bluuebunny/crossref_metadata_2025 huggingface dataset:
Heart Rate Turbulence After Atrial and Ventricular Premature Beats: Relation to Left Ventricular Function and Coupling Intervals
Authors: SAVELIEVA IRINA , WICHTERLE DAN , HARRIES MONICA , MEARA MAGGIE , CAMM A. JOHN , MALIK MAREK
Published: December 2004

SAVELIEVA, I., et al.: Heart Rate Turbulence After Atrial and Ventricular Premature Beats: Relation to Left Ventricular Function and Coupling Intervals.
Heart rate turbulence (HRT) represents a biphasic chronotropic response of the sinus node to a single ventricular premature beat (VPB). Objectives: To determine whether HRT is present after an atrial premature beat (APB) and to investigate the effects of paced VPB and APB coupling intervals on HRT quantifiers in patients with and without left ventricular dysfunction. Methods: A total of 37 subjects (

54 ± 16

years, 32 men) referred for electrophysiologic evaluation for ventricular tachycardia underwent a stimulation protocol consisting of 3 series of single atrial and ventricular extrastimuli with coupling intervals decremented from 750 to 400 ms at a 50 ms‐step. Turbulence onset (TO) and turbulence slope (TS) after an APB and a VPB were calculated separately using a dedicated computer algorithm. Results: After an APB, TS was significantly attenuated (

3.95 ± 0.99

vs

8.32 ± 1.9 ms/RR, P < 0.008

) and TO was positive (

1.37 ± 0.35%

vs

‐2.03 ± 0.42%, P < 0.001

) compared with those after a VPB. There was a strong correlation between TS

(r = 0.71, P = 0.0002)

but not between TO

(r = 0.07, P = 0.074)

after an APB and a VPB. In subjects with normal ejection fraction, the prematurity of ventricular coupling intervals was strongly related to TO

(r = 0.68)

and TS

(r =−0.61), P < 0.0001

for both. These effects were less pronounced in patients with left ventricular dysfunction (TO:

r = 0.25
, P < 0.01; TS:r =−0.07, P = ns). No correlation was found between the APB coupling interval and TS or TO in both groups. Conclusions: An APB induces HRT but the response is substantially attenuated and is not influenced by the APB coupling interval. In contrast to a VPB, TO is positive after an APB. Lack of correlation between HRT after a VPB and the VBP coupling interval indicates blunted baroreflex response in patients with left ventricular dysfunction. (PACE 2003; 26[Pt. II]:401–405)
Cardiac Arrhythmias and Risk Stratification After Myocardial Infarction:
Authors: HUIKURI HEIKKI V. , MAHAUX VÉRONIQUE , BLOCH‐THOMSEN POUL‐ERIK ,   CARISMA Investigators
Published: December 2004

HUIKURI, H.V.,

et al

.: Cardiac Arrhythmias and Risk Stratification After Myocardial Infarction: Results of the CARISMA Pilot Study.
CARISMA is a multicenter study enrolling patients with a left ventricular ejection fraction ≤40% after acute myocardial infarction (AMI), in whom an electrocardiogram (ECG) loop recorder (ILR) is implanted to measure the incidence of tachyarrythmia and bradyarrhythmia episodes. The value of 24 hour ambulatory ECG, signal‐averaged ECG late potentials, QT dispersion, T wave alternans, and electrophysiologic testing as predictors of life‐threatening arrhythmias is examined. The study tested the automatic documentation of arrhythmias by the ILR in 30 post‐AMI patients. Results: At a mean follow‐up of 47 days, the ILR had detected atrial tachyarrhythmias in 8 of 28 patients, nonsustained ventricular tachycardias in 2, and transient third degree atrioventricular block in 3. An indication for implantation of an implantable cardioverter defibrillator (ICD) or permanent pacemaker (PM) was observed in 9 out of 29 patients (31%). An average of 2.3 events stored by the ILR were due to inappropriate triggering. Because its memory size is limited to a maximum of 14 episodes, the ILR was unable to store arrhythmias 28% of the follow‐up time. False events rate and monitoring time were improved by suturing the device within its pocket. Conclusions: The ILR allowed the automatic detection of brady‐ and tachyarrhythmias in post‐AMI patients, though a high incidence of false activations were observed. Clinically significant arrhythmias were recorded in a large number of patients with depressed left ventricular function early after AMI. This prompted the implantation of ICD or PM in nearly one third of patients. (PACE 2003; 26[Pt. II]:416–419)
Clinical Application of Electroanatomical Mapping in the Characterization of “Incisional” Atrial Tachycardias
Authors: PEICHL PETR , KAUTZNER JOSEF , ČIHÁK ROBERT , VANČURA VLASTIMIL , BYTEŠNÍK JAN
Published: December 2004

PEICHL, P.,

et al.:

Clinical Application of Electroanatomical Mapping in the Characterization of “Incisional” Atrial Tachycardias.
Scar tissue after surgical procedures for congenital heart disease may create a complex arrhythmogenic substrate and expose patients to the risk of “incisional” tachycardia. We report the usefulness of electroanatomical mapping in the characterization of reentrant circuits and identification of sites of successful radiofrequency (RF) ablation. Methods: Electroanatomical mapping was used to draw activation maps of the right atrium in 6 men and 4 women (mean age

