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Zhang A, Ding L, Zhang H, Mi L, Yu F, Tang M. Radiofrequency catheter ablation for pulmonary hypertension patients with atrial flutter. ESC Heart Fail 2024; 11:883-892. [PMID: 38200382 DOI: 10.1002/ehf2.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS We aimed to evaluate the effects of radiofrequency catheter ablation (RFCA) and the factors influencing mortality after RFCA in patients with pulmonary hypertension (PH) and atrial flutter (AFL). METHODS AND RESULTS Fifty-eight consecutive PH patients with AFL who underwent an electrophysiological study and RFCA between April 2013 and August 2021 were selected for this study. In the study population, pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) was the most common type of PH (n = 34, 59%), followed by idiopathic pulmonary arterial hypertension (IPAH) (n = 19, 33%). Typical atrial flutter was the most common type of atrial flutter (n = 50, 86.2%). Sinus rhythm was restored in 53 (91.4%) patients during RFCA. After a mean follow-up of 33.8 months, AFL recurred in a total of 22 patients. Nine of them underwent repeat RFCA, and the site of the repeat ablation was not exactly the same as the first. At a median follow-up of 34.6 months after the last ablation, none of the patients who underwent repeat RFCA experienced AFL recurrence, and all of these patients survived. There were no procedure-related complications during hospitalization or follow-up. Univariate Cox regression analysis suggested that AFL recurrence after the last ablation was not associated with all-cause mortality. NT-proBNP (HR: 1.00024, 95% CI: 1.00008-1.00041, P = 0.004), pulmonary artery systolic pressure (PASP) (HR: 1.048, 95% CI: 1.020-1.076, P = 0.001), and IPAH (vs. PAH-CHD, HR 7.720, 95% CI: 1.437-41.483, P = 0.017) were independent predictors of all-cause mortality in PH patients with AFL after RFCA. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of PASP for predicting all-cause mortality was 0.708. There was no significant difference in the Kaplan-Meier curves for all-cause mortality between patients with AFL recurrence after the last ablation and those without recurrence (P = 0.851). Patients with higher PASP (≥110 mmHg) and IPAH showed the lower survival rate in Kaplan-Meier curves. CONCLUSION Repeat ablation was safe and feasible in patients with recurrent AFL and can maintain sinus rhythm. AFL recurrence was not associated with all-cause mortality, and patients with high PASP or IPAH were at higher risk for adverse outcomes.
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Affiliation(s)
- Aikai Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Ding
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lijie Mi
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Le Quilliec E, LeBlanc CA, Neuilly O, Xiao J, Younes R, Altuntas Y, Xiong F, Naud P, Villeneuve L, Sirois MG, Tanguay JF, Tardif JC, Hiram R. Atrial cardiomyocytes contribute to the inflammatory status associated with atrial fibrillation in right heart disease. Europace 2024; 26:euae082. [PMID: 38546222 PMCID: PMC11000822 DOI: 10.1093/europace/euae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Right heart disease (RHD), characterized by right ventricular (RV) and atrial (RA) hypertrophy, and cardiomyocytes' (CM) dysfunctions have been described to be associated with the incidence of atrial fibrillation (AF). Right heart disease and AF have in common, an inflammatory status, but the mechanisms relating RHD, inflammation, and AF remain unclear. We hypothesized that right heart disease generates electrophysiological and morphological remodelling affecting the CM, leading to atrial inflammation and increased AF susceptibility. METHODS AND RESULTS Pulmonary artery banding (PAB) was surgically performed (except for sham) on male Wistar rats (225-275 g) to provoke an RHD. Twenty-one days (D21) post-surgery, all rats underwent echocardiography and electrophysiological studies (EPS). Optical mapping was performed in situ, on Langendorff-perfused hearts. The contractility of freshly isolated CM was evaluated and recorded during 1 Hz pacing in vitro. Histological analyses were performed on formalin-fixed RA to assess myocardial fibrosis, connexin-43 levels, and CM morphology. Right atrial levels of selected genes and proteins were obtained by qPCR and Western blot, respectively. Pulmonary artery banding induced severe RHD identified by RV and RA hypertrophy. Pulmonary artery banding rats were significantly more susceptible to AF than sham. Compared to sham RA CM from PAB rats were significantly elongated and hypercontractile. Right atrial CM from PAB animals showed significant augmentation of mRNA and protein levels of pro-inflammatory interleukin (IL)-6 and IL1β. Sarcoplasmic-endoplasmic reticulum Ca2+-ATPase-2a (SERCA2a) and junctophilin-2 were decreased in RA CM from PAB compared to sham rats. CONCLUSIONS Right heart disease-induced arrhythmogenicity may occur due to dysfunctional SERCA2a and inflammatory signalling generated from injured RA CM, which leads to an increased risk of AF.
