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CARDIAC ARRHYTHMIAS, PACING & ELECTROPHYSIOLOGY

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CARDIAC ARRHYTHMIAS, PACING & ELECTROPHYSIOLOGY

Developments in Cardiovascular Medicine

VOLUME 201

The titles published in this series are listed at the end of this volume.

CARDIAC ARRHYTHMIAS,

PACING

&

ELECTROPHYSIOLOGY

EDITED BY

PANOS E. VARDAS Professor of Cardiology, University of Crete, Medical School, Heraklion, Crete, Greece

~ . • , SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.

Library of Congress Cataloging-in-Publication Data is available.

ISBN 978-94-010-6210-7 ISBN 978-94-011-5254-9 (eBook) DOI 10.1007/978-94-011-5254-9

Printed on acidjree paper

All Rights Reserved © 1998 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1998 Softcover reprint of the hardcover 18t edition 1998

No part of this publication may be reproduced or utilized in any form or by any means, electronic, mechanical, inc1uding photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner.

Dedicated to those who inspired me and encouraged me in this endeavour and especially to my beloved Anastasia, Katerina and Emmanuel.

CONTENTS

Foreword by S. Furman

Preface

List of contributors

PART ONE: CARDIAC ARRHYTHMIAS AND CLINICAL ELECTROPHYSIOLOGY

xiii

xv

xvii

1. Sinus node reentrant tachycardia versus ectopic atrial tachycardia: where lies the difference? 3 Rein Reidbtichel

2. AV nodal reentry: what have we learned from ablation techniques? 11 Mark E. Josephson

3. Severe paroxysmal atrial fibrillation: atrioventricular junction ablation and DDDR mode-switching pacemaker versus pharmacological treatment 29 Michele Brignole, Lorella Gianfranchi, Carlo Menozzi, Paolo Alboni, Giacomo Musso, Maria Grazia Bongiorni, Maurizio Gasparini, Antonio Raviele, Gino Lolli, Nelly Paparella and Simonetta Acquarone

4. Mechanisms of drug action in atrial fibrillation 35 Maria I. Anastasiou-Nana

5. Conclusions and questions from large trials of anticoagulants in patients with atrial fibrillation 43 Peter J. Koudstaal and Adriana Koudstaal

6. Role of the autonomic nervous system in sustained ventricular tachycardia after myocardial infarction 49 Maurizio Landolina, Ruggero Manfredini, Massimo Mantica and Gaetano M. de Ferrari

7. Does assessment of autonomic tone translate into new therapeutic approaches in survivors of myocardial infarction? 57 Federico Lombardi

8. Mechanisms of ventricular arrhythmias in ischaemic heart disease 61 Nabil El-Sherif

9. Basic mechanisms of vulnerability to ventricular fibrillation 71 Michiel1. Janse

10. Molecular and electrophysiological mechanisms of arrhythmias in hypertrophic cardiomyopathy 77 DanM. Roden

11. Risk stratification in patients with hypertrophic cardiomyopathy 83 Perry M. Elliott and William J. McKenna

viii • CONTENTS

12. Floppy mitral valve/mitral valve prolapse: cardiac arrhythmias 89 Harisios Boudoulas, Stephen F. Schaal and Charles F. Wooley

13. Pathology of arrhythmogenic right ventricular cardiomyopathies, dysplasia and Naxos disease: clinical, pathological and nosological classification 97 G. Fontaine, N. Protonotarios, F. Fontaliran, A. Tsatsopoulou and R. Frank

14. Ventricular arrhythmias in hypertensives 105 Dimitris A. Sideris

15. The value of electrophysiological testing in diagnosis of syncope in post-infarction patients, without complex ventricular arrhythmias detected in 24-hour ECG 109 Wieslawa Piwowarska, Danuta Mroczek-Czernecka, Artur Pietrucha, Marta W~grzynowska and Bozena Stobierska-Dzierzek

16. Value of different mapping strategies for ventricular tachycardia: sinus rhythm and pace mapping, activation and entrainment mapping 113 Jesus Almendral, Julhln P. Villacast:(n, Angel Arenal, Mercedes Ortiz, Julio Osende, Jose L. Martinez-Sande and Juan L. Delean

17. The Madit trial? What was wrong? 121 Philippe Coumel

18. Survival analysis and classification of death in patients under antiarrhythmic treatment 125 Hugo Ector, Hein Heidbtichel and Frans Van de Werf

