© 2002 by European Society of Cardiology
ELECTROPHYSIOLOGY
Programmed ventricular stimulation: influence of early versus late introduction of a third extrastimulus, a randomized, prospective study
Hospital of the Westfälische Wilhelms University of Münster, Department of Cardiology and Angiology and Institute for Arteriosclerosis Research Münster, Germany
Manuscript submitted 1 November 2000. Accepted after revision 20 October 2001.
Correspondence: Antoni Martínez-Rubio, MD, FESC, FACC, Hosp. de la Sta. Creu i St. Pau, Department of Cardiology, Avda. St. Antoni Ma. Claret 167, E-08025 Barcelona, Spain. E-mail: 22917amr{at}comb.es
Key Words: Programmed ventricular stimulation, ventricular tachycardia, ventricular fibrillation, syncope
Objective
The aim of this prospective study was to analyze the yield of early vs late introduction of a third extrastimulus during programmed ventricular stimulation.
Methods
Two randomized protocols of programmed ventricular stimulation were used in 94 consecutive patients with coronary artery disease who were studied because of non-sustained ventricular tachycardia (9·6%), sustained monomorphic ventricular tachycardia (46·8%), ventricular fibrillation (18·1%) or syncope (25·5%). During protocol A, a third extrastimulus was introduced during a basic drive cycle length of 500 ms after completion of programmed ventricular stimulation with 1 and 2 extrastimuli during sinus rhythm and paced cycle lengths of 500, 430, 370 and 330 ms. During protocol B, the third extrastimulus was introduced early (after 1 and 2 extrastimuli during sinus rhythm and a paced cycle length of 500 ms). Both protocols began at the right ventricular apex. If no sustained ventricular tachyarrhythmia had been induced, the same sequence of programmed ventricular stimulation was repeated at the right ventricular outflow tract.
Results
The overall incidence of induced arrhythmias did not differ between the two protocols. However, the use of the third extrastimulus (both protocols) increased the yield of ventricular fibrillation induction significantly (P< 0·04) compared with ventricular tachycardia induction.
Conclusions
The introduction of the third extrastimulus should be considered only at the end of stimulation protocols (especially in those patients without previously documented sustained ventricular tachyarrhythmias) in order to prevent induction of polymorphic ventricular tachycardia or fibrillation.
Footnotes
*The data in this manuscript are partly based on the doctoral thesis prepared by Jürgen Kuschyk 
Dr Gilberto Sierra is a research fellow from the Central Institute of Digital Research, Havana (Cuba), supported by a grant of the Deutsche Akademischer Austauschdienst (DAAD), Bonn-Bad Godesberg, Germany).
References
[1] Morady F, DiCarlo LA, Baerman JM, De Buitleir M. Comparison of coupling intervals that induce clinical and non clinical forms of ventricular tachycardia during programmed stimulation. Am J Cardiol 1986; 57: 1269–1273.[CrossRef][Web of Science][Medline]
[2] Martínez-Rubio A, Shenasa M, Borggrefe M, Chen X, Benning F, Breithardt G. Electrophysiologic variables characterizing the induction of ventricular tachycardia versus ventricular fibrillation after myocardial infarction: relation between ventricular late potentials and coupling intervals for the induction of sustained ventricular tachyarrhythmias. J Am Coll Cardiol 1993; 21: 1624–1631.[Abstract]
[3] Michelson EL, Spear JF, Moore EN. Initiation of sustained ventricular tachyarrhythmias in a canine model of chronic myocardial infarction: importance of the site of stimulation. Circulation 1981; 63: 776–783.
