Electrical devices for treatment of arrhythmias

doi:10.1016/0002-9149(88)90739-4

The American Journal of Cardiology

Volume 61, Issue 2, 15 January 1988, Pages A45-A57

https://doi.org/10.1016/0002-9149(88)90739-4 Get rights and content

Abstract

Electrical devices can be used for preventing and terminating tachycardia and for achieving hemodynamic improvement during a continuing tachycardia. Conventional approaches to tachycardia prevention include pacing at physiologic rates to prevent bradycardia-related tachycardia or tachycardias associated with prolonged QT-interval syndromes. More exotic techniques, such as those involving stimulation during the refractory period, are undergoing investigation. Some tachycardias cannot be easily terminated or recur incessantly. Hemodynamics can be improved by pacing methods that result in a narrower QRS complex by coupled pacing and, in supraventricular tachycardias, by pacing rapidly enough to create atrioventricular block. Most clinical tachycardias are caused by reentry. Careful analysis of the timing of individual stimuli that successfully terminate tachycardias indicate that critical relations exist in the conduction velocity, refractoriness and physical properties and dimensions of the reentry circuit and the remaining myocardium. Elucidating these relations has permitted inferences into the mechanisms by which pacing terminates or accelerates tachycardias. A vast number of pacing patterns have evolved for use in tachycardia termination. None of these appear to be foolproof. There is widespread and justified concern about the risk of acceleration of tachycardia when antitachycardia pacing is used in the ventricle. Experience indicates that only a few patients are suitable for termination of ventricular tachycardia by pacing, but these carefully selected patients may do well. Both the results and the potential for widespread use may be better with pacing for termination of supraventricular tachycardia. Life-threatening tachycardias or fibrillation can be terminated by direct-current countershock. Although many technical problems remain, implantable cardioverter-defibrillators, possibly combined with antitachycardia pacemakers, will play an increasing role in the management or serious arrhythmias.

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Cited by (45)

