Atrial Fibrillation, a Treatable Disease? Edited by J. H. Kingma N. M. van Hemel Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands and K.1. Lie Department ofCardiology, Thorax-center, University Hospital Groningen, Groningen, The Netherlands Springer Science+Business Media, B.V. ISBN 978-94-010-4801-9 ISBN 978-94-011-1816-3 (eBook) DOI 10.1007/978-94-011-1816-3 Printed on acid-free paper AII Rights Reserved @ 1992 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1992 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. Developments in Cardiovascular Medicine VOLUME 139 The titles published in this series are listed at the end of this volume. ATRIAL FIBRll..LATION, A TREATABLE DISEASE? CONTENTS Foreword Philippe Coumel xi Preface J. Herre Kingma, Norbert M. van Hemel, Kong I. Lie xv Acknowledgements xix SECTION 1: Concepts and Clinics of Atrial Fibrillation Chapter 1 From Experiment to Therapeutic Innovation in Atrial Fibrillation and Flutter. Norbert M. van Hemel, Jacques M. T. de Bakker, Anand Ramdat Misier, Jo A.M. Defauw. Introduction 2 The sinus node in atrial fibrillation 2 Refractory periods and atrial fibrillation 4 A theory to explain the different conversion rate of atrial fibrillation and flutter after Class Ic antiarrhythmics 8 Nonpharrnacologic treatment of atrial flutter 10 Nonpharmacologic treatment of atrial fibrillation 12 Concluding remarks 19 Chapter 2 Atrial Functional Anatomy. 23 Gerard M. Guiraudon, Colette M. Guiraudon. Introduction 24 Gross anatomy 24 Functional anatomy 36 Hemodynamic function 36 Comments 39 Chapter 3 The Pathology of Drug Resistant Lone Atrial Fibrillation in Eleven Surgically Treated Patients. 41 Colette M. Guiraudon, Nicolette M. Ernst, Gerard M. Guiraudon, Raymond Yee, George J. Klein. Introduction 42 Material and Methods 42 Results 44 Comments 53 Discussion 54 Conclusion 56 vi Chapter 4 Termination of Atrial Fibrillation by Class Ic Antiarrhyth mic Drugs, a Paradox? 59 Maurits A. Allessie, Charles Kirchhof. Pathophysiologic mechanisms of atrial fibrillation 60 The wavelength concept 61 The substrate of atrial fibrillation 62 The antifibrillatory action of Class Ic drugs 63 Chapter 5 Characteristics of Patients with Chronic Atrial Fibrillation and the Prediction of Successful DC Electrical Car dioversion. 67 Isabelle C. van Gelder, Harry J.G.M. Crijns, Kong I. Lie. Introduction 68 Characteristics of patients with chronic atrial fibrillation 69 Therapeutic strategy of chronic atrial fibrillation 72 Direct current electrical cardioversion 72 Immediate outcome of DC electrical cardioversion 75 Complications 79 Summary and guideline 82 SECTION 2: Recent Advances in the Treatment of Paroxysmal Atrial Fibrillation and Flutter Chapter 6 Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation or Atrial Flutter to Sinus Rhythm. 87 Maarten J. Suttorp, Emile R. Jessurun, J. Herre Kingma. Introduction 88 Possible mechanisms of antiarrhythmic drug effects 89 Acute pharmacological intervention of atrial fibrillation or flutter 90 Conclusions 99 Chapter 7 Drugs After Cardioversion to Prevent Relapses of Chronic Atrial Fibrillation or Flutter. 105 Harry J.G.M. Crijns, A. T. Marcel Gosselink, Isabelle C. van Gelder, Ans C.P. Wiesfeld, Maarten P. van den Berg, Ype S. Tuininga, Kong I. Lie. Introduction 106 Why prophylactic treatment after cardioversion? 106 Paroxysmal or chronic atrial fibrillation? 10 7 Definition of chronic arrhythmia 107 vii Recurrence rate with or without prophylactic antiarrhythmic treatment 108 Postcardioversion antiarrhythmic drug studies 109 Amiodarone in atrial fibrillation complicated by heart failure 120 Serial treatment 121 Differential effects of Class I and Class III antiarrhythmics on ventricular rate during atrial fibrillation: implication for clinical practice 123 Antiarrhythmics in the prevention of atrial fibrillation in the WPW-syndrome 125 Proarrhythmia during treatment of atrial fibrillation or flutter 126 General guidelines for drug treatment after cardioversion 139 Chapter 8 Episodic Treatment of Paroxysmal Atrial Fibrillation. 149 Loraine Lie-A-Huen, J. Herre Kingma. Introduction 150 Development of episodic treatment until now 151 (Dis)advantages 151 Paroxysmal atrial fibrillation 152 The 'ideal' formulation 155 Conclusion 157 Chapter 9 An AICD for Atrial Fibrillation? 159 Andrew M. Tonkin, Jonathan M. Kalman, Norma Gil/i. Introduction 160 Animal experimentation 160 Application to humans 162 Sensing algorithms 164 Conclusions 164 Chapter 10 The 'Corridor' Operation as an Alternative in the Treat ment of Atrial Fibrillation. 