鈴木信也: 不整脈の疫学．山下武志編．不整脈(患者抄録で究める循環器病シリーズ2)．羊土社，2010．.
W P Lien, Y S Lee, F Z Chang, S Y Lee, C M Chen, H C Tsai
The sick sinus syndrome: natural history of dysfunction of the sinoatrial node.
Chest. 1977 Nov;72(5):628-34.
Abstract/Text
H L GADBOYS, G WISOFF, R S LITWAK
SURGICAL TREATMENT OF COMPLETE HEART BLOCK. AN ANALYSIS OF 36 CASES.
JAMA. 1964 Jul 13;189:97-102.
Abstract/Text
小林洋一: 植込み型心電ループレコーダー．監修 杉本恒明. 不整脈2011．メディカルレビュー社，2011．.
A D Krahn, G J Klein, R Yee, A C Skanes
Randomized assessment of syncope trial: conventional diagnostic testing versus a prolonged monitoring strategy.
Circulation. 2001 Jul 3;104(1):46-51.
Abstract/Text
BACKGROUND: Establishing a diagnosis in patients with unexplained syncope is complicated by infrequent and unpredictable events. Prolonged monitoring may be an alternative strategy to conventional testing with short-term monitoring and provocative tilt and electrophysiological testing.
METHODS AND RESULTS: Sixty patients (aged 66+/-14 years, 33 male) with unexplained syncope were randomized to "conventional" testing with an external loop recorder and tilt and electrophysiological testing or to prolonged monitoring with an implantable loop recorder with 1 year of monitoring. If patients remained undiagnosed after their assigned strategy, they were offered crossover to the alternate strategy. A diagnosis was obtained in 14 of 27 patients randomized to prolonged monitoring compared with 6 of 30 patients undergoing conventional testing (52% versus 20%, P=0.012). Crossover was associated with a diagnosis in 1 of 6 patients undergoing conventional testing compared with 8 of 13 patients who completed monitoring (17% versus 62%, P=0.069). Overall, prolonged monitoring was more likely to result in a diagnosis than was conventional testing (55% versus 19%, P=0.0014). Bradycardia was detected in 14 patients undergoing monitoring compared with 3 patients undergoing conventional testing (40% versus 8%, P=0.005).
CONCLUSIONS: A prolonged monitoring strategy is more likely to provide a diagnosis than conventional testing in patients with unexplained syncope. Consideration should be given to earlier implementation of a monitoring strategy.
Todd T Tomson, Rod Passman
The Reveal LINQ insertable cardiac monitor.
Expert Rev Med Devices. 2015 Jan;12(1):7-18. doi: 10.1586/17434440.2014.953059. Epub 2014 Aug 26.
Abstract/Text
Insertable cardiac monitors (ICMs) are leadless subcutaneous devices that continuously monitor the heart rhythm and record events over a timeframe measured in years, allowing for the diagnosis of infrequent rhythm abnormalities that can be the cause of palpitations, syncope and stroke. To date, ICMs have primarily been used in the work-up and management of syncope; however, their use in other areas of rhythm evaluation, particularly atrial fibrillation monitoring, is increasing. The Reveal LINQ™ is the smallest and most versatile ICM available and represents a dramatic leap forward in ICM technology that has the potential to transform patient care in a number of circumstances. Device miniaturization, simplified implant procedure and enhanced automation vastly increase physician and patient acceptance. The next 5 years can be expected to bring a greatly increased use of ICMs for disease diagnosis and management in a variety of clinical settings.
Sampath Gunda, Yeruva Madhu Reddy, Jayasree Pillarisetti, Sandeep Koripalli, Courtney Jeffery, Jeanine Swope, Donita Atkins, Sudharani Bommana, Martin P Emert, Rhea Pimentel, Raghuveer Dendi, Loren D Berenbom, Luigi DiBiase, Andrea Natale, Dhanunjaya Lakkireddy
Initial real world experience with a novel insertable (Reveal LinQ(@Medtronic)) compared to the conventional (Reveal XT(@Medtronic)) implantable loop recorder at a tertiary care center - Points to ponder!
Int J Cardiol. 2015 Jul 15;191:58-63. doi: 10.1016/j.ijcard.2015.04.241. Epub 2015 May 1.
Abstract/Text
INTRODUCTION: Limited data is available regarding the novel Reveal LinQ (LinQ) which is a new generation implantable loop recorders (ILRs).
METHODS: We performed a prospective, observational study of all consecutive patients undergoing conventional (Reveal XT; XT) and LinQ devices at our institution between January 2012 and December 2014.