19. Quality of life in clinical trials and practice 131 Werner Jung, Susanne Herwig, Susanne Spehl, Christian Wolpert and Berndt Ltideritz

PART TWO: NON-INVASIVE ELECTROCARDIOLOGY 141

20. Heart rate variability in vasovagal syncope 143 George Kochiadakis and Panos Vardas

21. The role of non-invasive diagnostic techniques in reducing mortality in postmyocardial infarction survivors Ronald W.F. Campbell

22. QT prolongation and proarrhythmia Ronald W.F. Campbell

23. QT dispersion: its clinical value A. Bayes de Luna, M. Fiol, A. Bayes-Genis, X. Viiiolas, A. Cabrera and A. Martinez-Rubio

24. New perspective in non-invasive risk factors Yee Guan Yap and Marek Malik

25. Spectral analysis of cardiovascular variability signals Sergio Cerutti, Anna M. Bianchi, Luca T. Mainardi and Maria G. Signorini

151

153

155

159

171

CONTENTS • ix

26. Physiological background of the heart rate variability spectral components 185 Alberto Malliani, Nicola Montano and Massimo Pagani

27. Heart rate variability after myocardial infarction 193 Yee Guan Yap and Marek Malik

28. Signal averaging for risk stratification after myocardial infarction: do new technologies improve its predictive value? 199 Gioia Turitto

29. Artificial neural networks in cardiology: a review 205 Willem RM. Dassen, Michael Egmont-Petersen and Rob G.A. Mulleneers

PART THREE: RADIOFREQUENCY ABLATION IN ARRHYTHMIAS 213

30. Radiofrequency catheter modification of sinus node activity in patients with inappropriate sinus tachycardia 215 Melvin M. Scheinman, Jerold S. Shinbane, Michael D. Lesh and Randall J. Lee

31. Catheter ablation techniques for elimination of atrial fibrillation 223 Demosthenes G. Katritsis

32. Atrioventricular nodal ablation and VVIR pacing for rate control and regularisation of the ventricular rhythm in patients with established atrial fibrillation 229 Panos E. Vardas, E.N. Simantirakis and E.G. Manios

33. Ablation for ventricular tachycardia related to coronary artery disease 235 John D. Fisher

PART FOUR: ATRIAL AND VENTRICULAR DEFIBRILLATION 243

34. Historical perspectives on cardioversion and defibrillation 245 Berndt Liideritz

35. New concepts in electrical defibrillation 257 Werner Irnich

36. Role of implantable atrial defibrillators in the treatment of atrial fibrillation 265 Luc J. Jordaens

37. Management of atrial fibrillation by implantable devices: from electrophysiological studies to clinical application 271 Sanjeev Saksena and Philippe Delfaut

38. Design concepts for implantable atrial defibrillators 277 Gregory M. Ayers and Carolyn K. Wiemers

39. Criteria for selection of patients for lAD implantations 287 Alessandro Capucci, Daniela Aschieri, Giovanni Quinto Villani and Alessandro Rosi

X· CONTENTS

40. Survival benefits of implantable cardioverter/defibrillators in different groups of patients 29 Konrad Steinbach, Christine Hief and Andrea Podczeck

41. Continuing evolution of implantable cardioverter/defibrillators: smaller size, longer life, improved cost-effectiveness 29 Seab Nisam

42. Prophylactic implantation of the implantable defibrillator in asymptomatic patients 30 Poul Erik Bloch Thomsen

43. Prophylactic implantation of implantable cardioverter/defibrillators in postmyocardial infarction patients 30 Antonio Raviele, Aldo Bonso, Gianni Gasparini and Sakis Themistoclakis

44. Muscle-sparing subpectoral defibrillator implantation 31 Gijs Geskes

45. Follow-up techniques in patients with implantable cardioverters/defibrillators 31 Michael Block, Barbara Lamp, Max Weber and Gunther Breithardt

PART FIVE: CARDIAC PACING 329

46. The features of a paced heart beat 331 Lukas Kappenberger, Michel Grobety and Xavier Jeanrenaud

47. Clinical evaluation of chronotropic incompetence: implications for rate-adaptive pacing 337 Demosthenes Iskos, Marcus 1. Mianulli and David G. Benditt

