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Anand S, Cronin EM. Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies. J Clin Med 2024; 13:1866. [PMID: 38610631 PMCID: PMC11012772 DOI: 10.3390/jcm13071866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.
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Affiliation(s)
| | - Edmond M. Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA;
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Seitler S, Dimopoulos K, Ernst S, Price LC. Medical Emergencies in Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:777-796. [PMID: 37595615 DOI: 10.1055/s-0043-1770120] [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: 08/20/2023]
Abstract
The management of acute medical emergencies in patients with pulmonary hypertension (PH) can be challenging. Patients with preexisting PH can rapidly deteriorate due to right ventricular decompensation when faced with acute physiological challenges that would usually be considered low-risk scenarios. This review considers the assessment and management of acute medical emergencies in patients with PH, encompassing both pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), acknowledging these comprise the more severe groups of PH. Management protocols are described in a systems-based approach. Respiratory emergencies include pulmonary embolism, airways disease, and pneumonia; cardiac emergencies including arrhythmia and chest pain with acute myocardial infarction are discussed, alongside PH-specific emergencies such as pulmonary artery dissection and extrinsic coronary artery compression by a dilated proximal pulmonary artery. Other emergencies including sepsis, severe gastroenteritis with dehydration, syncope, and liver failure are also considered. We propose management recommendations for medical emergencies based on available evidence, international guidelines, and expert consensus. We aim to provide advice to the specialist alongside the generalist, and emergency doctors, nurses, and acute physicians in nonspecialist centers. A multidisciplinary team approach is essential in the management of patients with PH, and communication with local and specialist PH centers is paramount. Close hemodynamic monitoring during medical emergencies in patients with preexisting PH is vital, with early referral to critical care recommended given the frequent deterioration and high mortality in this setting.
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Affiliation(s)
- Samuel Seitler
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Konstantinos Dimopoulos
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Sabine Ernst
- Adult Congenital Heart Disease Service, Royal Brompton Hospital, London, United Kingdom
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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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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Havranek S, Fingrova Z, Skala T, Reichenbach A, Dusik M, Jansa P, Ambroz D, Dytrych V, Klimes D, Hutyra M, Kautzner J, Linhart A, Wichterle D. Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study. Europace 2023:7161651. [PMID: 37178136 DOI: 10.1093/europace/euad131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. METHODS AND RESULTS Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. CONCLUSION Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov; NCT04053361.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Tomas Skala
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Adrian Reichenbach
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Vladimir Dytrych
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dalibor Klimes
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Josef Kautzner
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dan Wichterle
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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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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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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Long term prognosis in patients with pulmonary hypertension undergoing catheter ablation for supraventricular tachycardia. Sci Rep 2021; 11:16176. [PMID: 34376719 PMCID: PMC8355112 DOI: 10.1038/s41598-021-95508-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/21/2021] [Indexed: 11/11/2022] Open
Abstract
Various forms of supraventricular tachycardia (SVT) occur in patients with severe pulmonary hypertension (PH). Despite the high efficacy of radiofrequency catheter ablation (RFCA) for SVT, insufficient data exist regarding patients with PH. Thirty SVTs in 23 PH patients (age 47 [35–60] years; mean pulmonary artery pressure 44 [32–50] mmHg) were analyzed. Procedural success rate, short- and long-term clinical outcomes, were evaluated during a median follow-up of 5.1 years. Single-procedure success rate was 83%; 94% (17/18) in typical atrial flutter, 73% (8/11) in atrial tachycardia (AT), and 100% (1/1) in atrioventricular nodal reentrant tachycardia. Antiarrhythmic drugs, serum brain natriuretic peptide levels and number of hospitalizations significantly decreased after RFCA than that before (p = 0.002, 0.04, and 0.002, respectively). Four patients had several procedures. After last RFCA, 12 patients had SVT and 8 patients died. Kaplan–Meier curves showed that patients with SVT after the last RFCA had a lower survival rate compared to those without (p = 0.0297). Multivariate analysis identified any SVT after the last RFCA as significant risk factor of mortality (hazard ratio: 9.31; p = 0.016). RFCA for SVT in patients with PH is feasible and effective in the short-term, but SVT is common during long-term follow-up and associated with lower survival.
