Management of Cardiac Arrhythmias

536 Pages·2002·13.85 MB·English

by  Mark E. Josephson MD

M CCC A
ANAGEMENT OF ARDIAC RRHYTHMIAS
C C
ONTEMPORARY ARDIOLOGY
CHRISTOPHER P. CCCANNON, MD
SSSERIESS EEEDITOR
Management of Cardiac Arrhythmias, edited by Leonard I. Ganz, MDD, 2002
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M
ANAGEMENT OF
C A
ARDIAC RRHYTHMIAS
Edited by
L I. G ,
EONARD ANZ MD
University of Pittsburgh Medical Center,
Pittsburgh, PA
Foreword by
E B ,
UGENE RAUNWALD MD
Brigham and Women's Hospital, Partners Health Care System,
and Harvard Medical School, Boston, MA
SPRINGER SCIENCE+BUSINESS MEDIA, LLC
© 2002 Springer Science+Business Media New York
Originally published by Humana Press Inc. in 2002
Softcover reprint of the hardcover 1st edition 2002
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Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information
published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the
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This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility
of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsi-
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Cover design by Patricia F. Cleary.
Cover illustration: Shown are four surface ECG leads ( I, III, aVL, and V) and an intracardiac recording (proximal
2
coronary sinus) in a patient with recurrent supraventricular tachycardia due to a manifest right posteroseptal accessory
pathway (Wolff-Parkinson-White Syndrome). Sinus rhythm is present. A delta wave and short PR interval are due to
ventricular pre-excitation; the atrial and ventricular electrograms in the proximal coronary sinus are continuous. At the
left of the figure, radiofrequency energy is applied to a catheter positioned at the site of the accessory pathway in the
posteroseptal tricuspid annulus. After three beats, the delta wave disappears, the PR interval normalizes, and the atrial
and ventricular electrograms separate, signifying successful ablation of the accessory pathway. Wolff-Parkinson-White
Syndrome, supraventricular tachycardia, and radiofrequency catheter ablation are discussed in detail in Chapters 3 and 4.
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Library of Congress Cataloging-in-Publication Data
Management of cardiac arrhythmias/edited by Leonard I. Ganz.
p. ; cm. – (Contemporary cardiology)
Includes bibliographical references and index.
ISBN 978-1-61737-218-6 ISBN 978-1-59259-090-2 (eBook)
DOI 10.1007/978-1-59259-090-2
1. Arrhythmia–Treatment. 2. Electric countershock. I. Ganz, Leonard I. II.
Contemporary cardiology (Totowa, N.J. : unnumbered)
[DNLM: 1. Arrhythmia–therapy. 2. Electrophysiology. WG 330M266 2002]
RC685.A65 M337 2002
616.1'2806–dc21 2001039366
D
EDICATION
For my parents, who instilled in me a life-long desire to learn; my wife Sue Ellen, who
continues to teach me the most important things; and my children Rachel, Alana, and
Michael, who keep me in rhythm.
Leonard I. Ganz,MD
v
F
OREWORD
During the past decade there have been enormous advances in the management of
patients with cardiac arrhythmias. Catheter ablation has become a first-line therapy for
a growing number of supraventricular tachyarrhythmias and idiopathic ventricular
tachycardia. Frequently performed on an outpatient basis, radiofrequency catheter
ablation actually cures the majority of patients with these disorders, restoring a normal
quality of life.
Implantable cardioverter defibrillators (ICDs) have progressed from a therapy of last
resort at the time of FDA approval in 1985, to the preferred therapy in the majority of
patients with life-threatening ventricular arrhythmias. ICD implantation, once a morbid
cardiothoracic surgical procedure, is now similar to pacemaker implantation. Advances
in pacemaker technology have restored normal physiology to many patients; current
trials focus on the utility of multisite atrial pacing to prevent atrial fibrillation and
biventricular pacing (cardiac resynchronization) in patients with advanced congestive
heart failure. For patients with syncope, new diagnostic approaches such as the implant-
able loop recorder, as well as new therapies, offer improved outcomes.
New nonpharmacologic therapies have been developed for virtually every type of
cardiac arrhythmia. Previously the mainstay of therapy for arrhythmia patients, pharma-
cologic therapies have assumed an adjunctive rather than primary role in many patients.
This paradigm shift, from pharmacologic to nonpharmacologic therapies, the prolifera-
tion of the types of devices and procedures available, as well as the growing number of
patients who may benefit, require that cardiac electrophysiologists keep their colleagues
in general cardiology, cardiac surgery, and primary care updated. The purpose of this
fine text is to help inform these physicians and surgeons about recent advances in the
diagnosis and management of patients with cardiac arrhythmias, and to describe how
electrophysiologists can best assist in the care of their patients. Written by leaders in the
field of cardiac electrophysiology, and well edited by Leonard I. Ganz,Management of
Cardiac Arrhythmiasprovides lucid descriptions of diagnostic and therapeutic strate-
gies in patients with heart rhythm disturbances. Tables, figures, and treatment algo-
rithms are used extensively to make this book a practical clinical guide as well as an
excellent reference source. This book will prove to be of enormous value both to special-
ists and generalists responsible for the care of patients with cardiac arrhythmias.
Eugene Braunwald, MD
Boston, MA
vii
P
REFACE
The last ten years have witnessed a tremendous change in the management of patients
with cardiac arrhythmias. Cardiac electrophysiology has evolved from a purely descrip-
tive discipline into an interventional field, in which procedures developed over the last
fifteen years directly improve the survival and quality of life of a broad population of
patients. Radiofrequency catheter ablation and implantable cardioverter defibrillator
(ICD) implantation have become standard therapies, and in many cases are performed
on an outpatient basis.
A recurring theme has been the development of new nonpharmacologic therapies for
virtually every type of cardiac arrhythmia. Unlike in the past, pharmacologic therapies