RESULTS: A total of 217 patients underwent ILR implantation. XT was implanted in 105 and LinQ in 112 patients. There were no significant differences in baseline characteristics between the two groups. LinQ implantation using the manufacturer's technique termed, "manufacturer's method" group had significantly higher incidence of pocket infection compared to XT (6/50, 12% vs 3/105, 3%, p=0.032). With modifications to the LinQ implantation technique (using a conventional scalpel and placing a suture when needed to the incision) termed "modified method" group, the rate of infection has decreased significantly compared to "manufacturer's method group" (0/62, 0% vs 6/50, 12%, p=0.004) (Table 3). In multivariate regression analysis, the only independent predictors of infection were younger age (OR 0.95; p=0.04), insertion of LinQ device (OR 30.02; p=0.006) and procedure time (OR 1.07; p=0.03).
CONCLUSION: In our single-center, prospective, observational study we found that with the current implantable techniques, the novel insertable LinQ device is associated with increased risk of complications.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Michele Brignole, Angel Moya, Frederik J de Lange, Jean-Claude Deharo, Perry M Elliott, Alessandra Fanciulli, Artur Fedorowski, Raffaello Furlan, Rose Anne Kenny, Alfonso Martín, Vincent Probst, Matthew J Reed, Ciara P Rice, Richard Sutton, Andrea Ungar, J Gert van Dijk, ESC Scientific Document Group
2018 ESC Guidelines for the diagnosis and management of syncope.
Eur Heart J. 2018 Jun 1;39(21):1883-1948. doi: 10.1093/eurheartj/ehy037.
Abstract/Text
Angel Moya, Roberto García-Civera, Francesco Croci, Carlo Menozzi, Josep Brugada, Fabrizio Ammirati, Attilio Del Rosso, Alejandro Bellver-Navarro, Jesús Garcia-Sacristán, Miriam Bortnik, Lluis Mont, Ricardo Ruiz-Granell, Xavier Navarro, Bradycardia detection in Bundle Branch Block (B4) study
Diagnosis, management, and outcomes of patients with syncope and bundle branch block.
Eur Heart J. 2011 Jun;32(12):1535-41. doi: 10.1093/eurheartj/ehr071. Epub 2011 Mar 28.
Abstract/Text
AIMS: Although patients with syncope and bundle branch block (BBB) are at high risk of developing atrio-ventricular block, syncope may be due to other aetiologies. We performed a prospective, observational study of the clinical outcomes of patients with syncope and BBB following a systematic diagnostic approach.
METHODS AND RESULTS: Patients with ≥1 syncope in the last 6 months, with QRS duration ≥120 ms, were prospectively studied following a three-phase diagnostic strategy: Phase I, initial evaluation; Phase II, electrophysiological study (EPS); and Phase III, insertion of an implantable loop recorder (ILR). Overall, 323 patients (left ventricular ejection fraction 56 ± 12%) were studied. The aetiological diagnosis was established in 267 (82.7%) patients (102 at initial evaluation, 113 upon EPS, and 52 upon ILR) with the following aetiologies: bradyarrhythmia (202), carotid sinus syndrome (20), ventricular tachycardia (18), neurally mediated (9), orthostatic hypotension (4), drug-induced (3), secondary to cardiopulmonary disease (2), supraventricular tachycardia (1), bradycardia-tachycardia (1), and non-arrhythmic (7). A pacemaker was implanted in 220 (68.1%), an implantable cardioverter defibrillator in 19 (5.8%), and radiofrequency catheter ablation was performed in 3 patients. Twenty patients (6%) had died at an average follow-up of 19.2 ± 8.2 months.
CONCLUSION: In patients with syncope, BBB, and mean left ventricular ejection fraction of 56 ± 12%, a systematic diagnostic approach achieves a high rate of aetiological diagnosis and allows to select specific treatment.
J H McAnulty, S H Rahimtoola, E Murphy, H DeMots, L Ritzmann, P E Kanarek, S Kauffman
Natural history of "high-risk" bundle-branch block: final report of a prospective study.
N Engl J Med. 1982 Jul 15;307(3):137-43. doi: 10.1056/NEJM198207153070301.
Abstract/Text
We conducted a prospective study in which 554 patients with chronic bifascicular and trifascicular conduction abnormalities were followed for an average of 42.4 +/- 8.5 months. Heart block occurred in 19 patients, and 17 were successfully treated. The actuarial five-year mortality from an event that could conceivably have been a bradyarrhythmia was 6 per cent (35 per cent from all causes). Of the 160 deaths 67 (42 per cent) were sudden; most of these were not ascribable to bradyarrhythmia but to tachyarrhythmia and myocardial infarction. Mortality was higher in patients with coronary-artery disease (P less than 0.01) and congestive heart failure (P less than 0.05). Patients in whom syncope developed before or after entry into the study had a 17 per cent incidence of heart block (2 per cent in those without syncope)(P less than 0.05); however, no single variable was predictive of which patients were at high risk of death from a bradyarrhythmia. The predictors of death were increasing age, congestive heart failure, and coronary-artery disease; the predictors of sudden death were coronary-artery disease and increasing age. The risks of heart block and of death from a bradyarrhythmia are low; in most patients, heart block can be recognized and successfully treated with a pacemaker.
