Changes in spontaneous sinus node rate after ventricular pacing as an estimate of autonomic tone: clinical applications

Brembilla-Perrot, B; Beurrier, Daniel; Alsagheer, S.

doi:10.1093/oxfordjournals.eurheartj.a060889

Cited by 5 publications

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“…7 Among 950 electrophysiological studies, we found 85 patients with signs of the latent presence of two separate atrioventricular (AV) nodal pathways with fast and slow conduction: there was an increase of > 50 ms in the HlH2 or A2H2 intervals in response to a 10 ms decrement in the A1A2 interval during introduction of premature atrial extrastimuli.9-" In 65 of these patients a 2:1 or Mobitz II retrograde ventriculoatrial block occurred during ventricular pacing at an incremental rate. In 25 patients the appearance of the retrograde block was associated with the transient appearence of QRS alternans, which disappeared at a higher rate of ventricular pacing.…”

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Mechanism of QRS electrical alternans.

Brembilla‐Perrot¹,

Lucron²,

Schwalm³

et al. 1997

Heart

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In patients with latent dual atrioventricular nodal pathways a 2:1 ventriculoatrial block often occurs during ventricular pacing and is generally associated with the concomitant appearance of QRS alternans. This type of QRS alternans is related to retrograde conduction, and a concealed retrograde conduction in the His Purkinje system could explain the QRS alternans. A case that confirms the hypothesis that electrical alternans is secondary to a 2:1 block in the activation of some part of the ventricles is reported. (Heart 1997;77:180-182 controversal mechanisms have been proposed to explain electrical alternans.We report a case of alternation of the amplitude and morphology of the QRS complex seen during a paced rhythm that throws light on this electrophysiological mechanism.Ventricular pacing at incremental rate is routinely performed in our institution during electrophysiological studies and the protocol has been reported elsewhere.7 Sinoatrial and atrioventricular conduction are studied by atrial pacing and programmed atrial stimulation with one and two extrastimuli delivered in sinus rhythm and at a paced rhythm (600 ms, 400 ms).8 Ventricular pacing is then performed at a progressively incremental rate at the apex of right the ventricle.7Among 950 electrophysiological studies, we found 85 patients with signs of the latent presence of two separate atrioventricular (AV) nodal pathways with fast and slow conduction: there was an increase of > 50 ms in the HlH2 or A2H2 intervals in response to a 10 ms decrement in the A1A2 interval during introduction of premature atrial extrastimuli.9-" In 65 of these patients a 2:1 or Mobitz II retrograde ventriculoatrial block occurred during ventricular pacing at an incremental rate. In 25 patients the appearance of the retrograde block was associated with the transient appearence of QRS alternans, which disappeared at a higher rate of ventricular pacing. The same phenomenon was observed at the same rate when pacing was performed at the right ventricular infundibulum. The QRS alternans was not seen in patients with a classic Wenckebach retrograde block.Case report An electrophysiological study was performed because of unexplained dizziness/syncope in a 60 year old patient with a prosthetic mitral valve. Sinoatrial and atrioventricular conduction were normal: corrected sinus node recovery time = 300 ms, AH interval = 80 ms, HV interval = 40 ms, and the rate at which second degree AV block occurred during atrial pacing at incremental rate = 150 beats/min. A single premature atrial extrastimulus revealed the existence of a latent double nodal pathway: a 10 ms shortening of the atrial extrastimulus provoked an abrupt increase in the AH interCardiology A,

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confidence: 99%

Mechanism of QRS electrical alternans.

Brembilla‐Perrot¹,

Lucron²,

Schwalm³

et al. 1997

Heart

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“…Recently, 16 AF was shown to depend on the variations of the autonomic tone with a primary increased tone followed by an abrupt shift toward vagile predominance. This phenomenon was demonstrated to occur after rapid ventricular pacing 17 . In patients with preserved autonomic tone, a sinus tachycardia related to adrenergic tone and then a sinus bradycardia related to vagile tone was reported at the termination of a rapid ventricular pacing (200 beats/min).…”

Section: Discussionmentioning

confidence: 96%

“…This phenomenon was demonstrated to occur after rapid ventricular pacing. 17 In patients with preserved autonomic tone, a sinus tachycardia related to adrenergic tone and then a sinus bradycardia related to vagile tone was reported at the termination of a rapid ventricular pacing (200 beats/min). This mechanism could be applied in the present study.…”

Section: Discussionmentioning

confidence: 99%

Significance of External Cardioversion Induced Atrial Tachyarrhythmias

Brembilla‐Perrot

Beurrier

Houriez

et al. 2003

Pacing Clinical Electrophis

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External cardioversion is used to stop VT or VF in emergency. Supraventricular tachyarrhythmias are sometimes noted after cardioversion in patients known to be previously in sinus rhythm. The purpose of the study was to evaluate the significance of supraventricular tachyarrhythmias induced by external cardioversion. The study population consisted of 22 patients who developed supraventricular tachyarrhythmias after transthoracic cardioversion (300 J) delivered to stop a VT or VF induced by electrophysiological study. Defibrillation used monophasic waveform. Supraventricular tachyarrhythmias complicated 6% of cardioversions for VT; before cardioversion, all patients were in sinus rhythm. After cardioversion, three patients developed a paroxysmal reentrant supraventricular tachycardia (PSVT), which was stopped by atrial pacing. The remaining patients developed AF that lasted from 3 minutes to 24 hours (n = 4). One patient remained in AF. AF developed after a sinus pause or bradycardia, which was due to the interruption of VT or VF in nine patients or was noted just when VT or VF stopped (n = 10). The analysis of clinical data indicated that all three patients who presented a PSVT had a history of PSVT. Among patients who developed a sinus pause dependent AF, two had a history of AF. Among ten patients who developed AF at the time of cardioversion, three had a history of AF. During follow-up (1-9 years), no patient without a history of AF developed spontaneous AF, but patients with history of tachycardias had arrhythmia recurrences. The mechanism of cardioversion related tachycardias can be a pause related dispersion of atrial refractoriness or an adrenergic reaction induced by VT or VF, factors that precipitate arrhythmias in patients with history of atrial arrhythmias (one third of patients). In conclusion, supraventricular tachyarrhythmia is relatively frequent after external cardioversion for ventricular tachyarrhythmia, has no prognostic significance in patients without previous history of atrial arrhythmias, but in those with history of tachycardias is associated with a high risk of recurrence.

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“…In those with preserved ejection fraction, increased vagal tone in response to tachycardia could explain the syncope when tachycardia stops [17]. Similar mechanism could explain that a ventricular monomorphic tachycardia can provoke a syncope in a patient with preserved ejection fraction; previous studies had shown that a ventricular tachycardia or a rapid ventricular pacing induce an adrenergic increase tone followed by a secondary vagal hypertonia [25,26].…”

Section: Discussionmentioning

confidence: 96%