48. Indications for permanent antibradycardia pacemakers. The official guidelines should be revised 343 S. Serge Barold

49. Regional electromechanical coupling during ventricular pacing 353 Frits W. Prinzen, Tarnmo Delhaas, Theo Arts and Robert S. Reneman

50. What kind of programming gives the optimal performance in rate-response ventricular pacing 361 Modesto Guerola

51. Atrial septal pacing: synchronising the atria 367 William H. Spencer III

52. Automatic mode switching in DDD(R) pacemakers: to make life easier or more complicated? 375 Ali Oto

53. Neurohumoral control of the pacemaker and heart system 379 Max Schaldach

54. Single-lead VDDIDDD pacing 389 I. Eli Ovsyshcher and Alan B. Wagshal

55. Clinical trials in cardiac pacing: justification, design and preliminary results of the United States trials 399 Gervasio A. Lamas

CONTENTS • xi

56. Can pacing be more physiological? 407 Massimo Santini, Antonio Auriti and Gerardo Ansalone

57. Improved follow-up procedure 411 Ole-J~rgen Ohm, Dejan Danilovic and Svein Faerestrand

58. Development of a true pacemaker Holter 421 S. Serge Barold, Gene Bornzin and Paul Levine

59. Electromagnetic interference in current implantable devices 427 Werner Imich

60. Potential impact of pacing in the treatment of dilated cardiomyopathy 437 Richard Sutton

61. Can reliable pacing be achieved in hypertrophic obstructive cardiomyopathy with normal conduction? 441 Daniel Gras, Dominique Pavin, Philippe Mabo and Claude Daubert

62. A V node ablation and DDD pacing in hypertrophic obstructive cardiomyopathy 451 Nicolas Sadoul, Bernard Dodinot, Daniel Beurrier, Christian de Chillou and Etienne Aliot

Index 459

FOREWORD

Europace '97 was held in Athens, Greece, on 8-11 June 1997 in the city of classical civilisation and learning. Though now held in modem surroundings and meeting facilities, the influence of the ancient city-state was un­mistakable, with the architecture and learning of antiquity looming over the city, by its influence over the intellectual activities of the symposium. The ancient magnificence of the site was matched by the novelty of modem art and science, Europace is a European symposium, begun in 1979, and has occurred every second year since. Con­sistent with its importance and continental reach the actual symposium has moved to different cities throughout Western Europe. The first symposium was held in London and subsequent symposia have been held in Torremolinos, Ostend, Florence, Istanbul and other cities. Because of the ease of modem travel it rapidly became a truly inter­national conference, with participation from the entire European continent and from every continent of the world. It has always served as a common ground for meeting of Europeans from East and West, and North and South Americans, at a site of mutual interest.

Unlike the administration of meetings of specific national and international organisations, Europace, under the auspices of the European Working Groups on Cardiac Pacing and Arrhythmias, has been administra­tively decentralised. Both the venue of the meeting and its organisation have constantly moved. In 1997 the organisation and conduct of Europace was conducted ably and efficiently by Professor P.E. Vardas of the Department of Cardiology of Heraklion University Hospital, Heraklion, Crete, Greece. Europace has always represented a most modem presentation of cardiac pacing techniques, and from the very beginning has mirrored the progressive expansion of the field.

One need only review the contents of the European pacing conferences over the years to note the evolution of arrhythmia diagnosis and management. The first con­gress dealt with pacing alone, and discussion of the classic indications for pacing of atrioventricular (A V) block and sinus node dysfunction and the haemo­dynamics of pacing those two conditions. At that time haemodynarnics largely dealt with rate change and the effect of exercise with single rate pacing. Artificial sensors in pacing were so new as not to be discussed.

Leads were, as usual, an important topic, with the earl­iest mention of the then-new polyurethane leads. Future conferences elaborated on these basic topics while pro­gressively adding sensors and sensor function, dual­chamber pacing, and recognising the development of clinical cardiac electrophysiology.

