The role of electrophysiologic concepts and procedures in managing patients with potentially life-threatening ar rhythmias in the intensive care unit is discussed. These patients may be survivors of sudden cardiac arrest or myocardial infarction or may be admitted for syncope or sustained or nonsustained ventricular tachycardia. The value of electrophysiologic testing is discussed in terms of the distinction between wide QRS complex tachycardias that are supraventricular or ventricular in origin and those in which preexcitation syndromes may be important. Drug-induced ventricular arrhythmias are discussed, with specific emphasis on torsades de pointes. Finally, the use of His bundle recordings in pa tients with atrioventricular conduction disturbances is discussed. The methodology of electrophysiologic test ing, including stimulation protocols and interpretation of results, is described.
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References
1.
Wellens Hjj, Brugada P., Stevenson WGProgrammed electrical stimulation of the heart in patients with life-threatening ventricular arrhythmias. Circulation1985;72: 1-7
2.
Brugada P., Wellens Hjj.Programmed stimulation of the heart in ventricular arrhythmias. Am J Cardiol1985;56: 187—190
3.
Scheinman MM , Morady F.Invasive cardiac electrophysiologic testing: the current state of the art. Circulation1983; G7:1169—1173
4.
Horowitz LN, Josephson ME, Kastor JAIntracardiac electrophysiologic studies as a method for the optimization of drug therapy in chronic ventricular arrhythmias. Prog Cardiovasc Dis1980;23:81-98
5.
McPherson CA , Rosenfeld LE, Batsford WPDay-to-day reproducibility of responses to right ventricular programmed electrical stimulation: implications for serial drug testing. Am J Cardiol1985;55:689—695
6.
Lombardi F., Stein J., Podrid PJ, et al. Daily reproducibility of electrophysiologic results in malignant ventricular arrhythmia. Am J Cardiol1986;57:96—101
7.
Bigger JTIdentification of patients at high risk for sudden cardiac death. Am J Cardidol1984;54:3D-8D
8.
Bigger JT, Fleiss JL, Klieger R., et al.The relationships among ventricular arrhythmias, left ventricular dysfunction and mortality in the 2 years after myocardial infarction. Circulation1984;69:250-258
9.
Lown B.Clinical management of ventricular arrhythmias. Hosp Pract1982 Apr:73-82
10.
Graboys TB, Lown B., Podrid PJ, DeSilva R.Long-term survival of patients with ventricular arrhythmia treated with antiarrhythmic drugs. Am J Cardiol1982;50:437-443
11.
Brugada P., Green M., Abdollah H., Wellens Hjj.Significance of ventricular arrhythmias initiated by programmed stimulation . Circulation1984;69:87-92
Buxton AE, Waxman HL, Marchlinski FE, et al. Role of triple extra-stimuli during electrophysiologic study of patients with documented sustained ventricular tachyarrhythmias. Circulation1984;69:532-540
14.
Morady F., DiCarlo LA, Winston S., et al. A prospective comparison of triple extrastimuli and left ventricular stimulation in studies of ventricular tachycardia induction. Circulation1984;70:52—59
15.
Morady F., DiCarlo LA, Liem LB, et al. Effects of high stimulation current on the induction of ventricular tachycardia. Am J Cardiol1985;56:73—78
16.
Spear JF, Moore EN, Horowitz LNEffect of current pulses delivered during the ventricular vulnerable period upon the ventricular fibrillation threshold. Am J Cardiol1973; 33:814—822
17.
Schoenfeld MH, McGovern B., Garan H., Ruskin JNLongterm reproducibility of responses to programmed cardiac stimulation in spontaneous ventricular tachyarrhythmias. Am J Cardiol1984;54:564—568
18.
Horowitz LN , Josephson ME, Farshidi A., et al.Recurrent sustained ventricular tachycardia: role of the electrophysiology study in the selection of antiarrhythmic regimens . Circulation1978;58:986-995
19.
Mason JW, Winkle RAElectrode catheter arrhythmia induction in the selection and assessment of antiarrhythmic drug therapy for recurrent ventricular tachycardia. Circulation1978;58:971-985
20.
