[Syncope in ventricular tachycardia as a first clinical sign of patent ductus arteriosus in an adulthood]

The case-report describes a 48-year-old-female patient with the patent ductus arteriosus with the following structural changes leading to the malignant arrhythmias manifested as a syncope. The patient was treated by Amplatzer occluder and the implantation of the cardioverter-defibrillator. The authors discuss the patent ductus arteriosus, arrhythmias and sudden cardiac death in the patients with the congenital heart disease in an adulthood.

[Ventricular fibrillation in chronic heart disease]

The objective of the work was to describe in subjects with spontaneous ventricular fibrillation, after elimination of acute cardiac disease, the strategy of antiarrhythmic treatment and to evaluate, based on prospective follow-up, the effectiveness of this treatment. The authors included in the group 36 patients (30 men and 6 women) within the range from 34 to 78 years (mean age 58 +/- 11 years) with spontaneous ventricular fibrillation. They divided the group into a subgroup (15 subjects) without revascularization of the heart muscle, into a subgroup (17 subjects) with revascularization of the myocardium (coronary angioplasty and bypasses) and a subgroup (4 subjects) where ischaemic heart disease was ruled out (mostly cardiomyopathies). In all subgroups they used programmed ventricular stimulation (apparatuses of Quinton Co. USA, Biotronik Co. GFR), in the subgroup with revascularization within 3 months. During the diagnostic procedure of ventricular stimulation they tested antiarrhythmic drugs most frequently amiodarone per os (for 4 weeks). An implantable cardioverter--defibrillator was implanted in 17 patients (8 subjects without revascularization, 6 subjects with revascularization, 3 subjects without ischaemic heart disease). All patients were followed up till death, maximum 24 months. The authors evaluated the rate of cardiac deaths (death on cardiac grounds, incl. sudden arrhythmic death) and sudden arrhythmic deaths (within one hour after the onset of symptoms or the first malignant ventricular tachyarrhythmia recorded after implantation of the defibrillator). In the subgroup without revascularization with electric instability of the ventricles according to programmed stimulation 66.7% they described seven cardiac deaths (46.7%) and 6 sudden "arrhythmic" deaths (40%) incl. 5 subjects with ineffective testing of antiarrhythmic drugs. Conversely in the subgroup with revascularization and with diagnostic programmed stimulation in 47.1% they found 3 cardiac deaths (17.7%), one sudden "arrhythmic" death (5.9%)--a subject with ineffective testing. In the subgroup without ischaemic heart disease they recorded cardiac and sudden "arrhythmic" deaths in half the subjects, in all instances in subjects without inducible ventricular tachyarrhythmia. The authors found in the course of a two-year investigation a relapse of cardiac arrest in 25% of subjects after spontaneous ventricular fibrillation. A third of these subjects (all without a cardioverter-defibrillator) died. They confirm the benefit of implantation of a defibrillator for all subjects regardless of the basic diagnosis and revascularization of the heart muscle.

[Myocardial revascularization in malignant ventricular tachyarrhythmia--prognostic significance]

BACKGROUND

The survival of patients with chronic ischaemic heart disease and malignant ventricular tachyarrhythmia is influenced positively in some instances by revascularization of the heart muscle and implantation of a cardioverter-defibrillator. The objective of the submitted work was to evaluate by perspective follow-up of subjects with chronic ischaemic heart disease and malignant ventricular tachyarrhythmia: a) the effect of revascularization of the heart muscle on the prognosis, making use of programmed stimulation of the ventricles and testing the effectiveness of antiarrhythmic treatment; b) the importance of implantation of a cardioverter-defibrillator in revascularized and non-revascularized subjects for the prevention of sudden "arrhythmic" deaths.