45 ± 13.7  years

) with 21 atrial tachycardias after corrections of atrial septal defects (n = 6) or tetralogy of Fallot (n = 4). The critical isthmus of reentrant circuits was ablated by RF energy. Results: Macroreentrant circuits were localized on the posterolateral wall of the right atrium in all cases. Scar tissue in that region often contained several pathways that allowed induction of different tachycardias. Interruption of all slow conducting pathways successfully abolished all inducible tachycardias. The cavotricuspid isthmus participated in a figure‐of‐eight reentrant circuit or in a typical flutter circuit in 6 patients. RF ablation was successful in all but one patient, without significant complications. Conclusion: Electroanatomical mapping allows the precise description of macroreentrant circuits and the identification of all slow conducting pathways. It is a powerful tool for the planning of ablation lines, navigation of ablation catheter, and verification of conduction block. (PACE 2003; 26[Pt. II]:420–425)
Autonomic Tone in Patients with Supraventricular Arrhythmia Associated with Mitral Valve Prolapse in Young Men
Authors: TERECHTCHENKO LARISSA , DORONINA SVETLANA A. , POCHINOK ELENA M. , RIFTINE ALEXANDER
Published: December 2004

TERECHTCHENKO, L., et al.: Autonomic Tone in Patients with Supraventricular Arrhythmia Associated with Mitral Valve Prolapse in Young Men.
This study examined the relation between autonomic tone and the frequency and duration of supraventricular arrhythmias (SVA) in 44 men (mean age

17 ± 5

years) with mitral valve prolapse (MVP), confirmed by echocardiography. Ambulatory and short‐term electrocardiograms (ECG) were recorded, and transesophageal pacing was performed. Frequency domain heart rate variability (HRV) indices were obtained from short‐term ECG recordings at rest and during postural stress. Results: In 14 patients, the index of parasympathetic activity was significantly higher (

2.1 ± 0,01

vs

‐1.5 ± 0.01, P < 0.01

), and associated with a high incidence of vagally‐mediated SVA. The frequency of SV premature beats in patients with parasympathetic prevalence was

58 ± 86/hour

versus

10 ± 27/hour

in patients with sympathetic prevalence
(P < 0.05). In 30 patients with high sympathetic activity, the index of sympathetic tone was significantly higher (3.1 ± 0.01vs0.5 ± 0.01) and the high frequency/low frequency ratio significantly lower (0.294 ± 0.03vs0.581 ± 0.02, P < 0.05), though the incidence of SVA was significantly lower and duration shorter. The algorithm allowed the noninvasive quantitative assessment of autonomic activity and mechanism behind the development of SVA, which may help in the choice of treatment. (PACE 2003; 26[Pt. II]:444–446)
Simplified Tilt Table Test Protocol with Continuous Upright Position During Medication Administration and No Hydration
Authors: FISHER JOHN D. , KIM SOO G. , FERRICK KEVIN J. , GROSS JAY N. , PALMA EUGEN C. , SCAVIN GALE M.
Published: December 2004

FISHER, J.D., et al.: Simplified Tilt Table Test Protocol with Continuous Upright Position During Medication Administration and No Hydration.
Recommendations for head‐up tilt testing (HUT) often include the prolonged abstaining from food and water consumption (nothing by mouth [NPO]) and intravenous fluids administration before HUT. After the baseline test, supine equilibration periods are recommended before and between each dose of medication. The aim of this study was to determine if similar results are obtainable with a simpler protocol. After 2–3 hours NPO, 1,540 HUTs were performed at 70 degrees for 30 minutes unless predetermined endpoints were reached. Then, with the patient remaining in the tilted position, isoproterenol (ISO) (1 μg/min), titrated every 3 minutes to a maximum of

5 μg/min

(

n = 803

patients), sublingual nitroglycerin (NTG) (300–400 μg) (

n = 143

patients), or edrophonium (EDP) (5 mg) repeated once after 3 minutes

(n = 46 patients)

were administered. No aspiration or other adverse effects attributable to the abbreviated fasting period were observed. ISO was well tolerated as doses were increased. Vasovagal manifestations developed in 31% of ISO tests, in 11% with EDP, and in 50% with NTG (

P < 0.001

). Time consumed with rehydration before and postural changes during HUTs may be avoided when ISO is administered. With NTG the response may be excessive. (PACE 2003; 26[Pt. II]:451–452)
Implications of National Guidance for Implantable Cardioverter Defibrillation Implantation in the United Kingdom
Authors: PLUMMER CHRISTOPHER J. , IRVING R. JOHN , MCCOMB JANET M.
Published: December 2004

PLUMMER, C.J., et al.: Implications of National Guidance for Implantable Cardioverter Defibrillation Implantation in the United Kingdom. To determine the number of patients fulfilling recently issued national guidelines on the use of ICDs in patients with arrhythmias, the authors undertook two observational audits of clinical records. The first audit included patients investigated and treated at a tertiary referral cardiothoracic center during a 1‐month period, and the second included patients admitted to the three coronary care units serving a circumscribed district population during a second month. Patient records were audited against the recommendations for ICD implantation made by the National Institute for Clinical Excellence to determine if the patient fulfilled the criteria for ICD implantation. The audit was repeated with the same patient records against the MADIT 2 selection criteria. The audit identified underprovision of ICD therapy in the United Kingdom for a variety of reasons. It also demonstrated that the number of patients fulfilling selection criteria defined by the national guidelines for ICD implantation is far in excess of the numbers predicted. The annual incidence of patients fulfilling national criteria is about 150/million, with an additional “prevalence” of at least 41/million. Applying the less restrictive MADIT II criteria to select patients for ICDs as a primary prevention increased the numbers to 504/million (“new incidence”) and 311/million (“prevalence”) per year, in excess of the predictions by a factor of between 10 and 25. (PACE 2003; 26[Pt. II]:479–482)
Safety of a Single Successful Conversion of Ventricular Fibrillation Before the Implantation of Cardioverter Defibrillators
Authors: GOLD MICHAEL R. , BREITER DAVID , LEMAN ROBERT , RASHBA ERIC J. , SHOROFSKY STEPHEN R. , HAHN STEPHEN J.
Published: December 2004

