Atrial Ectopic Beats Research Articles

Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter

Although the benefits of regular exercise in controlling cardiovascular risk factors have been extensively proven, little is known about the long-term cardiovascular effects of regular and extreme endurance sport practice, such as jogging, cycling, rowing, swimming, etc. Recent data from a small series suggest a relationship between regular, long-term endurance sport practice and atrial fibrillation (AF) and flutter. Reported case control studies included less than 300 athletes, with mean age between 40 and 50. Most series recruited only male patients, or more than 70% males, who had been involved in intense training for many years. Endurance sport practice increases between 2 and 10 times the probability of suffering AF, after adjusting for other risk factors. The possible mechanisms explaining the association remain speculative. Atrial ectopic beats, inflammatory changes, and atrial size have been suggested. Some of the published studies found that atrial size was larger in athletes than in controls, and this was a predictor for AF. It has also been shown that the left atrium may be enlarged in as many as 20% of competitive athletes. Other proposed mechanisms are increased vagal tone and bradycardia, affecting the atrial refractory period; however, this may facilitate rather than cause the arrhythmia. In summary, recent data suggest an association between endurance sport practice and atrial fibrillation and flutter. The underlying mechanism explaining this association is unclear, although structural atrial changes (dilatation and fibrosis) are probably present. Larger longitudinal studies and mechanistic studies are needed to further characterize the association to clarify whether a threshold limit for the intensity and duration of physical activity may prevent AF, without limiting the cardiovascular benefits of exercise.

Abstract 3501: Calmodulin Kinase II Activation of Mutant Ryanodine Channels Promotes Ectopic Activity and Atrial Fibrillation

Some individuals with mutations in the cardiac ryanodine receptor gene (RyR2) develop stress-induced atrial fibrillation (AF), but the underlying mechanisms are unknown. This study explored the molecular basis of AF susceptibility in mice heterozygous for the human arrhythmia-linked RyR2 mutation R176Q (RQ mice). AF inducibility was assessed with atrial burst pacing in WT (n=34), RQ mice (n=43) and RQ mice crossed with transgenic mice expressing the CaMKII-inhibitory peptide AC3I (RQxAC3I, n=6) or the inactive analog AC3C (RQxAC3C, n=9). Dual voltage (RH237) and calcium (Rhod-2 AM) optical mapping was applied to monitor simultaneous Ca2+ and membrane-voltage changes. Ca2+ fluorescence (Fluo-4 AM) was used to study SR Ca2+ release. Expression/phosphorylation of CaMKII and RyR2 were determined by immunostaining in mice and human atrial biopsies from sinus rhythm (SR) (n=7) and chronic AF (n=7) patients. Atrial burst pacing-induced AF was more common in RQ (55%) than in WT mice (11%*; *P<0.05) and was associated with ~50% higher CaMKII-dependent RyR2 phopshorylation (Ser2814 site). Expression and phosphorylation (Thr287) of CaMKIId were increased in AF patients by 63%* and 40%*, respectively, and CaMKII-phopshorylation of RyR2 at Ser2814 was 80%* higher in AF than in SR patients. Genetic inhibition of CaMKII reduced AF incidence in RQxAC3I (16%*), but not in RQxAC3C mice (62%). Optical mapping revealed more atrial burst pacing-induced ectopic beats (and re-entry) in RQ than WT atria (296 vs.19* ectopic beats, 120 ms cycle length) that were depressed by CaMKII inhibiton with KN-93 (1 μM). [Ca2+]i release by 10 mM local caffeine puffs (an index of SR Ca2+ content) were similar in RQ and WT mice (4.59±0.42 vs 4.04±0.41 [a.u.], respectively), whereas SR Ca2+ leak defined as tetracaine (5 μM)-sensitive decrease in diastolic [Ca2+]i was higher in RQ than in WT mice (% of SR Ca2+ content: 10.2±0.9 vs 7.7±0.8*). CaMKII inhibition with KN-93 suppressed SR Ca2+ leak. High rate-associated CaMKII activation promotes AF inducibility in mice with a stress-induced arrhythmia-linked R176Q mutation in RyR2. Inhibition of CaMKII may be a viable drug target for effective AF therapy. This research has received full or partial funding support from the American Heart Association, AHA South Central Affiliate (Arkansas, New Mexico, Oklahoma & Texas).