M Brignole, C Menozzi, A Moya, R Garcia-Civera, L Mont, M Alvarez, F Errazquin, J Beiras, N Bottoni, P Donateo, International Study on Syncope of Uncertain Etiology (ISSUE) Investigators
Mechanism of syncope in patients with bundle branch block and negative electrophysiological test.
Circulation. 2001 Oct 23;104(17):2045-50.
Abstract/Text
BACKGROUND: In patients with syncope and bundle branch block (BBB), syncope is suspected to be attributable to a paroxysmal atrioventricular (AV) block, but little is known of its mechanism when electrophysiological study is negative.
METHODS AND RESULTS: We applied an implantable loop recorder in 52 patients with BBB and negative conventional workup. During a follow-up of 3 to 15 months, syncope recurred in 22 patients (42%), the event being documented in 19 patients after a median of 48 days. The most frequent finding, recorded in 17 patients, was one or more prolonged asystolic pause mainly attributable to AV block; the remaining 2 patients had normal sinus rhythm or sinus tachycardia. The onset of the bradycardic episodes was always sudden but was sometimes preceded by ventricular premature beats. The median duration of the arrhythmic event was 47 seconds. An additional 3 patients developed nonsyncopal persistent III-degree AV block, and 2 patients had presyncope attributable to AV block with asystole. No patients suffered injury attributable to syncopal relapse.
CONCLUSIONS: In patients with BBB and negative electrophysiological study, most syncopal recurrences have a homogeneous mechanism that is characterized by prolonged asystolic pauses, mainly attributable to sudden-onset paroxysmal AV block.
Yaariv Khaykin, Nassir F Marrouche, David O Martin, Walid Saliba, Robert Schweikert, Mark Wexman, Brian Strunk, Salwa Beheiry, Eduardo Saad, Mandeep Bhargava, J David Burkhardt, George Joseph, Patrick Tchou, Andrea Natale
Pulmonary vein isolation for atrial fibrillation in patients with symptomatic sinus bradycardia or pauses.
J Cardiovasc Electrophysiol. 2004 Jul;15(7):784-9. doi: 10.1046/j.1540-8167.2004.03279.x.
Abstract/Text
INTRODUCTION: Sick sinus syndrome is commonly associated with tachyarrhythmias and bradyarrhythmias that often are symptomatic. The aim of this study was to assess the effect of pulmonary vein isolation in patients with sick sinus syndrome and atrial fibrillation (AF).
METHODS AND RESULTS: Three hundred fourteen consecutive patients who underwent pulmonary vein isolation between December 2000 and January 2002 were included in the study. Thirty-one patients had sick sinus syndrome, which was defined as a preprocedural history of symptomatic sinus bradycardia or pauses. Endpoints included AF recurrence, change in the frequency of sinus pauses, and symptoms of presyncope or syncope, as well as mean heart rate and percentage of atrial pacing in patients with pacemakers implanted prior to the pulmonary vein isolation. Patients had AF for an average of 6 +/- 3 years. Patients were 58 +/-8 years old and had ejection fractions of 55 +/- 4%. Sixty-one percent had implanted pacemakers. AF recurred within 6 months in 4 patients. Two had a successful second pulmonary vein isolation procedure. There were no recurrences of presyncopal events (P < 0.05) or documented sinus pauses (P < 0.05) after successful pulmonary vein isolation in the patients without permanent pacemakers. Patients with pacemakers had a 13-fold reduction in the percentage of atrial pacing (P < 0.05). Both groups showed a significant increase in average heart rates at 6-month follow-up.
CONCLUSION: Cure of AF by pulmonary vein isolation helped resolve the clinical manifestations of sick sinus syndrome, suggesting that the occurrence of AF and/or the associated treatment could be partially responsible for sick sinus syndrome.
安田正之，ほか：房室ブロックにおける補充収縮の検討．心電図1993;13: 591.
中里祐二，中田八洲郎：高度及び完全房室ブロックにおける臨床電気生理学的検討．心臓ペーシング 1987;3: 355.
峯田自章，中田八洲郎：房室ブロック．監修：矢崎義雄. 心電図を読む．メディカルビュー社，2004．.
S A LEVINE, H MILLER, G B PENTON
Some clinical features of complete heart block.
Circulation. 1956 Jun;13(6):801-24.
Abstract/Text
J C ROWE, P D WHITE
Complete heart block: a follow-up study.
Ann Intern Med. 1958 Aug;49(2):260-70.
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