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Tachycardia (> 270 Beats Per Minute) Provoked at Programmed Stimulation in Patients Without Br Heart J: First Published As 10.1136/Hrt.69.1.20 on 1 January 1993

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Tachycardia (> 270 Beats Per Minute) Provoked at Programmed Stimulation in Patients Without Br Heart J: First Published As 10.1136/Hrt.69.1.20 on 1 January 1993 20 Br HeartJ_ 1993;69:20-25 Clinical significance of rapid ventricular tachycardia (> 270 beats per minute) provoked at programmed stimulation in patients without Br Heart J: first published as 10.1136/hrt.69.1.20 on 1 January 1993. Downloaded from confirmed rapid ventricular arrhythmias Beatrice Brembilla-Perrot, Arnaud Terrier de la Chaise, Serge Brianqon, Maeva Takoordial, Christine Suty-Selton, Bernard Thiel, Jean Luc Brua Abstract patients who had inducible ventricular flutter Rapid uniform ventricular tachycardia and who did not have history of cardiac arrest (VT) (> 270 beats/min) or ventricular or rapid VT and compared the results with flutter induced during electrophysio- their clinical outcome. logical studies is thought not to be clini- cally significant in patients without cardiac arrest or documented rapid VT. Patients and methods The purpose of the study was to follow up PATIENTS 73 patients with inducible ventricular Ventricular flutter was induced by ventricular flutter but without confirmed rapid spon- stimulation in 73 (mean (SD) age 57 (12), taneous VT. A long follow up (mean 3-5 range 36-77) of the 1100 consecutive patients years) identified two groups of patients. who had electrophysiological testing between The first group had an excellent outcome January 1982 and December 1989 because of and was characterised by a normal 24 syncope, dilated cardiomyopathy, or myocar- hour Holter monitoring. In the second dial infarction. For the purpose of this analy- group, however, the risk of cardiac mor- sis, ventricular flutter was defined as having a tality was high (35%) and spontaneous cycle length of < 214 ms, being uniform on a VT was < 270 beatslmin (26%) and was 12 lead electrocardiogram, having an uniform characterised by couplets or salvos of QRS configuration and axis, having constant extrasystoles on Holter monitoring. In rate, and requiring overdrive pacing or defib- this group the history of syncope and rillation because of circulatory collapse and decreased left ejection fraction increased loss of consciousness. All patients with spon- the risk of mortality and VT. The pres- taneous cardiac arrest or documented rapid http://heart.bmj.com/ ence of late potentials increased the VT were excluded. risk of spontaneous VT. Electrophysio- Sixty patients had coronary disease and a logically guided antiarrhythmic therapy history of myocardial infarction. Five had reduced the risk of VT. idiopathic dilated cardiomyopathy, three had Ventricular flutter was a non-specific hypertrophic cardiomyopathy, two had mitral finding in patients with normal Holter valve prolapse, and one had corrected tetra- monitoring. In contrast, in patients with logy of Fallot. Two patients had no clinical on September 28, 2021 by guest. Protected copyright. salvos of extrasystoles, ventricular flutter evidence of heart disease. was associated with a high risk of cardiac The indication for ventricular stimulation mortality and VT. was unexplained syncope or dizziness (27 patients) and systematic evaluation at least (Br HeartJ 1993;69:20-25) one month after myocardial infarction to Department of identify patients at risk of ventricular tachy- Cardiology, Brabois Ventricular fibrillation (VF) induced during cardia (n = 41) or for systematic evaluation University Hospital, electrophysiological studies is believed to be a of patients with idiopathic dilated cardio- Vandoeuvre Les = Nancy, France non-clinical response in patients without myopathy (n 5). B Brembilla-Perrot clinical fibrillation' 2 whereas induced multi- A Terrier de la Chaise form ventricular tachycardia (VT) is an useful ELECTROPHYSIOLOGICAL STUDIES M Takoordial their informed consent C Suty-Selton index of electrical instability in patients with After they had given J Luc Brua cardiac arrest and haemodynamically sympto- patients were studied in a fasting non-sedated B Thiel matic VT.3 The clinical significance of state. Antiarrhythmic therapy was discon- Department of inducible rapid uniform VT or ventricular tinued for at least four half lives before the Epidemiology, flutter in patients without a history of cardiac study. Three quadripolar or bipolar electrode Brabois University and Hospital, Vandeouvre arrest or rapid VT is less established. Some catheters were inserted percutaneously Les Nancy, France. reports claim that the induction of ventricular were positioned in the heart under fluoro- S Briancon flutter after myocardial infarction is of no scopic guidance. The right ventricle was stim- Correspondence to: clinical unlike the induction of ulated at the apex and infundibulum with a Dr Beatrice significance,45 Brembilla-Perrot, a uniform and relatively slow arrhythmia. The programmable stimulater (Explorer 2000 Ela) Cardiologie, Chu De significance of ventricular flutter when it is that delivered square wave electrical impulses Brabois, 54500 Vandoeuvre, set at France. associated with another