Electrical devices for treatment of arrhythmias

Electrical devices can be used for preventing and terminating tachycardia and for achieving hemodynamic improvement during a continuing tachycardia. Conventional approaches to tachycardia prevention include pacing at physiologic rates to prevent brady-cardia-related tachycardia or tachycardias associated with prolonged QT-interval syndromes. More exotic techniques, such as those involving stimulation during the refractory period, are undergoing investigation. Some tachycardias cannot be easily terminated or recur incessantly. Hemodynamics can be improved by pacing methods that result in a narrower QRS complex by coupled pacing and, in supraventricular tachycardias, by pacing rapidly enough to create atrioventricular block. Most clinical tachycardias are caused by reentry. Careful analysis of the timing of individual stimuli that successfully terminate tachycardias indicate that critical relations exist in the conduction velocity, refractoriness and physical properties and dimensions of the reentry circuit and the remaining myocardium. Elucidating these relations has permitted inferences into the mechanisms by which pacing terminates or accelerates tachycardias. A vast number of pacing patterns have evolved for use in tachycardia termination. None of these appear to be foolproof. There is widespread and justified concern about the risk of acceleration of tachycardia when antitachycardia pacing is used in the ventricle. Experience indicates that only a few patients are suitable for termination of ventricular tachycardia by pacing, but these carefully selected patients may do well. Both the results and the potential for widespread use may be better with pacing for termination of supraventricular tachycardia. Life-threatening tachycardias or fibrillation can be terminated by direct-current countershock. Although many technical problems remain, implantable cardioverter-defibrillators, possibly combined with antitachycardia pacemakers, will play an increasing role in the management or serious arrhythmias.