Leadless Pacing
2016, Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy
Antitachycardia pacing and low-energy cardioversion for ventricular tachycardia termination: A clinical perspective
1994, American Heart Journal
When incorporated into tiered therapy implantable cardioverter defibrillators (ICDs), antitachycardia pacing (ATP) techniques have proved useful for termination of sustained monomorphic ventricular tachycardias (VT) and have the advantages of rapid delivery, absence of patient discomfort, and minimal battery drain. The efficacy of low-energy cardioversion (LEC) is similar to that of pacing techniques for VT termination, but LEC has the disadvantages of patient discomfort, atrial proarrhythmia, and greater battery drain compared with ATP. Acceleration of VT occurs with similar frequency with each technique. Neither technique should be used without back-up defibrillation capability in an ICD. VT termination algorithms are currently empiric and require repetitive arrhythmia induction and trials of ATP or LEC. Future studies of the risk and benefits of each technique are likely to define optimal programming strategies in tiered therapy ICDs.
Randomized controlled comparison of antitachycardia pacing algorithms for termination of ventricular tachycardia
1993, Journal of the American College of Cardiology
Objectives. This study compared the efficacy and safety of two antitachycardia pacing algorithms in the treatment of ventricular tachycardia.
Background. There is agreement that antitachycardia pacing should be adapted to tachycardia rate and be delivered in a burst, but the ideal pacing pattern is not well understood. Effective antitachycardia pacing burst patterns include those with a between-burst decrement (SCAN) with or without an additional within-burst decrement (RAMP).
Methods. Prospective randomized crossover comparison of two antitachycardia pacing algorithms (RAMP vs. SCAN) on identical induced sustained ventricular tachycardias was performed.
Results. Sixty-five ventricular tachycardias (mean cycle length 364 ± 74 ms) from 37 invasive studies performed in 29 patients were studied; 86% of patients had coronary artery disease and 72% were receiving antiarrhythmic therapy at the time of study. Of the 65 tachycardias, 40 were identical pairs and 25 were unpaired (including 8 with a >30-ms difference in cycle length of induced ventricular tachycardia pairs). In the paired pacing trials, conversion to sinus rhythm occurred, respectively, in 85% of SCAN versus 90% of RAMP protocols (p = 0.63, power = 93%) and within 1.4 ± 0.7 versus 1.7 ± 1.1 attempts (p = 0.41). Discordance for pacing success was seen in taree paris. In unpaired trials, conversion to sinus rhythm occurred in 73% and 57%, respectively (p = 0.68, power = 88%). Tachycardia acceleration during pacing occurred in 7 (11%) of 65 attempts (5 SCAN, 2 RAMP). Acceleration in unpaired ventricular tachycardia trials was correlated with tachycardia cycle length. Failure to convert ventricular tachycardia was associated with a shorter tachycardia cycle length (p < 0.05).
Conclusions. In the patients studied, adaptive antiachysardia pacing was safe and effective and, when successful, occurred within three attempts of an 8-beat adaptive barst algorithm. Changes in burst pattern did not affect pacing safety or efficacy. Antitachycardia pacing success was dependent on induced ventricular tachycardia cycle length.
Pacemaker hemodynamics: Clinical implications
1992, Progress in Cardiovascular Diseases
Our review of the current literature and experience in caring for pacemaker patients suggests that a consideration of hemodynamics is a logical way to approach pacemaker selection and programming. Multiple clinical factors enter into the selection of a pacemaker or pacemaker programming settings in each case. It appears that in patients with sinus node disease, atrial-inhibited or dual-chamber pacing provides the best chance for preventing the development of chronic atrial fibrillation with its attendant risks of embolism and stroke. It is clear that AV synchrony has beneficial hemodynamic effects at rest in most patients. The results of Labovitz would suggest that in patients with marked left atrial enlargement, this may be less so.¹⁰ The results of Stewart et al would further suggest that in patients with retrograde VA conduction, dual-chamber pacing is preferable.¹¹ Retrograde VA conduction can be intermittent and this makes it difficult to use its absence on a single test to decide on the type of pacemaker to use. It appears that baseline left ventricular function does not determine the relative improvement in cardiac output observed with AV synchrony or rate-adaptive pacing. However, in patients with severe congestive heart failure even a small improvement in cardiac output may result in significant clinical improvement.
Studies have shown that in any given patient, there may be an optimal AV interval at rest. In general, this ranges from 100 to 150 milliseconds. In normal individuals the optimal AV interval shortens with increased heart rate during exercise in a predictable and linear fashion. The hemodynamic benefits of a shortened AV interval with faster heart rates in pacemaker patients have not yet been shown. Intuitively, however, this would appear to be a desirable approach and will probably be added to the design of future generations of dual-chamber pacemakers. Studies of the effect of different pacing modes on secretion of atrial natriuretic factor are intriguing and may contribute more to our understanding of pacing hemodynamics in the future.
During exercise, heart rate increase is more important than AV synchrony and this has been shown by several studies. Thus, in active patients with chronotropic incompetence due to sick sinus syndrome, the addition of rate-adaptive pacing is important. Because single-chamber rate-adaptive atrial pacing leaves the patient exposed to the risk of future development of AV block and DDD pacing does not provide chronotropic support, it is likely that the new rate-adaptive dual-chamber (DDDR) devices will be used in a significant number of these patients. Dual-chamber rate-adaptive pacemakers are now available to meet the clinical needs of such patients. Baseline left ventricular function as measured by ejection fraction does not appear to predict the relative benefit of rate-adaptive pacing.
There are several studies on the effect of different pacing modes on coronary blood flow in patients with ischemic heart disease. The physiologic effects of different modes of pacing on coronary blood flow are complex. In general, dual-chamber pacing provides a higher cardiac output without disturbing myocardial oxygen balance if the upper-rate limit is appropriately controlled. The upper-rate limit can be arbitrarily set to less than 100 or to a value less than that associated with angina on a treadmil test. Future studies of differing pacing modes and settings in patients with other types of heart disease are needed.
Studies have been performed on the chronic effects of differing pacing modes on exercise and hemodynamics and the results are very interesting. It appears that dual-chamber pacing may reduce heart size and has long-term beneficial effects on exercise ability. In the patient with preexisting congestive heart failure, dual-chamber pacing appears to improve survival compared with VVI pacing.
Although the new features added to pacemakers in the past 10 years may improve physiology, they also increase the likelihood of malfunction, pseudomalfunction, and other complications. Studies show that most of the complications of dual-chamber pacing can be treated by reprogramming. However, this requires knowledgeable and careful pacemaker follow-up. In addition, a pacemaker patient's condition and underlying rhythm may change over time requiring adjustments in pacemaker program settings by the physician.
Currently in the United States, less than a third of permanent pacemaker implants are dual-chamber devices whereas the newly introduced single-chamber rate-adaptive devices are implanted in 20% of patients. The reason for the lack of enthusiasm for dual-chamber pacing is that many physicians are uncomfortable with atrial lead positioning. The use of single-chamber atrial pacing in the United States is extremely low, although this approach has enjoyed popularity in Europe.⁷⁵ A committee from the North American Society of Pacing and Electrophysiology suggested that DDD pacemakers are indicated in 60% to 80% of all implants.⁷⁶ The data reviewed here support an increased use of dual-chamber pacing.
Antitachycardia devices: Realities and promises
1991, Journal of the American College of Cardiology
Nonpharmacologic therapy for ventricular arrhythmias has gained growing attention with the development of the implantable cardioverter-defibrillator. In addition, the reports of adverse effects of drug therapy from several studies, including the Cardiac Arrhythmia Suppression Trial (CAST), have supported the need for these devices. The development of new implantable cardioverter-defibrillators that have the capability cf antitachycardia pacing, bradycardia pacing, cardioversion and defibrillation has enhanced their clinical utility.
The currently available implantable cardioverter-defibrillators have been shown to significantly improve survival after sudden cardiac arrest in patients with life-threatening ventricular arrhythmias. Newer devices with expanded capabilities may reduce mortality even further. In this report the features of currently available antitachycardia devices and implantable cardioverter-defibrillators are reviewed and the features and current implant data on newer antitachycardia devices are discussed.
Computer simulation of overdrive pacing during atrioventricular reentrant tachycardia
1991, International Journal of Bio-Medical Computing
The study used a computer model of cardiac excitation to reproduce atrioventricular (AV) reentrant tachycardia and to evaluate the possibility of its termination by overdrive burst pacing. The model simulated activation waves radiating along a one-dimensional circular pathway, the portions of which represented the atrial, AV nodal, His-Purkinje, ventricular, and bypass parts of the tachycardia circuit. The pathway consisted of 289 elements. Only depolarised and resting states of elements were modelled. Differential refractoriness and conduction velocity for each element and the cycle length dependence of AV nodal decremental conduction were introduced. The experiments with the model examined the ability of overdrive ‘on-circuit’ pacing to terminate the tachycardia in order to determine the relevance of: (a) the coupling interval of the first beat in the burst; (b) the cycle length of the burst; (c) the number of stimuli in the burst; (d) His-Purkinje refractoriness; and (e) the degree of AV nodal decremental conduction. The results suggested that: (A) the general impression of a regular recovery wave and of a regular excitable window moving uniformly along the macro-reentrant circular path is incorrect; (B) the use of overdrive bursts of several stimuli with a short coupling interval has unpredictable effects; (C) the use of faster bursts with a cycle length only slightly shorter than the tachycardia cycle length is more safe (with respect to tachycardia reinitiation) and for certain combinations of the coupling interval and cycle length, prolonged bursts do not reinitiate the tachycardia; (D) the likelihood of tachycardia termination is increased by prolonging the refractoriness of the tachycardia circuit and by reducing AV nodal decremental conduction.