underlying heart dis- of 1-8 ms duration with the amplitude ease is not known. twice the diastolic threshold. Accepted for publication 7 August 1992. We analysed data from 73 consecutive Our protocol for ventricular premature Clinical significance of rapid ventricular tachycardia (> 270 beats per minute) provoked at programmed stimulation 21 Table 1 Clinical characteristics and outcome in patients with inducible ventricular electrocardiographic monitoring and serial flutter programmed stimulation were used to deter- mine the appropriate drug. If the class I drug Cardiac SD VT Alive mortality (VT-VF excluded) (+VF) (VT excluded was ineffective, amiodarone was tested and Br Heart J: first published as 10.1136/hrt.69.1.20 on 1 January 1993. Downloaded from Variable (n = 14) (n = 6) (n = 10) (n = 53) then a combination of P blocker and amio- Age (yr) (mean (SD)) 52 (15) 37 (17) 57 (17) 57 (11) darone. All 36 patients were treated with a Syncope (%) 10/14 (71%) 4/6 (67%) 7/10 (70) 14/53 (26) combination of at least a class I drug LVEF 31 (16) 35 (19) 29 (13) 46 (5) and Late potentials 5/7 1/2 6/7 15/35 (43%) amiodarone. At electrophysiological testing Holter monitoring 12/14 (86%) 6/6 9/10 15/53 (32%) protection was defined as the inability (grade IVA-IVB) to Treatment follow up: provoke either a sustained VT or a non None* 3 1 4 39 sustained VT (> 15 repetitive 8In AA: protected 3 2 0 7 responses). AA: not protected 8 3 6 7 13 patients an effective drug regimen was identified. When the VT was still inducible SD, sudden death; VT, ventricular tachycardia; VF, ventricular fibrillation; LVEF, left ven- tricular ejection fraction. the patient was treated with the drug that *Patient was not given an antiarrhythmic drug (AA). Protected, VT induction was supressed by resulted in the disappearance of ventricular AA. Not protected, patient received AA drug but the VT was still inducible. extrasystoles on the Holter monitoring, increased the tachycardia cycle length, and was tolerated best.9 stimulation has been described elsewhere.6 Ventricular overdrive pacing was performed STATISTICAL ANALYSIS at cycle lengths of 500-300 ms. Ventricular Continuous values were expressed as the programmed stimulation was then performed at three cycle lengths (sinus and 600, and 400 ms) with one and two extrastimuli. If VT, ventricular flutter, or VF was not initiat- ed, the next ventricular site was then stimu- lated in a similar fashion until VT, ventricular flutter, or VF lasting ) 30 seconds or circula- tory collapse was initiated. SIGNAL AVERAGED ELECTROCARDIOGRAPHY A signal-averaged electrocardiogram was VT obtained on the same day as programmed stimulation in 45 patients without bundle branch block. Recordings were processed and - CD analysed according to the methods described 0) by Simson7 by electrocardiograph developed a) http://heart.bmj.com/ by the Dr Ing Osypka GmbH. We measured the magnitude of the high frequency signal in the last 40 ms of the QRS complex (V40) and the total QRS duration. Late potentials were defined as a root mean c._ square of the amplitude of the signal that was s 20 jV in the last 40 ms of the filtered QRS. 4. on September 28, 2021 by guest. Protected copyright. QRS duration was regarded as abnormal ._08 when it was > 120 ms. Signals were analysed CU without knowledge of the clinical status of the E patient. 00) OTHER INVESTIGATIONS Ambulatory electrocardiographic monitoring Twenty four hour ambulatory electrocardio- graphic recordings were analysed manually. The total number of extrasystoles each hour and every 24 h was noted, as was the maxi- 0-20 mum Lown grade. Radionuclide ventriculography The resting left ventricular ejection fraction (LVEF) was measured during sinus rhythm by 9QmTc radionuclide ventriculography and computer generated time activity curves. 0-0 FOLLOW UP During follow up, 36 patients in whom frequent extrasystoles of Lown grade IVA or IVB were recorded during ambulatory Months electrocardiographic monitoring were started Figure 1 Life table analysis with survival curves for total on antiarrhythmic drugs. Oral therapy was cardiac deaths (CD) andfor ventricular arrhythmic events started with a class I drug and ambulatory (VT)). 22 Brembilla-Perrot, Chaise, Brianpon, Takoordial, Suty-Selton, Thiel, Brua tricular flutter before overdrive pacing or defibrillation was 18 s. Sixty four patients No syncope required transthoracic direct current defibril- lation with 200 to 4001 because of circulatory Br Heart J: first published as 10.1136/hrt.69.1.20 on 1 January 1993. Downloaded from collapse and loss of consciousness. In the VT nine remaining patients ventricular flutter was .-- stopped by overdrive pacing. The frequency of ventricular flutter varied from 280 to 340 080 CD beats/min (mean 305 beats/min). Signal-averaged electrocardiogram Twenty seven patients had late potentials and the cope VT remaining patients (n = 23) had a normal -_______ signal-averaging. a) a) Ambulatory electrocardiographic monitoring- 4-5., Lown grade IVA or IVB ventricular arrhy- 060 thmias were seen in 36 patients. VT was non a) CD sustained. All episodes of VT with ) 10 c cn C cL EF ¢ 40% 0Q 0 > 0.40 a) VT ) CD E U3 0.20 -VT CD http://heart.bmj.com/ , , 0.0 10 20 30 40 50 60 70 80 Months on September 28, 2021 by guest.
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