GOLD, M.R., et al.: Safety of a Single Successful Conversion of Ventricular Fibrillation Before the Implantation of Cardioverter Defibrillators.
Multiple successful conversions of ventricular fibrillation (VF) at 10 J below the maximum output of implantable cardioverter defibrillator (ICD) have been recommended as a minimum device implantation criterion. This recommendation is based on the probabilistic properties of defibrillation that necessitates multiple shocks to establish an adequate safety margin for the conversion of subsequent spontaneous arrhythmias. We hypothesized that a single successful shock at a 14 J may suffice. Methods and Results: The Low Energy Safety Study (LESS) enrolled 720 patients undergoing initial ICD implantation with a dual‐coil transvenous lead and active pulse generator. At implant, an enhanced defibrillation threshold (DFT++) was determined by a rigorous protocol beginning at 14 J, and requiring at least 4 shocks. Fifty percent of all patients were then randomized to full output shock energy and the conversion rates for spontaneous ventricular tachyarrhythmias at rates >200 beats/min were measured. There were 318 patients randomized to 31 J, of whom 254 were successfully defibrillated by an initial 14 J shock. During a mean follow‐up of

24 ± 12

months, 112 spontaneous VF episodes occurred in 31 patients. The combined conversion success of the first and second shock (when needed) did not differ between the subgroup of patients who were successfully defibrillated by an initial 14 J shock, regardless of the results of additional testing, and the whole cohort who underwent more systematic testing (97% vs 97%). All spontaneous episodes of VF were successfully treated during long‐term follow‐up. Conclusions: A first successful shock of 14 J may be a sufficient endpoint to allow the implantation of ICDs with the Triad lead configuration, when programming all shocks to 31 J. (PACE 2003; 26[Pt. II]:483–486)
DDD Pacemaker Implantation After Fontan‐Type Operations
Authors: HEINEMANN MARKUS K. , GASS MATTHIAS , BREUER JOHANNES , ZIEMER GERHARD
Published: December 2004

HEINEMANN, M.K., et al.: DDD Pacemaker Implantation After Fontan‐Type Operations.
Bradyarrhythmias developing after Fontan‐type operations impair the function of the univentricular heart causing fatigue, headaches, ascites, and protein‐losing enteropathy (PLE). Transvenous inaccessibility, requiring epicardial implantation, accounts for the reluctance to implant a pacemaker (PM). Between 1997 and 2000, 24 patients (mean age 9.5 years, range 6 months to 19 years) with Fontan‐type operations received DDD pacing systems with atrial steroid‐eluting stitch‐on electrodes (mean capture threshold 1.9 V/0.5 ms, range 0.4–3.5 V) and ventricular screw‐in electrodes (mean capture threshold 1.7 V/0.5 ms, range 0.1–3 V). The systems were implanted at the time of conversion from atrio‐ to cavopulmonary connections in 5 patients, at the time of a total cavopulmonary Fontan operation in 6, and 1–50 months thereafter (mean = 18) in 13 patients. A right ventricular anatomy was present in 13 (54%) of 24 of PM recipients, versus 35% of the overall population. After a mean follow‐up of 3.5 years, the PM were functioning in DDD mode in 23 of the 24 patients. Length of hospital stay in the ten patients who underwent repeat sternotomy was 5 days, without procedure related complications. In three children a repeat sternotomy was avoided by implanting the atrial electrodes during the Fontan operation. All patients improved clinically, including resolution of PLE in four patients. Bradyarrhythmias may lead to significant morbidity after Fontan‐type operations. Electrophysiological evaluation is advised at follow‐up. The indication for implantation of a DDD pacemaker system should be liberal. Placing atrial electrodes during the Fontan operation, especially in the presence of a right ventricular anatomy, avoids repeat sternotomy. (PACE 2003; 26[Pt. II]:492–495)
Catheter Cryoablation of Supraventricular Arrhythmias:
Authors: LOWE MARTIN D. , MEARA MAGGIE , MASON JAMES , GRACE ANDREW A. , MURGATROYD FRANCIS D.
Published: December 2004

LOWE, M.D.,

et al

.: Catheter Cryoablation of Supraventricular Arrhythmias: A Painless Alternative to Radiofrequency Energy.
Cryothermy has potential advantages over RF energy for catheter ablation, including reversibility of lesion formation, catheter stability, and less procedural discomfort. Cryoablation procedures were performed in 14 patients with atrioventricular reentrant tachycardias (AVNRTs), 13 patients with accessory pathway (AP)‐mediated tachycardias, and 5 patients with atrial fibrillation. The numbers of energy applications, pain scores, procedural times, and outcomes were recorded and compared with age‐ and sex‐matched patients undergoing similar RF procedures. Cryoablation was successful in 26 of 32 patients (11/14 AVNRT, 10/13 AP, 5/5 AF) compared with 30 of 32 undergoing RF procedures, with similar numbers of energy applications and procedural times. Cryothermy was painless in all patients, and the overall procedural discomfort was significantly less than in patients treated with RF

(1.3 ± 2.2 vs 6.1 ± 3.5)
. In patients with anteroseptal pathways, cryomapping successfully identified safe sites to target the delivery of energy. Cryothermy is a painless and safe alternative to RF. It may be particularly useful for catheter ablation of patients with pathways close to the atrioventricular node. (PACE 2003; 26[Pt. II]:500–503)
Catheter Ablation of Chronic Atrial Fibrillation with Noncontact Mapping:
Authors: SEIDL KARLHEINZ , SCHWACKE HARALD , ZAHN RALF , RAMEKEN MONIKA , DRÖGEMÜLLER AXEL , SENGES JOCHEN
Published: December 2004