[4] Doherty JU, Kienzle MG, Waxman HL, Buxton AE, Marchlinski FE, Josephson ME. Programmed ventricular stimulation at a second right ventricular site: an analysis of 100 patients, with special reference to sensitivity, specificity and characteristics of patients with induced ventricular tachycardia. Am J Cardiol 1983; 52: 1184–1189.[CrossRef][Web of Science][Medline]
[5] Doherty JU, Kienzle MG, Buxton AE, Marchlinski FE, Waxman HL, Josephson ME. Discordant results of programmed ventricular stimulation at different right ventricular sites in patients with and without spontaneous sustained ventricular tachycardia: a prospective study of 56 patients. Am J Cardiol 1984; 54: 336–342.[CrossRef][Web of Science][Medline]
[6] Lin HT, Mann DE, Luck JC, et al. Prospective comparison of right and left ventricular stimulation for induction of sustained ventricular tachycardia. Am J Cardiol 1987; 59: 559–563.[CrossRef][Web of Science][Medline]
[7] Klein LS, Armstrong WF, Miles WM, Heger JJ, Zipes DP, Prystowsky EN. Electrophysiologic and anatomic characteristics of ventricular tachycardia induced at the right ventricular outflow tract but not at the apex. Am Heart J 1991; 122: 464–468.[CrossRef][Web of Science][Medline]
[8] Morady F, Kadish A, DeBuitler M, et al. Prospective comparison of a conventional and an accelerated protocol for programmed ventricular stimulation in patients with coronary artery disease. Circulation 1991; 83: 764–773.
[9] Naccarelli GV, Prystowsky EN, Jackman WM, Heger JJ, Rahilly GT, Zipes DP. Role of electrophysiologic testing in managing patients who have ventricular tachycardia unrelated to coronary artery disease. Am J Cardiol 1982; 50: 165–171.[CrossRef][Web of Science][Medline]
[10] Buxton AE, Waxman HL, Marchlinski FE, Josephson ME. Electrophysiologic studies in nonsustained ventricular tachycardia: relation to underlying heart disease. Am J Cardiol 1983; 52: 985–991.[CrossRef][Web of Science][Medline]
[11] Martínez-Rubio A, Schwammenthal Y, Schwammenthal E, et al. Patients with valvular heart disease presenting with sustained ventricular tachyarrhythmias or syncope. Circulation 1997; 96: 500–508.
[12] Haverkamp W, Martínez-Rubio A, Hief C, et al. Efficacy and safety of d,l-sotalol in patients with ventricular tachycardia and in survivors of cardiac arrest. J Am Coll Cardiol 1997; 30: 487–495.[Abstract]
[13] Breithardt G, Borggrefe M, Podczeck A, Budde T. Influence of the cycle length of basic drive on induction of sustained ventricular tachycardia associated with coronary artery disease. Am J Cardiol 1987; 60: 1306–1310.[CrossRef][Web of Science][Medline]
[14] Martínez-Rubio A, Stachowitz A, Borggrefe M, et al. Comparison of the results of programmed ventricular stimulation from the right ventricular apex and outflow tract: a randomized, prospective study. Eur Heart J 1995; 16: 1234–1243.
[15] Cox DR and Oakes D. Analysis of Survival Data. 1984; London Drapman & Hall 44–52.
[16] Lee ET. Statistical Methods for Survival Data Analysis. 1980; Belmont Lifetime Learning Publications, Wadsworth, Inc 125–6.
[17] Doherty JU, Kienzle MG, Waxman HL, Buxton AE, Marchlinski FE, Josephson ME. Relation of mode of induction and cycle length of ventricular tachycardia: analysis of 104 patients. Am J Cardiol 1983; 52: 60–64.[CrossRef][Web of Science][Medline]
[18] Robertson JF, Cain ME, Horowitz LN, et al. Anatomic and electrophysiologic correlates of ventricular tachycardia requiring left ventricular stimulation. Am J Cardiol 1981; 48: 263–268.[CrossRef][Web of Science][Medline]
[19] Morady F, DiCarlo L, Winston S, Davis JC, Scheinman MM. A prospective comparison of triple extrastimuli and left ventricular stimulation in studies of ventricular tachycardia induction. Circulation 1984; 70: 52–57.
[20] Kus T, Fromer M, Dubuc M, Shenasa M. Dispersion of refractoriness in ventricular tachycardia induction from the right ventricle. J Electrophysiol 1989; 3: 117–126.