Clinical cardiac electrophysiology and compre­hension of arrhythmias has been largely a development of the twentieth century. With the description and recording of the bundle of His depolarisation, by direct access and by catheter, modem clinical investigation of arrhythmias and cardiac electrophysiology began. The disciplines of cardiac stimulation and of investigation of arrhythmias, impulse formation and A V conduction were essentially separate for many years. Investigators in the two areas appeared at different meetings and seldom corresponded with each other. In 1980 the first human implantation of an implantable cardioverterl defibrillator (ICD) occurred. That became an epochal event in this work, though unrecognised at the time. The defibrillator managed ventricular tachyarrhythmia, a capability which cardiac pacing did not have, other than indirectly, where the establishment of a regular and con­sistent ventricular rate might suppress the tachycardia by suppressing the escape ventricular arrhythmias which caused a small portion of Morgagni-Adams-Stokes episodes. With the presentation of the complexities of ICD therapy it progressively became clear that this therapy combined the capabilities and problems of cardiac stimulation while directed at management of the two most lethal of cardiac arrhythmias, ventricular tachycardia and ventricular fibrillation. The European and other world symposia then began to present pacing and defibrillation, especially as it became clearer that pacing was an integral component in overall tach­yarrhythmia management when combined with the ICD. During the mid-1980s world symposia dealt with pacing, defibrillation and more and more with inter­ventional cardiac electrophysiology. Even as late as the mid-1980s pacemaker and ICD programmability was relatively rudimentary compared to what it has become in 1997.

With the development of highly complex program­mability and the transvenous approach to ICD implanta-

xiv • FOREWORD

tion a truly new era has occurred. The ICD is now suit­able for any patient, can manage both tachyarrhythmias and brady arrhythmias and has begun to exercise increasing competitiveness with medications. Stimu­lation of yet another portion of the heart, the atrium, is now being evaluated for the management of atrial fibril­lation, an arrhythmia beginning to receive closer scrutiny for its effect on cardiac health and its ability to be restrained and effectively reversed. With ablation of ventricular and atrial foci and the A V conduction system, there are now a range of powerful interventions in the management of cardiac arrhythmias. All brady­arrhythmias can be managed with an implantable pace­maker, either single- or dual-chamber, either pacing the ventricle alone and disregarding a chronically fibrillat­ing or fluttering atrium or with dual-chamber pacing which restores the normal A V sequence. Even the inter­mittently fibrillating or fluttering atrium can be paced with a dual-chamber device because of sensor avail­ability, which permits the automatic change of mode from dual-chamber to single-chamber pacing in the presence of an atrial arrhythmia. Reentry tachyarrhyth­mias and those dependent on a ventricular or atrial pathological focus can be managed by ablation tech­niques and drugs which still play a major, though diminishing, role. Ventricular tachyarrhythmias and fibrillation can be managed with the ICD and with drugs. Atrial arrhythmias may yet fall to the atrial defibrillator. The overall management of cardiac arrhythmias has progressed immeasurably in the past two decades. It is unrecognisable compared to manage­ment at the time of the first European Symposium on Cardiac Pacing.

The new frontiers of arrhythmology now deal with the use of pacing for management of hypertrophic obstructive cardiomopathy, the management of v&gal syndromes and further expansion of non-invasive elec­trocardiology, in order to enhance diagnostic capability at minimum patient discomfort and cost. In cardiac pacing new areas presented included the pacing tech­niques to resynchronise the atria and further evaluation of the technique of single-lead VDD pacing. The dis­cussion of randomised prospective trials in cardiac pacing and ICD therapy were also presented and dis­cussed. Without doubt the technique of the randomised prospective trial is of immense value in discerning dif­ferences between therapeutic approaches. It is as new an approach as is the field itself. The power of the statist­ical technique has brought clarity to many investigations, and has enabled the detection of therapeutic directions which are sufficiently subtle so that they are not imme­diately obvious. This tool is one which will continue to thrive, and will expand in its value, as the years pass.

Europace '97, a superbly executed and scientifically distinguished international symposium, reflected credit upon its organisers, the European Working Groups and its immediate Greek organisers. It continued the line of Euro­pean symposia in a way which makes the high quality of the next congress a necessity. It has also advanced the dis­semination of the art and science of arrhythmia manage­ment throughout the world, but especially to those portions of Europe which are still unable readily to access symposia in other parts of the world. Everyone involved in the event is to be congratulated and commended.

Seymour Furman

PREFACE

Cardiology as a whole, and in particular cardiac ar­rhythmias, electrophysiology and pacing, are developing so rapidly in both the diagnostic and therapeutic fields that even the many associated publications barely man­age to keep up with scientific progress.

Scientific congresses and symposia, as components of continuing medical education, provide a bridge between established medical knowledge and future ground­breaking research. This volume includes articles on a large number of topics which were presented at the re­cent congress on arrythmias, electrophysiology and pacing, Europace '97.