SEIDL, K., et al.: Catheter Ablation of Chronic Atrial Fibrillation with Noncontact Mapping: Are Continuous Linear Lesions Associated with Ablation Success?
Catheter‐based, right and left atrial compartmentalization procedure was evaluated using a noncontact mapping (NCM) system. Its usefulness to identify and close discontinuities in linear lesions in both atria was evaluated. The impact of linear lesion continuity on ablation success of chronic AF was also investigated. Nineteen patients with symptomatic, drug refractory chronic AF were studied. Right atrial ablation with three predefined lines was attempted in all patients. In 18 patients, left atrial ablation was performed with four linear lesions. During a follow‐up of 12 ± 3 months, 6 of 19 patients remained in sinus rhythm (SR) without antiarrhythmic agents (AAs). In addition, four patients were maintained in SR with AA. Thirteen of 14 patients with gaps identified during off‐line analysis had recurrence of AF. Only one patient with a gap was free of recurrence without AAs. In the remaining five patients without recurrence of AF, no gap was observed during off‐line analysis. In all four patients who were free of AF with additional treatment of AAs, two gaps had been identified. In the remaining nine patients with chronic AF recurrence, a mean of 4.9 gaps were identified. Excluding the initial learning period (first five patients) the success rate increased to 43% (6/14 patients) without and to 71% (10/14 patients) with AA. NCM identifies discontinuities in lines of ablation. Successful ablation of chronic AF is associated with continuity of linear lesions and good clinical technique demands a vigilant search for and closure of every gap. (PACE 2003; 26[Pt. I]:534–543)
Role of Vagal Control in Vasovagal Syncope
Authors: SUZUKI MASARU , HORI SHINGO , NAKAMURA IWAO , NAGATA SHINYA , TOMITA YUTAKA , AIKAWA NAOKI
Published: December 2004

SUZUKI, M., et al.: Role of Vagal Control in Vasovagal Syncope.
The vasovagal reaction is thought to be caused by sympathetic withdrawal and vagal augmentation. While measurements of muscle sympathetic nerve activity support sympathetic withdrawal in tilt induced syncope, the results of previous attempts to quantify vagal control using spectral analyses of heart rate variability (HRV) remain controversial. The sampling period used in the HRV studies is related to the discordant results. In the present study, HRV was computed every second using wavelet transformation to clarify the role of vagal control in tilt induced syncope during the 80‐degree head‐up tilt test (positive: 10 patients with vasovagal syncope; negative: 10 patients with vasovagal syncope, and 10 control subjects). Autonomic modulations were assessed using the absolute power of the low frequency (LF) (0.04–0.15 Hz) and high frequency (HF) (0.15–2.00 Hz) oscillatory components of R‐R variability. Although the LF did not change during the tilt procedure, a decrease in the systolic arterial pressure (SAP) and increases in the R‐R interval and HF were observed for the last 30 seconds before the tilt induced syncope in the tilt‐positive group. Analyzing the hemodynamic measurements and spectral indices for the last 5 minutes preceding the tilt induced syncope, the study found that the SAP, R‐R interval, and HF changed simultaneously during the 30‐second period immediately before the tilt induced syncope. Further, the HF was positively correlated with the R‐R interval and negatively correlated with the SAP. In conclusion, continuous spectral analysis of the R‐R interval demonstrated increased vagal influence on the heart in tilt induced syncope. (PACE 2003; 26[Pt. I]:571–578)
Biventricular Pacing Exclusively Via a Persistent Left‐Sided Superior Vena Cava:
Authors: LANE REBECCA E. , CHOW ANTHONY W.C. , MAYET JAMIL , DAVIES D. WYN
Published: December 2004

LANE, R.E., et al.: Biventricular Pacing Exclusively Via a Persistent Left‐Sided Superior Vena Cava: Case Report.
Biventricular pacing in association with a persistent left‐sided superior vena cava is technically challenging. The presence of an associated innominate vein enables a conventional approach via the right atrium for coronary sinus intubation and left ventricular lead placement. In its absence, the coronary sinus lead must be positioned exclusively via the left‐sided superior vena cava. The acute angulation of the branch ostia encountered when catheterizing the coronary sinus “downstream” makes this difficult, but with the use of preshaped cardiac catheters and over‐the‐wire pacing leads selective intubation of a left ventricular vein is possible. (PACE 2003; 26[Pt. I]:640–642)
Biventricular Pacing for Severe Mitral Reguritation Following Atrioventrgicular Nodal Ablation
Authors: DISNEY PATRICK J.S. , ASHBY DALE T. , YOUNG GLENN D. , BRADLEY JULIE A.
Published: December 2004

DISNEY, P.J.S., et al.: Biventricular Pacing for Severe Mitral Regurgitation Following Atrioventricular Nodal Ablation.
A 69‐year‐old woman developed acute pulmonary edema and severe mitral regurgitation (MR) 2 days following an uncomplicated AV nodal (AVN) ablation and insertion of VVI pacemaker for chronic atrial fibrillation. There was no history of significant mitral valve disease. Left ventricular function was normal and there was no evidence of an acute cardiac ischemic event. Transthoracic echo and right heart catheterization studies showed reduction in the severity of MR with biventricular pacing as opposed to RV pacing alone. A permanent pacemaker configured for biventricular pacing was implanted with complete resolution of symptoms and significant reduction in degree of MR. (PACE 2003; 26[Pt. I]:643–644)
Reversible Myoglobinuric Renal Failure Following Rhabdomyolysis as a Rare Complication of Cardioversion
Authors: CAVUSOGLU YUKSEL , ENTOK EMRE , GORENEK BULENT , KUDAIBERDIEVA GULMIRA , UNALIR AHMET , GOKTEKIN OMER , BIRDANE ALPARSLAN , ATA NECMI , TIMURALP BILGIN
Published: December 2004