Hartzler GO , Maloney JDProgrammed ventricular stimulation in management of recurrent ventricular tachycardia. Mayo Clin Proc1977;731-742
21.
Waxman HL, Buxton AE, Sadowski IM, Josephson MEResponse to procainamide during electrophysiologic study for sustained ventricular tachyarrhythmias predicts response to other medications. Circulation1982;67:30—37
22.
Ferrick K] , Bigger JF, Reiffel JA, et al. Congruence in efficacy of procainamide and quinidine for induced ventricular tachycardia. Circulation1982;68(suppl II):II-142
23.
Oseran DS, Gang ES, Rosenthal ME, et al. Electropharmacologic testing in sustained ventricular tachycardia associated with coronary heart disease: value of the response to intravenous procainamide in predicting the response to oral procainamide and oral quinidine treatment. Am J Cardiol1985;56:883-886
24.
Swerdlow CD , Winkle RA, Mason JWDeterminants of survival in patients with ventricular arrhythmias. N Engl J Med1983 ;308:1436—1442
25.
Ross DLVentricular tachycardia: electrophysiology studies. Hosp Phys1982 Apr:A8—A27
26.
Platia EV, Reid PRComparison of programmed electrical stimulation and ambulatory electrocardiographic (Holter) monitoring in the management of ventricular tachycardia and ventricular fibrillation. J Am Coll Cardiol1984;4:493-500
27.
Herling IM, Horowitz LN, Josephson MEVentricular ectopic activity after medical and surgical treatment for recurrent sustained ventricular tachycardia. Am J Cardiol1980;46:948—955
28.
Gradman AH, Batsford WP, Rieur EC, et al. Ambulatory electrocardiographic correlates of ventricular inducibility during programmed electrical stimulation. J Am Coll Cardiol1985;5:1087-1093
29.
Hamer AW, Finerman WB, Peter T., Mandel WJDisparity between the clinical and electrophysiologic effects of amiodarone in the treatment of recurrent ventricular arrhythmias. Am Heart J1981;102:992—998
30.
Heger JJ, Prystowsky EN, Jackman WM, et al. Amiodarone. Clinical efficacy and electrophysiology during long-term therapy for recurrent ventricular tachycardia or ventricular fibrillation . N Engl J Med1981;305:539-545
31.
Waxman HL, Groh WC, Marchlinski FE, et al. Amiodarone for control of sustained ventricular tachyarrhythmias: clinical and electrophysiologic effects in 51 patients. Am J Cardiol1982;50:1066-1074
32.
McGovern B. , Garan H., Malacoff FR, et al. Long-term clinical outcome of ventricular tachycardia or fibrillation treated with amiodarone. Am J Cardiol1984;53:1558-1563
33.
Horowtiz LN, Greenspan AM, Spielman SR, et al. Usefulness of electrophysiologic testing in evaluation of amiodarone therapy for sustained ventricular tachyarrhythmias associated with coronary heart disease. Am J Cardiol1985;55:367—371
34.
Ruskin JN, Di Marco JP, Garan H.Out of hospital cardiac arrest: electrophysiologic observations and selection of long-term antiarrhythmic therapy. N Engl J Med1980; 303:607—613
35.
Buxton AE, Waxman HL, Marchlinski FE, Josephson MEElectrophysiologic studies in non-sustained ventricular tachycardia. Relation to underlying heart disease. Am J Cardiol1983;52:985-991
36.
Ruskin JN, Di Marco JP, Garan H. Repetitive responses to single ventricular extra stimuli in patients with serious ventricular arrhythmia: incidence and clinical significance . Circulation1981;63:767-777
37.
Livelli FD, Bigger JT, Reiffel JA, et al. Response to programmed ventricular stimulation: sensitivity, specificity and relation to heart disease. Am J Cardiol1982;50:452—458
Buda AJ, Stinson EB, Harrison DCSurgery for life-threatening ventricular tachyarrhythmias. Am J Cardiol1979;44:1171—1177
40.
Mason JW, Stinson EB, Winkel RA, et al. Relative efficacy of blind left ventricular aneurysm resection for the treatment of recurrent ventricular tachycardia. Am J Cardiol1982; 49:241-248
41.