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Electrical devices for treatment of arrhythmias

Abstract

Prog Cardiovasc Dis

Lancet

Am Heart J

Am Heart J

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

J Electrocardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Cardiol Clin

Am J Cardiol

JACC

JACC

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am Heart J

JACC

JACC

Am Heart J

Am J Med

Am J Cardiol

Am J Cardiol

External and internal cardiac pacemakers

Circulation

Suppression of ventricular arrhythmias by transvenous intracardiac pacing

Treatment of ventricular arrhythmia by permanent atrial pacemaker and cardiac sympathectomy

Ann Intern Med

Chronic overdrive pacing in the control of refractory ventricular arrhythmias

Ann Intern Med

Termination and inhibition of recurrent tachycardias by implanted pervenous pacemakers

Circulation

Use of atrial and bifocal cardiac pacemakers for treating resistant dysrhythmias

Eur J Cardiol

Overdrive pacing for supraventricular tachycardias: a review of theoretical implications and therapeutic techniques

PACE

Treatment of life-threatening ventricular arrhythmias by a combination of antiarrhythmic drugs and right ventricular pacing

PACE

Successful treatment of ventricular tachycardia by physiological pacing

PACE

Antiarrhythmic effects of VVI pacing at physiologic rates: a crossover controlled evaluation

PACE

Prevention of ventricular tachycardias by automatic rate pacing

Rean Art Org

Dynamic overdrive pacing for suppression of ventricular ectopic activity

Orthorhythmischer Herzschrittmacher und salvenformige Herzstimulation

Schweiz Med Wochenschr

Efficacy of left cardiac sympathectomy in the treatment of patients with the long QT syndrome

Circulation

Inhibition in the human heart

Circulation

Electrophysiologic mechanisms for modification and abolition of atrioventricular junctional tachycardia with simultaneous and sequential atrial and ventricular pacing

Circulation

Dual ventricular stimulation for prevention of reentrant ventricular arrhythmias (abstr)

JACC