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10
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Zhou B, Zhu YJ, Zhai ZQ, Weng SX, Ma YZ, Yu FY, Qi YJ, Jiang YZ, Gao X, Xu XQ, Jiang X, Jing ZC, Tang M. Radiofrequency Catheter Ablation of Supraventricular Tachycardia in Patients With Pulmonary Hypertension: Feasibility and Long-Term Outcome. Front Physiol 2021; 12:674909. [PMID: 34220537 PMCID: PMC8249814 DOI: 10.3389/fphys.2021.674909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background Supraventricular tachycardia (SVT) occurs commonly and is strongly correlated with clinical deterioration in patients with pulmonary hypertension (PH). This study aimed to investigate the feasibility and long-term outcome of radiofrequency catheter ablation (RFCA) in PH patients with SVT. Materials and Methods Consecutive PH patients with SVT who were scheduled to undergo electrophysiological study and RFCA between September 2010 and July 2019 were included. The acute results and long-term success of RFCA were assessed after the procedure. Results In total, 71 PH patients with 76 episodes of SVT were analyzed. Cavotricuspid isthmus-dependent atrial flutter (n = 33, 43.5%) was the most common SVT type, followed by atrioventricular nodal reentrant tachycardia (n = 16, 21.1%). Of the 71 patients, 60 (84.5%) underwent successful electrophysiological study and were subsequently treated by RFCA. Among them, acute sinus rhythm was restored in 54 (90.0%) patients, and procedure-related complications were observed in 4 (6.7%) patients. Univariate logistic regression analysis showed that cavotricuspid isthmus-independent atrial flutter [odds ratio (OR) 25.00, 95% confidence interval (CI) 3.45–180.98, p = 0.001] and wider pulmonary artery diameter (OR 1.19, 95% CI 1.03–1.38; p = 0.016) were associated with RFCA failure. During a median follow-up of 36 (range, 3–108) months, 7 patients with atrial flutter experienced recurrence, yielding a 78.3% 3-year success rate for RFCA treatment. Conclusion The findings suggest that RFCA of SVT in PH patients is feasible and has a good long-term success rate. Cavotricuspid isthmus-independent atrial flutter and a wider PAD could increase the risk for ablation failure.
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Affiliation(s)
- Bin Zhou
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiology, Zhujiang Hospital, Laboratory of Heart Center, Southern Medical University, Guangzhou, China
| | - Yong-Jian Zhu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zheng-Qin Zhai
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Si-Xian Weng
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya-Zhe Ma
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng-Yuan Yu
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying-Jie Qi
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Zhou Jiang
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- State Key Laboratory of Complex Severe and Rare Diseases, Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Tang
- State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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Reddy SA, Nethercott SL, Khialani BV, Grace AA, Martin CA. Management of arrhythmias in pulmonary hypertension. J Interv Card Electrophysiol 2021; 62:219-229. [DOI: 10.1007/s10840-021-00988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
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12
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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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13
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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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14
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Fingrova Z, Havranek S, Ambroz D, Jansa P, Linhart A. The left atrial substrate plays a significant role in the development of complex atrial tachycardia in patients with precapillary pulmonary hypertension. BMC Cardiovasc Disord 2019; 19:157. [PMID: 31253083 PMCID: PMC6599239 DOI: 10.1186/s12872-019-1142-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/25/2019] [Indexed: 01/05/2023] Open
Abstract