The main purpose of this publication is to provide an up to date presentation of aspects of arrhythmiology, clinical electrophysiology, internal defibrillation and pacing by pioneers in these fields. The book is aimed principally at specialised cardiologists and is not in­tended to cover the daily needs of patient care.

The advantages of this publication are undoubtedly

the large number of chapters, 62 in all, the in depth analysis of particular scientific topics and the presenta­tion of the clinical and research experience of many of the authors. I would like to take the opportunity to thank all the contributors especially for their willingness to contribute to this volume, as well as for the efforts they have made towards progress in their particular fields.

I would also like to thank my colleagues in our own cardiology department for their contribution to the de­velopment of the academic, research and authoring ac­tivities of the department. In particular, I would like to mention the contribution made by the head of the de­partment's computer section, Mr. Philip Lees, and to thank him for his ideas and initiative.

Finally, I would like to express my gratitude to the staff of Kluwer Academic Publications, in particular Nettie Dekker, for their valuable cooperation and their assistance in the preparation of this book.

P.E. Vardas

LIST OF CONTRIBUTORS

JESUS ALMENDRAL Department of Cardiology Hospital General Gregorio Marafi6n Dr Esquerdo 46 E-28007 Madrid Spain Co-authors: Julian P. Villacastin, Angel Arenal,

Mercedes Ortiz, Julio Osende, J6se L. Mart:Cnez-Sande and Juan L. Delean

MARIA I. ANASTASIOU·NANA University of Athens School of Medicine Department of Clinical Therapeutics 2 Vas. Sophias and K. Lourou GR-11528 Athens Greece

GREGORY M. AYERS Clinical Research InControl, Inc. 6675-185th Avenue NE Redmond, W A 98052 USA Co-author: Carolyn K. Wiemers

S. SERGE BAROLD Cardiac Arrhythmia Service One Mt. Sinai Drive Cleveland, OH 44106 USA Co-authors Chapter 58: Gene Bornzin and Paul Levine

A.J. BAYES DE LUNA Department of Cardiology Hospital de la Santa Creu i Sant Pau St. Antoni M. Claret 167 E-08025 Barcelona Spain Co-authors: M. FioI, A. Bayes-Genis, X. Vifiolas,

A. Cabrera and A. Martinez-Rubio

POUL ERIC BLOCH THOMSEN Cardiology Department Copenhagen Country Gentofte Hospital University of Copenhagen 65 Niels Andersensvej DK-2900 Hellerup Denmark

MICHAEL BLOCK Medical Clinic and Polyclinic, Internal Medicine C Hospital Westf. Wilhelms-University Munster D-48129 Munster Germany Co-authors: Barbara Lamp, Max Weber and Gunther

Breithardt

HARISIOS BOUDOULAS Division of Cardiology The Ohio State University 621 Means Hall 1654 Upham Drive Columbus, OH 43210-1228 USA Co-authors: Stephen F. Schaal and Charles F. Wooley

MICHELE BRIGNOLE Via A. Grilli 164 1-16041 Borzonasca (GE) Italy Co-authors: Lorella Gianfranchi, Carlo Menozzi,

Paolo Alboni, Giacomo Musso, Maria Grazia Bongiorni, Maurizio Gasparini, Antonio Raviele, Gino Lolli, Nelly Paparella and Simonetta Acquarone

RONALD W.F. CAMPBELL Department of Academic Cardiology Freeman Hospital Newcastle Upon Tyne NE7 7DN UK

xviii • LIST OF CONTRIBUTORS

ALESSANDRO CAPUCCI Division of Cardiology Ospedale Civile di Piacenza Via Taverna 49 1-29100 Piacenza Italy Co-authors: Daniela Aschieri, Giovanni Quinto Villani

and Alessandro Rosi

SERGIO CERUTTI Department of Biomedical Engineering Polytechnic University, via Gogli 39 Plaza Leonardo da Vinci 32 1-20133 Milan Italy Co-authors: Anna M. Bianchi, Luca T. Mainardi and

Maria G. Signorini

PHILIPPE COUMEL Department of Cardiology Hospital Lariboisiere 2 rue Ambroise-Pare F-75010 Paris France

WILLEM R.M. DASSEN Department of Cardiology University of Maastricht PO Box 616 6200 MD Maastricht The Netherlands Co-authors: Michael Egmont-Petersen and Rob G.A.