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Affiliation(s)
- Ewen Le Quilliec
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Charles-Alexandre LeBlanc
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Orlane Neuilly
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jiening Xiao
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Rim Younes
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Yasemin Altuntas
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Feng Xiong
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Patrice Naud
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Louis Villeneuve
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Martin G Sirois
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jean-François Tanguay
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
| | - Roddy Hiram
- Department of Medicine, Montreal Heart Institute, University of Montreal, 5000 Belanger Street, Montreal, QC HIT 1C8, Canada
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Savale L, Kularatne M, Roche A, Pichon J, Baron A, Boucly A, Sitbon O, Humbert M. Management of Acutely Decompensated Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:762-770. [PMID: 37369216 DOI: 10.1055/s-0043-1770119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Pulmonary arterial hypertension is a severe life-threatening condition associated with increased pulmonary vascular resistance and resulting right heart dysfunction. Admission to intensive care unit with acutely decompensated right heart failure is a significant negative prognostic event with a high risk of multisystem organ dysfunction and death. Presentations are heterogenous and may combine signs of both diastolic and systolic dysfunction complicating management. Renal dysfunction is often present, but other organ systems can be involved resulting in findings such as acute hepatic dysfunction or bowel wall congestion and ischemia. The goals of therapy are to rapidly reverse ventriculo-arterial decoupling and reduce right ventricular afterload to prevent progression to refractory or irreversible right heart failure. Triggering events must be investigated for and addressed urgently if identified. Volume status management is critical and both noninvasive and invasive testing can aid in prognostication and guide management, including the use of inotropes and vasopressors. In cases of refractory right heart dysfunction, consideration of urgent lung transplantation and mechanical circulatory support is necessary. These patients should be managed at expert centers in an intensive care setting with a multidisciplinary team of practitioners experienced in the management of right heart dysfunction given the high short- and long-term mortality resulting from acute decompensated right heart failure.
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Affiliation(s)
- Laurent Savale
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Mithum Kularatne
- Division of Respiratory Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Anne Roche
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Jérémie Pichon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Audrey Baron
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Athenaïs Boucly
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Olivier Sitbon
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
| | - Marc Humbert
- INSERM UMR_S 999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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Morales-Lara AC, Elkhatib W, Oluleye O, Alhusain R, Saad A, Salwa N, Siddiqui H, Wieczorek MA, Ray J, Parikh P, Burger C, Shapiro B, Kusumoto F, Pillai D, Adedinsewo D. Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation. Cardiology 2023; 148:353-362. [PMID: 37276844 DOI: 10.1159/000531402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH. METHODS We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF. RESULTS Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003). CONCLUSION We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.
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Affiliation(s)
| | - Wiaam Elkhatib
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Rashid Alhusain
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Amjad Saad
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Najiyah Salwa
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Habeeba Siddiqui
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Mikolaj A Wieczorek
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Jordan Ray
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Pragnesh Parikh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Charles Burger
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Brian Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Fred Kusumoto
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Dilip Pillai
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Demilade Adedinsewo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Sammut MA, Condliffe R, Elliot C, Hameed A, Lewis R, Kiely DG, Kyriacou A, Middleton JT, Raithatha A, Rothman A, Thompson AAR, Turner R, Charalampopoulos A. Atrial flutter and fibrillation in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension in the ASPIRE registry: Comparison of rate versus rhythm control approaches. Int J Cardiol 2023; 371:363-370. [PMID: 36130620 DOI: 10.1016/j.ijcard.2022.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The development of atrial flutter and fibrillation (AFL/AF) in patients with pre-capillary pulmonary hypertension has been associated with an increased risk of morbidity and mortality. Rate and rhythm control strategies have not been directly compared. METHODS Eighty-four patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) with new-onset AFL/AF were identified in the ASPIRE registry. First, baseline characteristics and rates of sinus rhythm (SR) restoration of 3 arrhythmia management strategies (rate control, medical rhythm control and DC cardioversion, DCCV) in an early (2009-13) and later (2014-19) cohort were compared. Longer-term outcomes in patients who achieved SR versus those who did not were then explored. RESULTS Sixty (71%) patients had AFL and 24 (29%) AF. Eighteen (22%) patients underwent rate control, 22 (26%) medical rhythm control and 44 (52%) DCCV. SR was restored in 33% treated by rate control, 59% medical rhythm control and 95% DCCV (p < 0.001). Restoration of SR was associated with greater improvement in functional class (FC) and Incremental Shuttle Walk Distance (p both <0.05). It also independently predicted superior survival (3-year survival 62% vs 23% in those remaining in AFL/AF, p < 0.0001). In addition, FC III/IV independently predicted higher mortality (HR 2.86, p = 0.007). Right atrial area independently predicted AFL/AF recurrence (OR 1.08, p = 0.01). DCCV was generally well tolerated with no immediate major complications. CONCLUSIONS Restoration of SR is associated with superior functional improvement and survival in PAH/CTEPH compared with rate control. DCCV is generally safe and is more effective than medical therapy at achieving SR.
