Book Review

Nonpharmacological Therapy of Arrhythmias for the 21st Century: The state of the art

N Engl J Med 1999; 340:740-741March 4, 1999

Article

Nonpharmacological Therapy of Arrhythmias for the 21st Century: The state of the art
Edited by Igor Singer, S. Serge Barold, and A. John Camm. 908 pp., illustrated. Armonk, N.Y., Futura, 1998. $125. ISBN: 0-87993-6908

The disappointing results of pharmacologic therapy in the treatment of cardiac arrhythmias have been an important stimulus for the development of nonpharmacologic approaches to the management of rhythm disturbances. This book presents these approaches in a logical, easily understandable way.

The book has four sections. The first discusses the use of catheter ablation in the treatment of cardiac arrhythmias. This is an attractive form of therapy because it may (and frequently does) result in a cure, which is rare in cardiology. Most of our therapeutic efforts are palliative, made with the hope that the result will not only improve the quality of life but also prolong survival. That catheter ablation can be curative has been shown in patients with various types of supraventricular tachycardia, such as atrial tachycardia, atrial flutter, and atrioventricular nodal reentrant tachycardia, and in patients with tachycardia involving an accessory atrioventricular connection. Catheter ablation may also be curative in patients with idiopathic ventricular tachycardia, because removal of the site of abnormal impulse formation restores normal rhythm in a normal heart. The two types of arrhythmia that are still challenges with respect to curative treatment are atrial fibrillation and ventricular tachycardia in patients with heart disease. As discussed in this book, progress is being made in the treatment of patients with these two types of arrhythmia, and the results of catheter approaches are improving, but in view of the structural changes that are usually present in such patients, it is unlikely that catheter ablation will be a curative procedure in all of them. The section on catheter ablation carefully reviews our current knowledge. It contains valuable chapters on the physics and design of catheters and on the anatomy of cardiac structures involved in arrhythmias. Understanding these aspects is essential if the ablationist is to perform the correct procedure. What is missing in this section is a separate chapter on the complications of catheter ablation and the hazards of radiation.

The second section, on implantable cardioverter–defibrillators, includes discussions of recent technical developments and expanded indications in the light of the findings in large clinical trials. Growing concern about the predictive value of current methods of stratification for the risk of sudden death has resulted in increased use of implantable defibrillators and has led to studies comparing their use with pharmacologic therapy in patients with pump failure. The use of implantable devices for atrial fibrillation, alone or in combination with ventricular defibrillators, is also discussed. What this section lacks is a chapter on sudden death out of the hospital and the nonpharmacologic measures that have to be taken to increase the number of patients who are resuscitated, who then become candidates for implantable defibrillators.

The third section, on surgical approaches to the treatment of arrhythmias, is the shortest, an indication that catheter ablation has overtaken nonpharmacologic treatment in most cases of supraventricular tachycardia and that implantable defibrillators have done the same in cases of life-threatening ventricular arrhythmias. Surgery is still being performed to treat atrial fibrillation, usually in combination with other surgical corrections of cardiac abnormalities. In these cases, observations should be made to help develop successful catheter-ablation approaches.

Recent advances in cardiac pacing are discussed in the final section of the book. Several chapters discuss new developments in rate-adaptive pacing, mode switching, and pacing for vasovagal syncope. Since intracardiac catheters for long-term pacing have been used for more than two decades, large numbers of patients have several intracardiac catheters, necessitating transvenous extraction of the old ones when lead replacement is required. Practical advice is given on how to deal with this problem. Another important chapter discusses new indications for pacing, such as obstructive hypertrophic cardiomyopathy and congestive heart failure. Technical refinements and better selection of patients are required before major breakthroughs can be expected in this area.

This is a good book for anyone needing information on where we stand with respect to the nonpharmacologic treatment of arrhythmias. There is a paradox, however, in the book's subtitle, The State of the Art. In the preface, the editors note that interventional electrophysiology is evolving with breathtaking speed. They are correct. In cardiology, 50 percent of our knowledge is replaced within five years by new information. Therefore, the state of the art as presented in this book will be applicable only through the first year or two of the 21st century.

Hein J.J. Wellens, M.D.
Academic Hospital Maastricht, 6202 AZ Maastricht, the Netherlands