Information on atrial arrhythmia associated with right ventricular cardiomyopathy/dysplasia (ARVC/D) is limited. In 36 patients with task force criteria for ARVC/D and history of ventricular tachycardia (VT), we confirmed the incidence and type of atrial arrhythmia, onset related to referral for VT ablation, fastest documented ventricular rate, management, and clinical and hemodynamic factors associated with their development. Thirty-six patients (28 men) had a mean age of 47 years (range 17 to 80) and mean follow-up of 56 ± 44 months. Thirty-five patients (97%) had implantable cardioverter–defibrillator (ICD) devices, 15 with atrial leads. Fifteen of 36 patients (42%) had documented atrial arrhythmias, with atrial flutter (aFL) in 11, atrial fibrillation (AF) in 11 patients, and aFL and AF in 7 patients. Maximum heart rate noted with atrial arrhythmia was 62 to 150 beats/min. In 9 patients, initial atrial arrhythmia preceded or was concurrent with presentation for VT ablation. In the remaining 6 patients, atrial arrhythmia (symptomatic in 4 patients) followed VT presentation. Three of these patients received ICD shock therapy for atrial arrhythmias. Seven of 11 patients with recurrent aFL required aFL ablation, 1 patient underwent His-bundle ablation for AF with rapid rate, and 8 patients required long-term drug therapy for AF control. Atrial arrhythmias were more common in patients with RV enlargement and moderate/severe tricuspid regurgitation. In conclusion, in patients with ARVC/D and VT, atrial arrhythmias are common, frequently necessitate ablative or pharmacologic treatment, and are more common in patients with moderate/severe tricuspid regurgitation and markedly enlarged right ventricle.
The purpose of this study was to describe our clinical experience with spontaneous atrial arrhythmias in a consecutive series of patients with atrial arrhythmia associated with right ventricular cardiomyopathy/dysplasia (ARVC/D) referred for catheter-based ablation for ventricular arrhythmias. Specifically, we confirmed the incidence and type of atrial arrhythmia, timing related to presentation for ventricular tachycardia (VT) ablation, fastest documented associated ventricular rate, factors associated with their development, and clinical management.
Methods
Thirty-six consecutive patients who met task force criteria for ARVC/D and had a clinical history of VT referred for VT ablation were included. Analysis of surface electrocardiograms when available and stored implantable cardioverter–defibrillator (ICD) electrographic information confirmed the incidence and type of atrial arrhythmia. Discrimination between atrial arrhythmia and VT was based on stored intracardiac electrograms using standard diagnostic criteria including regularity of ventricular arrhythmia and electrogram morphology. In patients with an atrial lead and stored atrial electrogram, the relation of atrial and ventricular electrograms was analyzed to establish the correct arrhythmia diagnosis. Atrial arrhythmia was also characterized with respect to time of onset related to presentation for VT ablation and fastest ventricular rate with any documented atrial arrhythmia episode.
To gain insight into the possible relation of atrial arrhythmias to cardiac structure and function, transthoracic echocardiogram from the surrounding time (within 3 months) of hospitalization for a VT ablation procedure was reviewed when available. Presence of marked tricuspid regurgitation or marked increase in right atrial size was identified. Tricuspid regurgitation velocity was obtained using continuous-wave Doppler from the apical 4-chamber or RV inflow view. Right atrial dimension and volume were determined using 2-dimensional echocardiography in the apical 4-chamber view. Left ventricular ejection fraction measured by echocardiogram was recorded. RV volume in milliliters was assessed at the time of the ablation procedure using detailed electroanatomical mapping, during which a complete endocardial shell of the right ventricle was created and RV volume was calculated using software available in the CARTO mapping system (Biosense-Webster, Inc., Diamond Bar, California).
Beta-blocker therapy as tolerated was used routinely regardless of outcome of VT ablation. Antiarrhythmic drugs were typically reserved for patients with recurrent atrial and/or ventricular arrhythmias.
Patients with and without atrial arrhythmias were compared. Categorical echocardiographic variables were compared using chi-square analysis, with Fisher’s exact test used if a number was ≤5 for ≥1 value. Continuous variables (expressed as mean ± SD) were compared using unpaired Student’s t test in case of normal distribution or Wilcoxon test in case of non-normal distribution (paired variable). A p value ≤0.05 was considered statistically significant.
Results
The 36 patients, 28 men, had a mean age of 47 years (range 17–80) and mean follow-up of 56 ± 44 months from presentation for VT ablation. Thirty-five patients (97%) had ICD devices; 15 with atrial leads.
Fifteen of 36 patients (42%) had electrocardiographic or ICD electrographic documented atrial arrhythmias, including 11 with atrial flutter (aFL), 11 with atrial fibrillation (AF), and 7 with aFL and AF. In all patients with aFL the mechanism appeared to be cavotricuspid isthmus-dependent right atrial flutter based on established surface electrocardiographic criteria and was confirmed at the time of aFL ablation in 7 patients using standard recording and pacing techniques. Maximum heart rate noted with atrial arrhythmia was 62 to 150 beats/min. In 9 patients, initial atrial arrhythmia preceded or was concurrent with presentation for VT ablation. In the remaining 6 patients, atrial arrhythmia (symptomatic in 4 patients) followed VT presentation. Three of these patients had ICD therapy for atrial arrhythmias with a rapid ventricular response.
Seven of 11 patients with aFL required cavotricuspid isthmus ablation for recurrent aFL; 1 patient underwent His-bundle ablation for recurrent AF with rapid rate, and 8 patients required long-term drug therapy for AF despite apparent control of VT without antiarrhythmic drugs after ablation. Antiarrhythmic drug therapy included sotalol in 6 patients and 1 each on propafenone and quinidine. All patients were being treated with β blockers. All patients had prevention of recurrent shocks and clinical control of symptomatic atrial arrhythmias using the described treatment strategies. Nine of 15 patients were on long-term warfarin anticoagulation and no patients had thromboembolic events.
A comparison of clinical and echocardiographic imaging characteristics of patients with versus without atrial arrhythmias is presented in Table 1 . RV size was more dramatically increased and moderate to severe tricuspid regurgitation more likely present in patients with atrial arrhythmias. An RV volume >250 ml had 79% sensitivity and 81% specificity for being associated with manifest atrial arrhythmias. There was also a trend for patients with atrial arrhythmias to be older.
| Variable | AF/aFL | p Value | |
|---|---|---|---|
| Yes (n = 15) | No (n = 21) | ||
| Men (%) | 12 (80%) | 16 (76%) | NS |
| Age (years) | 52 ± 16 | 43 ± 16 | 0.08 |
| Moderate–severe tricuspid regurgitation | 8/13 ⁎ (62%) | 4/19 ⁎ (21%) | ≤0.05 |
| Moderate–severe right atrial dilatation | 7/14 ⁎ (50%) | 5/19 ⁎ (26%) | NS |
| Left ventricular ejection fraction (%) | 43 ± 19 | 53 ± 11 | NS |
| Right ventricular volume from electroanatomical map (ml) | 313 ± 94 | 195 ± 53 | ≤0.01 |
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