METHODS AND RESULTS

The authors examined 37 patients (32 men and 5 women), age bracket 34 to 78 years (mean age 61 +/- 11) with IHD and spontaneous ventricular tachyarrhythmia after ruling out acute myocardial infarction. The group was divided into sub-groups without revascularization (21 subjects) and with revascularization (16 subjects). In both sub-groups programmed stimulation of the ventricles was implemented. During the diagnostic finding of programmed stimulation they tested antiarrhythmic drugs, most frequently amiodarone administered orally. A cardioverter-defibrillator was implanted to 10 patients. All patients were followed-up to death, the longest period being 24 months. They evaluated the frequency of cardiac deaths (death on cardiac grounds incl. sudden "arrhythmic" death) and sudden "arrhythmic" deaths (death within on hour after onset of symptoms or first recorded malignant ventricular tachyarrhythmia). In the sub-group without revascularization with diagnostic inducibility of the heart muscle in 85.7% of patients the authors described 9 cardiac deaths (42.9%) and 8 sden "arrhythmic" deaths (38.1%). Conversely in the sub-group with revascularization and with diagnostic programmed stimulation of the ventricles in half the subjects 5 clinical deaths were found (31.3%) and 3 sudden "arrhythmic" deaths (18.8%). Analysis of 11 sudden "arrhythmic" deaths revealed that no subjects with an implanted cardioverter-defibrillator (5) died (documented malignant ventricular tachyarrhythmia). Five of the six patients who died (all without a cardioverter-defibrillator) were not revascularized.

CONCLUSIONS

Revascularization of the heart muscle in patients with ischaemic heart disease (after elimination of acute cardiac infarction) and malignant ventricular tachyarrhythmia reduces the risk of relapse of this arrhythmia. The benefit of implantation of a cardioverter-defibrillator was recorded in all subjects regardless of the revascularization of the heart muscle.

[Revascularization of the myocardium and electrical instability of the ventricles]

The objective of the investigation was to evaluate in patients with chronic ischaemic heart disease (IHD) and malignant ventricular tachyarrhythmia the asset of myocardial revascularization for improvemet of the electric instability of the ventricular myocardium and a subsequent outline of the tactics of antiarrhythmic treatment. The authors included in the group a total of 35 patients (30 men and 5 women), age 34-78 years (mean 61 +/- 11) with IHD (according to selective coronarography) with spontaneous ventricular fibrillation (18 sebjects) or persistent (above 30s) marked symptomatic ventricular tachycardia (17 subjects), after ruling out acute cardiac infarction. The group was divided into a subgroups of 16 subjects with revascularization of the heart muscle (coronary angioplasty, coronary bypass) and a subgroup (19 subjects) without revascularization of the hearth muscle. In both groups programmed stimulation of the cardiac chambers was implemented (PSSK) (apparatuses of Qinton Co. USA, Biotronik, GFR), in the subgroup after revascularization within three months. In case of a PSSK finding the authors tested antiarrhythmic drugs, most frequently amiodarone by the oral route (within one month). Treatment not causing permanent ventricular arrhythmia was considered effective. In the subgroup with revascularization the authors described diagnostic PSSK in 8 subject where testing of antiarrhythmics was made in 6 patients (an effective antiarrhythymic agent was found in one instance, i.e. in 16.7%). In the subgroup without revascularization diagnostic PSSK was implemented in 17 subject. Antiarrythmic drugs were tested in 16 patients (effective treatment in 12.5%--always amiodaroe by the oral route). Diagnostic ventricular tachyarrhythmia was found in patients with spontaneous ventricular tachycardia in all instances with revascularization and in 92.3% without revascularization. In patients with spontaneous ventricular fibrillation they proved diagnostic PSSK in 33.3% of the patients with revascularization and in 66.7% without revascularization. The relative number of implantation of cardioverter-defibrillators in group with and without revascularization was similar (25%, 26.3%). Revascularization of the heart muscle in patients with chronic IHD reduces markedly the electric instability of the ventricular heart muscle, in particular in case of spontaneou ventricular fibrillation. Selective coronarography and possibly revascularization of the heart muscle is esential in those patients. The tactics of antiarrhythymic treatment of revascularization of the heart muscle were not affected.

Atrial contribution to ventricular ejection in sequentially paced patients

A new method for quantitative assessment of the atrial contribution to ventricular ejection in sequentially paced patients is described. The atrial contribution (AC) has been defined as the pulse pressure decrement (invasive arterial measurement by a canulla inserted into the brachial artery), expressed in percent of the control pulse pressure, induced by switching off the atrium activating impulse for one beat. In 17 patients, the AC was found to be atrioventricular (AV) interval dependent, the measurements were well reproducible (the mean difference between two measurements at different times was 93%, S.D. 8.4). For the AV interval of 170 ms, it was found to be 293% (+8.9) in patients with the sick sinus syndrome, 27.0% (+3.2) in patients with complete AV block and only 10.8% (+2.1) in a patient with complete AV block and heart dysfunction.