Background Atrial fibrillation (AF) and related atrial tachyarrhythmias (AT), including type I atrial flutter (AFL) are frequently observed in patients with pulmonary hypertension (PH). Their relationship to hemodynamic changes, atrial size, and ventricular function are still not fully verified. Methods We retrospectively studied hemodynamic data, echocardiographic findings and arrhythmia incidence in 814 patients with invasively diagnosed precapillary PH (aged 59 ± 14 years; 46% males). Patients with combined or post-capillary PH were excluded. Results AF / AT were identified in 225 (28%) of all the study population. Compared to the subgroup without arrhythmia, patients with AF / AT had elevated right atrial pressure (11 ± 5 vs. 9 ± 5 mmHg), wedge pressure (11 ± 3 vs. 10 ± 3), a more enlarged right atrium (50 ± 12 vs. 47 ± 11 mm) and an increased left atrial diameter in the parasternal long axis projection, p < 0.05 for all comparisons. In the multivariate model, the left atrial size, patient age, arterial hypertension, diabetes and type of PH were associated with AF / AT occurrence, p < 0.05. Patients with type I AFL were more frequently male (39 (80%) vs. 62 (42%)), were younger (61 ± 11 vs. 67 ± 10 years), had increased pulmonary artery mean pressure (50 ± 12 vs. 45 ± 12 mmHg), less advanced left atrial dilatation (38 ± 10 vs. 42 ± 7 mm), and a more enlarged right atrium (56 ± 12 vs. 48 ± 11) as compared to subjects with AF or other AT, p < 0.05. Conclusions The evidence of elevated wedge pressure and the enlargement of the left atrium especially in patients with AF suggest a parallel involvement of the left atrial substrate in arrhythmia formation despite invasively confirmed evidence of purely isolated precapillary PH. Substantial differences were noticed between patients with type I AFL and the remaining patients with other arrhythmia types.
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Affiliation(s)
- Zdenka Fingrova
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, U Nemocnice 2, 12808, Prague, Czech Republic.,2nd Department of Medicine - Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 12808, Prague, Czech Republic
| | - Stepan Havranek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, U Nemocnice 2, 12808, Prague, Czech Republic. .,2nd Department of Medicine - Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 12808, Prague, Czech Republic.
| | - David Ambroz
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, U Nemocnice 2, 12808, Prague, Czech Republic.,2nd Department of Medicine - Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 12808, Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, U Nemocnice 2, 12808, Prague, Czech Republic.,2nd Department of Medicine - Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 12808, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, U Nemocnice 2, 12808, Prague, Czech Republic.,2nd Department of Medicine - Department of Cardiovascular Medicine, 1st Faculty of Medicine, Charles University in Prague, U Nemocnice 2, 12808, Prague, Czech Republic
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15
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Mantini N, Zipse M, Tompkins C, Varosy PD, Sauer WH, Nguyen DT. Ablation of atrial arrhythmias in patients with cardiogenic shock on mechanical circulatory support. HeartRhythm Case Rep 2019; 5:115-119. [PMID: 30891405 PMCID: PMC6404096 DOI: 10.1016/j.hrcr.2018.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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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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Nashat H, Montanaro C, Li W, Kempny A, Wort SJ, Dimopoulos K, Gatzoulis MA, Babu-Narayan SV. Atrial septal defects and pulmonary arterial hypertension. J Thorac Dis 2018; 10:S2953-S2965. [PMID: 30305956 PMCID: PMC6174141 DOI: 10.21037/jtd.2018.08.92] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/20/2018] [Indexed: 12/19/2022]
Abstract
Atrial septal defects (ASD) are a common congenital heart defect. The majority of patient with ASDs often follow an uncomplicated course of events. However, a proportion of patients with ASDs, may have their condition complicated by pulmonary hypertension (PH), with a subsequent significant impact on management, morbidity and mortality. The presence of PH, influences the suitability for defect closure. In this review we describe the different types of ASDs, the classification of PH related to congenital heart disease (CHD), when ASD closure is contraindicated and the management of patients who develop pulmonary arterial hypertension (PAH), including the most extreme form, Eisenmenger syndrome (ES).