[21] Mitchell LB, Wyse DG, Duff HJ. Programmed electrical stimulation studies for ventricular tachycardia induction in humans. The role of ventricular functional refractoriness in tachycardia induction. J Am Coll Cardiol 1986; 8: 567–575.[Abstract]
[22] Kennedy EE, Rosenfeld LE, McPherson CA, Stark SI, Batsford WP. Mechanisms and relevance of arrhythmias induced by high-current programmed ventricular stimulation. Am J Cardiol 1986; 57: 598–603.[CrossRef][Web of Science][Medline]
[23] Somberg JC and Schwartz J. Refractoriness as a determinant of tachycardia inducibility in the right ventricle. Am J Cardiol 1987; 114: 311–314.
[24] Herre JM, Mann DE, Luck JC, et al. Effect of increased current, multiple pacing sites and number of extrastimuli on induction of ventricular tachycardia. Am J Cardiol 1986; 57: 102–107.[CrossRef][Web of Science][Medline]
[25] Buxton AE, Waxman HL, Marchlinski FE, Untereker WJ, Waspe LE, Josephson ME. Role of triple extrastimuli during electrophysiologic study of patients with documented sustained ventricular tachyarrhythmias. Circulation 1984; 69: 532–540.
[26] Brugada P, Abdollah H, Heddle B, Wellens HJJ. Results of a maximum of four premature extrastimuli in patients without documented or suspected ventricular arrhythmias. Am J Cardiol 1983; 52: 1214–1218.[CrossRef][Web of Science][Medline]
[27] Mann DE, Luck JC, Griffin JC, et al. Induction of clinical ventricular tachycardia using programmed stimulation: value of third and fourth extrastimuli. Am J Cardiol 1983; 52: 501–506.[CrossRef][Web of Science][Medline]
[28] Akhtar M. Clinical application of rapid ventricular burst pacing versus extrastimulation for induction of ventricular tachycardia. J Am Coll Cardiol 1984; 4: 305–307.[Web of Science][Medline]
[29] Bayés de Luna A, Coumel Ph, Leclerq JF. Ambulatory sudden death: Mechanism of production of fatal arrhythmia on the bases of data from 156 cases. Am Heart J 1989; 117: 151–159.[CrossRef][Web of Science][Medline]
[30] Leclercq JF, Maisonblanche P, Cauchemez B, Coumel P. Respective role of sympathetic tone and of cardiac pauses in the genesis of 62 cases of ventricular fibrillation recorded during Holter monitoring. Eur Heart J 1988; 9: 1276–1283.
[31] Brugada P, Green M, Abdollah H, Wellens HJJ. Significance of ventricular arrhythmias initiated by programmed ventricular stimulation: the importance of the type of ventricular arrhythmia induced and the number of premature stimuli required. Circulation 1984; 69: 87–92.
[32] Miller JM, Kienzle MG, Harken AH, Josephson ME. Subendocardial resection for ventricular tachycardia: predictors of surgical success. Circulation 1984; 70: 624–631.
[33] Krafchek J, Lawrie GM, Roberts R, Magro SA, Wyndham CRC. Surgical ablation of ventricular tachycardia: improved results with a map-directed regional approach. Circulation 1988; 73: 1239–1247.
[34] Moss AJ, Hall WJ, Cannom DS, et al. For the Multicenter Automatic Defibrillator Implantation Trial Investigators. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med 1996; 335: 1933–1940.
[35] Mittal S, Hao SC, Iwai S, et al. Significance of inducible ventricular fibrillation in patients with coronary artery disease and unexplained syncope. J Am Coll Cardiol 2001; 38: 371–376.
[36] Morady F, Kou WH, Kadish AH, Schmaltz S, Summitt J, Rosenheck S. Effect of basic drive train cycle length of induction of ventricular tachycardia by a single extrastimulus. J Electrophysiology 1989; 3: 111–116.
[37] Brugada P and Wellens HJJ. Comparison in the same patient of two programmed ventricular stimulation protocols to induce ventricular tachycardia. Am J Cardiol 1985; 55: 380–383.[CrossRef][Web of Science][Medline]
[38] Summitt J, Rosenheck S, Kou WH, Schmaltz S, Kadish AH, Morady F. Effect of basic drive cycle length on the yield of ventricular tachycardia during programmed ventricular stimulation. Am J Cardiol 1990; 65: 49–52.[Web of Science][Medline]
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