Sami M., Chiltman BR, Bourassa MG, et al. Long-term follow-up of aneurysmectomy for recurrent ventricular tachycardia. Am Heart J1978;96:303—308
42.
Mason JW, Stinson EB, Winkle RASurgery for ventricular tachycardia: efficacy of left ventricular aneurysm resection compared with operation guided by electrical activation mapping . Circulation1982;65:1149-1155
43.
Harken AH, Horowitz LN, Josephson MEComparison of standard aneurysmectomy and aneurysmectomy with directed endocardial resection for the treatment of recurrent sustained ventricular tachycardia . J Thorac Cardiovasc Surg1980;80:527—533
44.
Josephson ME , Horowitz LN, Farshidi A., et al. Recurrent sustained ventricular tachycardia. 2. Endocardial mapping. Circulation1978;57:440-447
45.
Josephson ME , Horowitz LN, Spielman SR, et al. Comparison of endocardial catheter mapping with intraoperative mapping of ventricular tachycardia. Circulation1980; 61:395—404
46.
Spielman SR , Michelson EL, Horowitz LN, et al. The limitations of surgical therapy of ventricular tachycardia. Circulation1978 ;57:666—673
47.
Klein H., Karp RB, Kouchoukos NT, et al. Intraoperative electrophysiologic mapping of the ventricles during sinus rhythm in patients with a previous myocardial infarction. Circulation1982;66:847—852
48.
Cassidy DM, Vassallo JA, Buxton AE, et al. The value of catheter mapping during sinus rhythm to localize site of origin of ventricular tachycardia. Circulation1984;69:1103— 1110
49.
Waxman HL, Josephson MEVentricular activation during ventricular endocardial pacing: I. Electrocardiographic patterns related to the site of pacing. Am J Cardiol1982;50:1-10
50.
Josephson ME , Waxman HL, Cain ME, et al. Ventricular activation during ventricular endocardial pacing. II. Role of pacemapping to localize origin of ventricular tachycardia. Am J Cardiol1982;50:11-22
51.
Harken AH, Josephson ME, Horowitz LNSurgical endocardial resection for the treatment of malignant ventricular tachycardia. Ann Surg1979;190:456-465
52.
Josephson ME , Horowitz LNEndocardial excision: a new surgical technique for the treatment of recurrent ventricular tachycardia. Circulation1979;60:1430-1438
53.
Josephson ME , Harken AH, Horowitz LNLong-term results of endocardial resection for sustained ventricular tachycardia in coronary disease patients. Am Heart J1982;104:51
54.
Moran JM, Kehoe RF, Loeb JMExtended endocardial resection for the treatment of ventricular tachycardia and ventricular fibrillation. Ann Thorac Surg1982;34:538-552
55.
Guiraudon G. , Fontaine G., Frank R., et al. Encircling endocardial ventriculotomy: a new surgical treatment for life-threatening ventricular tachycardias resistant to medical therapy following myocardial infarction. Ann Thorac Surg1978;26:438—444
56.
Camm AJ, Ward DE, Spurrell R., Rees GMCryothermal mapping and cryoablation in the treatment of refractory cardiac arrhythmias. Circulation1980;62:67-74
57.
Fisher JD, Cohen HL, Mehra R., et al. Cardiac pacing and pacemakers II. Serial electrophysiologic-pharmacologic testing for control of recurrent arrhythmias. Am Heart J1977;93:658—671
58.
Wiener I.Pacing techniques in the treatment of tachycardias. Ann Intern Med1980;93:326-332
59.
Fisher JD, Kim SG, Furman S., Matos JARole of implantable pacemakers in control of recurrent ventricular tachycardia . Am J Cardiol1982;49:194-207
60.
Luderitz B. , d'Almoncourt CN, Steinbeck G., Beyer J.Therapeutic pacing in tachyarrhythmias by implanted pacemakers. PACE1982;5:366-377
61.
Haft JITreatment of arrhythmias by intracardiac electrical stimulation. Prog Cardiovasc Dis1974;16:539-554
62.
Mirowski M. , Reid PR, Mower MM, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med1980; 303:322—334
63.