CAVUSOGLU, Y., et al.: Reversible Myoglobinuric Renal Failure Following Rhabdomyolysis as a Rare Complication of Cardioversion.
Reversible myoglobinuric renal failure following rhabdomyolysis that was related to repeated countershocks delivered for the treatment of refractory recurrent VT and VF attacks during acute myocardial infarction is presented in this case report, in which scan with technetium‐99m pyrophosphate has been used for in the diagnosis of extensive skeletal muscle damage. (PACE 2003; 26[Pt. I]:645–646)
Right Diaphragm Paralysis Following Cardiac Radiofrequency Catheter Ablation for Inappropriate Sinus Tachycardia
Authors: DURANTE‐MANGONI EMANUELE , VECCHIO DAVIDE DEL , RUGGIERO GIUSEPPE
Published: December 2004

DURANTE‐MANGONI, E., et al.: Right Diaphragm Paralysis Following Cardiac Radiofrequency Catheter Ablation for Inappropriate Sinus Tachycardia.
We describe a case of permanent right diaphragm paralysis following a radiofrequency cardiac ablation procedure. The relationship between the procedure and the phrenic nerve lesion is discussed with respect to the possible pathogenetic mechanisms. Radiofrequency current used in cardiac electrophysiology may cause serious thoracic nerve injuries. Means to avoid this complication are pointed out. (PACE 2003; 26:783–784)
Suppression of Electrical Storm by Biventricular Pacing in a Patient with Idiopathic Dilated Cardiomyopathy and Ventricular Tachycardia
Authors: TANABE YASUTAKA , CHINUSHI MASAOMI , WASHIZUKA TAKASHI , MINAGAWA SHIROU , FURUSHIMA HIROSHI , WATANABE HIROSHI , HOSAKA YUKIO , KOMURA SATORU , AIZAWA YOSHIFUSA
Published: December 2004

TANABE, Y.,

et al.

: Suppression of Electrical Storm by Biventricular Pacing in a Patient with Idiopathic Dilated Cardiomyopathy and Ventricular Tachycardia.
This study presents a patient with idiopathic dilated cardiomyopathy who had suffered from multiple ICD shocks. Amiodarone and a β‐blocker failed to suppress ventricular tachycardia. His ECG showed a very wide QRS complex with an intraventricular conduction delay, so biventricular (BV) pacing was attempted. The BV pacing successfully prevented the multiple ICD shocks accompanied with an improvement in left ventricular systolic function and physical activity.(PACE 2003; 26[Pt. I]:101–102)
Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol
Authors: Cohen Ira Todd , Finkel Julia C. , Hannallah Raafat S. , Hummer Kelly A. , Patel Kantilal M.
Published: December 2004

Background: Emergence agitation in children is frequently associated with the use of the new highly insoluble volatile anaesthetics. Rapid emergence has been cited as one of the possible causes. Propofol also permits rapid emergence from general anaesthesia but is not associated with agitation.

Methods: The emergence characteristics of children receiving sevoflurane and propofol anaesthesia were examined. After induction with sevoflurane, 53 children, aged 2–36 months, who were undergoing ambulatory surgery, were randomized to receive maintenance anaesthesia with either sevoflurane or propofol. Introperative analgesia with either 2 µg·kg−1 of intravenous fentanyl or a caudal block with 0.25% bupivacaine was supplied according to surgical procedure. An observer blinded to anaesthetic technique recorded the time to achieve extubation and recovery and assessed emergence behaviour. Data were analysed using Wilcoxon scores, Kruskal–Wallis test, chi‐square and multiple regression analysis.

Results: The results showed that the time to extubation and recovery were similar between the two study groups, but that emergence agitation was significantly higher in the sevoflurane group compared with the propofol group. No relationship between analgesic technique and agitation scores was found.

Conclusions: Although both sevoflurane and propofol allow for rapid emergence from general anaesthesia, only sevoflurane is associated with a high incidence of emergence agitation in infants and young children. Rapid emergence does not fully explain this phenomena.
Perioperative care of the child with the Johanson–Blizzard syndrome
Authors: Fichter Christopher R. , Johnson Garry A. , Braddock Stephen R. , Tobias Joseph D.
Published: December 2004

The Johanson–Blizzard Syndrome (JBS) is an autosomal recessive disorder with a characteristic phenotype, including dwarfism, a beaked nose with aplastic alae nasi, a high forehead, mid‐line ectodermal scalp defects with sparse hair and absent eyelashes/eyebrows, prominent scalp veins, low set ears, a large anterior fontanelle, micrognathia, thin lips, absent permanent dentition and microcephaly. In addition to the characteristic facial features, associated conditions include congenital heart disease, exocrine/endocrine pancreatic dysfunction, hypothyroidism, hypopituitarism, mental retardation, sensorineural hearing loss and vesico‐ureteral reflux. A case is presented and the potential anaesthetic implications of this syndrome are discussed.
Spinal anaesthesia in a child with hypoplastic left heart syndrome
Authors: Sacrista S. , Kern D. , Fourcade O. , Izard P. , Galinier P. , Samii K. , Cathala B.
Published: December 2004

Summary Hypoplastic left heart syndrome (HLHS), a complex congenital heart disease, is the most common lethal cardiac defect in neonates. Its treatment includes cardiac transplantation and/or surgical palliation. Associated extracardiac congenital abnormalities are exceptional. We report the case of a neonate with HLHS and anorectal atresia who required urgent surgical management to relieve intestinal obstruction. The surgery was successfully performed under spinal anaesthesia.
Haemodynamic changes during high spinal anaesthesia in children having open heart surgery
Authors: Finkel Julia C. , Boltz M. Gail , Conran Aisling M.
Published: December 2004

Background: This prospective series examined the haemodynamic effects of high spinal anaesthesia in combination with light general anaesthesia in infants and children undergoing open heart surgery who were candidates for immediate or early postoperative extubation.