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Affiliation(s)
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Robert Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Andreas Kyriacou
- Department of Cardiology, Northern General Hospital, Sheffield, UK
| | - Jennifer T Middleton
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ajay Raithatha
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Alex Rothman
- Department of Cardiology, Northern General Hospital, Sheffield, UK; Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Richard Turner
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.
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Bandorski D, Heibel S, Höltgen R, Bogossian H, Ghofrani HA, Zarse M, Gall H. Incidence and prognostic significance of malignant arrhythmias during (repetitive) Holter electrocardiograms in patients with pulmonary hypertension. Front Cardiovasc Med 2023; 10:1084051. [PMID: 37139131 PMCID: PMC10150006 DOI: 10.3389/fcvm.2023.1084051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
Background In patients with pulmonary hypertension (PH), increased pulmonary vascular resistance (PVR) may lead to increased right ventricular afterload and cardiac remodelling, potentially providing the substrate for ventricular arrhythmias. Studies dealing with long term monitoring of patients with PH are rare. The present study evaluated the incidence and the types of arrhythmias retrospectively recorded by Holter ECG in patients with newly detected PH during a long-term Holter ECG follow-up. Moreover, their impact on patient survival was evaluated. Patients and methods Medical records were screened for demographic data, aetiology of PH, incidence of coronary heart disease, level of brain natriuretic peptide (BNP), results from Holter ECG monitoring, 6-minute walk test distance, echocardiographic data and hemodynamic data derived from right heart catheterization. Two subgroups were analyzed: 1. patients (n = 65) with PH (group 1 + 4) and derivation of at least 1 Holter ECG within 12 months from initial detection of PH and 2. patients (all PH etiologies, n = 59) with 3 follow-up Holter ECGs. The frequency and complexity of premature ventricular contractions (PVC) was classified into "lower" and "higher" (=non sustained ventricular tachycardia, nsVT) burden. Results Holter ECG revealed sinus rhythm (SR) in most of the patients (n = 60). Incidence of atrial fibrillation (AFib) was low (n = 4). Patients with premature atrial contractions (PAC) tend to have a shorter period of survival (p = 0.098), PVC were not correlated with significant survival differences. During follow-up PAC and PVC were common in all PH groups. Holter ECG revealed non sustained ventricular tachycardia in 19/59 patients [(32.2%); n = 6 during first Holter-ECG, n = 13 during second/third Holter-ECG]. In all patients suffering from nsVT during follow-up previous Holter ECG revealed multiform/repetitive PVC. PVC burden was not linked to differences in systolic pulmonary arterial pressure, right atrial pressure, brain natriuretic peptide and results of six-minute walk test. Conclusion Patients with PAC tend to have a shortened survival. None of the evaluated parameters (BNP, TAPSE, sPAP) was correlated with the development of arrhythmias. Patients with multiform/repetitive PVC seem to be at risk for ventricular arrhythmias.
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Affiliation(s)
- Dirk Bandorski
- Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Correspondence: Dirk Bandorski
| | - Sebastian Heibel
- Medical Clinic III, Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Reinhard Höltgen
- Klinikum Westmünsterland, St. Agnes-Hospital Bocholt-Rhede, Bocholt, Germany
| | | | - Hossein Ardeschir Ghofrani
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Markus Zarse
- Cardiology Department, School of Medicine, Witten/Herdecke University, Witten, Germany
| | - Henning Gall
- The German Center for Lung Research (DZL), University of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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Andersen MØ, Diederichsen SZ, Svendsen JH, Carlsen J. Continuous cardiac monitoring in a patient with terminal pulmonary hypertension and eventual bilateral lung transplantation. BMJ Case Rep 2022; 15:15/6/e248304. [PMID: 35667702 PMCID: PMC9171191 DOI: 10.1136/bcr-2021-248304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
As pulmonary arterial hypertension (PAH) progress, arrhythmias are becoming an increasingly prominent phenomenon. Supraventricular tachycardias have been shown to have an incidence of up to 35% in pulmonary hypertension. Continuous cardiac monitoring was deployed in a patient with severe PAH 100 days before bilateral lung transplantation (BLTX). Despite being graded as WHO functional class IV, no arrhythmias were observed before BLTX. Furthermore, the case describes clinical improvement, along with a significant increase in heart rate variability (HRV) and decrease in night-time heart rate in the post-transplantation period. No arrhythmias were observed preoperatively during continuous monitoring in a 100-day period despite the patient’s intrinsically high risk for arrhythmias. Increasing HRV and lower resting heart rate were observed after BLTX. Since these parameters correlate with the clinical condition, they might be valuable in risk assessment in patients with pulmonary hypertension.