Clinical importance of short–long–short sequences: Analysing the mode of onset of ventricular tachycardias and atrial fibrillation

Clinical importance of atrial and ventricular ectopic beats are investigated in some experimental and clinical trials. They are common and occur in a broad spectrum of the population. This includes patients without structural heart disease and those with any form of cardiac disease, independent of severity. Although we know something about the mechanisms and etiology of serious ventricular arrhythmias and atrial fibrillation, we don't know a lot about mode of onset of those arrhythmias. Can short–long–short sequences, related ectopic beats predict AF and ventricular tachycardias in some selected groups of patients? In this paper we will try to answer this important question.

Focal paroxysmal atrial fibrillation. Experiences with treatment using high frequency catheter ablation

As has recently been discovered, paroxysmal atrial fibrillation (PAF) can be induced by focal extrasystoles or tachycardia. This raises the question of whether this form of atrial fibrillation can be cured by high-frequency catheter ablation of the focal trigger. Seven men and eleven women (mean age 45.6 +/- 11 years) with severe symptoms and treatment-resistant PAF underwent electrophysiological tests with the aim of high-frequency catheter ablation, if long-term ECG monitoring had demonstrated frequent atrial extrasystoles or tachycardia as pointer to a focal origin. Ablation was performed at the point of earliest excitation after the origin of the ectopic focus had been localized. The end-point was reached if the atrial ectopic rhythm had ceased for more than 60 min. In 18 of the 20 patients an ectopic focus was found and successfully ablated (1 in the superior vena cava, 3 in the right atrium and 16 in a pulmonary vein). Atrial ectopic beats recurred within 24 hours of ablation in 6 of the 14 patients with a pulmonary vein focus: a second focus was found in two, re-emergence of the original focus in two, no re-investigation in another two. 13 of the 18 patients have had no further symptoms after a mean follow-up of 11 months without anti-arrhythmia treatment. The results indicate that focally induced paroxysmal atrial fibrillation can be cured by locally applied high-frequency ablation.

Can short–long–short sequences predict atrial fibrillation in acute inferior myocardial infarction?

Short–long–short sequences (SLSS), related to atrial ectopic beats (AEBs), predict the recurrence of atrial fibrillation (AF) in some clinical situations. We investigated whether SLSS predict the occurrence of AF in acute phase of inferior myocardial infarction (MI). In patients who developed AF AEBs were more frequent. We concluded that the presence of frequent SLSS could be predictors or preceding factors of the occurrence of AF in acute inferior MI.

Magnetic Resonance Imaging Guiding Pacemaker Implantation for Severe Sinus Node Dysfunction Due to Cardiac Involvement in Erdheim-Chester Disease

A 64-year-old woman was referred to the arrhythmia outpatient clinic after she had experienced syncope without preceding symptoms and frequent paroxysmal, near syncopal episodes over the last 8 months. The ECG revealed alternation of sinus bradycardia and frequent ectopic atrial beats, normal PR interval and right bundle branch block with consecutive repolarization abnormalities. Holter ECG showed frequent periods of asystole up to 4.3 seconds. Laboratory findings were normal. Pacemaker therapy for symptomatic sinus node dysfunction was clearly indicated. The patient’s past history revealed the diagnosis of Erdheim-Chester disease with osseous, cutaneous, mesenteric, and right atrial involvement 22 years ago. This disease belongs to …

Prominent Crista Terminalis: As An Anatomic Structure Leading to Atrial Arrhythmias and Mimicking Right Atrial Mass

Crista terminalis is a fibromuscular ridge at the posterolateral region of the right atrium (RA). Superiorly localized prominent crista terminalis can mimic pathologic RA mass on transthoracic echocardiograms. Transesophageal echocardiography can be used to differentiate nonpathologic structures from pathologic ones. Besides mimicking RA mass, crista terminalis is an important anatomic structure responsible for paroxysmal atrial fibrillation and atrial flutter by initiating ectopic atrial beats. In this case we discuss a patient with atrial arrhythmias who had prominent crista terminalis misdiagnosed as RA mass.