Methods: After midazolam premedication and sevoflurane inhalation induction, 30 patients, aged 7 months to 13 years, who were undergoing open heart surgery, received spinal anaesthetics with 0.5% tetracaine D10 mixed with morphine. The spinal blocks were placed at the L2,3 or L3,4 interspace with cephalad spread being promoted by positioning the patient in 30° of Trendelenburg for a minimum of 10 min. Maintenance of anaesthesia was with isoflurane 0.2–0.5% in 70% nitrous oxide to maintain heart rate and blood pressure within 20% of postinduction baseline values. Haemodynamic values were recorded at predetermined timed intervals and intraoperative events up to and including aortic cannulation. For analysis of the data, patients were divided into four age groups (< 1 years, 1–3 years, 4–6 years and > 7 years).

Results: Haemodynamic stability was demonstrated in all four age groups. Statistically significant slowing of the heart rate did occur in the groups older than 1 year at 25 min, although clinically significant bradycardia requiring treatment never occurred. Hypotension did occur during specific surgical manipulations but recovered spontaneously. Atropine, fluid boluses and vasopressors were never used. At the conclusion of surgery, all patients met extubation criteria and could move all four extremities.

Conclusions: High spinal anaesthesia with hyperbaric tetracaine and morphine in combination with light general anaesthesia is well tolerated haemodynamically by the paediatric population studied.
Cerebral blood flow velocity in children anaesthetized with desflurane*
Authors: Luginbuehl Igor A. , Fredrickson Michael J. , Karsli Cengiz , Bissonnette Bruno
Published: December 2004

Background: Desflurane allows for rapid emergence and changes in depth of anaesthesia which makes it especially suitable for neuroanaesthesia. This study was designed to determine the effects of different desflurane concentrations on cerebral blood flow velocity (CBFV) in healthy children.

Methods: Twenty children, aged 1–7 years undergoing urological surgery were studied. Anaesthesia was induced with sevoflurane in oxygen. After tracheal intubation, sevoflurane was discontinued and ventilation with desflurane in air/oxygen was initiated and normoventilation maintained. A caudal block was performed. The patients were randomized to receive three different desflurane concentrations (0.5, 1.0 and 1.5 MAC). Fifteen minutes were allowed to reach steady‐state at which time CBFV was measured by transcranial Doppler sonography. Mean arterial pressure (MAP) and heart rate (HR) were simultaneously recorded at 1‐min intervals.

Results: Cerebral blood flow velocity increased from 0.5 to 1.0 MAC (P < 0.05), but not from 1.0 to 1.5 MAC. HR increased from 0.5 to 1.0 (P < 0.001) and from 1.0 to 1.5 MAC (P < 0.001), whereas the MAP decreased only from 0.5 to 1.0 MAC (P < 0.001).

Conclusions: Desflurane in concentrations of 1.0 and 1.5 MAC in children increases CBFV significantly when compared with 0.5 MAC. These changes were associated with a significant increase in HR and decrease in MAP.
Tramadol for pain relief in children undergoing tonsillectomy: a comparison with morphine
Authors: Engelhardt Thomas , Steel Elizabeth , Johnston Graham , Veitch Derek Y.
Published: December 2004

Summary Background: Pain control for paediatric patients undergoing tonsillectomy remains problematic. Tramadol is reported to be an effective analgesic and to have a side‐effect profile similar to morphine, but is currently not licensed for paediatric use in the UK.

Methods: We conducted a prospective, double‐blind, randomized controlled trial in children who were scheduled for elective tonsillectomy or adenotonsillectomy at the Royal Aberdeen Children Hospital. Following local ethics committee approval and after obtaining a drug exemption certificate from the Medicines Licensing Agency for an unlicensed drug, we recruited 20 patients each into morphine (0.1 mg·kg−1), tramadol (1 mg·kg−1) and tramadol (2 mg·kg−1) groups. These drugs were given as a single injection following induction of anaesthesia. In addition, all patients received diclofenac (1 mg·kg−1) rectally. The postoperative pain scores, analgesic requirements, sedation scores, signs of respiratory depression and nausea and vomiting, as well as antiemetic requirements, were noted at 4‐h intervals until discharge.

Results: There were no statistically significant differences in age, weight, type of operation or induction of anaesthesia, 4‐h sedation and pain scores and further analgesic requirements. There were no episodes of respiratory depression. Morphine was associated with a significantly higher incidence of vomiting following discharge to the wards (75% versus 40%, P=0.03) compared with both tramadol groups.

Conclusions: Tramadol has similar analgesic properties, when compared with morphine. The various pharmaceutical presentations and the availability as a noncontrolled substance may make it a useful addition to paediatric anaesthesia if it becomes licensed for paediatric anaesthesia in the UK.
Spread of radioopaque dye in the epidural space in infants
Authors: Vas Lakshmi , Kulkarni Vinay , Mali Madhusudhan , Bagry Hema
Published: December 2004

Summary Background: This prospective study aimed to assess the extent of spread of dye in the epidural space and whether it would vary in direct proportion to the volume when injecting two volumes of dye.