Roy D., Waxman HL, Kienzle MG, et al. Clinical characteristics and long-term follow-up in 119 survivors of cardiac arrest: relation to inducibility at electrophysiology testing. Am J Cardiol1983;52:969—974
64.
Ruskin JN, Di Marco JP, Garan H. Out of hospital cardiac arrest. N Engl J Med1980;303:607-613
65.
Skale BT, Miles WM, Heger JJ, et al. Survivors of cardiac arrest: prevention of recurrence by drug therapy as predicted by electrophysiologic testing or electrocardiographic monitoring. Am J Cardiol1986;57:113-119
66.
Milner PG, Platia EV, Reid PR, Griffith Lsc.Ambulatory electrocardiographic recordings at the time of fatal cardiac arrest . Am Cardiol1985;56:588—592
67.
Kempf FC, Josephson MECardiac arrest recorded on ambulatory electrocardiograms. Am J Cardiol1984;53:1577-1582
68.
Stevenson WG , Brugada PL, Waldecker B., et al. Significance of polymorphic ventricular arrhythmias induced by programmed ventricular stimulation. Am J Cardiol (in press)
69.
Morady F., Di Carlo L., Winston S., et al. Clinical features and prognosis of patients with out of hospital cardiac arrest and a normal electrophysiologic study. J Am Coll Cardiol1984;4:39—44
70.
Olshansky B. , Maryuz M., Martins JBSignificance of inducible tachycardia in patients with syncope of unknown origin. A long term follow up. J Am Coll Cardiol1985;5:216-223
71.
Doherty JU, Pembrook-Rogers D., Grogan EW, et al. Electrophysiologic evaluation and follow up characteristics of patients with recurrent unexplained syncope and presyncope. Am J Cardiol1985;55:703-708
72.
Di Marco JP, Garan H.Harthorne JW, Ruskin JMIntracardiac electrophysiologic techniques in recurrent syncope of unknown cause. Ann Intern Med1981;95:542-548
73.
Morady F., Higgins J., Peters RW, et al. Electrophysiologic testing in bundle branch block and unexplained syncope. Am J Cardiol1984;54:587—591
74.
Hamer Awf, Rubin SA, Peter T., Mandel WJFactors that predict syncope during ventricular tachycardia in patients. Am Heart J1984;107:997—1005
75.
Gomes Jac, Hariman RI, Kang PS, et al. Programmed electrical stimulation in patients with high-grade ventricular ectopy: electrophysiologic findings and prognosis for survival . Circulation1984;70:43—51
76.
Velebit V., Podrid P., Lown B., et al. Aggravation and provocation of ventricular arrhythmias by antiarrhythmic drugs. Circulation1982;65:886-894
77.
Buxton AE, Marchlinski FE, Waxman HL, et al. Prognostic factors in nonsustained ventricular tachycardia. Am J Cardiol1984;53:1275-1279
78.
Veltri EP, Platia EV, Griffith Lsc, Reid PRProgrammed electrical stimulation and long term follow up in asymptomatic, nonsustained ventricular tachycardia. Am J Cardiol1985; 56:309—314
79.
Platia EV, Reid PRNonsustained ventricular tachycardia during programmed ventricular stimulation: criteria for a positive test. Am J Cardiol1985;56:79—83
80.
Chung EKTorsade de pointes. Prim Cardiol1982 Nov:A31—A38
81.
Sandor R., Morrison D.Recognizing drug-induced torsade de pointes tachycardia. Drug Ther1983 June:75—84
82.
Moss AJ, Schwartz PJ, Crampston RS, et al. The long QT syndrome: a prospective international study. Circulation1985;71:17—21
83.
Lewis BH, Antman EM, Graboys TBDetailed analysis of 24 hour ambulatory electrocardiographic recordings during ventricular fibrillation or torsades-de-pointes. J Am Coll Cardiol1983;2:426-436
84.
Topol EJ, Lerman BBHypomagnesemic torsades de pointes. Am J Cardiol1983;52:1367-1368
85.
Herrmann HC , Kaplan LM, Bierer BEQT prolongation and torsade de pointes ventricular tachycardia produced by the tetracyclic antidepressant agent moprotiline. Am J Cardiol1983;904—906
86.