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Affiliation(s)
- Mads Ørbæk Andersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Boyle TA, Daimee UA, Simpson CE, Kolb TM, Mathai SC, Akhtar T, Nyhan D, Calkins H, Spragg D. Left Atrial Ablation for the Management of Atrial Tachyarrhythmias in Patients with Pulmonary Hypertension: A Case Series. HeartRhythm Case Rep 2022; 8:275-279. [PMID: 35497477 PMCID: PMC9039084 DOI: 10.1016/j.hrcr.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Thomas A. Boyle
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
- Address reprint requests and correspondence: Dr Thomas A. Boyle, Division of Cardiology, Johns Hopkins Hospital, 600 North Wolfe St, Baltimore, MD 21287.
| | - Usama A. Daimee
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Catherine E. Simpson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Tauseef Akhtar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Daniel Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - David Spragg
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
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9
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Chen H, Ma Y, Wang Y, Luo H, Xiao Z, Chen Z, Liu Q, Xiao Y. Progress of Pathogenesis in Pediatric Multifocal Atrial Tachycardia. Front Pediatr 2022; 10:922464. [PMID: 35813391 PMCID: PMC9256911 DOI: 10.3389/fped.2022.922464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/23/2022] [Indexed: 11/18/2022] Open
Abstract
Multifocal atrial tachycardia (MAT) is defined as irregular P-P, R-R, and P-R intervals, isoelectric baseline between P waves, and ventricular rate over 100 beats/min. Although the prognosis of pediatric MAT in most patients is favorable, adverse outcomes of MAT have been reported, such as cardiogenic death (3%), respiratory failure (6%), or persistent arrhythmia (7%), due to delayed diagnosis and poorly controlled MAT. Previous studies demonstrated that pediatric MAT is associated with multiple enhanced automatic lesions located in the atrium or abnormal automaticity of a single lesion located in the pulmonary veins via multiple pathways to trigger electrical activity. Recent studies indicated that pediatric MAT is associated with the formation of a re-entry loop, abnormal automaticity, and triggering activity. The occurrence of pediatric MAT is affected by gestational disease, congenital heart disease, post-cardiac surgery, pulmonary hypertension, and infectious diseases, which promote MAT via inflammation, redistribution of the autonomic nervous system, and abnormal ion channels. However, the pathogenesis of MAT needs to be explored. This review is aimed to summarize and analyze the pathogenesis in pediatric MAT.
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Affiliation(s)
- Huaiyang Chen
- Academy of Pediatrics, University of South China, Changsha, China.,Hunan Children's Hospital, Changsha, China
| | - Yingxu Ma
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | | | - Haiyan Luo
- Hunan Children's Hospital, Changsha, China
| | - Zhenghui Xiao
- Academy of Pediatrics, University of South China, Changsha, China.,Hunan Children's Hospital, Changsha, China
| | - Zhi Chen
- Hunan Children's Hospital, Changsha, China
| | - Qiming Liu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yunbin Xiao
- Academy of Pediatrics, University of South China, Changsha, China.,Hunan Children's Hospital, Changsha, China
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10
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Abstract
PURPOSE OF REVIEW Need for intensive care in the patient with pulmonary arterial hypertension is associated with high mortality. This review will provide an overview of causes of ICU admission for patients with pulmonary hypertension and provide guidance on management. RECENT FINDINGS There is a paucity of evidence-based medical literature on management of patients with pulmonary arterial hypertension. This article will summarize the available literature and expert guidance on the topic. Patients with pulmonary arterial hypertension may require ICU care as a direct consequence of decompensated right heart failure. Alternatively, patients with pulmonary arterial hypertension may be affected by the myriad of maladies encountered every day in the ICU including acute respiratory failure, septic shock, and gastrointestinal bleeding. The treatment plan should focus on identifying and treating the cause for decompensation. In addition, optimization of right ventricular preload, reduction of right ventricular afterload, correction of hypotension and augmentation of right ventricular inotropy should be considered. SUMMARY The approach to ICU care of patients with pulmonary arterial hypertension requires special consideration with regard to intubation and mechanical ventilation and management of volume status and hemodynamics. Whenever possible, these patients should be transferred to centers with experience in treating this complex, vulnerable population.