Mulleneers

HUGO ECTOR Department of Cardiology University Hospital Gasthuisberg Herestraat 49 B-3000 Leuven Belgium Co-authors: Hein Heidbtichel and Frans Van de Werf

NABEL EL·SHERIF Director, Cardiology Division SUNY Health Science Center 450 Clarkson Ave Box 1199 Brooklyn, NY 11203 USA

PERRY M. ELLIOTT Department of Cardiological Sciences St George's Hospital Medical School Cranmer Terrace London SW17 ORE UK Co-authors: William 1. McKenna

JOHN D. FISHER Cardiology - Arrhythmia Offices, North 2 Montefiore Medical Center 11 E 210th Street Bronx, NY 10467-2490 USA

GUY FONTAINE Cardiology Department Hopital Jean Rostand 39-41 Rue Jean Ie Galleau F-94200 Ivry-Sur-Seine France Co-authors: N. Protonotarios, F. Fontaliran,

A. Tsatsopoulou and R. Frank

SEYMOUR FURMAN 285 College Road Bronx, NY 10471 USA

GUSGESKES Department of Cardiothoracic Surgery Academic Hospital Maastricht PO Box 5800 6202 AZ Maastricht The Netherlands

DANIEL GRAS Cardiologie A Hotel-DieulCHRU 2, Rue de I'Hotel Dieu F-35033 Rennes Cedex 9 France Co-authors: Dominique Pavin, Philippe Mabo and

Claude Daubert

MODESTO GUEROLA Centre de Maladies Cardiovasculars Diputacion 279, 2a E-08007 Barcelona Spain

HEIN HEIDBUCHEL Department of Cardiology University of Hospital Gasthuisberg Herestraat 49 B-3000 Leuven Belgium

WERNER IRNICH Department of Medical Engineering Justus Liebig University Aulweg 123 D-35392 Giessen Germany

DEMOSTHENES ISKOS Section of Cardiology University of Minnesota Medical School Cardiac Arrhythmia Center, Box 508 420 Delaware Street SE Minneapolis, MN 55410 USA Co-authors: Marcus 1. Mianulli and David G. Benditt

MICHIEL J. JANSE Department of Clinical and Experimental Cardiology Academisch Medisch Centrum, M-0-52 Meibergdreef 9 1105 AZ Amsterdam Zuidoost The Netherlands

LUC J. JORDAENS Department of Cardiology Universty Hospital De Pintelaan 185 B-9000 Gent Belgium

MARK E. JOSEPHSON Harvard-Thorndike Electrophysiology Institute &

Arrhythmia Service Beth Israel Deaconess Medical Center 330 Brookline Avenue RW 453 Boston, MA 02215 USA

WERNER JUNG Department of Cardiology University of Bonn Clinic and Policlinic 25 Sigmund Freud Str

D-53105 Bonn Germany

LIST OF CONTRIBUTORS • xix

Co-authors: Susanne Herwig, Susanne Spehl, Christian Wolpert and Berndt Ltideritz

LUKASKAPPENBERGER Division of Cardiology CHUV 17 Rue de Bugnon CH -10 11 Lausanne Switzerland Co-authors: Michel Grobety and Xavier Jeanrenaud

DEMOSTHENES G. KATRITSIS Department of Cardiology Onassis Cardiovascular Surgical Center 356 Syngrou Ave GR-17674 Athens Greece

GEORGE KOCHIADAKIS Department of Cardiology Heraklion University Hospital PO Box 1352 Stavrakia Heraklion, Crete Grece Co-author: Panos Vardas

PETER J. KOUDSTAAL Department of Neurology University of Hospital Dijkzigt Dr Molewaterplein 40 3015 GD Rotterdam The Netherlands Co-author: Adriana Koudstaal

GERVASIO A. LAMAS Mount Sinai Medical Center Ste 207A 4300 Alton Road Miami Beeach, FL 33140 USA

MAURIZIO LANDOLINA Viale Lazio 26 1-20135 Milan Italy Co-authors: Ruggero Manfredini, Massimo Mantica and

Gaetano M. de Ferrari

xx • LIST OF CONTRIBUTORS

FREDERICO LOMBARDI Biomedical Science Institute Ospedale San Paolo Via A. di Rudini 8 1-20142 Milan Italy