Methods: Ten infants, aged 2–36 days (mean ± SD, 13.30 ± 13.68 days) and weighing 1.8−4.5 kg (mean ± SD, 2.60 ± 0.97 days), who were undergoing major thoracoabdominal surgery under epidural and general anaesthesia, were studied. At the end of surgery, two volumes of radioopaque dye (omnipaque) 0.5 ml·kg−1 and 1 ml·kg−1 were injected into the epidural space at a rate of 1 ml·2 min−1. The spread was studied by taking X‐rays after both injections in the left lateral position.

Results: There were 10 different patterns of spread in the 10 cases. Uniformly circumferential and cylindrical spread was seen only in one infant. In the others, there were segregated patches of anterior and posterior spread with or without interspersed patches of circumferential spread. There was variation in the extent, location and the density of spread, filling defects and skipped segments with both volumes. Back leak of dye along the needle track was seen in three cases. Statistically, segments were 9.30 ± 3.68 for 0.5 ml·kg−1, for 1 ml·kg−1 11.50 ± 3.03, 3.03, S, P=0.014; circumferential spread for 0.5 ml·kg−1 2.70 ± 2.16, for 1 ml·kg−1 5.90 ± 3.14 3.59, P=0.006; anterior spread for 0.5 ml·kg−1 3.60 ± 1.58, for 1 ml kg−1 7.90 ± 2.33 5.88, P=0.001; posterior spread for 0.5 ml·kg−1 8.20 ± 3.71, for 1 ml·kg−1 9.80 ± 3.68 3.54, P=0.006. Doubling of spread with doubling of the volume occurred in only one patient. There was a variable increase in extent or in the density of spread with reduction of skipped segments with the 1 ml·kg−1. The probable reasons for this variable spread and the mechanism of epidural anaesthesia in the presence of such spread are discussed.

Conclusions: There is a difference in quantitative as well as qualitative spread in different patients and in the same patient with different volumes. There were statistically significant increases in the number of segments, circumferential, anterior and posterior locations in the 1.0 ml group. Both extent and density of spread improve with the higher volume but not in direct proportion to volume. 1 ml·kg−1 has a better quantitative as well as qualitative spread than 0.5 ml and has a better chance of producing adequate anaesthesia.
Effects of halothane and sevoflurane on QT dispersion in paediatric patients
Authors: Gürkan Yavuz , Canatay Hakan , Agacdiken Aysen , Ural Ertan , Toker Kamil
Published: December 2004

Summary Background: The QT dispersion (QTd) of the ECG is an indirect measure of heterogeneity of ventricular repolarization which may contribute to complex ventricular arrhythmias. We compared the effects of halothane and sevoflurane on QTd, and heart‐rate corrected QT dispersion (QTcd).

Methods: Fifty ASA physical status I patients, aged 5–15 years, undergoing general anaesthesia were studied. A control ECG recording was printed before induction of anaesthesia. In the halothane group, anaesthesia was induced with halothane 4% in 2 : 1 ratio of air : O2 mixture and in the sevoflurane group with sevoflurane 8% in 2 : 1 ratio of air : O2 mixture. The ECG was recorded 1 and 3 min after induction of anaesthesia, 1 and 3 min after the administration of vecuronium 0.08 m·kg−1 intravenous and 1 and 3 min after the tracheal intubation. All ECGs were analysed by two cardiologists blinded to the anaesthetic.

Results: Although QTd increased in both groups following intubation, this difference was not statistically significant when compared with control values. Following intubation five patients in the halothane group had ventricular arrhythmias of short duration, whereas no arrhythmias were recorded in the sevoflurane group (P = 0.052). Following intubation, QTd (45 ± 15 ms vs 40 ± 14 ms) and QTcd (60 ± 17 ms vs 55 ± 16 ms) values in the halothane group were significantly greater than the sevoflurane group (P < 0.05).

Conclusion: Neither sevoflurane nor halothane caused a significant increase in QTd compared with control values before induction. Only QTd following intubation was significantly greater in the halothane group than the sevoflurane group.
Immediate control of life‐threatening digoxin intoxication in a child by use of digoxin‐specific antibody fragments (Fab)
Authors: Husby P. , Farstad M. , Brock‐Utne J.G. , Koller M.E. , Segadal L. , Lund T. , Ohm O.J.
Published: December 2004

SummaryDigoxin‐immune antibody fragments (Fab) for treatment of digitalis intoxication was introduced in 1976. Many reports have been published concerning this therapy for children, but few have focused on itsimmediatereversal of cardiac as well as extracardiac life‐threatening manifestations of digoxin toxicity. We present a case of life‐threatening digitalis intoxication in a child with postoperative renal insufficiency, after a Sennings procedure for transposition of the great arteries. Digoxin administration according to the nationally recommended dosage and intervals unexpectedly resulted in serum levels in the toxic range. Severe cardiac arrhythmias, haemodynamic instability and a rapid‐increasing serum potassium level resulted. This report demonstrates how administration of Fab according to the manufacturer's dosage recommendation reversed the tachyarrhythmia immediately and re‐established a normal level of serum potassium within minutes.
Assessment of risk factors for emergence distress and postoperative behavioural changes in children following general anaesthesia
Authors: Tripi Paul A. , Palermo Tonya Mizell , Thomas Susan , Goldfinger Mark M. , Florentino‐Pineda Ivan
Published: December 2004

Background:  Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress.

Methods:  A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7‐point Likert type cooperation scale.

Results:  One‐way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (χ2 = 5.57, P < 0.06) and children with frequent temper tantrums (χ2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour.

