Atrial fibrillation (Afib) is the most common arrhythmia with clinical significance, and its incidence increases with advanced age. Afib is associated with a 3- to 5-fold increased risk of stroke, a 3-fold increase in the risk of heart failure, and higher mortality than without Afib. The treatment of Afib is multifold but revolves around one essential issue: whether to attempt to restore sinus rhythm or to simply control the ventricular rate. This decision depends on symptom severity, the age of the patient, underlying heart disease, and other comorbidities that may limit therapeutic options. The management of Afib with antiarrhythmic medications was reviewed.
Arrhythmias, Cardiac ; Atrial Fibrillation* ; Comorbidity ; Electric Countershock ; Heart Diseases ; Heart Failure ; Heart Rate ; Humans ; Incidence ; Mortality ; Stroke

Supraventricular arrhythmias during and after thoracotomy for pulmonary resections are well documented, and risk factors of post-pulmonary resection arrhythmias are old age, magnitude of surgery, and coexisting cardiopulmonary disease etc. Among of supraventricular arrhythmias, atrial fibrillation is the most common rhythm disturbance that may be associated with increased morbidity and mortality. We experienced a case of paroxysmal supraventricular tachycardia with severe hypotension which was escalated from atrial fibrillation during pulmonary bilobectomy for tuberculosis in a 44-year old male patient. Instead of usual electrical cardioversion or common antiarrhythmic agents, we selected phenylephrine bolus injection which induced normal sinus rhythm successfully from paroxysmal supraventricular tachycardia of the patient.
Adult ; Arrhythmias, Cardiac ; Atrial Fibrillation ; Electric Countershock* ; Humans ; Hypotension ; Lung* ; Male ; Mortality ; Phenylephrine* ; Risk Factors ; Tachycardia, Supraventricular* ; Thoracotomy ; Tuberculosis

PURPOSE: Hybrid therapy with catheter ablation of the cavo-tricuspid isthmus (CTI) and continuation of anti-arrhythmic drugs (AAD), or electrical cardioversion with AADs might be alternative treatments for patients with persistent atrial fibrillation (AF). The goal of study was to assess the long term success rate of hybrid therapy for persistent AF compared to antiarrhythmic medication therapy after electrical cardioversion and identify the independent risk factors associated with recurrence after hybrid therapy. MATERIALS AND METHODS: A total of 32 patients with persistent AF who developed atrial flutter after the administration of a class Ic or III anti-arrhythmic drug were enrolled. This group was compared with a group (33 patients) who underwent cardioversion and received direct current cardioversion with AADs. Baseline data were collected, and electrocardiogram and symptom driven Holter monitoring were performed every 2-4 months. RESULTS: There was no significant difference in the baseline characteristics between the groups. The 12 month atrial arrhythmia free survival was better in the hybrid group, 49.0% vs. 33.1%, p=0.048. However, during a mean 55.7+/-43.0 months of follow up, the improved survival rate regressed (p=0.25). A larger left atrium size was an independent risk factor for the recurrence of AF after adjusting for confounding factors. CONCLUSION: Despite favorable outcome during 12 month, the CTI block with AADs showed outcomes similar to AAD therapy after electrical cardioversion over a 12 month follow up period. Minimal substrate modification with AADs might be an alternative treatment for persistent AF with minimal atrial remodeling.
Adult ; Aged ; Anti-Arrhythmia Agents/*therapeutic use ; Atrial Fibrillation/*drug therapy/mortality/*surgery ; Catheter Ablation/*methods/mortality ; Combined Modality Therapy ; *Electric Countershock/mortality ; Female ; Humans ; Male ; Middle Aged ; Postoperative Complications/mortality/prevention & control ; Retrospective Studies ; Risk Factors ; *Tricuspid Valve