Olshansky B. , Martins J., Hunt S.N-acetyl procainamide causing torsades-de-pointes . Am J Cardiol1982;50:1439—1441
87.
Surawicz B. , Knoebel SBLong QT: good, bad or indifferent? J Am Coll Cardiol1984;4:398-413
88.
Tzivoni D., Keren A., Cohen AM, et al. Magnesium therapy for torsades-de-pointes. Am J Cardiol1984;53:528-530
89.
Bhandari AK , Scheinman MM, Morady F., et al. Efficacy of left cardiac sympathectomy in the treatment of patients with the long QT syndrome. Circulation1984;70:1018-1023
90.
Bhandari AK , Shapiro WA, Morady F., et al. Electrophysiologic testing on patients with the long QT syndrome. Circulation1985 ;71:63-71
91.
Richards DL , Cody DV, Denniss AR, et al. Ventricular electrical instability: a predictor of death after myocardial infarction. Am J Cardiol1983;51:75-80
92.
Waspe LE, Seinfeld D., Ferrick A., et al. Prediction of sudden death and spontaneous ventricular tachycardia in survivors of complicated myocardial infarction. J Am Coll Cardiol1985;5:1292—1301
93.
Denniss RA, Baaijens H., Cody DV, et al. Value of programmed stimulation and exercise testing in predicting one-year mortality after acute myocardial infarction. Am J Cardiol1985;56:213-220
94.
Roy D., Marchand E., Theronx P., et al. Programmed ventricular stimulation in survivors of an acute myocardial infarction. Circulation1985;72:487-494
95.
Wellens Hjj , Bar Fwhm, Lie KIThe value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex. Am J Med1978;64:27—33
96.
Castellanos A., Sung RJ, Mallon SM, et al. His bundle electrocardiography in manifest and concealed right bundle branch extrasystoles. Am Heart J1977;94:307—314
97.
Massumi RA, Ertem GE, Vera Z.Aberrancy of functional escape beats. Evidence for origin in the fascicles of the left bundle branch. Am J Cardiol1972 ;29:351-361
98.
Massumi RA, Hilliard G., DeMaria A., et al. Paradoxic phenomenon of premature beats with narrow QRS in the presence of bundle branch block. Circulation1973;47:543-554
99.
Farshidi A. , Josephson ME, Horowitz LHElectrophysiologic characteristics of concealed bypass tracts: clinical and electrocardiographic correlates. Am J Cardiol1978;41:1052-1060
100.
Gillette P.Concealed anomalous cardiac conduction pathways: a frequent cause of supraventricular tachycardia. Am J Cardiol1977;40:848-852
101.
Sung RJ, Gelband H., Castellanos A., et al. Clinical and electrophysiologic observations in patients with concealed accessory atrioventricular bypass tracts. Am J Cardiol1977; 40:839—847
102.
Pritchett Elc, Gallagher JJ, Sealy WC, et al. Supraventricular tachycardia dependent upon accessory pathways in the absence of ventricular preexcitation. Am J Med1978;64:214-220
103.
Akhtar M.Electrophysiologic basis for wide QRS complex tachycardia. PACE1983;6:81-98
104.
Bardy GH, Parker DL, German CD, Gallagher JJPreexcited reciprocating tachycardia in patients with Wolff-Parkinson-White syndrome: incidence and mechanisms. Circulation1984;70:377—391
Castellanos A., De Luna AB, Zaman L., Myerburg RJRisk factors for ventricular fibrillation in the preexcitation syndromes. Pract Cardiol1983;9:167-175
107.
Sharma AD, Klein GJ, Guiraudon GM, Milstein S.Atrial fibrillation in patients with Wolff-Parkinson-White syndrome. Circulation1985;72:161-169
108.
Morady F., Sledge C., Shen E., et al. Electrophysiology testing in the management of patients with the Wolff-Parkinson-White syndrome and atrial fibrillation. Am J Cardiol1983;51:1623—1628
109.
Bardy GH, German LD, Parker DL, et al. Mechanism of tachycardia using a nodofascicular Mahaim fiber . Am J Cardiol1984;54:1140-1141.
110.