are frequently supplemental rather than primary therapy. Atrial fibrillation, the most
common sustained arrhythmia encountered, has recently been the target of a variety of
nonpharmacologic therapies. Previously considered unattainable, a curative catheter
ablation procedure for atrial fibrillation appears within reach.
This major shift in paradigm—from pharmacologic to nonpharmacologic therapies—
has been accompanied by a marked expansion in the pool of patients who may benefit
from these therapies. The mission of this text is to help inform our colleagues in general
cardiology and primary care about recent advances in the diagnosis and management of
patients with cardiac arrhythmias. Written by leaders in the field of cardiac electrophysi-
ology, Management of Cardiac Arrhythmias provides both an overview and in-depth
discussion of diagnostic and therapeutic strategies in patients with heart rhythm distur-
bances. Tables, figures, and treatment algorithms are used extensively to make this book
a practical clinical guide as well as a reference. After an historical perspective on the
development of cardiac electrophysiology is a chapter outlining the evaluation of patients
with arrhythmia. From there, supraventricular tachycardia, atrial fibrillation, syncope,
ventricular tachycardia, and sudden cardiac death are covered. There are also chapters
devoted to specific treatment modalities, including catheter ablation, pacemakers, and
implantable cardioverter defibrillators. Finally, the book closes with detailed reviews
describing the management of special populations with arrhythmia: children, pregnant
and nursing women, and patients suffering acute myocardial infarction.
In editing this text, I have been extremely privileged to have had the opportunity to
work with such distinguished colleagues. It has been a pleasure, and I have learned a
great deal from the contributors. I would like to thank Kim Potter, Craig Adams, and Paul
Dolgert at Humana Press for their hard work and dedication to this project, and to
Christopher Cannon, MD, the Contemporary CardiologySeries Editor, for giving me this
opportunity. Finally, I would like to thank several individuals who have been instrumen-
tal in my development as a physician and electrophysiologist. Elliott Antman and Eugene
Braunwald triggered my interest in cardiology as well as academic medicine. Peter Fried-
man and William Stevenson sparked and nurtured my interest in cardiac electrophysiol-
ogy. Mark Josephson has been and continues to be a tremendous inspiration, instilling
ix
x Preface
in me the desire to take care of patients with arrhythmias, to understand the mechanisms
of arrhythmias, and to teach others.
Leonard I. Ganz,MD
C
ONTENTS
Dedication ......................................................................................................................v
Foreword ..................................................................................................................... vii
Preface...........................................................................................................................ix
Contributors................................................................................................................ xiii
Color Plates..................................................................................................................xv
1 Historical Perspectives on Clinical Cardiac Electrophysiology......1
Mark E. Josephson, Leonard I. Ganz, and Hein J. J. Wellens
2 Diagnosis of Cardiac Arrhythmias...................................................9
Allison W. Richardson and Peter J. Zimetbaum
3 Approach to the Patient with Supraventricular Tachycardia.........29
Leonard I. Ganz
4 Catheter Ablation of Supraventricular Tachycardias.....................51
Walter L. Atiga and Hugh Calkins
5 Approach to the Patient with Atrial Fibrillation ............................75
Otto Costantini and Bruce Stambler
6 Pharmacologic Management of Atrial Fibrillation........................97
John K. Finkle, Kenneth Plunkitt, and Peter R. Kowey
7 Nonpharmacologic Treatment of Atrial Fibrillation....................119
Peter Gallagher and J. Marcus Wharton
8 Percutaneous Catheter Ablation to Cure Atrial Fibrillation........145
David Schwartzman
9 The Management of Atrial Flutter ..................................................163
Robert W. Rho and David J. Callans
10 Evaluation and Management of Syncope.....................................183
Blair P. Grubb and Daniel Kosinski
11 Bradyarrhythmias and Indications for Pacing:
Current and Emerging..............................................................209
Robert W. Peters and Michael R. Gold
12 Approach to the Patient with Ventricular Tachycardia
or Ventricular Fibrillation ........................................................233
Reginald T. Ho and Francis E. Marchlinski
13 Nonsustained Ventricular Tachycardia:
Evaluation and Treatment........................................................265
Brian Olshansky
xi
xii Contents
14 Indications for Implantable Cardioverter Defibrillators:
Current and Emerging..............................................................297
Richard N. Fogoros
15 Implantable Cardioverter Defibrillator Therapy:
Technical and Implant Issues...................................................317
Ralph S. Augostini, Robert A. Schweikert,
and Bruce L. Wilkoff
16 Pharmacologic Therapy of Ventricular Tachyarrhythmias .........331
Kelley P. Anderson, Susan Brode, Venkateshwar Gottipaty,
Alaa Shalaby, Vladimir Shusterman, and Raul Weiss
17 Center Ablation of Ventricular Tachycardia................................359
William G. Stevenson
18 Long QT Syndrome, Brugada Syndrome, Right Ventricular
Cardiomyopathy, Hypertrophic Cardiomyopathy,
and Commotio Cordis...............................................................379
Eric J. Rashba, Mark S. Link, and N. A. Mark Estes III
19 Cardiac Arrhythmias During AcuteMyocardial Infarction.........419
Leonard I. Ganz and Elliott M. Antman
20 Arrhythmias in Pediatric Patients: Special Considerations.........461
John K. Triedman
21 Arrhythmias During Pregnancy: Special Considerations............491
José A. Joglar and Richard L. Page
Index..............................................................................................509