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11
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Andersen MØ, Diederichsen SZ, Svendsen JH, Carlsen J. Assessment of cardiac arrhythmias using long-term continuous monitoring in patients with pulmonary hypertension. Int J Cardiol 2021; 334:110-115. [PMID: 33819493 DOI: 10.1016/j.ijcard.2021.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/17/2021] [Accepted: 03/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiac arrhythmias are considered a prominent phenomenon in patients with pulmonary hypertension (PH). Older studies reported that 8% to 35% of patients with PH had supraventricular tachycardia (SVT), associated with adverse outcomes. Still, these arrhythmias have only been investigated via short-term monitoring or limited electrocardiogram recordings. METHODS Patients without previous arrhythmias diagnosed with PH at a tertiary facility received an insertable cardiac monitor as part of a prospective cohort study. Baseline assessments included World Health Organization functional class, six-minute walk test, echocardiography, and cardiac magnetic resonance imaging. RESULTS Thirty-four patients with PH were included. Twenty-four patients had pulmonary arterial hypertension (PAH) and 10 had chronic thromboembolic PH (CTEPH). During 46 patient-years of continuous monitoring (median: 594 (range: 334-654) days per patient), 70 arrhythmia episodes were recorded in 13 patients (38%), with a median of two (range: 1-3) episodes and an arrhythmic burden median of 1.6 (range: 0.1-228) minutes per patient. SVTs were the most common arrhythmias, with 16% of episodes being atrial fibrillation and 84% being other types of SVTs. Additionally, three patients experienced bradycardias, including one resulting in syncope and subsequent pacemaker implantation. None of the patients had sustained ventricular arrhythmias. CONCLUSIONS Arrhythmias were seen in 38% of contemporary patients with PH during long-term continuous monitoring; however, the vast majority of episodes were short and self-limiting. Modern therapy may alleviate the development of arrhythmias in stable patients with PH. This study is the first study to deploy long-term continuous monitoring in patients with PH.
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Affiliation(s)
- Mads Ørbæk Andersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, 9- Blegdamsvej, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Copenhagen 2200, Denmark.
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12
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Inampudi C, Tedford RJ, Hemnes AR, Hansmann G, Bogaard HJ, Koestenberger M, Lang IM, Brittain EL. Treatment of right ventricular dysfunction and heart failure in pulmonary arterial hypertension. Cardiovasc Diagn Ther 2020; 10:1659-1674. [PMID: 33224779 PMCID: PMC7666956 DOI: 10.21037/cdt-20-348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/09/2023]
Abstract
Right heart dysfunction and failure is the principal determinant of adverse outcomes in patients with pulmonary arterial hypertension (PAH). In addition to right ventricular (RV) dysfunction, systemic congestion, increased afterload and impaired myocardial contractility play an important role in the pathophysiology of RV failure. The behavior of the RV in response to the hemodynamic overload is primarily modulated by the ventricular interaction and its coupling to the pulmonary circulation. The presentation can be acute with hemodynamic instability and shock or chronic producing symptoms of systemic venous congestion and low cardiac output. The prognostic factors associated with poor outcomes in hospitalized patients include systemic hypotension, hyponatremia, severe tricuspid insufficiency, inotropic support use and the presence of pericardial effusion. Effective therapeutic management strategies involve identification and effective treatment of the triggering factors, improving cardiopulmonary hemodynamics by optimization of volume to improve diastolic ventricular interactions, improving contractility by use of inotropes, and reducing afterload by use of drugs targeting pulmonary circulation. The medical therapies approved for PAH act primarily on the pulmonary vasculature with secondary effects on the right ventricle. Mechanical circulatory support as a bridge to transplantation has also gained traction in medically refractory cases. The current review was undertaken to summarize recent insights into the evaluation and treatment of RV dysfunction and failure attributable to PAH.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ryan J. Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Irene Marthe Lang
- Division of Cardiology, Department of Medicine, Medical University of Vienna, Vienna
| | - Evan L. Brittain
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Translational and Clinical Cardiovascular Research Center, Nashville, TN, USA
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13
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Bandorski D, Bogossian H, Ghofrani A, Schmitt J, Höltgen R. [Tachycardia and pulmonary arterial hypertension]. Herzschrittmacherther Elektrophysiol 2020; 31:33-38. [PMID: 32048010 DOI: 10.1007/s00399-020-00668-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Abstract
Pulmonary hypertension is newly defined as an elevation of the mean pulmonary arterial pressure >20 mmHg and a pulmonary vascular resistance ≥3 Wood units. Arrhythmias are an increasing problem in patients with pulmonary hypertension. Pathophysiological aspects leading to supraventricular arrhythmias are atrial fibrosis caused by increased right atrial pressure and dilation. An increased sympathetic tone leads to prolongation of action potential and delayed polarisations causing arrhythmias. Therapy of arrhythmias includes drugs (preferred amiodarone) and electrophysiological therapy like electric cardioversion and ablation, which is safe in patients with pulmonary hypertension.
