A13-6 Neurocardiogenic syncope in patients with dilated cardiomyopathy
0 N. Aggelopoulou , E.G. Livanis, A. Kostopoulou, D. Leftheriotis, P. Flevari, G.N. Theodorakis, D.T.H. Kremastinos. 2nd Dept
1 D. Zysko, .I. Gajek. Department Wroclaw , Wroclaw , Poland
2 M. Scaglione , P. Didonna, D. Caponi, G. Azzaro, S. Leuzi, F. Fermis, G. Rossetti , M. Bocchiardo. Elechvphysiology Laboratory. Division
3 J.L. Merino , M. Abello, R. P&ado, M. Gnoatto , .I. Ruiz-Cmtador, M. Gonzalez-Vasserot, J.A. Sobrim. Hospital Universitario Ala Paz” , Madrid , Spain
4 A. Pastor, A. Nunez, A. Martin-Penato , C. Alonso, J.-C. Garcia, F.-G. Cosio. Cardiology Department. Hospital Universitario De Getafe
tions after 30 minutes of supine rest and immediately after the syncope. The change of A D M concentration was expressed as ADM2IADMl. All the pts had 24.hour ECG bolter monitoring and heart rate variability analysis was performed for 2 minutes time period before NTG administration if the syncope occurred in active phase or 2 minutes period immediately before the syncope in the passive phase, not including the slowing of heart rate. The following HRV parameters were assessed:mRR, SDNN, rMSSD, TP, LF, HF and B calculated as LF,'HF. Results: The plasma level of A D M in group I decreased signiiicantly 31,9&33,6 vs 17,0&14,5 pg/ml (p<O,O5) and in group II increased signiiicantly 13,0&7,6 vs 27,4&13,0 pgiml @<0,05).
The statistical analysis revealed significant correlation between the
ADM2IADMl and phase of positive HU’IT (r=O,51 p<O,O2) (II- passive
phase, I - active phase), and with LF (r=0,51, p<O,O5) and B parameter
Conclusions: 1. There is a different type of neurohumoral response in the
course of vasovagal syncope during the passive and active phase of the test.
2. The activation of sympathetic nervous system during gravitational stress
correlates with the increase of A D M secretion.
IAl 3 4
.I. Gajek, D. Zysko. Department
Wroclaw, Wroclaw, Poland
THE INFLUENCE OF HEAD-UP TILT TEST ON PLASMA
ADRENOMEDULLIN CONCENTRATION IN PATIENTS
WITH CARDIODEPRESSIVE VASOVAGAL SYNCOPE
Background: Adrenomedullin (ADM) is a potent vasodilator playing role in
regulation of central hemodymmic. The concentration of plasma A D M in
healthy persons increase under the influence of orthostatic stress. In patients
with vasovagal syncope (VS) the changes in A D M concentration could be
responsible either for syncope provocation or prevention. The aim of the study
was to assess the influence of phase of the head-up tilt test (HU’ITJ in which
the syncope occurred on the plasma concentration of ADM.
Material and method: The study was performed in 23 patients (pts) with
vasovagal syncope (17 w o m e n and 6 men), m e a n age 45,7&16,lyears, in
w h o m the cardiodepressive vasovagal syncope during HU’IT according to the
Italian protocol with nitroglycerine (NTG) prowcation was produced. In 6 pts
VS occurred in the passive phase of tilt (group 1) and in 17 pts after NTG
provocation (group 2). The head-up tilt test was performed according to ESC
guidelines. The blood for A D M concentration was drawn after 30 min supine
rest (ADM 1) and immediately after the syncope (ADM 2). A D M level was
measured using radioimmunological method.
The results are shown in table as mea&SD:
In group 1 plasma level of A D M increased significantly after the HU’IT
and in group 2 decreased significantly comparing to baseline values. The A D M
concentration did not differ between the groups in baseline conditions and was
signiiicantly higher after the syncope in group 1.
Conclusions: 1. The excessive increase of A D M concentration during the
passive phase of HU’IT could play the causative role in pathogen&s of VS
occurring early during the HU’IT 2. In patients with VS after NTGprovocation
the decrease of A D M concentration can be the result of hemodynamic changes
in the presence of vasodilating drug and may be the mechanism that could
prevent the syncope.