BERNDT LUDERITZ Department of Medicine-Cardiology University of Bonn 25, Sigmund Freud Str. D-53105 Bonn Germany

ALBERTO MALLIANI Medicina II Cardiovascular Research Institute Ospedale L. Sacco Via G.B. Grassi 74 1-20157 Milan Italy Co-authors: Nicola Montano and Massimo Pagani

SEAHNISAM CPIIGuidant European Headquarters Excelsiorlaan 37 B-1930 Zaventem Belgium

OLE J0RGEN OHM Department of Cardiology Hauke1and University Hospital N-5021 Bergen Norway Co-authors: Dejan Danilovic and Svein Faerestrand

M.ALI OTO Department of Cardiology Hacettepe University School of Medicine Ankara Turkey

I. ELI OVSYSHCHER Arrhythmia Service Soroka Medical Center PO Box 151 Beer-Sheva 84105 Israel Co-author: Alan B. Wagshal

WIESlAWA PIWOWARSKA Department of Coronary Disease Institute of Cardiology Nicolaus Copernicus University School of Medicine 80 Pradnicka Str Cracow 31-202 Poland Co-authors: Danuta Mroczek-Czernecka, Artur

Pietrucha, Marta Wygrzynowska and Bozena Stobierska-Dzierzek

FRITS W. PRINZEN Department of Physiology Cardiovascular Research Institute University of Maastricht PO Box 616 6200 MD Maastricht The Netherlands Co-authors: Tammo Delhaas, Theo Arts and

Robert S. Reneman

ANTONIO RA VIELE Division of Cardiology Ospedale Umberto I Via Circonvallazione 1-30170 Mestre-Venezia Italy Co-authors: Aldo Bonso, Gianni Gasparini and Sakis

Themistoclakis

DANM.RODEN Division of Clinical Pharmacology Vanderbilt University Medical Center 532 Medical Research Building-I Nashville, TN 37232-6602 USA

NICOLAS SADOUL Service de Cardiologie Hopital Central 29 Ave de Lattre de Tassigny F-54035 Nancy Cedex France Co-authors: Bernard Dodinot, Daniel Beurrier,

Christian de Chillou and Etienne Aliot

SANJEEV SAKSENA Cardiac Medicine & EP, PA 55 Essex Street, Suite 3-2

Millburn, NJ 07041-1606 USA Co-authors: Philippe Delfaut

MASSIMO SANTINI Via de Collegio Capranica 30 1-00180 Rome Italy Co-authors: Antonio Auriti and Gerardo Ansalone

MAX SCHALDACH Department of Biomedical Engineering Friedrich-Alexander -University Turnstrasse 5 D-91054 Erlangen Germany

MELVIN M. SClIEINMAN Cardiovascular Research Institute University of California at San Francisco 505 Parnassus Avenue MU East 48, Box 1354 San Francisco, CA 94143-1354 USA Co-authors: Jerold S. Shinbane, Michael D. Lesh and

Randall J. Lee

DIMITRIS A. SIDERIS Department of Internal Medicine University of loannina Medical School GR-4511O loannina Greece

WILLIAM H. SPENCER III Section of Cardiology Baylor College of Medicine 6550 Fannin, Suite-1025 Houston, TX 77030 USA

KONRAD K. STEINBACH Ludwig Bolzman Institute for Arrhythmias

Research Wilhelminenspital Montleartstrasse 37

A-1171 Vienna Austria

LIST OF CONTRIBUTORS • xxi

Co-authors: Christine Hief and Andrea Podczeck

RICHARD SUTTON Pacing and Electrophysiology Royal Brompton Hospital Sydney Street London SW3 6NP UK

GIOIA TURITTO Division of Cardiovascular Medicine SUNY Health Science Center at Brooklyn 450 Clarkson Ave, Box 1199 New York, NY 11203 USA

PANOS E. VARDAS Department of Cardiology Heraklion University Hospital PO Box 1352 Stavrakia Heraklion, Crete Greece Co-author Chapter 20: G. Kochiadakis Co-authors Chapter 32: E.N. Simantirakis and

E.G. Manios

ALAN B. WAGSHAL Arrhythmia Service Soroka Medical Center PO Box 151 Beer-Sheva 84105 Israel Co-author: I. Eli Ovysyshcher

YEEGUANYAP Department of Cardiological Sciences St George's Hospital Medical School Cranmer Terrace London SW17 ORE UK Co-author: Marek Malik