Fundamental Approaches to the Management of Cardiac Arrhythmias

808 Pages·2000·54.15 MB·English

by  Ruey J. Sung M.D.

FundamentalApproaches to the
ManagementofCardiacArrhythmias
Fundamental Approaches
to the Management of
Cardiac Arrhythmias
by
Ruey J. Sung, M.D.
Professor ofM edicine,
Stanford University School ofM edicine, and
Director, Cardiac Electrophysiology & Arrhythmia Service,
Stanford University Medical Center,
Stanford, California, USA.
lind
Michael R. Lauer, M.D., Ph. D.
Clinical Assistant Professor ofM edicine,
Stanford University School ofM edicine,
Stanford, California, USA. and
Attending Cardiac Electrophysiologist,
The Permanente Medical Group,
Assistant Director, Cardiac Electrophysiology Laboratory,
Kaiser-Permanente Medical Center,
San lose, California, USA.
SPRINGER SCIENCE+BUSINESS MEDIA, B.V.
A C.I.P. Catalogue record for this book is available from the Library of Congress.
ISBN 978-94-010-5879-7 ISBN 978-94-011-4371-4 (eBook)
DOI 10.1007/978-94-011-4371-4
Printed on acid-free paper
All Rights Reserved
© 2000 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 2000
Softcover reprint ofthe hardcover 1st edition 2000
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
including photocopying, recording or by any information storage and
retrieval system, without written permission from the copyright owner.
DEDICATION
To mymentor, ProfessorAgustin Castellanos, Jr., mywife, Kuei, my
mother, Ping-ShingLin, andmychildren, Janet, Emory, and Tain-Yen.
-RJS
To mywife, Leslie, andmymother, Lillian.
-MRL
"Whatdeserves the mostemphasisandwhatdoes unite us all inscience is
ourunconflictedandoverridingdevotiontothecultureofscience. Whatis
great is the discipline ofscience not the people doing it. Science enables
us - ordinarypeople doing ordinarythings, whichwhen assembledreveal
theextraordinaryandawesomebeautiesofnature."
ArthurKornberg,M.D.
Nobel Laureate
EmmaPfeifferMernerProfessorofBiochemistry,Emeritus
Stanford University SchoolofMedicine
PREFACE
Our purpose in writing this book was to produce a clinically-oriented, non-multi-au
thoredtextbookofcardiac electrophysiologythat wouldbe useful to practicing electro
physiologists, cardiologists, fellows in training as well as associatedelectrophysiology
professionals, including nurses and technologists. While all clinical textbooks riskbe
comingoutdatedevenbeforethey're published, andfew textbooks ofamanageablesize
canclaimto becompletelycomprehensive, ourgoal was toproduce abookthatsystem
atically presents a thorough discussionofthefundamentalprinciples andconcepts im
portant to the practice ofclinical electrophysiology. We do not discuss basic cellular
electrophysiologyforitssakealone,butinsteadincludebasicsciencematerialonlywhen
itishelpfulinexplainingthe overlyingclinicalprinciples. Cardiacelectrophysiology,as
with any subspecialty, behaves as a living organismwith continuous evolution ofits
standards and practices. However, even though the details and tools ofmanagement
(catheters, drugs, devices, etc.)maychangewithdazzlingspeed, thefundamentalprinci
ples ofdiagnosis andmanagementgenerallychange very littleandtheyremain the criti
calunderpinningofthe day-to-daymanagementofpatientswithcardiac arrhythmias.
Inthefirstthirdofthebookwepresenttheprinciplesofclinicalcardiacelectrophysiolo
gyas itis currentlypracticed. Weassume thereaderhas abasicbackgroundinthe eval
uation ofpatients with cardiac rhythm disturbances, including the history-taking,
performance ofthe physical examination, routine laboratory evaluation, and acomfort
able familiarity with surface 12-leadelectrocardiography includingbasicrhythm and ar
rhythmiaanalysis. Inchapters 1and2ourfocus is onthe arrhythmogenicanatomyand
understanding the fundamentals ofthe diagnostic electrophysiology study in patients
with brady- and tachyarrhythmias. In chapters 3through 6, respectively, we proceedto
discuss thebasicprinciples ofantiarrhythmic drug therapy, catheterablation, anddevice
therapyusingpacemakersand implantablecardioverter-defibrillators.