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Affiliation(s)
- D Bandorski
- Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Lohmühlenstraße 5/Haus P, 20099, Hamburg, Deutschland. .,Intensivmedizin und internistische Diagnostik, Neurologische Klinik Bad Salzhausen, Am Hasensprung 6, 63667, Nidda, Deutschland.
| | - H Bogossian
- Abteilung für Kardiologie, Elektrophysiologie und Angiologie, Märkische Kliniken GmbH, Klinikum Lüdenscheid, Paulmannshöher Str. 14, 58515, Lüdenscheid, Deutschland.,Universität Witten/Herdecke, Witten, Deutschland
| | - A Ghofrani
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - J Schmitt
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - R Höltgen
- St. Agnes-Hospital Bocholt Rhede, Medizinische Klinik, Kardiologie/Elektrophysiologie, Klinikum Westmünsterland, Barloer Weg 125, 46397, Bocholt, Deutschland
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14
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Vahdatpour CA, Luebbert JJ, Palevsky HI. Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910685. [PMID: 32215200 PMCID: PMC7065292 DOI: 10.1177/2045894020910685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.
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Affiliation(s)
- Cyrus A. Vahdatpour
- Department of Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jeffrey J. Luebbert
- Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Harold I. Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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15
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Bandorski D, Höltgen R, Ghofrani A, Johnson V, Schmitt J. [Arrhythmias in patients with pulmonary hypertension and chronic lung disease]. Herzschrittmacherther Elektrophysiol 2019; 30:234-239. [PMID: 31440896 DOI: 10.1007/s00399-019-00637-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
Pulmonary arterial hypertension (PAH) occurs in 1% of the global population and can be divided in different disease groups. Pathophysiological aspects leading to supraventricular arrhythmias in these patients are due to increased pulmonary and right atrial pressure, increased activity of the sympathetic nervous system leading to right atrial electrical remodeling and ischemia in the right atrium. In the clinical setting these patients present with atrial flutter, atrial fibrillation or with ectopic atrial tachycardia. Regarding ventricular tachycardia there is a lack of data. Occurrence of arrhythmia in these patients leads to a deterioration of PAH, so rhythm control should be the aim. This can be achieved by right atrial ablation, especially in patients presenting with atrial flutter; electric cardioversion or antiarrhythmic drug therapy are without definite guideline recommendations since there are too few clinical trials. Ablation with a transseptal approach in the left atrium is considered rather dangerous and should be avoided. Regarding arrhythmias in patients with chronic lung disease, few data are available. For patients with chronic obstructive pulmonary disease (COPD), there are good data available. These patients often suffer from coronary heart disease, atrial fibrillation, and ventricular tachycardia. Beta-blockers play an important role in COPD patients, even during exacerbation. Interventional therapies are safe but the arrhythmogenic foci often located outside of the pulmonary veins (in the right atrium).
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Affiliation(s)
- Dirk Bandorski
- Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Lohmühlenstraße 5/Haus P, 20099, Hamburg, Deutschland. .,Intensivmedizin und internistische Diagnostik, Asklepios Neurologische Klinik Bad Salzhausen, Am Hasensprung 6, 63667, Nidda, Deutschland.
| | - Reinhard Höltgen
- Medizinische Klinik, Kardiologie/Elektrophysiologie, Klinikum Westmünsterland, St. Agnes-Hospital Bocholt Rhede, Barloer Weg 125, 46397, Bocholt, Deutschland
| | - Ardeschir Ghofrani
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Viktoria Johnson
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
| | - Jörn Schmitt
- Medizinische Klinik 1, Innere Medizin/Kardiologie, Universitätsklinikum Gießen, Klinikstraße 33, 35392, Gießen, Deutschland
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16
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Cirulis MM, Ryan JJ, Archer SL. Pathophysiology, incidence, management, and consequences of cardiac arrhythmia in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019834890. [PMID: 30747032 PMCID: PMC6410395 DOI: 10.1177/2045894019834890] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Arrhythmias are increasingly recognized as serious, end-stage complications of pre-capillary pulmonary hypertension, including pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). Although arrhythmias contribute to symptoms, morbidity, in-hospital mortality, and possibly sudden death in PAH/CTEPH, there remains a paucity of epidemiologic, pathophysiologic, and outcome data to guide management of these patients. This review summarizes the most current evidence on the topic: from the molecular mechanisms driving arrhythmia in the hypertrophied or failing right heart, to the clinical aspects of epidemiology, diagnosis, and management.