Sudden cardiac death (SCD) is a significant issue affecting national health policies. The National Emergency Department Information System for Cardiac Arrest (NEDIS-CA) consortium managed a prospective registry of out-of-hospital cardiac arrest (OHCA) at the emergency department (ED) level. We analyzed the NEDIS-CA data from 29 participating hospitals from January 2008 to July 2009. The primary outcomes were incidence of OHCA and final survival outcomes at discharge. Factors influencing survival outcomes were assessed as secondary outcomes. The implementation of advanced emergency management (drugs, endotracheal intubation) and post-cardiac arrest care (therapeutic hypothermia, coronary intervention) was also investigated. A total of 4,156 resuscitation-attempted OHCAs were included, of which 401 (9.6%) patients survived to discharge and 79 (1.9%) were discharged with good neurologic outcomes. During the study period, there were 1,662,470 ED visits in participant hospitals; therefore, the estimated number of resuscitation-attempted CAs was 1 per 400 ED visits (0.25%). Factors improving survival outcomes included younger age, witnessed collapse, onset in a public place, a shockable rhythm in the pre-hospital setting, and applied advanced resuscitation care. We found that active advanced multidisciplinary resuscitation efforts influenced improvement in the survival rate. Resuscitation by public witnesses improved the short-term outcomes (return of spontaneous circulation, survival admission) but did not increase the survival to discharge rate. Strategies are required to reinforce the chain of survival and high-quality cardiopulmonary resuscitation in Korea.
Cardiopulmonary Resuscitation/*mortality ; Critical Care/*statistics & numerical data ; Death, Sudden, Cardiac/*epidemiology ; Electric Countershock/mortality ; Emergency Medical Services ; Humans ; Out-of-Hospital Cardiac Arrest/*epidemiology/*mortality/therapy ; Registries ; Republic of Korea/epidemiology ; Survival Rate ; Treatment Outcome

Considerable controversy exists as to whether rhythm or rate control is the more appropriate management for the patients with persistent atrial fibrillation (AF). Until recently, it was our belief that the initial approach to rhythm management should give primary consideration to the restoration and maintenance of the sinus rhythm (SR), which provides the potential benefits of reducing the risk of thromboembolism and the need for anticoagulants, and improved the hemodynamics and quality of life. However, there are negative aspects of rhythm control, including the poor efficacy of the antiarrhythmic drugs and the potential of adverse effects. Five recent clinical trials; AFFIRM (The Atrial Fibrillation Follow-Up Investigation of Rhythm Management), RACE (Rate Control versus Electrical Cardioversion), PIAF (Pharmacological Intervention in Atrial Fibrillation), HOT CAFE (How to Treat patients with Chronic Atrial Fibrillation) and STAF (The Strategies of Treatment of Atrial Fibrillation), have looked specifically at the issue of the balance between the benefits and risks of restoration and maintenance of the SR, primarily with drug therapy. The conclusions of these trials were consistent, although the study subjects were heterogeneous;1) Rhythm control, with anti-arrhythmics, does not lead to an improvement in the symptom control, quality of life or a reduction in the short to median term clinical events, in fact, in the longer term the mortality may increase. 2) Maintenance of the SR remains poor, even with an aggressive strategy. Hence, long term anticoagulation is needed for most patients treated with rhythm control, even if the SR is restored in the short term. A number of non-pharmacological therapies have emerged, such as catheter ablation and pacing, for patients remaining highly symptomatic, despite the use of several anti-arrhythmics and serial electrical cardioversion. In conclusions, rate control should be considered as the initial strategy in the majority of the patients with persistent AF. For the minority that remain highly symptomatic, aggressive rhythm control, with invasive treatments, such as pulmonary vein isolation or rate control, with atrioventricular nodal ablation and ventricular pacing, should be considered.
Anti-Arrhythmia Agents ; Anticoagulants ; Atrial Fibrillation* ; Catheter Ablation ; Continental Population Groups ; Drug Therapy ; Electric Countershock ; Follow-Up Studies ; Hemodynamics ; Humans ; Mortality ; Pulmonary Veins ; Quality Control ; Quality of Life ; Risk Assessment ; Thromboembolism