Holmes DR, Osborn MS, Gersh B., et al. The Wolff Parkinson-White syndrome: a surgical approach. Mayo Clin Proc1982;57:345—350
111.
Burchell HBThe surgical treatment of reentrant atrioventricular tachycardia (Wolff Parkinson-White syndrome). Mayo Clin Proc1982;57:387-393
112.
Gallagher JJ, Svenson RH, Kassell JH, et al. Catheter technique for closed-chest ablation of the atrioventricular conduction system. N Engl J Med1982;306:194-203
113.
Scheinman M., Morady F., Hess D., Gonzales R.Transvenous catheter technique for induction of damage to the atrioventricular junction in man. Am J Cardiol1982;49:1013
114.
Fischer JD , Matos JA, Kim SGThe sparkling joules of internal cardiac stimulation: cardioversion, defibrillation and ablation. Am Heart J1982;104:177—182
115.
Brodman R., Fisher JDTechnique for ablation of anomalous conduction using a catheter placed in the coronary sinus: canine studies (abstract). Circulation1982;66:II-217
116.
Fisher JD, Broadman R., Kim SG, Matos JANon-surgical Kent bundle ablation via the coronary sinus in patients with the Wolff-Parkinson-White syndrome (abstract). Circulation1982;6G:II-375
117.
Belhassan B., Miller HI, Geller E., Laniado L.Transcatheter electrical shock ablation of ventricular tachycardia. J Am Coll Cardiol1986;7:1347—1355
118.
Rokseth R. , Hatle L.Sinus arrest in acute myocardial infarction . Br Heart J1971;33:639—647
119.
James TNThe coronary circulation and conduction system in acute myocardial infarction . Cardiovasc Dis1968;10:410— 417
120.
Mullins CB , Atkins JMPrognosis and management of ventricular conduction blocks in acute myocardial infarction. Mod Concepts Cardiovascular Dis1975;90:439-455
121.
Lev M.The normal anatomy of the conduction system in man and its pathology in atrioventricular block. Ann NY Acad Sci1964;111:817-829
122.
Brown RW, Hunt D., Sloman JGThe natural history of atrioventricular conduction defects in acute myocardial infarction. Am Heart J1969;78:460—467
123.
Norris RMArrhythmia in acute myocardial infarction. In: Sandol E, Flensted-Jensen E, and Olesen KH, eds. Symposium on cardiac arrhythmias. Sodertalje, Sweden: A. B. Astra, 1970:734
124.
Rosen KM, Loeb HS, Chuquimia R., et al. Site of heart block in acute myocardial infarction. Circulation1970;42:925-933
125.
Feigl D., Ashkenazy J., Kishan Y.Early and late atrioventricular block in acute inferior myocardial infarction . J Am Coll Cardiol1984;4:35-38
126.
Lie KF, Wellens HJ, Schuilenburg R., et al. Factors influencing prognosis of bundle branch block complicating acute anteroseptal infarction. The value of His bundle recordings. Circulation1974;50:935-941
127.
Hindman MC , Wagner GS, Jaro M., et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 1. Clinical characteristics, hospital mortality and one year follow-up. Circulation1978;58:679-668
128.
Demenighetti G., Perret C.Intraventricular conduction disturbances in acute myocardial infarction: short and longterm prognosis. Eur J Cardiol1980;11:51—59
129.
Rotman M., Wagner GS, Wallace AGBradyarrhythmias in acute myocardial infarction. Circulation1973;45:703-710
130.
Hindman MC , Wagner GS, Jaro M., et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Elucidations for temporary and permanent pacemaker insertion. Circulation1978;58:689-699
131.
Ritter WS, Atkins JM, Blomqvist CG, Mullins CBPermanent pacing in patients with transient trivascicular block during acute myocardial infarction. Am J Cardiol1976;38:205-208
132.
Altschuler H., Seinfeld D., Fisher JDUnpredictability of site of conduction system injury due to acute myocardial infarction. Circulation1975;55, 56 (suppl III):220-232
133.
Frye RL, Collins JJ, DeSanctis RW, et al. Guidelines for permanent cardiac pacemaker implantation. J Am Coll Cardiol1984;4:434—442