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Affiliation(s)
- Meghan M Cirulis
- 1 Division of Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - John J Ryan
- 2 Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Stephen L Archer
- 3 Department of Medicine, Queen's University, Kingston, ON, Canada
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17
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Mercurio V, Peloquin G, Bourji KI, Diab N, Sato T, Enobun B, Housten-Harris T, Damico R, Kolb TM, Mathai SC, Tedford RJ, Tocchetti CG, Hassoun PM. Pulmonary arterial hypertension and atrial arrhythmias: incidence, risk factors, and clinical impact. Pulm Circ 2018; 8:2045894018769874. [PMID: 29575972 PMCID: PMC5912291 DOI: 10.1177/2045894018769874] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Atrial arrhythmia (AA) occurrence in pulmonary arterial hypertension (PAH) may determine clinical deterioration and affect prognosis. In this study we assessed AA incidence in idiopathic (IPAH) and systemic sclerosis related PAH (SSc-PAH) and evaluated risk factors, management, and impact on mortality. We collected baseline data from consecutive IPAH or SSc-PAH patients prospectively enrolled in the Johns Hopkins Pulmonary Hypertension Registry between January 2000 and July 2016. During follow-up AA onset, treatment, and outcome were recorded. Among 317 patients (201 SSc-PAH, 116 IPAH), 42 developed AA (19 atrial fibrillation, 10 flutter-fibrillation, 9 atrial flutter, and 4 atrial ectopic tachycardia) with a 13.2% cumulative incidence. Most events were associated with hospitalization (90.5%). Electrical or pharmacological cardioversion was attempted in most cases. Patients with AA had higher right atrial pressure, pulmonary wedge pressure (P < 0.005), NT-proBNP (P < 0.05), and thyroid disease prevalence (P < 0.005). Higher mortality was observed in patients with AA, though not statistically significant (LogRank P = 0.323). Similar long-term mortality between IPAH with AA and SSc-PAH without AA was observed (LogRank P = 0.098). SSc-PAH with AA had the worst prognosis. In PAH patients AA occurrence is a matter of significant concern. Therapeutic strategies aimed at restoring sinus rhythm may represent an important goal.
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Affiliation(s)
- Valentina Mercurio
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA.,2 Department of Translational Medical Sciences, 1466 Federico II University, Naples, Italy
| | - Grace Peloquin
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Khalil I Bourji
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Nermin Diab
- 3 25802 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Takahiro Sato
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Blessing Enobun
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Traci Housten-Harris
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Rachel Damico
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Todd M Kolb
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Stephen C Mathai
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
| | - Ryan J Tedford
- 4 Division of Cardiology, 1466 Department of Medicine, Johns Hopkins University , Baltimore, MD, USA
| | - Carlo G Tocchetti
- 2 Department of Translational Medical Sciences, 1466 Federico II University, Naples, Italy
| | - Paul M Hassoun
- 1 Division of Pulmonary and Critical Care Medicine, 1466 Department of Medicine, Johns Hopkins University, Baltimore , MD, USA
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18
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Waligóra M, Tyrka A, Miszalski-Jamka T, Urbańczyk-Zawadzka M, Podolec P, Kopeć G. Right atrium enlargement predicts clinically significant supraventricular arrhythmia in patients with pulmonary arterial hypertension. Heart Lung 2018; 47:237-242. [PMID: 29454666 DOI: 10.1016/j.hrtlng.2018.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 01/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Right atrial (RA) enlargement is a common finding in patients with pulmonary arterial hypertension (PAH) and an important predictor of mortality, however its relation to the risk of atrial arrhythmias has not been assessed. OBJECTIVES To assess whether RA enlargement is associated with supraventricular arrhythmias (SVA) and whether it predicts new clinically significant SVA (csSVA). METHODS Patients with PAH were recruited between January 2010 and December 2014 and followed until January 2017. csSVA was diagnosed if it resulted in hospitalization. To assess predictors of new csSVA, only patients without a history of SVA at baseline were analyzed. RESULTS Among 97 patients, any SVA was observed in 45 (46.4%) and included permanent atrial fibrillation(AF, n = 8), paroxysmal AF (n = 10), permanent atrial flutter (AFl, n = 1), paroxysmal AFl (n = 2) or other types of supraventricular tachycardia (n = 24). Patients with SVA as compared to patients without SVA were characterized by older age, lower distance in a 6-minute test, higher NT-proBNP, higher RA area index (RAai), left atrial area index, mean right atrial pressure (mRAP) and were more commonly treated with β-blocker. Eighty five patients who were in sinus rhythm at baseline assessment and had no history of significant SVA were observed for 37 ± 19.9 months. During that time csSVA occurred in 15.3%. In univariate models, the occurrence of csSVA were predicted by age, right ventricular ejection fraction, right ventricular end diastolic index, RAai and mRAP, but in multivariate model only RAai remained significant predictor for csSVA (HR of 1.23, 95%CI: 1.11-1.36, p < 0.001). The optimal threshold for RA enlargement as discriminator of csSVA was 21.7 cm2/m2. CONCLUSIONS In PAH patients RA enlargement is associated with increased prevalence of SVA. RAai is an independent predictor of hospitalization due to csSVA.
