(Circulation. 1999;100:e123.)
© 1999 American Heart Association, Inc.
Circulation Electronic Pages |
Nonpharmacological Therapy of Arrhythmias for the 21st Century: The State of the Art
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Introduction |
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 Top Introduction |
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Igor Singer, S. Serge Barold, John Camm. 908 pp, illustrated. New York: Futura Publishing Company, Inc; 1998. $125.00. ISBN 0-87993-690-8.
This text represents an ambitious undertaking by the editors Igor Singer, S. Serge Barold, and John Camm. It comprises four sections and has contributions from 82 authors. In this up-to-date text, the editors and authors present an excellent overview of the current state of the art in nonpharmacological therapies for cardiac arrhythmias. The first section is entitled "Advances in Catheter Ablation." The section opens with a review of the "Physics and Biology of Catheter Ablation" by Paul J. Wang and N.A. Mark Estes. This chapter provides a useful summary of radiofrequency ablation and advances in monitoring such as temperature measurement. The authors go beyond the current clinical state of the art with information on microwave, laser, ultrasound, and cryoablation.
The chapter by Bruce M. McManus and Shirley M. Wood on "Morphological Features of Normal and Abnormal Conduction System" is essential for the electrophysiologist interested in ablative techniques. This chapter is beautifully illustrated and describes not only the usual anatomic locations of arrhythmic substrates but also provides information on conductive anatomy in such anomalies as univentricular heart, tetralogy of Fallot, septal defects, and transposition of the great arteries. These descriptions are particularly helpful to the electrophysiologist involved in caring for patients with congenital heart disease.
The chapters on ablation of the various substrates are contained in this first section of the book and deal with the usual suspects: AV node modification, and left-sided, right-sided, Mahaim, and septal pathways. Chapters on technical approaches to ablation and newer therapies such as atrial fibrillation, atrial tachycardia, and flutter complete the supraventricular discussions. These chapters are up-to-date and provide relevant references. Section I is rounded out by discussions of ventricular ablations. The chapters on ventricular tachycardia in coronary disease (Ross D. Fletcher and Pamela Karasik) and idiopathic left ventricular and right ventricular outflow tract tachycardias (William M. Miles and Jeffrey E. Olgin) are well-written and practical. The section on ablation finishes strongly with a chapter on "Catheter Designs for Interventional Electrophysiology" by Boaz Avitall, Gopal Gupta, Scott Millard, and Ray Helms.
The second section of the textbook is devoted to "Implantable Cardioverter-Defibrillators." Both atrial and ventricular defibrillation therapies are discussed. Although there is some redundancy in the topics, the authors’ approaches in each chapter are different enough to make the section as a whole readable and extremely useful. Again, in this section the discussion goes beyond the current state of the art and speculates on "Future Implantable Cardioverter-Defibrillator Technologies" in a well-written chapter by Edwin G. Duffin. Also contained in this section is a chapter examining in the "Impact of Implantable Cardioverter-Defibrillators on Survival." Seah Nisam asks the interesting question, "Can the ICD impact on arrhythmic mortality?" and provides an insightful discussion on potential causes for lower nonarrhythmic mortality in ICD patients.
This section has a cogent chapter authored by J. Thomas Bigger, reviewing the clinical trials designed to evaluate survival benefit in implantable defibrillator patients. The current trials discussed include the Cardiac Arrest Study of Hamburg (Cash); Canadian Implantable Defibrillator Study (CIDS); Antiarrhythmics Versus Implantable Defibrillators (AVID); Multicenter Unsustained Tachycardia Trial (MUSTT); the Multicenter Automatic Defibrillator Implantation Trial (MADIT); the CABG patch trial; the CABG surgery survey; and the sudden cardiac heart failure trial, which is just underway.
In a deviation from the title of the textbook, a chapter by Brent Mitchell, entitled "The Role of Pharmacologic Therapy for Ventricular Tachyarrhythmias: Where Do We Go From Here?," is offered. This chapter ties in nicely with the book because, as the author points out, pharmacological therapy plays an important role as an adjunct to ICD therapy. High-risk patients and most patients with ventricular tachyarrhythmia or ventricular fibrillation will benefit from ancillary "antiarrhythmic therapies" such as ß-blockers, revascularization, aspirin, and ACE inhibitors.
The third section of the text is entitled "Surgical Alternatives for Arrhythmia Management." This section opens with a thorough review of the "Cardiac Mapping Systems and Their Use in Treating Tachyarrhythmias" by Gregory P. Walcott, Sven Reek, Helmut U. Klein, William M. Smith, and Raymond E. Ideker. The authors provide a detailed look at surgical therapies and mapping systems that many trainees today will have only a limited opportunity to observe. In the chapter by Gerard M. Guiraudon, George J. Klein, Raymond Yee, and Donald Switzer, entitled "Surgical Treatment of Ventricular Tachycardias," there is an interesting discussion as to the discrepant targets or desired outcomes of catheter ablation versus surgical intervention. This chapter is well worth perusal by those who plan to undertake either modality of therapy.
The fourth section of the text is "Advances in Cardiac Pacing." Peter Belott provides a meticulous review of pacemaker implantation techniques with clear and useful figures and anatomic diagrams. Different approaches, including anterior axillary line incisions, are discussed. The chapter by Bruce L. Wilcoff and Ayman S. Al-Khandra on "The Technique of Transvenous Lead Extraction" is well done and provides important caveats for those preparing to undertake this technique. Excellent discussions are also contained in this section on "New Indications for Pacing" (S. Serge Barold); "Newest Developments in Rate-Adaptive Pacing" (David L. Hayes); "Clinical Applications of Mode-Switching for Dual Chamber Pacemakers" (Kenneth A. Ellenbogen, Mark A. Wood, Harry G. Mond, S. Serge Barold); and "Pacemaker Automaticity" (Paul A. Levine, S. Serge Barold).
Discussions on pacing therapy for a variety of clinical situations, such as treatment of vasovagal syncope (Dave G. Benditt, Keith G. Lurie, Gerard Fahy, Demosthenes Iskos, Scott Sakaguchi), or as novel therapies for hypertrophic and dilated cardiomyopathy (Barold), round out this well-written section.
In summary, this book provides a useful reference for electrophysiologists. It is likely of limited interest to those outside the field of electrophysiology, but it does provide an excellent up-to-date reference for those in practice and in training in electrophysiology. It could serve as a standard textbook for training. The illustrations are generally very helpful and the references invaluable. The authors and editors have done a superb job covering a broad area that has undergone rapid development and shows signs of increasing change in the future.
Cynthia Tracy, MD
Department of Cardiology
Georgetown University
Washington, DC
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