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Implantable defibrillators as originally conceived by Michel
Mirowski were limited to the detection and automatic termination of
ventricular fibrillation. In the original "AID" device, the
detection algoritlun sought to distinguish sinus rhytlun from
ventricular fibrillation by identifying the "more sinusoidal
waveform of ventricular fibrillation. " The therapeutic
intervention was elicited only once deadly polymorphic rhythms had
developed. It was rapidly learned, however, that ventricular
fibrillation is usually preceded by ventricular tachycardia.
Mirowski recognized the pivotal importance of developing
algoritllms based on heart rate. Ventricular tachycardia detection
allowed the successful development of interventions for the
termination of ventricular tachyarrhythmias before they degenerated
into ventricular fibrillation. Current device therapy no longer
confines itself to tlle termination of chaotic rhythms but seeks to
prevent them. Diagnostic algorithms moved upward along the chain of
events leading to catastrophic rhytlulls. Rate smoothing algorithms
were developed to prevent postextrasystolic pauses from triggering
ventricular and atrial tachyarrhytlmlias. Beyond the renaissance of
ectopy-centered strategies, long-term prevention received
increasing attention. Multisite pacing therapies provided by
"Arrhythmia Management Devices" were designed to reduce the
"arrhytlunia burden" and optimize the synergy of cardiac
contraction and relaxation. Clinical evidence now suggests that
atrial fibrillation prevention by pacing is feasible and tllat
biventricular pacing may be of benefit in selected patients with
heart failure. However, these applications of device therapy that
generally require ventricular defibrillation backup remain
investigational and were not considered in this book.
The past 10 years have seen a remarkable change in the approach to
cardiac arrhythmias, from a position of confidence and a feeling of
well-being about pharmacological treatment to a situation in which
there is now marked uncertainty and general apprehension about the
role of antiarrhythmic drugs. Until relatively recently the
prevailing concept in antiarrhythmic therapy was that arrhythmias
could be controlled by drugs which slowed conduction or suppressed
automaticity, goals well served by the sodium channel-blocking
drugs and glycosides. Drug re search was based largely on the
development of agents mimicking those already available, but with
greater efficacy, fewer side effects or a more favourable phar
macokinetic profile. The CAST trial stands out as a landmark in the
evolution of arrhytmia manage ment; rarely has a single trial had
such a profound impact not only on clinical prac tice, but also on
the whole approach of those involved in the research, development
and regulation of antiarrhythmic drugs. The results of the CAST
trial, designed to redress the shortcomings of earlier trials which
had failed to demonstrate the anticipated improvement in mortality
post-myocardial infarction with the use of class I agents, are well
known. The CAST and CAST II showed an increase in mor tality
associated with the active agent (encainide, flecainide or
morizicine) com pared to placebo treatment. They firmly established
the potential danger in the use of class I drugs."
Implantable defibrillators as originally conceived by Michel
Mirowski were limited to the detection and automatic termination of
ventricular fibrillation. In the original "AID" device, the
detection algoritlun sought to distinguish sinus rhytlun from
ventricular fibrillation by identifying the "more sinusoidal
waveform of ventricular fibrillation. " The therapeutic
intervention was elicited only once deadly polymorphic rhythms had
developed. It was rapidly learned, however, that ventricular
fibrillation is usually preceded by ventricular tachycardia.
Mirowski recognized the pivotal importance of developing
algoritllms based on heart rate. Ventricular tachycardia detection
allowed the successful development of interventions for the
termination of ventricular tachyarrhythmias before they degenerated
into ventricular fibrillation. Current device therapy no longer
confines itself to tlle termination of chaotic rhythms but seeks to
prevent them. Diagnostic algorithms moved upward along the chain of
events leading to catastrophic rhytlulls. Rate smoothing algorithms
were developed to prevent postextrasystolic pauses from triggering
ventricular and atrial tachyarrhytlmlias. Beyond the renaissance of
ectopy-centered strategies, long-term prevention received
increasing attention. Multisite pacing therapies provided by
"Arrhythmia Management Devices" were designed to reduce the
"arrhytlunia burden" and optimize the synergy of cardiac
contraction and relaxation. Clinical evidence now suggests that
atrial fibrillation prevention by pacing is feasible and tllat
biventricular pacing may be of benefit in selected patients with
heart failure. However, these applications of device therapy that
generally require ventricular defibrillation backup remain
investigational and were not considered in this book.
Dieses Buch beschreibt die experimentellen Grundlagen und die
ersten klinischen Erfahrungen mit der Anwendung der
Hochfrequenzablation bei Patienten mit tachykarden
Herzrhythmusstorungen. Es stellt auch neue Kriterien zur
Lokalisationsdiagnostik akzessorischer Leitungsbahnen sowie von
Kammertachykardien dar. Diese zusammenfassende Darstellung in
deutscher Sprache legt einen Grundstein fur Elektrophysiologen und
Kardiologen, die an der nichtmedikamentosen Behandlung von
tachykarden Herzrhythmusstorungen interessiert sind - einem
Therapieverfahren, das in den letzten Jahren zunehmend an Bedeutung
gewonnen hat. Sie bietet jedem Arzt, der Herzrhythmusstorungen
behandelt, fundierte Information uber diese neue Therapietechnik.
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