[Recurrent spontaneous dislocation of the catheter in a venous vascular access port system]

The authors describe the problem of spontaneous changes of the position of the catheter in venous vascuports with a cannula inserted via the vena subclavia or internal jugular vein into the vena cava superior, used most frequently for repeated administration of chemotherapy. The correct position of the catheter is important in the venous port system for the proper function of the whole system. During dislocation of the catheter the function is impaired to a varying extent and the number of inflammatory and thrombotic complications increases and dislocations beyond the venous system lead to extravasal administration of the drug. Possible diagnosis of this condition and subsequent correction of the position of the cannula is described in a 48-year old man who developed spontaneous dislocation of the position of the cannula from the vena cava superior into the internal jugular vein. Correction by means of a hook inserted via the ipsilateral femoral vein into the vena cava inferior and via the vena cava superior into the internal jugular vein was successful only temporarily. Because of repeated dislocation the port system was removed.

[A fully implantable port system for venous access. Personal experience with 91 patients]

A fully implantable venous port system with a cannula inserted into the central venous system was implanted to 91 patients. The system was used for the administration of different types of intravenous preparations, incl. transfusions of erythrocyte mass and parenteral nutrition. With in the framework of autologous transplantation via the port system haematopoietic progenitor cells from the peripheral blood stream were administered. Part of the introduced systems was used for monitoring of the central venous overpressure and for collecting blood samples. The system was introduced on an average for 289 days, with a median of 245 days, range 82-872 days. During the implantation seven complications developed, in three instances the port was removed prematurely. During treatment 16 complications were observed, which in six instances led to early explantation of the venous port. The number of complications in total amounted to 0.87 per 1000 treatment days. The system was well tolerated by the patients because of its functional effectiveness and minimal cosmetic changes, and because it is not demanding it was also accepted well by the nursing staff.

[The role of the atrium and optimal values of AV intervals in sequentially paced patients]

In 1995, 2249 dual chamber pacemakers were implanted in the Czech Republic. These pacemakers make it possible to set an optimal AV delay between the atrial and ventricular impulse. Although the optimization of the AV interval has its well defined physiologic advantages, it does not seem to be necessary in otherwise healthy individuals with a good atrial and ventricular function. In these patients the default value, usually about 170 ms, is acceptable. However, AV interval optimization--i.e. finding the interval at which the atrial contribution to ventricular filling is maximal--should be done in all patients with left ventricular dysfunction, indicated for pacing because of bradyarrhthmia. In this subset of patients, even a small improvement in ventricular filling is believed to be clinically useful. Moreover, it has been documented, that in some types of ventricular dysfunction the so-called "primary optimization" (i.e. optimization of the AV interval in patients, in whom the pacemaker is not indicated for bradyarrhthmia but for ventricular dysfunction that might be improved by AV interval optimization) may be clinically useful. It is the case in patients with hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy with presystolic regurgitation and AV interval prolongation, and perhaps even in some patients with impairment of ventricular systolic function and substantial prolongation of the AV interval. Despite all that, optimization of the AV interval is not routinely performed because even the best available optimization procedures (stroke volume measurements at different AV intervals by aortic Doppler echography) is observer dependent, time-consuming and costly.

[Severe antihistamine poisoning complicated by ventricular tachycardia]

A 26-year-old female clerk without previous heart disease ingested with suicidal intensions antihistaminic drugs--H1 blockers, astemizole (a total of 700 mg) and terfenadine (a total of 900-1200 mg). The main sign of intoxication was repeated polymorphous ventricular tachycardia type torsade de pointes, which at the onset of hospitalization changed into ventricular fibrillation. Therapeutically the impaired rhythm was controlled by electric cardioversion and atrial stimulation with a frequency of 120/min. On the third day it was possible to discontinue atrial stimulation and later the patient was discharged without any permanent sequelae.