Conclusions:  Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.
Effects of Angiotensin‐Converting Enzyme Inhibitor Therapy on QT Dispersion Post Acute Myocardial Infarction
Authors: KASSOTIS JOHN , MONGWA MBU , REDDY C.V.R.
Published: December 2004

KASSOTIS, J., et al.: Effects of Angiotensin‐Converting Enzyme Inhibitor Therapy on QT Dispersion Post Acute Myocardial Infarction.
The aim of this study was to determine the effect of an angiotensin‐converting enzyme inhibitor (ACEI), initiated within 24 hours of an acute myocardial infarction (AMI), on the QT dispersion (QTd). ACEIs have proven beneficial in improving left ventricular remodeling, following an AMI while contributing to a reduction in sudden cardiac death (SCD). A prolonged QTd is a marker of electrical instability predisposing to ventricular arrhythmias and SCD. No one has looked at the effects on the QTd of ACEI therapy initiated within 24 hours of an AMI. The study included 239 consecutive patients who presented with an AMI between January 1, 1998 and December 31, 1998. A total of 105 patients had never been treated with an ACEI, and 51 patients were started on enalapril within 24 hours of presentation. Patient demographics were similar in both groups. All patients were treated with aspirin and β‐blocker therapy. A baseline QTd was determined and recalculated on days 3–4 and 6–7 following the AMI. There was no significant difference in the baseline QTd, heart rate, QTcmin, and QTcmax between the two groups. On days 3–4 the QTd in the treatment group (A) was

39.2 ± 19.4 ms

, as opposed to

84.4 ± 31.2 ms

in the control group (B) (P = 1.0E‐06). This reduction in QTd was accounted for by a significant difference in the QTcmax. The QTd shortened in both groups on days 6–7 with a QTd of

30.0 ± 17.5

in group A and a QTd of

54.1 ± 26.3

in group B

(P = 1.0E‐05)

. There was a significant difference in ejection fraction (EF) between the two groups with the ACEI treated group exhibiting a lower EF, (0.403 (A), 0.494 (B),

P < 0.043

). The mean dose of enalapril was 6.45 mg daily in the treatment group. ACEIs have been previously shown to reduce the QTd after two months of therapy following an AMI. This study shows that the beneficial effects of ACEI occur early following administration of the drug. The authors speculate that the reduction in SCD conferred by ACEI therapy may be attributed to its effect on reducing the degree of ventricular dispersion of repolarization following a myocardial infarction. (PACE 2003; 26[Pt. I]:843–848)
Follow‐up X Rays Play a Key Role in Detecting Implantable Cardioverter Defibrillator Lead Fracture:
Authors: MORISHIMA ITSURO , SONE TAKAHITO , TSUBOI HIDEYUKI , KONDO JUNICHIRO , MUKAWA HIROAKI
Published: December 2004

MORISHIMA, I., et al.: Follow‐up X Rays Play a Key Role in Detecting Implantable Cardioverter Defibrillator Lead Fracture: A Case of Incessant Inappropriate Shocks Due to Lead Fracture.
A patient with an implantable cardioverter defibrillator (ICD) received incessant inappropriate shocks due to a lead fracture 3 years after implantation. Routine lead measurements at 3‐month intervals had shown no abnormal findings even at the most recent measurement performed 2 months prior to the event. In contrast, serial observation of chest X rays clearly disclosed progressive lead narrowing starting 11 months prior to the event. This case indicates the importance of the routine chest X rays in long‐term follow‐up of ICDs and sets a precedent for interpreting lead narrowing in such X rays. (PACE 2003; 26[pt. I]:911–913)
Clinical Performance of Automatic Closed‐Loop Stimulation Systems
Authors: GRIESBACH LOTHAR , GESTRICH BRIGITTA , WOJCIECHOWSKI DARIUSZ , WEYERS GEORG , TÖNGES JÜRGEN , SCHIER MATTHIAS , DANILOVIC DEJAN ,   RAPID study investigators
Published: December 2004

Inos pacemakers use contraction dynamics to regulate the pacing rate according to the Closed‐Loop Stimulation (CLS) principle. The physician can program only the lower and upper rate limits, while the internal rate responsive parameters are continually adjusted to changing patient conditions. Seventy‐two patients with sinus node disease were enrolled in the multicenter Rate Behavior of the Pacing System Inos2 CLS during Daily Life (RAPID) study to evaluate the appropriateness of CLS rates during daily activities and the long‐term stability of the system. The pacemakers clearly differentiated between climbing stairs, descending stairs, and slow walking, with the corresponding peak rates of

104 ± 18, 95 ± 15

, and

88 ± 11  beats/min

, respectively (

P < 0.001

for any pair of activities). The peak CLS rate during the color‐word test was significantly higher than that at rest (

80 ± 8

vs

67 ± 7  beats/min, P = 0.002

). The 24‐hour heart rate trends retrieved from the pacemaker memory at 3, 6, and 12 months after implantation appeared appropriate in all patients except for two whose pacing rates were occasionally too fast during the night. Mean diurnal and nocturnal rates determined at 3‐month, 6‐month, and 12‐month examinations fluctuated only slightly, from 74.6–75.3 beats/min (diurnal,

P = NS

) and from 67.0–68.1 beats/min (nocturnal,

P = NS

), indicating a satisfactory long‐term stability of the system. The incidence of atrial pacing events during the entire follow‐up was

82 ± 18%

. A 6.5–8.3 beats/min difference, on average, between day and night

(P < 0.001)

and distinction between different daily activities seem to evidence sensitivity of the automatic CLS‐driven pacemakers to physiological demands despite minimum programming requirements. (PACE 2003; 26[Pt. I]:1432–1437)