In the remainingchapters ofthebook, we focus onthe details ofthe diagnosis andman
agementofspecificbrady- andtachyarrhythmias using theprinciplesoutlinedinthe ear
liersections ofthe book applied to clinical material collected overthe years. Formore
advancedreaders, mostchapters canberead individually as self-containedunits assum
ing an understanding ofthe diagnostic and therapeutic principles presented in the first
portion ofthe book. In chapters 7 and 8we briefly discuss the acute management of
brady-andtachyarrhythmias, whileinchapters9and lOwediscuss disorders ofsinoatri
al node function and atrioventricularfunction, respectively. In chapters 11 through 14
we presentmajor topics includingAV nodal reentrant tachycardia, preexcitation syn
dromes and their concealedvariants, atrial tachycardias and flutter, and finally atrial fi
brillation, respectively. Finally, we focus on ventricular tachyarrhythmias, with a
discussion ofthe spectrumofmonomorphic ventriculartachycardia inchapter 15, poly-
vii
viii
morphic ventriculartachycardiaandthe longQTsyndromes inchapter 16,andventricu
larfibrillationandsuddenarrhythmicdeathinchapters 17.
As withall authors, we greatlyvalue the inputofourreaders. Suggestions, corrections,
andconstructivecriticismsofalltypesarewelcomed. Wecanbecontactedbyelectronic
mailatthe addressesbelow.
Ruey1. Sung,M.D.
[email protected]
MichaelR. Lauer,M.D., Ph.D. Stanford, California
[email protected] June, 2000
CONTENTS
Preface vii
Acknowledgments xiii
1 Functional Anatomy and Mechanisms of Cardiac Arrhythmias
1.1 FunctionalAnatomyofthe ConductionSystem 1
1.2VascularSupplyto the ConductionSystem 6
1.3 Autonomic Innervation& NervousControl. 6
1.4Mechanisms ofCardiacArrhythmias 7
1.5ArrhythmogenicAnatomy 11
2 Basic Principles ofClinical Cardiac Electrophysiology
2.1 ElectrophysiologyProcedures: PreparationandPerformance 21
2.2TheBasicDiagnostic ElectrophysiologicalEvaluation : .41
3 Principles of Pharmacotherapy and Antiarrhythmic Drugs
3.1 PrinciplesofPharmacokinetics andPharmacodynamics 91
3.2 MolecularandBiophysicalTargets for AntiarrhythmicDrugs 102
3.3 ClassificationofAntiarrhythmicDrugs 113
3.4ModulatedReceptorTheoryofAntiarrhythmicDrugAction 114
3.5 Proarrhythmic EffectsofAntiarrhythmicDrugs 125
4 Principles of Electrode Catheter Ablation
4.1 Indications for AblationofCardiac Arrhythmias 131
4.2 ABCs ofElectrodeCatheterAblation 131
4.3 ArrhythmiaInduction 135
4.4ArrhythmiaLocalization 136
4.5 DeliveryofAblationEnergy 153
4.6ConfirmationofSuccessfulAblation 165
4.7 FutureDirections 167
5 Principles of PacemakerTherapy
5.1 HistoricalPerspectives 173
5.2 Indicationsfor PacemakerTherapy 174
5.3 Basic Concepts& BiophysicalAspectsofPacing 175
5.4 PacemakerOperation,Programmability& TimingCycles 211
5.5 PacemakerImplantation 245
5.6PacemakerFollow-up 248
5.7 PacemakerTroubleshooting 265
ix
x CONTENTS
6 Implantable Cardioverter-DefibrillatorTherapy
6.1 HistoricalPerspectives 288
6.2 IndicationsforICDTherapy 290
6.3 BasicConceptsofDefibrillation 291
6.4ComponentsoflCD Systems 303
6.5 CDOperationandProgrammability 317
6.6BradyarrhythmiaTherapy 364
6.7 ICD SystemImplantation 364
6.8 ClinicalFollow-upandTroubleshootingoflCD Systems 386
7 Diagnosis and Acute Management of Patients with Symptomatic