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Affiliation(s)
- Heba Nashat
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Claudia Montanaro
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Wei Li
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Aleksander Kempny
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Stephen J Wort
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Konstantinos Dimopoulos
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael A Gatzoulis
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
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18
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Grünig E, Benjamin N, Krüger U, Kaemmerer H, Harutyunova S, Olsson KM, Ulrich S, Gerhardt F, Neurohr C, Sablotzki A, Halank M, Marra AM, Kabitz HJ, Thimm G, Fliegel KG, Klose H. General measures and supportive therapy for pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:30-36. [PMID: 30190156 DOI: 10.1016/j.ijcard.2018.08.085] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to general measures (i.e. physical activity/supervised rehabilitation, pregnancy/contraception, elective surgery, infection prevention, psychological support, travel) and supportive therapy (i.e. anticoagulants, diuretics, oxygen, cardiovascular medications, anaemia/iron deficiency, arrhythmias) for PAH. While the European guidelines provide detailed recommendations for the use of targeted PAH therapies as well as supportive care, detailed treatment decisions in routine clinical care may be challenging, and the relevance of supportive care is often not sufficiently considered. In addition, new evidence became available, thus requiring a thorough reevaluation of specific recommendations. The detailed results and recommendations of the working group on general measures and supportive therapy for PAH, which were last updated in the spring of 2018, are summarized in this article.
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Affiliation(s)
- Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany.
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Ulrich Krüger
- Department of Cardiology, Heart Centre Duisburg, Germany
| | - Harald Kaemmerer
- Department of Paediatric Cardiology and Congenital Heart Disease Munich, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, German Centre for Lung Research (DZL), Hannover, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich, Switzerland
| | - Felix Gerhardt
- Department of Cardiology, University Hospital Cologne, Germany
| | - Claus Neurohr
- Dept. of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich, Munich, Germany
| | - Armin Sablotzki
- Clinic for Anesthesiology St. Georg Hospital, Leipzig, Germany
| | - Michael Halank
- Department of Pneumology, Carl Gustav Carus University Hospital, Dresden, Germany
| | - Alberto M Marra
- Centre for Pulmonary Hypertension, Thoraxclinic at University Hospital Heidelberg and German Center for Lung Research (DZL), Heidelberg, Germany; IRCCS S.D.N., Via Gianturco 113, 80143 Naples, Italy
| | - Hans-Joachim Kabitz
- Department of Pneumology and Intensive Care Medicine, Academic Teaching Hospital, Klinikum Konstanz, Germany
| | - Günther Thimm
- Patientenvereinigung Pulmonale Hypertonie e.V., Rheinstetten, Germany
| | | | - Hans Klose
- Department of Pneumology, University Hospital Hamburg-Eppendorf, Germany
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19
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Smith B, Genuardi MV, Koczo A, Zou RH, Thoma FW, Handen A, Craig E, Hogan CM, Girard T, Althouse AD, Chan SY. Atrial arrhythmias are associated with increased mortality in pulmonary arterial hypertension. Pulm Circ 2018; 8:2045894018790316. [PMID: 29969045 PMCID: PMC6058427 DOI: 10.1177/2045894018790316] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/02/2018] [Indexed: 12/30/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a deadly vascular disease, characterized by increased pulmonary arterial pressures and right heart failure. Considering prior non-US studies of atrial arrhythmias in PAH, this retrospective, regional multi-center US study sought to define more completely the risk factors and impact of paroxysmal and non-paroxysmal forms of atrial fibrillation and flutter (AF/AFL) on mortality in this disease. We identified patients seen between 2010 and 2014 at UPMC (Pittsburgh) hospitals with hemodynamic and clinical criteria for PAH or chronic thromboembolic pulmonary hypertension (CTEPH) and determined those meeting electrocardiographic criteria for AF/AFL. We used Cox proportional hazards regression with time-varying covariates to analyze the association between AF/AFL occurrence and survival with adjustments for potential cofounders and hemodynamic severity. Of 297 patients with PAH/CTEPH, 79 (26.5%) suffered from AF/AFL at some point. AF/AFL was first identified after PAH diagnosis in 42 (53.2%), identified prior to PAH diagnosis in 27 (34.2%), and had unclear timing in the remainder. AF/AFL patients were older, more often male, had lower left ventricular ejection fractions, and greater left atrial volume indices and right atrial areas than patients without AF/AFL. AF/AFL (whether diagnosed before or after PAH) was associated with a 3.81-fold increase in the hazard of death (95% CI 2.64-5.52, p < 0.001). This finding was consistent with multivariable adjustment of hemodynamic, cardiac structural, and heart rate indices as well as in sensitivity analyses of patients with paroxysmal versus non-paroxysmal arrhythmias. In these PAH/CTEPH patients, presence of AF/AFL significantly increased mortality risk. Mortality remained elevated in the absence of a high burden of uncontrolled or persistent arrhythmias, thus suggesting additional etiologies beyond rapid heart rate as an explanation. Future studies are warranted to confirm this observation and interrogate whether other therapies beyond rate and rhythm control are necessary to mitigate this risk.