Identifying the Origin of Right and Left Ectopic Atrial Beats Triggering Atrial Fibrillation before Atrial Transseptal Procedure

Atrial premature depolarizations (APDs) triggering atrial fibrillation (AF) originate from mainly the pulmonary veins (PVs), but, in some cases, atrial ectopic beats (AEBs) triggering AF originate from the right atrium (RA) or the superior vena cava. Accurate identification of the origin of APDs in the PVs by means of RA and coronary sinus mapping is difficult. Purpose: The aim of this study was to identify the origin of AEBs triggering AF before transseptal catheterization. Electrode catheters were placed in the posteroseptal RA (PSRA), right pulmonary artery (RPA), left pulmonary artery (LPA), and esophagus in 10 patients with paroxysmal AF. We analyzed endocardial electrograms from the PSRA, RPA and LPA, and epicardial electrograms from the esophagus. The origin of the AEBs in the PVs was determined before PV ablation by mapping 4 PVs simultaneously. Four AEBs originated from the left superior PV (LSPV), 2 from the left inferior PV (LIPV), 4 from the right superior PV (RSPV), 2 from the RA or superior vena cava. In AEBs originating from the RA, the PSRA activation was the earliest and it proceeded in a cranial to caudal direction. In AEBs originating from the RUPV, RPA was the earliest. The esophageal activation sequence was in a cranial to caudal direction. In AEBs from the LSPV, LPA was the earliest and the esophageal activation sequence proceeded in a cranial to caudal direction. In AEDs from LIPV, LPA was the earliest, and the esophageal activation sequence was nearly simultaneous. Atrial activation sequences from the PSRA, RPA, LPA, and esophageal catheters can accurately identify the location of the initiating foci of AF before a transseptal procedure.

Cardiac arrhythmias and conduction disturbances in autoimmune rheumatic diseases

Rhythm and conduction disturbances and sudden cardiac death (SCD) are important manifestations of cardiac involvement in autoimmune rheumatic diseases (ARDs). In patients with rheumatoid arthritis (RA), a major cause of SCD is atherosclerotic coronary artery disease, leading to acute coronary syndrome and ventricular arrhythmias. In systemic lupus erythematosus (SLE), sinus tachycardia, atrial fibrillation and atrial ectopic beats are the major cardiac arrhythmias. In some cases, sinus tachycardia may be the only manifestation of cardiac involvement. The most frequent cardiac rhythm disturbances in systemic sclerosis (SSc) are premature ventricular contractions (PVCs), often appearing as monomorphic, single PVCs, or rarely as bigeminy, trigeminy or pairs. Transient atrial fibrillation, flutter or paroxysmal supraventricular tachycardia are also described in 20-30% of SSc patients. Non-sustained ventricular tachycardia was described in 7-13%, while SCD is reported in 5-21% of unselected patients with SSc. The conduction disorders are more frequent in ARD than the cardiac arrhythmias. In RA, infiltration of the atrioventricular (AV) node can cause right bundle branch block in 35% of patients. AV block is rare in RA, and is usually complete. In SLE small vessel vasculitis, the infiltration of the sinus or AV nodes, or active myocarditis can lead to first-degree AV block in 34-70% of patients. In contrast to RA, conduction abnormalities may regress when the underlying disease is controlled. In neonatal lupus, 3% of infants whose mothers are antibody positive develop complete heart block. Conduction disturbances in SSc are due to fibrosis of sinoatrial node, presenting as abnormal ECG, bundle and fascicular blocks and occur in 25-75% of patients.