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Affiliation(s)
- Marcin Waligóra
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Anna Tyrka
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Tomasz Miszalski-Jamka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | | | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka 80, Kraków, Poland.
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19
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Wanamaker B, Cascino T, McLaughlin V, Oral H, Latchamsetty R, Siontis KC. Atrial Arrhythmias in Pulmonary Hypertension: Pathogenesis, Prognosis and Management. Arrhythm Electrophysiol Rev 2018; 7:43-48. [PMID: 29636972 DOI: 10.15420/aer.2018.3.2] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Atrial arrhythmias, including atrial fibrillation and atrial flutter, are common in patients with pulmonary hypertension and are closely associated with clinical decompensation and poor clinical outcomes. The mechanisms of arrhythmogenesis and subsequent clinical decompensation are reviewed. Practical implications and current evidence for the management of atrial arrhythmias in patients with pulmonary hypertension are summarised.
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Affiliation(s)
| | | | | | - Hakan Oral
- University of MichiganAnn Arbor, MI, USA
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20
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Vaillancourt M, Chia P, Sarji S, Nguyen J, Hoftman N, Ruffenach G, Eghbali M, Mahajan A, Umar S. Autonomic nervous system involvement in pulmonary arterial hypertension. Respir Res 2017; 18:201. [PMID: 29202826 PMCID: PMC5715548 DOI: 10.1186/s12931-017-0679-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 11/13/2017] [Indexed: 01/28/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic pulmonary vascular disease characterized by increased pulmonary vascular resistance (PVR) leading to right ventricular (RV) failure. Autonomic nervous system involvement in the pathogenesis of PAH has been demonstrated several years ago, however the extent of this involvement is not fully understood. PAH is associated with increased sympathetic nervous system (SNS) activation, decreased heart rate variability, and presence of cardiac arrhythmias. There is also evidence for increased renin-angiotensin-aldosterone system (RAAS) activation in PAH patients associated with clinical worsening. Reduction of neurohormonal activation could be an effective therapeutic strategy for PAH. Although therapies targeting adrenergic receptors or RAAS signaling pathways have been shown to reverse cardiac remodeling and improve outcomes in experimental pulmonary hypertension (PH)-models, the effectiveness and safety of such treatments in clinical settings have been uncertain. Recently, novel direct methods such as cervical ganglion block, pulmonary artery denervation (PADN), and renal denervation have been employed to attenuate SNS activation in PAH. In this review, we intend to summarize the multiple aspects of autonomic nervous system involvement in PAH and overview the different pharmacological and invasive strategies used to target autonomic nervous system for the treatment of PAH.
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Affiliation(s)
- Mylène Vaillancourt
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Pamela Chia
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Shervin Sarji
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Jason Nguyen
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Nir Hoftman
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Gregoire Ruffenach
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, Division of Molecular Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, BH 520A CHS, USA.
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Savale L, Weatherald J, Jaïs X, Vuillard C, Boucly A, Jevnikar M, Montani D, Mercier O, Simonneau G, Fadel E, Sitbon O, Humbert M. Acute decompensated pulmonary hypertension. Eur Respir Rev 2017; 26:26/146/170092. [PMID: 29141964 PMCID: PMC9488744 DOI: 10.1183/16000617.0092-2017] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 09/17/2017] [Indexed: 12/02/2022] Open
Abstract
Acute right heart failure in chronic precapillary pulmonary hypertension is characterised by a rapidly progressive syndrome with systemic congestion resulting from impaired right ventricular filling and/or reduced right ventricular flow output. This clinical picture results from an imbalance between the afterload imposed on the right ventricle and its adaptation capacity. Acute decompensated pulmonary hypertension is associated with a very poor prognosis in the short term. Despite its major impact on survival, its optimal management remains very challenging for specialised centres, without specific recommendations. Identification of trigger factors, optimisation of fluid volume and pharmacological support to improve right ventricular function and perfusion pressure are the main therapeutic areas to consider in order to improve clinical condition. At the same time, specific management of pulmonary hypertension according to the aetiology is mandatory to reduce right ventricular afterload. Over the past decade, the development of extracorporeal life support in refractory right heart failure combined with urgent transplantation has probably contributed to a significant improvement in survival for selected patients. However, there remains a considerable need for further research in this field. Acute decompensated PH is a life-threatening condition requiring specific management in a specialised centrehttp://ow.ly/non530fkhmA
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