IAl 3 5
SLOWING OF THE SINUS RHYTHM AND THE PAlTERN
OF ACTIVATION OF THE SYMPATHETIC NERVOUS
SYSTEM DURING HEAD-UP TILT TEST
The dysautonomic reaction and vasovagal syncope are the most frequently
observed types of positive reaction to head-up tilt test (HU’IT. The widely
accepted explanation of that reactions is the failure of the autonomic nervous
system in dysautonomic and its ‘hyperactivity’ of reflex origin in vasovagal
reaction. The slowing of heart rate during vasovagal reaction is commonly more
abrupt because of the reflex mechanism.
The aim of the study was to assess the activation of autonomic nervous
system by means of heart rate variability (HRV) in the time period S-10
minutes after the positive HUTT and the ‘time of slowing’ as a novel parameter
describing the course of HLJ’IT
Material and methods: The study group consisted of 49 patients (pts) with
positive HUTT according to Italian protocol with NTG provocation. In 32
pts vasovagal reaction was diagnosed (group I) and in 17 pts dysautonomic
reaction was established (group II). The following parameters were analyzed:
time of slowing of heart rate measured as the time from shortest to the longest
RR interval and the time and frequency domain parameters of HRV in the 2
minutes time periods: immediately before and between S-10 minutes after the
cessation of the HUTT In patients with vasovagal reaction the presence of
pauses or escape rhythm was assessed.
Results: There were no differences between the studied HRV parameters
before the HU’IT The selected results of HRV parameters analysis after the
HU’IT and ‘time of slowing’ are shown in the table:
In patients with VVS RR pauses or junctional escape rhythm was present
in 22 pts. In all studied patients significant negative correlation between time
of slowing and the B HRV parameter (I=-0,41 p<O,OO5) was established. The
time of slowing correlated with m R R before the HU’IT (r=0,29 p<O,O5). In
the patients with dysautonomic reactions the time of slowing correlated only
with B before HU’IT (r=O,59 p<O,O2). In the VVS group the time of slowing
correlated with m R R before, rMSSD before, pNN50 before, m R R after the
study and negatively with B after (I=-0,45 p<O,Ol) and the presence of pauses
or escape rhythm (I=-0,44 p<O,O2).
Conclusion: Short time of slowing of heart rate reflecting abrupt vasovagal
reaction is connected with signs of sympathetic nervous system activation in
the period S-10 minutes after the HUTT
NEUROCARDIOGENIC SYNCOPE IN PATIENTS WITH
Background: The prevalence of neurocardiogenic syncope (NCS) in patients
(pts) with dilated cardiomyopathy (DCM) is not well known. Due to overall
systolic impairment and blunted baroreceptor sensitivity, central mechanisms
may be the most important, if not exclusive, pathophysiologic mechanism of
NCS in D C M pts. Clomipramine (CLOM) infusion during tilt test seems to be
the most appropriate tool to investigate the pathophysiology of NCS in D C M
pts, as it is the only challenge drug acting on the central nervous system and has
been successfully tested in pts with NCS and preserved cardiac function. The
purpose of the study was to investigate if the activation of central serotonergic
mechanisms can provoke NCS in D C M pts.
Methods: Fifteen pts with D C M and an AICD implanted in the past due
to life threatening arrhythmias, (11 men, m e a n age 59.5&9.35 years), were
studied. Three (20%) pts were in NYHA class I-II, 7 in class II (47%), and
5 in class III (33%). The m e a n EF was 33&6.1%, LVEDD 64.7&5.7 m m
and LVESD 49&7.7 mm. Thirteen pts (874o) were treated with fi-blockers, 13
(87%) with ACE inhibitors, 9 (60%) with diuretics, 5 (33%) with a&rhythmic
drugs and 2 (13%) with AT II inhibitors. Seven (47%) pts reported syncopal or
presyncopal episodes 35.7&31.5 months after AICD implantation. Arrhythmic
causes of syncope or presyncope were excluded by AICD interrogation. All pts
underwent a CLOM tilt test after discontinuation of diuretics for 2 days. They
were tilted at 60” for 20 min and 5 m g of CLOM were iv infused at the first 5
min of the test. Six pts (40%) had a positive response at the 11.5&5.6 min. The
type of positive response was cardioinhibitory in 2 pts and mixed in 4 pts. No
differences were found in pts with positive and negative CLOM test in relation
to age, EF, NYHA class and drug treatment (except for antiarrhythmia). All
pts with positive CLOM test and only 1 with negative CLOM test reported
syncope or presyncope.