Behavior of atrial ectopic beats before and after pulmonary vein isolation in patients with atrial fibrillation: A reduction in the number and arrhythmogenicity of ectopic firings

No studies evaluating in a quantitative manner the effect of pulmonary vein (PV) isolation on the behavior of atrial premature beats have been reported. The purpose of this study was to reveal the behavior of atrial premature beats before and after PV isolation in patients with paroxysmal atrial fibrillation (AF). In 108 patients free from AF following PV isolation, both the number of atrial premature beats and their coupling intervals before and following PV isolation were evaluated with periodic 24-hour ambulatory monitoring. After a successful PV isolation procedure (group 1, n = 78), the number of atrial premature beats significantly decreased with two distinct time courses: an acute reduction on the following day and a subsequent gradual decrease throughout the whole observation period. The mean atrial premature beat coupling interval at baseline was 420 +/- 30 ms, which was significantly prolonged to 560 +/- 100 ms at 3 months after PV isolation (P <.01). Although patients with AF recurrence after PV isolation (group 2, n = 30) had transiently depressed atrial premature beats shortly after the procedure, they recovered to the former level 3 months after PV isolation. Repeat PV isolation targeting the reconnected PVs successfully suppressed these residual atrial premature beats both in their number and the coupling interval in a manner similar to those in group 1. Successful PV isolation reduced the number of atrial premature beats with both rapid and gradual time courses. The residual atrial premature beats appeared less arrhythmogenic, with longer coupling intervals than those at baseline. AF recurrences after PV isolation were associated with increased atrial premature beat number and shortened coupling interval, which were depressed by reisolation of reconnected PVs.

Identifying the Origin of Right and Left Ectopic Atrial Beats Triggering Atrial Fibrillation before Atrial Transseptal Procedure

Identifying the Origin of Right and Left Ectopic Atrial Beats Triggering Atrial Fibrillation before Atrial Transseptal Procedure

Recent Advances in Surgery for Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac rhythm disturbance, which carries significant cardiovascular morbidity and mortality. The medical treatment for AF is cumbersome and unsatisfactory, which has highlighted the need to develop alternative treatments for AF. The recent discovery that AF is often initiated by atrial ectopic beats has resulted in treatments designed to target the ectopic sources, particularly those within the pulmonary veins. Building on the pioneering work of Cox et al., a recent reported series demonstrated the feasibility of treating patients undergoing cardiac surgery for other structural heart diseases with limited, left-atrial ablation lesion sets using alternative energy sources. As less complex modifications of the Maze procedure have been developed, a number of energy sources have been introduced to create of electrically isolating lesions within the atria. These sources have been used both endocardially in arrest heart procedures as well as epicardially in a beating heart setting. This review summarizes the recent advances in surgery for AF that will aid in the development of an effective, minimally invasive surgical procedure to cure patients with AF.

Does the isolated finding of a single umbilical artery warrant referral for fetal echocardiography?