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Affiliation(s)
| | - Michael V. Genuardi
- Center for Pulmonary Vascular Biology
and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute,
Division
of Cardiology, Department of Medicine, University of Pittsburgh Medical Center,
USA
| | - Agnes Koczo
- Department
of Medicine, University of Pittsburgh,
USA
| | | | | | - Adam Handen
- Center for Pulmonary Vascular Biology
and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute,
Division
of Cardiology, Department of Medicine, University of Pittsburgh Medical Center,
USA
| | - Ethan Craig
- Department
of Medicine, University of Pittsburgh,
USA
| | | | - Timothy Girard
- Clinical Research, Investigation, and
Systems Modeling of Acute illness (CRISMA) Center;
Department
of Critical Care Medicine, University of Pittsburgh School of Medicine,
USA
| | | | - Stephen Y. Chan
- Center for Pulmonary Vascular Biology
and Medicine, Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute,
Division
of Cardiology, Department of Medicine, University of Pittsburgh Medical Center,
USA
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20
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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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21
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Price LC, Dimopoulos K, Marino P, Alonso-Gonzalez R, McCabe C, Kemnpy A, Swan L, Boutsikou M, Al Zahrani A, Coghlan GJ, Schreiber BE, Howard LS, Davies R, Toshner M, Pepke-Zaba J, Church AC, Peacock A, Corris PA, Lordan JL, Gaine S, Condliffe R, Kiely DG, Wort SJ. The CRASH report: emergency management dilemmas facing acute physicians in patients with pulmonary arterial hypertension. Thorax 2017; 72:1035-1045. [DOI: 10.1136/thoraxjnl-2016-209725] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 07/06/2017] [Accepted: 07/17/2017] [Indexed: 12/18/2022]
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22
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
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23
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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24
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Wen L, Sun ML, An P, Jiang X, Sun K, Zheng L, Liu QQ, Wang L, Zhao QH, He J, Jing ZC. Frequency of supraventricular arrhythmias in patients with idiopathic pulmonary arterial hypertension. Am J Cardiol 2014; 114:1420-5. [PMID: 25217453 DOI: 10.1016/j.amjcard.2014.07.079] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/30/2014] [Accepted: 07/30/2014] [Indexed: 11/18/2022]
Abstract
Supraventricular arrhythmias (SVA) may be risk factors of prognosis in patients with pulmonary arterial hypertension. SVA are increasingly reported in patients with pulmonary hypertension, but little is known about their incidence and outcomes for patients with idiopathic pulmonary arterial hypertension (IPAH) in a large cohort. In this 6-year prospective multicenter study, 280 patients with IPAH were enrolled to investigate the incidence of SVA and assess risk factors, clinical manifestation, management, and impact on survival. The cumulative 6-year incidence of SVA was 15.8%. The most common types of SVA were atrial fibrillation (n = 16) and atrial flutter (n = 13), followed by atrial tachycardia (n = 11). Most episodes of SVA were associated with significant clinical deterioration and right-sided cardiac failure. Sinus rhythm was successfully restored in most patients, resulting in clinical recovery. Increased right ventricular diameter, left atrial area, and higher right atrial pressure and pulmonary vascular resistance were associated with increased risk for experiencing SVA. SVA predicted a greater risk for mortality in a stepwise forward Cox analysis (hazard ratio 4.757, 95% confidence interval 2.695 to 8.397, p <0.001). Kaplan-Meier survival curves showed that patients with SVA, mainly permanent SVA, had a lower survival rate than those who did not develop SVA (p = 0.008). In conclusion, SVA often lead to clinical deterioration and may be associated with an increased risk for death in a large cohort of patients with IPAH. Restoration and maintenance of sinus rhythm are important treatment goals in patients with IPAH.
