Zeitschrift für Kardiologie
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Review Comparative Study
[Endocardial mapping and high frequency catheter ablation of ventricular tachycardia after myocardial infarction].
Recurrent ventricular tachycardia in the setting of remote myocardial infarction are frequently resistant to antiarrhythmic drug treatment. Endocardial mapping and ablation is feasible in case of hemodynamically tolerable and reproducibly inducible forms. Identification of critical components of the reentrant circuit is mainly guided by entrainment mapping and the analysis of the post-pacing interval. ⋯ Furthermore, this method can be life-saving in the setting of incessant forms. Currently, catheter ablation represents an adjunctive treatment to antiarrhythmic drugs and the implantation of a cardioverter-defibrillator. Improvement of mapping and ablation technologies may help to further increase the efficacy of this treatment strategy in the near future.
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For the emergency treatment of sustained, hemodynamically stable ventricular tachycardia, antiarrhythmic drugs are the therapy of choice. Mostly class I antiarrhythmic drugs, such as lidocaine or ajmaline, are preferred. ⋯ For the primary prevention of sudden cardiac death, beta-blockers and/or amiodarone are the only effective drugs. In the secondary prevention, only the implantable cardioverter/defibrillator has proved to improve the prognosis of the patients.
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Aortic dissection with no entry or false lumen flow was recently identified as intramural hemorrhage of the aortic wall (IMH). Analysis of the literature revealed 209 cases of in vivo diagnosed IMH reflecting 17% of all dissections, whereas in postmortem studies this condition is found in 4-13%. Transesophageal echocardiography, computed tomography, magnetic resonance imaging and aortography (to rule out dissection) have been applied for diagnosing IMH in 57, 49, 43 and 38% of the cases, respectively. ⋯ With surgical repair, mortality of type A IMH is lowered to 18% compared to 60% with medical treatment (p < 0.01). In contrast, with 8% mortality associated with medical treatment, prognosis of type B IMH is more favorable without surgical intervention, the latter associated with a 30-day mortality of 33% (p < 0.05). Thus, IMH is a potential precursor of dissection and should be managed like dissection with undelayed surgical intervention in patients with type A IMH and with medical treatment in type B IMH.
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Cheyne-Stokes respiration (CSR) during sleep is common in patients with severe congestive heart failure induces repetitive oxygen desaturation with arousals, and impairs sleep. This causes daytime symptoms and likely an increase in sympathetic activity. It has, therefore, been suggested that CSR is independently related to mortality. ⋯ Nocturnal oxygen reduces CSR and improves exercise tolerance as well as sleep. This and its apparent safety makes oxygen an appropriate treatment for nocturnal CSR. Whether successful treatment of nocturnal CSR has any impact on the natural course of heart failure needs to be determined in further studies.
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Patients with therapeutically refractory angina pectoris do not respond to adequate anti-anginal medication and are not suitable anymore for revascularisation procedures. This group of patients has a poor quality of life, since their exercise capacity is severely afflicted. A new additional therapy for patients with refractory angina is neurostimulation. ⋯ The mechanisms of action of SCS are unclear, although there is evidence of an increase in myocardial oxygen supply, as is shown in peripheral vascular disease. Sympathetic nervous activity, prostaglandins, and endogenous opiates may also play a role in pain suppression by SCS. As soon as the safety and the complication rate are established, SCS may be commonly used as an additional therapy in patients with so-called "intractable angina pectoris".