REFERRAL FOR FETAL ECHOCARDIOGRAPHY? RICHARD BENOIT, Women & Infants’ Hospital, Obstetrics & Gynecology, Providence, Rhode Island OBJECTIVE: To determine whether referral for fetal echocardiogram is warranted when isolated single umbilical artery is noted on detailed fetal anatomical survey. STUDY DESIGN: A retrospective cohort study was conducted utilizing a database of 3829 fetal echocardiograms performed at a prenatal diagnosis center affiliated with a university hospital during the period July 1996 to July 2004. All fetal echocardiograms with the reported indication of isolated single umbilical artery, two vessel cord, 2 vessel cord, or SUA on detailed anatomic survey were included. Ultrasound reports were reviewed and categorized with respect to findings in order to determine the frequency of abnormalities noted on the detailed examination of the fetal heart among those fetuses with isolated single umbilical artery as the indication for examination. RESULTS: A total of 191 fetuses underwent fetal echocardiogram evaluation with the sole indication of a single umbilical artery detected on detailed fetal anatomic examination. 10 fetuses were found to have a three vessel cord during the fetal echocardiogram. Of the remaining 181 in which SUA was confirmed, a total of 8 fetuses, or 4.4%, were noted to have abnormal findings on echocardiogram. Among the abnormal antenatal echocardiogram findings, 5/ 181 were noted to be benign atrial ectopic beats or APC’s (2.8%), while 3/181 or 1.7% were found to have a structural cardiac anomaly (1 with transposition of the great arteries, 1 finding of ASD, and 1 fetus with abnormal cardiac axis). CONCLUSION: The utility of referral for fetal echocardiogram when the isolated finding of a single umbilical artery is noted on detailed fetal anatomical survey was assessed. Overall, 4.4% of these fetuses were found to have abnormal findings on echocardiogram, with 1.7% noted to have a structural cardiac anomaly detectable by detailed fetal cardiac examination. This rate is increased over the general population baseline. Thus, detailed fetal cardiac examination is warranted among fetuses with apparently isolated single umbilical aretry after intial targeted survey.

Autonomic nervous system and paroxysmal atrial fibrillation: A study based on the analysis of RR interval changes before, during and after paroxysmal atrial fibrillation

Aims To evaluate the presence of an abnormal autonomic modulation before, during and immediately after paroxysmal atrial fibrillation (PAF). Methods and results We analysed Holter recordings of 65 patients with 110 PAF episodes lasting more then 30 s. Mean RR interval, co-efficient of variation and short-term heart rate variability were measured before, during and after PAF episodes. We observed a significant correlation between the coupling interval and both the cycle length measured from 30 min up to few cycles before PAF onset, and ventricular response. When comparing the heart rate variability (HRV) before and after PAF we observed a significant reduction of the low frequency/high frequency components (LF/HF) ratio (from 6.2±7.4 to 3.2±4.1). A short–long–short cycle sequence was detectable in 37 PAF onsets associated with a greater incidence of atrial ectopic beats and a greater LF component (62±25 vs. 53±27 normalised units) in comparison to the remaining episodes. When onsets were divided for a LF/HF ratio cut-off value of ⩾2 to separate episodes with a predominant sympathetic, as opposed to those with a prevailing vagal (LF/HF<2) modulation, we observed opposite changes (from 9.1±7.8 to 4±3.7 and from 0.8±0.5 to 2±3.6, respectively) consistent with a recovery of a more physiological sympatho-vagal balance immediately after recovery of sinus rhythm. No changes in co-efficient of variation of ventricular response were detectable before PAF termination. Conclusions A predominant sympathetic modulation characterises the majority of PAF onsets whereas a vagal predominance was detectable in about 30% of episodes. These patterns are no longer detectable after recovery of sinus rhythm.

Autonomic nervous system and paroxysmal atrial fibrillation: a study based on the analysis of RR interval changes before, during and after paroxysmal atrial fibrillation.

To evaluate the presence of an abnormal autonomic modulation before, during and immediately after paroxysmal atrial fibrillation (PAF). We analysed Holter recordings of 65 patients with 110 PAF episodes lasting more then 30 s. Mean RR interval, co-efficient of variation and short-term heart rate variability were measured before, during and after PAF episodes. We observed a significant correlation between the coupling interval and both the cycle length measured from 30 min up to few cycles before PAF onset, and ventricular response. When comparing the heart rate variability (HRV) before and after PAF we observed a significant reduction of the low frequency/high frequency components (LF/HF) ratio (from 6.2+/-7.4 to 3.2+/-4.1). A short-long-short cycle sequence was detectable in 37 PAF onsets associated with a greater incidence of atrial ectopic beats and a greater LF component (62+/-25 vs. 53+/-27 normalised units) in comparison to the remaining episodes. When onsets were divided for a LF/HF ratio cut-off value of > or = 2 to separate episodes with a predominant sympathetic, as opposed to those with a prevailing vagal (LF/HF<2) modulation, we observed opposite changes (from 9.1+/-7.8 to 4+/-3.7 and from 0.8+/-0.5 to 2+/-3.6, respectively) consistent with a recovery of a more physiological sympatho-vagal balance immediately after recovery of sinus rhythm. No changes in co-efficient of variation of ventricular response were detectable before PAF termination. A predominant sympathetic modulation characterises the majority of PAF onsets whereas a vagal predominance was detectable in about 30% of episodes. These patterns are no longer detectable after recovery of sinus rhythm.