Pts with syncopeof presyncope
Conclusion: Central serotonergic activation is involved in the pathogenesis
of NCS in DCM patients. The possibility that NCS is the cause of a syncopal
episode should always be considered when assessing pts with DCM.
O F ATRIAL F L U T T E R
I Al 4 1
USE OF IRRIGATED
TIP CATHETERS IN
ABLATION OF ATRIAL FLUTTER
Z. Starek, L. Haman, Z. Csanadi, D. Herman. Fn USvAnq
Republic, Fn Hradec Kralove, Czech Republic, University
Hungary Fn Kralovske Vinohrady, Prague, Czech Republic,
Background: Radiofrequency ablation of common atrial flutter requires the
creation of a complete transmural ablation line across cavotricuspid region to
achieve bidirectional conduction block. Irrigated tip catheters facilitate rapid
achievement of this block by creation larger and deeper lesions. The EASTHER
registry was organized to collect data about the efficacy of the procedure in
small and middle volume centm in Central and Eastern Europe, all using
THERMOCOOL’ catheter technology.
Methods: EASTHER is a prospective registry (April 2002 - February 2003).
133 consecutive patients (81.1% male, age 59.0*10.4 years, range 30-81 years)
with common atria1 flutter were enrolled. Coincidence with atypical flutter was
observed in 2.7%. Patients had a history of flutter of 31.0&53.6 months (range
l-403) and concomitant AFib was observed in 42.9%. Stmchml heart disease
was present in 38.9%. Amount of redo cases was 14%. RF energy was applied
during 60 sec. in power-controlled mode at a setting between 40 to 50 W with
an average flow rate of 19.0 mumin.
Results: Acute success rate, defined as bi-directional block was achieved
in 93.1%. Average number of RF applications was 12.0&7.0 (range 2-40) per
procedure. Average delivered power varied between an minimum of 36.1&15.1
W till an maximum of 45.3&13.0 W, while the average maximum temperature
observed at the same time was varied between 39.0&3.4”C and 45.4&4.O”C.
Total procedure time was 100.1&42.7 min (range 20-280 min.) and fluoroscopy
time was 15.8&9.6 min. (range 4 - 45 min.) Two serious adverse events were
reported. These results are comparable with the literature data published.
Conclusions: Irrigated tip catheters are effective and safe in ablation of
common atria1 flutter. This technology helps to accelerate and facilitate achievement
of bi-directional isthmus block.
I Al 4 2
LIMITATIONS OF ABLATION CAVOTRICUSPID ISTHMUS AFTER ATRIAL FLUTTER
LINES RECORDINGS BLOCK ASSESSMENT ABLATION FOR
Background: Cm-tricuspid isthmus (CTI) block is the goal of typical atria1
flutter (FLTJ ablation. The study of the recorded potentials at the ablation line
(AbL) has been proposed, accepting the presence of double potentials (DP)
as a marker of block. We analysed the difficulty in the interpretation of DP
recording at the Abl line after FLT Abl.
Methods: 38 flutter ablation procedures were performed guided by anterior
and septal right atrium (RA) activation sequence (AS) pacing from both sides
of the AbL and by mapping the AbL 19 patients (P) with a complete study of
DP including differential pacing (Dif P) m counter-clockwise and clockwise
direction were selected for analysis. A 24-p& catheter allowed lo-12
simultaneous recordings from anterioriseptal RA and Dif P, and a bipolar catheter
(2X4 mm) was used for ablation and recording in the CTI. Dif P was performed
from low anterior and septal RA near the AbL, and from another level 1-2 cm
above. CT1 block: descending pattern in the AS of the opposite RA pacing
from both low anterior and septal RA. CT1 conduction: ascending pattern or
fusion of activation front.