167 Jo AM. Defauw, Norbert M. van Hemel, J. Herre Kingma, Wybren Jaarsma, Freddy E.E. Vermeulen, Jacques M. T. de Bakker, Gerard M. Guiraudon. Introduction 168 Methods 168 Surgical procedure and in-hospital electrophysiologic studies 170 Results 174 Discussion 176 Conclusions 180 viii SECTION 3: Why Aggressive Therapy in Atrial Fibrillation? Chapter 11 Tachycardiomyopathy in Patients with Supraventricular Tachycardia. 183 Hein J.J. Wellens, Luz-Maria Rodriquez, Joep L.R.M. Smeets, Emile C. Cher/ex, Frans Pieters, Karel den Dulk. Introduction 184 Pathophysiologic background 184 Observations in the human heart 184 Practical implications 192 Chapter 12 Sinus Rhythm, the Autonomic Nervous System, and Quality of Life. 195 Francis D. Murgatroyd, A. John Camm. Introduction 196 Autonomic factors 196 Electrophysiology of AF patients In SR 201 Quality of life 205 Conclusions 208 Chapter 13 Atrial Tachyarrhythmias Following Coronary Bypass Surgery: Sympathetic Mechanisms. 211 Jonathan M. Kalman, Muhammad Munawar, Anthony Yapanls, Laurence G. Howes, William J. Louis, Brian F. Buxton, Lawrence A. Doolan, Jane Tippett, Andrew M. Tonkin. Introduction 212 Methods 214 Results 215 Discussion 220 Chapter 14 Management of Paroxysmal Atrial Fibrillation and Atrial Flutter Shortly after Coronary Artery Bypass Graft Surgery. 227 Maarten J. Suttorp, J. Herre Kingma, Norbert M. van Hemel, Jo A.M. Defauw, Freddy E.E. Vermeulen, Sjef M.P.G. Ernst. Introduction 228 Cardiovascular risk factor analysis for developing post- operative supraventricular tachyarrhythmias 229 ix Prevention of supraventricular tachyarrhythmias after cardiac surgery 230 Conclusions 234 Chapter 15 Risk and Prevention of Embolism in Atrial Fibrillation. 237 A. T. Marcel Gosselink, Harry J.G.M. Crijns, Kong I. Lie. Introduction 238 Prevalence and Incidence of atrial fibrillation 238 Underlying heart disease 238 Atrial fibrillation and stroke 239 Mechanisms of embolism 243 Prevention of embolism -antithrombotic therapy 244 Antithrombotics in cardioversion of atrial fibrillation 251 Summary and recommendation 252 Chapter 16 Value of Left Atrial Appendage Flow Velocities in Patients with Nonrheumatic Atrial Fibrillation and Systemic Embolism. 259 Otto Kamp, Patrick M.J. Verhorst, Cees A. Visser. Introduction 260 Methods 260 Statistics 263 Results 263 Discussion 265 Limitations of the present study 267 Clinical implications 267 Chapter 17 Management of Atrial Fibrillation: From Palliation to Intervention. 271 J. Herre Kingma, Maarten J. Suttorp, Willem P. Beukema. Introduction 272 General approach to atrial fibrillation 272 Clinical management 277 Conclusions 282 Index 285 FOREWORD by Philippe Coumel The atrium is a particularly convenient tool for the electrophysiologist in experimental as well as clinical conditions. Curiously, the atrium was relatively neglected during the early years of clinical electrophysiology when attention was focused on the atrioventricular junction, and then on the ventricle. At the junctional level, the progress of knowledge was very fast and fruitful. In the ventricle some disappointment came from therapeutic conclusions drawn from invasive as well as noninvasive investigations. This was partly due to concepts developed in a too straightforward way, making artificially-induced tachy arrhythmias, or spontaneous trivial arrhythmias supposedly reliable surrogates of the real phenomena that finally lead to death. With these considerations in mind, one realizes how important it is to pay more attention to atrial fibrillation. The ventricle and the atrium may develop identical electrophysiological mechanisms of arrhythmias such as reentry, automaticity and triggered activity. Although, the causal diseases are different at each level the fibrillation process represents something like the end of the road and poses the most difficult problems of comprehension and treatment. At this point, the atrium possesses considerable advantages over the ventricle. Two are of paramount importance. For the investigator the atrium has the advantage of being a two rather than a three-dimensional tissue, which makes it very easy to explore precisely and completely, to map, to represent and to model with computers. For the clinician the atrium has the definite advantage not to be hemodynami cally essential, so that fibrillation does not directly threaten life: the practical consequence is, that therapeutic errors that are catastrophic in the ventricle are forgivable in the atrium. Although obvious, one must realize how much this difference in the hemodynamic consequences of fibrillation completely changes the situation from every viewpoint. As long as the first therapeutic mistake is the last one, xi