Frequent Additional Tachyarrhythmias in Patients with Inappropriate Sinus Tachycardia Undergoing Sinus Node Modification: An Important Cause of Symptom Recurrence

Abstract

Symptom recurrence following sinus node modification (SNM) for inappropriate sinus tachycardia (IST) remains significant despite achieving acute procedural success. The impact of non-IST tachyarrhythmias on symptom recurrence remains poorly characterized. The objective was to determine the prevalence and nature of additional tachyarrhythmias preceding and following SNM for IST. Consecutive patients with IST undergoing SNM at the University of Pennsylvania were studied. SNM was initially performed using an anatomic approach targeting the superolateral crista terminalis under intracardiac echocardiographic guidance and later using an electrophysiologic approach, targeting the site of the earliest right atrial activation during maximum heart rate (HR) with isoproterenol infusion. An effort was made to shift the site more caudally until a decrease of >25% in resting HR was achieved, with a blunted response to isoproterenol and flattening of the P-wave axis in leads III and aVF. Patients were followed for arrhythmia recurrence. Tachyarrhythmias were documented with electrocardiographic monitoring and then characterized during EP study. Thirty-three patients underwent SNM and were followed for a mean of 2.0 ± 1.5 years. During follow-up, 27% developed a non-IST tachyarrhythmia and 18% developed recurrent IST. Additionally, 42% of patients had a non-IST tachyarrhythmia prior to SNM. Non-IST tachyarrhythmias are common in patients with IST before and after SNM. A major reason for symptom recurrence following SNM is development of a non-IST tachyarrhythmia. These tachyarrhythmias should be detected and treated to optimize patient outcomes.