had complex ventricular ectopy. Owing to the good condition of this group of patients after a mean follow-up of 12 months, we were unable to determine the influence of stimulation-induced arrhythmia on mortality. However, it must be noted that spontaneous sustained tachycardia occurred in the group of patients with significant induced ventricular arrhythmia.
Adult↗
[Reduction of ventricular tachycardia by programmed electric stimulation. Clinical implications].
The mode of termination by programmed electrical stimulation of sustained ventricular tachycardia (VT) (more than 30 seconds) and induced by stimulation was investigated in 33 patients. In 27 patients (82%) programmed stimulation was possible because VT did not require an immediate electric shock or did not terminate spontaneously, but constant reduction of VT was obtained with one extrasystole in only 1 patient (3%), with two extrasystoles in 5 patients (15%) and by overdrive stimulation in 12 patients (36%). The remaining 15 patients (45%) required an external electric shock either because VT was poorly tolerated clinically, or because stimulation had failed. In 8 of the 27 cases in whom stimulation was attempted (30%), acceleration of VT was observed. A significant correlation was found between the need for electrical shock and the VT cycle length. It is concluded that reduction of VT by programmed electrical stimulation can only be successful in a limited number of patients and carries a significant risk of acceleration. These data must be taken into account when temporary treatment of VT by stimulation is contemplated. They should incite to considerable caution in the use of implantable pacemakers for tachycardia termination.
Adult↗
[Sinus dysfunction associated with catecholaminergic ventricular tachycardia. Therapeutic implications].
The presence of resting sinus bradycardia (less than or equal to 45 bpm) with junctional escapes in an 8 year old child with catecholamine induced ventricular tachycardia, raised the problem of an underlying sinus node dysfunction. This was an important consideration bearing in mind the potential risk of the high dose betablocker therapy aggravating the sinus bradycardia. Electrophysiological studies showed pathological sinus node recovery times. Betablocker therapy did not aggravate the bradycardia, even after 6 months' treatment. A review of the literature showed the association of sinus bradycardia and catecholamine-induced ventricular tachycardia to be relatively common (39 p. 100). However, no mention was found of aggravation of this sinus bradycardia by betablocker therapy.
Adrenergic beta-Antagonists↗
[Total or partial electrical interruption of the atrioventricular pathway. Evaluation of clinical results and indications].
After checking on the efficacy and innocuity of catheter ablation of the His bundle in an experimental study in the sheep, 22 patients with supraventricular tachycardia resistant to an average of 5.5 +/- 1.7 antiarrhythmic drugs per patient underwent this procedure. The most common arrhythmias were atrial fibrillation or flutter (poorly tolerated in 14 cases), and reciprocating tachycardia (8 cases, including 3 with accessory atrioventricular pathways). In 3 of the 5 patients with intranodal tachycardia, an initial attempt was made to modify one of the two AV nodal conduction pathways. Although complete atrioventricular block was obtained in all patients, atrioventricular conduction returned in 15 patients between the 30th minute and 4th day after the procedure. A second attempt at His bundle ablation was carried out in 9 patients. During follow-up ranging from 1 to 38 months, complete or an advanced degree of atrioventricular block persisted in 5 patients, the other patients being in sinus rhythm (12 cases) or slow atrial fibrillation (2 cases). The remaining patient who was in complete atrioventricular block died of septicaemia 2 months after the procedure. The clinical results were evaluated by electrophysiological investigation, exercise testing and Holter monitoring. There were 15 satisfactory clinical results (83.3 p. 100) and 3 poor results. This series shows that interruption or modification of the normal atrioventricular conduction pathway may be performed at low risk and with good results in a high percentage of cases. It is a valuable therapeutic option in patients with supraventricular tachycardia resistant to antiarrhythmic therapy.
Adult↗