Percutaneous catheter ablation procedures for the treatment of atrial fibrillation.

In light of the significant morbidity and mortality from atrial fibrillation (AF), there has been significant interest in the development of percutaneous catheter ablation procedures for the suppression of AF. Given the success of the surgical Maze procedure, initial catheter-based approaches involved creation of linear atrial lesions. Success rates were low and utility was limited by a high complication rate and long procedural times. The recent discovery that AF is often initiated by atrial ectopic beats has resulted in therapies designed to target the ectopic sources, particularly those within the pulmonary veins. Experience and technological advances have improved the efficacy and safety of such procedures. This article will review catheter ablation procedures for the maintenance of sinus rhythm in patients with AF.

How to perform pulmonary vein isolation.

The advent of technology for the delivery of radiofrequency energy via electrode catheters, in the late 1980s, led to the perfection of techniques for the ablation of accessory pathways and classical flutter [1–4]. This has been so successful that these substrates for arrhythmia are rarely seen in the Western world. Two major arrhythmias, however, still remain to be conquered—atrial fibrillation and ventricular tachycardia/fibrillation. The occurrence of atrial fibrillation (AF) seems to be dependent on a number of factors [5]. In most situations there is some form of underlying atrial substrate, which is usually the presence of intra-atrial conduction delay. In addition, initiating factors for AF are required and the commonest of these appear to be atrial ectopic beats [6]. The major sources of these ectopic beats appear to be the pulmonary veins [7], although extrapulmonary vein sources are being increasingly reported [8,9]. Numerous recent studies suggest that AF may be treated by the techniques based on ablation within or around the pulmonary veins. Initial reports were based on the identification of pulmonary vein ectopic foci and the abolition of these sources [10]. The difficulties of making pulmonary foci fire and thereby identifying the culprit vein [11] led to the approach of attempting to achieve electrical isolation of all four pulmonary veins in the hope of abolishing the initiating triggers [12]. The recent results reported by Haissaguerre's group suggest that around 70% of patients with paroxysmal atrial fibrillation in normal hearts, can be made to hold long-term sinus rhythm by means of this technique [12,13]. Most patients have four pulmonary veins, two on the left and two on the right (Fig. 1). Many patients will have veins on the right or left side merging to a common ostium before entering …

Differences in the morphology and duration between premature P waves and the preceding sinus complexes in patients with a history of paroxysmal atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Experimental and human mapping studies have demonstrated that perpetuation of AF is due to the presence of multiple reentrant wavelets with various sizes in the right and left atria. Atrial fibrillation may be induced by atrial ectopic beats originating in the pulmonary veins, and premature P-wave (PPW) patterns may help to identify the source of firing. To evaluate the morphology and duration of PPWs, 12-lead digital electrocardiogram (ECG) strips containing clearly definable PPWs not merging with the preceding T waves were obtained in 25 patients with AF history (9 men, mean age 59.5 +/- 2.2 years) and 25 subjects without any previous AF history (11 men, mean age 53.6 +/- 25 years). The polarity of PPWs was evaluated in all 12 ECG leads. Previously described indices, such as P maximum, P dispersion (= P maximum-P minimum), P mean, and P standard deviation were also calculated. Premature P-wave patterns were characterized by more positive P waves in lead V1. All P-wave analysis indices were significantly higher in patients with AF than in controls when calculated in the sinus beat, whereas they did not differ between the two groups when calculated in the PPW. P-wave indices did not differ between the PPW and the sinus either patients with AF or controls, except for P mean, which was significantly higher in the sinus (110.1 +/- 1.7 ms) than in the PPW (100 +/- 2 ms) only in patients with AF (p = 0.001). The evaluation of PPW patterns is only feasible in a small percentage of short-lasting digital 12-lead ECG recordings containing ectopic atrial beats. Premature P wave patterns characterized by more positive P waves in lead V1, which indicates a left atrial origin in the ectopic foci. The observed differences in P-wave analysis indices between patients with AF and controls and between sinus beats and PPWs may be attributed to the presence of electrophysiologic changes in the atrial substrate.