Results: In 18 P, RA AS pacing both sides of the AbL showed bidirectional
CT1 block appearance. DP study mapping the AbL were concordant and easy
to assess in 15 P with a RA AS suggestive of counter-clockwise CT1 block, 10
P with a RA AS suggestive of clockwise CT1 block, DP study was complex
and difficult to analyse even by Dif P, arising doubts of residual clockwise CT1
conduction. In these P, no FLT recurrences occurred after a mean follow-up of
29 month (range 11-48 m). The P with a bidirectional CT1 conduction pattern,
the AS and AbL recordings were concordant, and FLT recurred at eighth month
Conclusion: In FLT ablation, complexity of electrograms recorded from the
CT1 in a quite number of patients, make difficult the study of DP, even with Dif
P, being recommended its use combined with RA activation sequences during
pacing. The use of a catheter covering septal RA eases the procedure.
ATRIAL FLUTTER DUE TO REENTRY FOSSA OVALIS: REENTRANT CIRCUIT AND ABLATION
Different reentrant circuits responsible for atypical atria1 flutter (AFTJ have
been reported in the right atrium. However, information about circuit delineation
and ablation approach of septal AFT is limited.
Methods: Reentry around a septal obstacle was found the AFT mechanism
at electrohysiological evaluation in 3 (2 females, ages of 64, 81, and 84 years)
out of 124 patients with AFT. No patient had significant heart disease except for
mild systemic hypertension. This mechanism of AFT presented clinically in all
of them and had a cycle length of 205, 340, and 350 ms respectively. This AFT
could be induced, entrained with fusion, and terminated by atria1 stimulation in
all patients. Activation mapping around the fossa ovalis demonstrated double
electrograms spanning through almost the entire AFT cycle length. Postpacing
intervals following AFT entrainment by pacing around the fossa ovalis and
the subeustaquian isthmus were similar (~20 ms) to or longer than the AFT
cycle length respectively in all the patients. Reversal of rotation around the
fossa ovalis resulting in AFT with a different activation sequence and similar
cycle length to the clinical AFT was demonstrated in two patients. Sequential
radiofrequency application from the fossa ovalis to the mid posterior wall of the
right atrium, where low electrical activity was recorded prior ablation,
terminated the AFT in two patients. Additional radiofrequency application from the
fossa ovalis to the superior vena cava was performed in the remaining patient
prior to AFT termination following a new radiofrequency application from the
fossa ovalis to the right atrium posterior wall. Typical atria1 flutter, as other
mechanism of AFT, could be induced in all the patients.
Conclusions: Reentry around a septal obstacle, possibly the fossa ovalis, is
a distinct mechanism responsible for no isthmus dependent atria1 flutter. This
circuit can be ablated by radiofrequency application form the fossa ovalis to
the posterior wall of the right atrium.
ATYPICAL ATRIAL FLUTTER:
USING NON FLUOROSCOPIC
Aim: To evaluate the electrophysiological features of atypical atria1 flutter
(AFI) and its response to radiofrequency catheter ablation.
Methods: Twentyone patients (pts), 13 males and 8 females (mean age
47&25 yrs) with atypical drug refractory AFI, including amiodarone,
underwent 3D electroanatomic mapping during clinical arrhythmia. RF ablation was
performed using a 4 mm cooled tip catheter targeting conduction isthmuses.
Results: The 3D mapping revealed macroreentrant circuits with one or more
loops in all pts and allowed to identify isthmuses for ablation. In 6 pts the circuit
was located in the left atrium while in the remaining 15 in the right atrium. Two
pts presented functional reentry circuits while in the remaining pts the circuits
were anatomical. The total number of circuits was 30 for 21 pts. The acute
success was obtained in 20121 pts. The abolition of the conduction isthmuses
determined arrhythmia interruption in 18121 pts. In two of the remaining 3 pts,
AFI interruption was obtained ablating all the conduction isthmuses and was
preceded by a change in morphology and cycle length of the arrhythmia. In the
last pt the ablation of conduction isthmuses determined only the modification
of the arrhythmia which stopped only after administration of flecainide iv. No
acute or late complications were observed.
During a mean follow up of 14&4 months there were no recurrences. All
but one pts were free from ant&rhythmic drugs.
Europace Supplements, Vol. 4, December 2003 B21