Methods

This is a retrospective, single-center, cohort study enrolling patients with PAH followed from January 2008 to January 2015 in the Registry of Pulmonary Hypertension Service of the Città della Salute e della Scienza of Turin. Inclusion criteria were (1) diagnosis of PAH according to the current guidelines, including right-sided cardiac catheterization demonstrating a mean pulmonary artery pressure ≥25 mm Hg, pulmonary vascular resistance >3 UW, and a mean pulmonary arterial capillary pressure ≤15 mm Hg ; (2) PAH classified as group 1, PAH group 3, or group 4 (without indication to thromboendarterectomy [TEA] or with residual PAH after TEA) according to the updated classification of pulmonary hypertension ; (3) a follow-up of at least 6 months; and (4) sinus rhythm at baseline. Exclusion criteria were (1) other types of pulmonary hypertension and (2) patients with preexisting SVA.

Demographic characteristics, cardiovascular risk factors, World Health Organization functional class (WHO-FC), 6-minute walking distance (6MWD), electrocardiographic (ECG) and echocardiographic features, N-terminal-pro-brain natriuretic peptide (NT-proBNP), diffusing capacity for carbon monoxide (DLCO), right-sided cardiac catheterization data, the REVEAL score, and pharmacologic history were collected for all patients at baseline and at follow-up.

The primary end point was the occurrence of a morbidity end point, composed by death for any cause and hospitalization for heart failure/respiratory insufficiency. The secondary end points were all-cause mortality and hospitalization for heart failure/respiratory insufficiency.

Analysis was stratified on the basis of the development of SVA during the follow-up period. SVA were specified to include (a) atrial fibrillation (AF), classified as permanent, persistent or paroxysmal AF, (b) atrial flutter, or (c) paroxysmal SVA (as definite by current guidelines ). SVA were detected by means of a routine electrocardiogram performed during the follow-up, by an electrocardiogram performed during hospitalizations for heart failure or for SVA-related symptoms, or by ECG Holter performed because of the occurrence of palpitations. No preplanned ECG Holter were performed to screen asymptomatic SVA. Data about the SVA treatment with drugs, electric cardioversion or transcatheter ablation, and their effectiveness to restore sinus rhythm were collected. The study was performed according to good clinical practice and in compliance with the Declaration of Helsinki.

Continuous variables were expressed as median with interquartile ranges (IQR), and categorical variables were expressed as number and percentages (%). Correlations between parameters and study groups were tested in cross tabulation tables by means of Pearson’s chi-square test or Fisher’s exact test for categorical variables and by Mann-Whitney nonparametrical analysis for continuous variables. Survival analysis was performed by Cox regression analysis and by Kaplan-Meier survival curves, whereas multivariate models for each study end point were run including variables relating to those same end points at univariate analysis. A 2-sided p value <0.05 was considered as statistically significant; all analysis were performed with SPSS 21.0 (IBM Corporation, Armonk, New York).

Results

One hundred six patients were followed at the Pulmonary Hypertension Service of the Città della Salute e della Scienza of Turin from January 2008 to January 2015. Twenty-nine patients did not meet inclusion criteria and were excluded: 9 for follow-up <6 months, 5 for successful pulmonary TEA without residual PAH, 11 for out of proportion group 2 PAH, and 4 for preexisting SVA. Overall, 77 patients met eligibility criteria and were included in the present analysis.

During a median follow-up of 35 months (IQR 21.5 to 53.5), 17 patients (22%) experienced SVA. Persistent AF was the more frequent rhythm disturbance (8 patients, 47%), followed by permanent AF (3, 17%), paroxysmal SVA (3, 17%: 2 atrial ectopic tachycardia and 1 atrioventricular nodal re-entry tachycardia), right atrial flutter (2, 12%), and paroxysmal AF (1, 6%). Patients who experienced SVA had a median age of 67.7 years (IQR 56 to 70.2) at the time of the arrhythmia presentation and arrhythmias occurred after a median of 15. 1 months (IQR 11.3 to 43.2) from the diagnosis of PAH. Detection of SVA occurred occasionally during the routine follow-up in 4 cases (23%), during hospitalization for the onset of palpitations or dizziness in 4 patients (23%), during hospitalization for heart failure or respiratory insufficiency in 7 patients (41%), and in 2 cases (12%) during ECG Holter monitoring executed for palpitations.

The baseline characteristics of the study population, in relation to insurgence of SVA, are reported in Table 1 . No significant differences between the 2 study groups were reported, with no clinical or instrumental characteristics at baseline able to predict development of SVA during follow-up.

Concerning arrhythmia management, a rhythm control strategy was attempted in 13 patients (76%): 10 with drugs (3 patients with sotalol, 4 with amiodarone, and 2 with Ic antiarrhythmic drugs), 8 with electrical cardioversion, and 3 with radiofrequency transcatheter ablation (1 patient underwent atrioventricular nodal re-entry tachycardia transcatheter ablation 1 month after lung transplantation, 1 patient underwent cavotricuspid isthmus ablation for common atrial flutter, and 1 patient underwent cavotricuspidal isthmus and pulmonary vein isolation for common atrial flutter and AF with the need of a subsequent redo AF ablation procedure with pulmonary vein isolation). Sinus rhythm restoration was obtained in 11 cases (65%), and recurrent episodes of SVA were reported in 9 patients (see Table 2 ). Development of SVA was associated with worsening of prognostic parameters at follow-up: SVA group presented a significant worsening of WHO-FC (p = 0.005), a reduction of 6MWD (p = 0.048), tricuspid annular plane systolic excursion (TAPSE) (p = 0.041), and DLCO (p = 0.025), and higher values of NT-proBNP (p = 0.018) compared with those who did not develop SVA ( Table 3 ).

Table 3

Characteristics of study population at the end of the follow-up, expressed as median (IQR) or number and percentages (%), in relation to insurgence of supraventricular arrhythmia

Variable	Supraventricular arrhythmia + (n = 17)	Supraventricular arrhythmia – (n = 60)	p value
Systemic systolic pressure (mmHg)	105 (100; 140)	120 (110; 128.7)	0.82
Heart rate (bpm)	90 (75; 117.5)	80 (70; 95)	0.07
SaO 2 (%)	89 (88; 95)	93 (88.2; 95)	0.24
WHO-FC worsening at follow-up	8 (47%)	9 (15%)	0.005
6MWD variation (metres)	−45 (-207.5; -1.25)	0 (-55.5; +72.5)	0.048
NT-proBNP variation (pg/ml)	+635 (-80; +4042)	-84 (-1544; +261.5)	0.018
DLCO variation (10%)	-10 (-19.5; -5)	−1 (-9; +7.5)	0.025
TAPSE variation (mm)	-2 (-3; +2)	+1 (-1.2; +4)	0.041
Pericardial effusion	6 (35%)	9 (15%)	0.06
Right atrial pressure variation (mmHg)	+1 (-7.5; +5)	+ 2 (-4; +6)	0.5
PAPm variation (mmHg)	0 (-4; +2)	0 (-7; +15)	0.82
Cardiac Index variation (l/min/m 2 )	+0.03 (-2.13 – +1.22)	+0.15 (-0.13; +0.7)	0.5

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