Long-short sequence may predict immediate recurrence of atrial fibrillation after external cardioversion.

We thought, that analysis of surface electrocardiograms recorded immediately after electrical external cardioversion (EC) might enlighten the mechanisms responsible for immediate recurrence of atrial fibrillation (AF) and especially to test whether atrial ectopic beats (PAC) with long-short (LS) sequence are related to the recurrence of arrhythmia after cardioversion in patients with chronic AF. One hundred and thirty-seven patients (mean age 57+/-7 years) undergoing EC for chronic AF entered the study. Evaluation of the patients included clinical history, physical examination, ECG, routine laboratory tests, and transthoracic echocardiography. The cardioversion was performed with monophasic waveform shock and immediately after successful EC, 1 min of recording of the ECG lead II was analysed. One hundred and twenty patients (87%) of 137 patients enrolled in the study had had successful EC and 33 (27%) of them experienced immediate recurrence of AF within 1 min (Group I) and 87 patients had no arrhythmia recurrence (Group II). In group I in 24 patients (73%) recurrence of AF was initiated by PAC with LS sequence. In only 12 of 87 (13%) patients who did not experience immediate recurrence of AF (Group II) PACs were recorded. Atrial ectopic beats (PACs) with LS sequence, being responsible for AF relapse in about 70% of patients, might predict early re-initiation of arrhythmia after EC. Electrocardiograms, recorded immediately after EC, are a potentially feasible approach in establishing the patterns of AF relapse that may be useful in the management of AF recurrence.

Electrocardiographic changes in elderly patients during endoscopic retrograde cholangiopancreatography.

Cardiorespiratory complications may occur during gastrointestinal endoscopy, and elderly people seem to be more vulnerable to these complications during endoscopic procedures involving the manipulation of abdominal viscera. To determine the incidence of cardiac arrhythmias, changes in oxygen saturation, heart rate and blood pressure during endoscopic retrograde cholangiopancreatography (ERCP) via Holter monitoring in elderly patients older than 70 years of age. Holter monitoring and 12-lead electrocardiograms were performed in 30 elderly patients undergoing ERCP and in 30 control subjects undergoing routine chest, abdomen, bone and upper gastrointestinal small bowel follow-through studies. A computerized nontriggered template system was used to analyze the electrocardiograms qualitatively and quantitatively. Arrhythmias, cardiac axis, conduction defects, pauses, ST segment changes, ectopic beats, oxygen desaturation and changes in blood pressure and rate-pressure product were evaluated. Increased heart rate, ST segment changes resulting from myocardial ischemia, oxygen desaturation and transient atrial and ventricular ectopic beats were frequent during ERCP compared with the control group. In one patient, transient left bundle branch block developed and this was attributed to pre-existing hypertension with cardiomegaly. One patient developed ventricular tachycardia and one other sinus bradycardia, but this was attributed to sick sinus syndrome. Transient myocardial ischemia and various cardiac arrhythmias are frequent in elderly patients undergoing ERCP. Appropriate noninvasive monitoring seems to be justified during this procedure.