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Affiliation(s)
- Li Wen
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China; Department of Cardiology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ming-Li Sun
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Pei An
- Department of Cardiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xin Jiang
- Thrombosis and Vascular Medicine Center, State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kai Sun
- Thrombosis and Vascular Medicine Center, State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lu Zheng
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qian-Qian Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jing He
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhi-Cheng Jing
- Thrombosis and Vascular Medicine Center, State Key Lab of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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25
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Electrophysiological studies in patients with pulmonary hypertension: a retrospective investigation. BIOMED RESEARCH INTERNATIONAL 2014; 2014:617565. [PMID: 24977152 PMCID: PMC4058223 DOI: 10.1155/2014/617565] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/23/2014] [Accepted: 05/01/2014] [Indexed: 11/24/2022]
Abstract
Few studies have investigated patients with pulmonary hypertension and arrhythmias. Data on electrophysiological studies in these patients are rare. In a retrospective dual-centre design, we analysed data from patients with indications for electrophysiological study. Fifty-five patients with pulmonary hypertension were included (Dana Point Classification: group 1: 14, group 2: 23, group 3: 4, group 4: 8, group 5: 2, and 4 patients with exercised-induced pulmonary hypertension).
Clinical data, 6-minute walk distance, laboratory values, and echocardiography were collected/performed. Nonsustained ventricular tachycardia was the most frequent indication (n = 15) for an electrophysiological study, followed by atrial flutter (n = 14). In summary 36 ablations were performed and 25 of them were successful (atrial flutter 12 of 14 and atrioventricular nodal reentrant tachycardia 4 of 4). Fluoroscopy time was 16 ± 14.4 minutes. Electrophysiological studies in patients with pulmonary hypertension are feasible and safe. Ablation procedures are as effective in these patients as in non-PAH patients with atrial flutter and atrioventricular nodal reentrant tachycardia and should be performed likewise. The prognostic relevance of ventricular stimulations and inducible ventricular tachycardias in these patients is still unclear and requires further investigation.
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26
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Atrial flutter and fibrillation in patients with pulmonary hypertension. Int J Cardiol 2013; 167:2300-5. [DOI: 10.1016/j.ijcard.2012.06.024] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 05/30/2012] [Accepted: 06/08/2012] [Indexed: 11/18/2022]
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27
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Abstract
Cardiac arrhythmias are important contributors to morbidity and mortality in patients with pulmonary arterial hypertension (PAH). Such patients manifest a substrate resulting from altered autonomics, repolarization abnormalities, and ischemia. Supraventricular arrhythmias such as atrial fibrillation and flutter are associated with worsened outcomes, and maintenance of sinus rhythm is a goal. Sudden death is a relatively common issue, though the contribution of malignant ventricular arrhythmias versus bradyarrhythmias differs from non-PAH patients. Congenital heart disease patients with PAH benefit from catheter ablation of medically refractory arrhythmias. Clinical studies of defibrillator/pacemaker therapy for primary prevention against sudden death in PAH patients are lacking.
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Affiliation(s)
- Archana Rajdev
- Department of Medicine, Section of Cardiology, Danbury Hospital, Danbury, CT, USA
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28
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Garlitski AC, Mark Estes NA. Ablation of atrial flutter in severe pulmonary hypertension: pushing the outside of the envelope. J Cardiovasc Electrophysiol 2012; 23:1191-2. [PMID: 22823280 DOI: 10.1111/j.1540-8167.2012.02401.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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