Bradyarrhythmias
7.1 LocalizationofConductionDisturbance .418
7.2UrgentManagementofConductionFailure 421
8 Diagnosis and Acute Management of Patients with Symptomatic
Tachyarrhythmias
8.1 SupraventricularTachyarrhythmias .429
8.2VentricularTachyarrhythmias .439
9 Disturbances ofSinoatrial Node Function
9.1 SinoatrialNodeDysfunctionandExitBlock .454
9.2AssessmentofSinoatrialNodeFunction 458
9.3 TreatmentStrategiesforPatientswithSANodeDysfunction .464
10 Disturbances ofAtrioventricular Conduction
10.1 NormalAVConduction .469
10.2AbnormalitiesofAVConduction .472
10.3ManagementofAVConductionDisturbances 484
11 Atrioventricular Nodal Reentrant Tachycardia
11.1 CellularElectrophysiologyoftheAVNode .488
11.2NeuropharmacologicResponsesoftheAVNode .492
11.3 ClinicalElectrophysiology .493
11.4CatheterAblationofAVNodalReentrantTachycardia 509
12 Ventricular Preexcitation Syndromes~ The Wolff-Parkinson-
White Syndrome and Variants
12.1 ThePhysiologyofVentricularPreexcitation 539
12.2ElectrophysiologyStudy 541
12.3 ConcealedWolff-Parkinson-White Syndrome 556
CONTENTS xi
12.4AccessoryConnectionswithDecrementalConductionProperties 561
12.5 PharmacologicalEffectsonAccessoryConnections 572
12.6DifferentialDiagnosis 575
12.7RadiofrequencyCatheterAblation 586
12.8 Surgery 602
13 Atrial Tachycardias and Atrial Flutter
13.1 ClassificationofAtrialTachycardias 609
13.2FocalAtrialTachycardia 609
13.3 Inappropriate SinusTachycardia 624
13.4MacroreentrantAtrialTachycardia 626
13.5 PharmacologicalTherapyforAtrialTachyarrhythmias 634
13.6CatheterAblationofAtrialTachyarrhythmias 637
13.7PacemakerTherapyforAtrialTachyarrhythmias 649
14Atrial Fibrillation
14.1 PathologicalFindings 657
14.2ElectrophysiologicMechanisms 659
14.3 ClassificationofAtrialFibrillation 661
14.4PharmacotherapyforAtrialFibrillation 662
14.5 Non-pharmacologicalTherapies 669
15The Spectrum of Monomorphic VentricularTachycardia
15.1 Electrophysio10gicMechanisms 687
15.2Electrophysiology Study 691
15.3 PharmacologicTesting 692
15.4Verapamil-nomesponsiveVentricularTachycardia 692
15.5 Verapamil-ResponsiveVentricularTachycardia 696
15.6Exercise-inducedVentricularTachyarrhythmias 703
15.7IdiopathicVentricularTachycardia 709
15.8ManagementofChronicRecurrentVentricularTachycardia 712
15.9RadiofrequencyCatheterAblation 713
15.10ChemicalAblationofVentricularTachycardia 719
15.11 SurgicalIntervention 720
16 Polymorphic Ventricular Tachycardia and Long QT Syndromes
16.1 ClinicalSignificance 732
16.2MechanismsofQRSComplexPolyrnorphism 733
16.3 ClassificationofLongQTSyndromes 735
16.4CellularMechanismsofLongQTSyndromesandTorsadede Pointes 738
16.5TheAcquiredLongQTSyndromesandTorsadedePointes 742
xii CONTENTS
16.6TheHereditaryLongQTSyndromes 745
16.7TreatmentofPolymorphicVentricularTachycardia& LongQTSyndromes746
17 Ventricular Fibrillation and Sudden Cardiac Death
17.1 DefinitionandEpidemiology 764
17.2TypeofArrhythmiasAssociatedwithSuddenCardiacDeath 764
17.3 ClinicalProfileofSurvivorsofSuddenCardiac Death 766
17.4Role ofAutonomicNervous SysteminSuddenArrhythmicDeath 766
17.5RiskStratification&PredictorsofSuddenArrhythmicDeath 768
17.6EvaluationofPatients SurvivingaCardiacArrest.. 770
17.7TreatmentofSurvivors ofSuddenArrhythmicDeath 773
17.8PrimaryPreventionofSuddenCardiacDeath 780
Index 793