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Arrhythmias in Right Heart Failure due to Pulmonary Hypertension

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The Right Heart

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Abstract

The clinical relevance of cardiac arrhythmias has not been systematically studied in patients with right heart failure and pulmonary arterial hypertension (PAH) despite being important contributors to morbidity and mortality. Electro-anatomical remodeling of the right ventricle and right atrium in response to longstanding pressure and volume overload, resulting from altered autonomics, repolarization abnormalities, and ischemia, may be the underlying substrate predisposing to enhanced arrhythmogenicity in patients with right heart failure and PAH.

Supraventricular tachycardias, such as atrial fibrillation, atrial flutter and more rarely atrio-ventricular nodal reentry tachycardia, are associated with worsened outcomes, and maintenance of sinus rhythm is a goal. Given the significant potential side effects of antiarrhythmic drugs for supraventricular tachycardias, percutaneous catheter ablation represents a safe and reliable alternative approach.

In contrast to patients with advanced left heart disease, life-threatening arrhythmias, such as ventricular tachycardia and ventricular fibrillation, are relatively rare in patients with PAH. Conversely, patients with PAH may often show bradycardia as pulseless electrical activity. Prophylactic antiarrhythmic therapy is not indicated for primary prevention of sudden cardiac death, and an implantable cardioverter-defibrillator should be offered as a treatment option to PAH patients who manifest either syncope or cardiac arrest in the setting of documented ventricular tachycardia/fibrillation. The role of pacing in PAH patients for relative bradycardia is not well established, highlighting the intrinsic difficulty in clinical management of PAH patients during cardiac arrest. Finally, the exact role of cardiac resynchronization therapy in these patients remains undefined.

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Abbreviations

6MWD:

Six-minute walk distance

AF:

Atrial fibrillation

AFl:

Atrial flutter

APD:

Action potential duration

AVNRT:

Atrio-ventricular nodal reentry tachycardia

CPR:

Cardiopulmonary resuscitation

CTEPH:

Chronic thromboembolic pulmonary hypertension

CTI:

Cavo-tricuspid isthmus

ECG:

Electrocardiogram

Ito :

Transient outward potassium current

LV:

Left ventricle

NCX:

Na+-Ca2+ exchanger

PAH:

Pulmonary arterial hypertension

QTc:

Corrected QT interval

RV:

Right ventricle

SCD:

Sudden cardiac death

SR:

Sinus rhythm

SVT:

Supraventricular tachycardia

VF:

Ventricular fibrillation

VT:

Ventricular tachycardia

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Authors and Affiliations

  1. Department of Cardiology, Pulmonary Hypertension Unit, Monaldi Hospital, Second University of Naples, Piazzale Ettore Ruggieri, Naples, 80128, Italy

    Michele D’Alto MD, PhD, FESC & Giangiacomo Di Nardo MD, PhD

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  1. Michele D’Alto MD, PhD, FESC
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  2. Giangiacomo Di Nardo MD, PhD
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Correspondence to Michele D’Alto MD, PhD, FESC .

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  1. National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland

    Sean P. Gaine

  2. Department of Cardiology, Erasme University Hospital, Brussels, Belgium

    Robert Naeije

  3. Scottish Pulmonary Vascular Unit, Regional Heart and Lung Centre, Glasgow, United Kingdom

    Andrew John Peacock

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D’Alto, M., Di Nardo, G. (2014). Arrhythmias in Right Heart Failure due to Pulmonary Hypertension. In: Gaine, S., Naeije, R., Peacock, A. (eds) The Right Heart. Springer, London. https://doi.org/10.1007/978-1-4471-2398-9_17

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