BACKGROUND AND OBJECTIVE: A new porcine model of acute myocardial infarction (AMI), ischemic heart failure and pathologic findings of coronary artery by a transcatheter intracoronary ethyl alcohol injection has been developed. MATERIALS AND METHODS: Twelve female pigs underwent a transcatheter injection in the left anterior descending artery (LAD), using alcohol, to produce an apicoanteriorseptal AMI. Low pressure ballooning using a 2.5 mm over-the-wire balloon, just above the second and first diagonal branches, followed by a 1 mL injection of 99.9% ethyl alcohol was administered to 8 and 4 pigs, respectively. Follow-up coronary and left ventricular (LV) angiograms and echocardiography were performed 4 weeks after the alcohol injection. Myocardial SPECT using 201Tl (and 99mTc-MIBI) and triphenyl tetrazolium chloride (TTC) stain were performed after sacrifice. The quantity of TTC stain and amount of 201Thallium uptake were compared using the Vision Workstation. The histopathological findings of the infarcted myocardium and coronary artery were demonstrated after 28 days. RESULTS: Procedure-related mortality was observed in two-pigs of the proximal LAD injection group. Four pigs suffered from ventricular tachycardia, which was converted into sinus rhythm by dc cardioversion. The four-week follow-up coronary angiography revealed persistently occluded LAD in all pigs. The LV angiogram showed akinetic movement in the apicoanteriorseptal wall with an ejection fraction of 46.5+/-3.3%. Myocardial SPECT revealed a perfusion defect in the apicoanterior wall of all pigs. The percentage area of perfusion defect was 22.2+/-3.06%. The TTC did not stain the myocardium in the apicoanterior wall. The percentage of non-stained myocardium was 23.5+/-2.70%. A histological examination revealed severe fibrosis in the infarcted myocardium and massive thrombus, with organization and calcification. CONCLUSION: The porcine model of acute myocardial infarction using an intracoronary ethanol injection into the distal LAD is safe, reliable and reproducible, and can be used for future research into myocardial regeneration and ischemic LV failure.
Angioplasty ; Arteries ; Coronary Angiography ; Coronary Vessels ; Echocardiography ; Electric Countershock ; Ethanol* ; Female ; Fibrosis ; Follow-Up Studies ; Heart Failure* ; Heart* ; Humans ; Mortality ; Myocardial Infarction ; Myocardium ; Perfusion ; Regeneration ; Swine ; Tachycardia, Ventricular ; Thrombosis ; Tomography, Emission-Computed, Single-Photon

We validated the basic life support termination of resuscitation (BLS TOR) rule retrospectively using Out-of-Hospital Cardiac Arrest (OHCA) data of metropolitan emergency medical service (EMS) in Korea. We also tested it by investigating the scene time interval for supplementing the BLS TOR rule. OHCA database of Seoul (January 2011 to December 2012) was used, which is composed of ambulance data and hospital medical record review. EMS-treated OHCA and 19 yr or older victims were enrolled, after excluding cases occurred in the ambulance and with incomplete information. The primary and secondary outcomes were hospital mortality and poor neurologic outcome. After calculating the sensitivity (SS), specificity (SP), and the positive and negative predictive values (PPV and NPV), tested the rule according to the scene time interval group for sensitivity analysis. Of total 4,835 analyzed patients, 3,361 (69.5%) cases met all 3 criteria of the BLS TOR rule. Of these, 3,224 (95.9%) were dead at discharge (SS,73.5%; SP,69.6%; PPV,95.9%; NPV, 21.3%) and 3,342 (99.4%) showed poor neurologic outcome at discharge (SS, 75.2%; SP, 89.9%; PPV, 99.4%; NPV, 11.5%). The cut-off scene time intervals for 100% SS and PPV were more than 20 min for survival to discharge and more than 14 min for good neurological recovery. The BLS TOR rule showed relatively lower SS and PPV in OHCA data in Seoul, Korea.
Adult ; Advanced Cardiac Life Support/*mortality ; Cardiopulmonary Resuscitation/*mortality ; Critical Care/statistics & numerical data ; Decision Support Techniques ; Electric Countershock/*mortality ; Emergency Medical Services ; Female ; Hospital Mortality ; Humans ; Male ; Out-of-Hospital Cardiac Arrest/*epidemiology/*mortality/therapy ; Refusal to Treat ; Republic of Korea/epidemiology ; Retrospective Studies ; Survival Rate ; Time Factors ; Time-to-Treatment ; Treatment Outcome