Biomed Res Int. 2014;2014:617565. doi: 10.1155/2014/617565.

Electrophysiological studies in patients with pulmonary hypertension: a retrospective investigation.

Bandorski D1, Schmitt J2, Kurzlechner C1, Erkapic D2, Hamm CW3, Seeger W1, Ghofrani A1, Höltgen R4, Gall H1.
  • 1The German Centre for Lung Research (DZL), University of Giessen and Marburg Lung Centre (UGMLC), Klinikstrasse 33, 35392 Giessen, Germany.
  • 2Medical Clinic 1, University Hospital Giessen and Marburg GmbH, Klinikstrasse 33, 35392 Giessen, Germany ; Department of Cardiology, Kerckhoff Heart and Thorax Centre, Benekestrasse 2-8, 61231 Bad Nauheim, Germany.
  • 3Medical Clinic 1, University Hospital Giessen and Marburg GmbH, Klinikstrasse 33, 35392 Giessen, Germany.
  • 4Medical Clinic III, St. Agnes Hospital Bocholt, Barloer Weg 125, 46397 Bocholt, Germany.

 

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.

PMID: 24977152

 

Supplement:

Pulmonary hypertension (PH) is defined as mean pulmonary arterial pressure ³ 25 mm Hg at rest and a pulmonary capillary wedge pressure (PcWP) £/³ 15 mm Hg in precapillary/postcapillary forms. The current classification distinguishes five groups of PH considering pathophysiological underlying mechanisms leading to PH. Patients with PH mostly suffer from supraventricular tachycardias like atrial flutter, atrial fibrillation and atrial tachycardia. Causal are morphological changes in the right cardiac chambers caused by chronic pressure overload deteriorating right ventricular function resulting in cardiac decompensation and heart failure. Loss of coordinated atrial contraction is not tolerated well. Failure to reestablish sinus rhythm in patients with PH increases mortality. Ventricular arrhythmias are rarely reported in studies investigating these patients. Own data revealed non-sustained ventricular arrhythmias (nsVT) in 12 of 92 patients who underwent Holter-ECG over 72 hours (1).

Because general data on electrophysiological studies (EPS) in patients with PH are rare and studies investigating results of EPS in patients with PH for arrhythmias other than atrial flutter and atrioventricular reentrant tachycardia (AVNRT) are lacking we retrospectively analysed the indications and results of EPS at two experienced PH centres in these patients.

We first investigated the indications of EPS and found that the most common arrhythmia was nsVT (15/55 Patients) followed by atrial flutter (14/55 patients). In none of the patients VT or VF could be induced during EPS. Flutter isthmus ablation was successful and without complications in 12/14 patients. In 2 patients ablation was not successful because of impossibility of catheter placement and complicated by a third degree heart block in 1 patient necessitating cardiac pacemaker implantation. One patient with atrial fibrillation underwent AV-node ablation for rate control. Puncture of the interatrial septum was avoided because of the risk of right to left shunting. Ablation of incisional reentry tachycardia, AVNRT and slow VT were successful in all patients. The lowest success was found in patients with atrial tachycardia because of multifocal tachycardia. Remarkably 11 of 15 patients with nsVTs were not suffering from coronary heart disease indicating that other mechanism than ischemia seem account for ventricular tachycardias.

We analysed fluoroscopy time of EPS expecting a prolongation in our patients because of enlargement of the right atrium and ventricle. In comparison to other studies we found in our patients with pulmonary arterial hypertension a longer fluoroscopy time than Luesebrink et al. (19.8±17.4 min vs. 14.5±8.9 min) and shorter than in Bradfield´s study (44 ±20 min). Enlargement of right atrium (58 mm in our study) can significant complicate placement of the EPS catheters and should be taken into consideration as a reason for impossibility of placement of the EPS catheters and for the differences between the studies. Luesebrink and Bradfield did not give information about echocardiographic data of their patients.

In contrast to other studies investigating the incidence of arrhythmias in patients with PH by follow up ECGs we did not reveal correlations between arrhythmias and echocardiographic data (diameter of left and right heart, left ventricular hypertrophy, left ventricular ejection fraction, tricuspid annular plane systolic excursion, systolic pulmonary artery pressure) and right heart catheterization (mean pulmonary artery pressure, pulmonary vascular resistance, right atrial pressure, pulmonary capillary wedge pressure).

The importance of the study is two-fold. First, it shows in accordance with other studies that the incidence of arrhythmias in patients with PH who underwent ablation is low. Ablation of supraventricular tachycardias like atrial flutter and AVNRT is in nearly all cases successful. Ablation of atrial tachycardias is often difficult because patients often had multifocal complex substrate without possibility for ablation. Ablation in patients with incisional reentry tachycardia (n=2) and (slow) ventricular tachycardias (n=2) is feasible and safe.

Second, the study revealed nsVT detected by Holter ECG monitoring as the most indication for EPS (PH-group 1: n=3/14, PH-group 2: n=7/23). Another study of our group confirmed the results and revealed high incidence of nsVT in 12 of 92 patients with PH of group 1, 4 and 5; none of the patients in this study suffered from PH of group 2 (1). Nevertheless the prognostic relevance of nsVT and treatment of PH-patients with this arrhythmia remains unclear and closer monitoring, e.g. using implantable event recorders, might be useful to identify patients at high risk.

Limitations of the study are not using navigations systems for electroanatomic mapping for detection of morphologic substrate of arrhythmias used in a study of Medi et al. revealing conduction slowing with regional abnormalities, reduced tissue voltage and regions of electrical silence.

 

References:

  1. Bandorski D, Erkapic D, Stempfl J, Höltgen R, Grünig E, Schmitt J, Chasan R, Grimminger J, Neumann T, Hamm CW, Seeger W, Ghofrani A, Gall H. Ventricular tachycardias in patients with pulmonary hypertension: An underestimated prevalence? – A prospective clinical study. Herzschr Elektrophys 2015 (in press).
  2. Luesebrink U, Fischer D, Gezgin F, Duncker D, Koenig T, Oswald H, Klein G, Gardiwal A. Ablation of typical right atrial flutter in patients with pulmonary hypertension. Heart, Lung and Circulation 2012; 21:695–699.
  3. Bradfield J, Shapiro S, Finch W, Tung R, Boyle NG, Buch E, Mathuria N, Mandapati R, Shivkumar K, Bersohn M. Catheter ablation of typical atrial flutter in severe pulmonary hypertension. J Cardiovasc Electrophysiol 2012; 23:1185–1190.
  4. Medi C, Kalman JM, Ling LH, The AW, Lee G, Lee G, Spence S, Kaye D, Kistler P. Atrial electrical and structural remodeling associated with longstanding pulmonary hypertension and right ventricular hypertrophy in humans. J Cardiovasc Electrophysiol 2012; 23:614-520.

 

 

Dirk Bandorski, MD, FESC FACC

University of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Klinikstrasse 33, 35392 Giessen

 

Reinhard Höltgen, MD

Medical Clinic III, St.-Agnes Hospital Bocholt, Barloer Weg 125,

46397 Bocholt

 

Contact to:

Dirk Bandorski

e-mail: dirk.bandorski@hkw.med.uni-giessen.de

 

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