RATE VS RHYTHM CONTROL IN A PATIENT WITH PULMONARY ARTERIAL HYPERTENSION AND ATRIAL FLUTTER: USE OF DIRECT HEMODYNAMIC MEASUREMENTS

Abstract

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Atrial arrhythmias in patients with pulmonary arterial hypertension (PAH) are generally felt to be poorly tolerated hemodynamically [1]. Although this observation has driven expert recommendations to attempt rhythm control first, there is no high-quality evidence to support this approach in rate-controlled arrhythmias. We present a case in which management in a patient with PAH and rate-controlled atrial flutter was informed by invasive hemodynamic measurements performed before and after cardioversion. CASE PRESENTATION: A 45-year-old female with history of PAH, treated with subcutaneous treprostinil and macitentan, and atrial flutter, was admitted for decompensated right heart failure and rate-controlled atrial flutter. Atrial flutter was recurrent after prior cardioversion, prompting consideration of ablation.As the patient was rate-controlled and given the potential risk of anesthesia and an invasive procedure, we measured hemodynamics before and immediately after electrical cardioversion. Hemodynamics are summarized in Table 1. Initial hemodynamics showed significant pulmonary hypertension, with evidence of both pre-capillary and post-capillary components and a reduced cardiac index. Cardioversion to sinus rhythm did not result in a significant change in hemodynamics. Given no hemodynamic improvement with restoration of sinus rhythm, ablation was not pursued. DISCUSSION: Attempting rhythm control in patients with rate-controlled atrial arrhythmias and PAH is the currently accepted practice, although the evidence to support this approach is insufficient. Improvement in cardiac function in heart failure with reduced ejection fraction can be seen immediately after electrical cardioversion, with significant improvement in stroke volume, even in rate-controlled populations[2]. In our case, hemodynamic measurements showed no improvement in cardiac performance or pulmonary pressures after cardioversion. This suggests that some patients with PAH and rate-controlled atrial arrhythmias merit an assessment of the potential benefit of a rhythm control strategy. Understanding the benefit of rhythm-control is particularly important in patients with PAH given the high-risk nature of anti-arrhythmic medications and cardiac ablation. Patients with PAH more often have atypical ablative targets leading to longer procedures, time under anesthesia, and more detrimental consequences if an iatrogenic ASD occurs[1]. CONCLUSIONS: While a rhythm control strategy may be beneficial for some PAH patients, hemodynamic evaluation may help inform the management strategy for rate-controlled atrial arrhythmias in this population. REFERENCE #1: Wanamaker, B., et al., Atrial Arrhythmias in Pulmonary Hypertension: Pathogenesis, Prognosis and Management. Arrhythm Electrophysiol Rev, 2018. 7(1): p. 43-48. REFERENCE #2: Fumagalli, S., et al., External Cardioversion of Atrial Fibrillation Causes an Early Improvement of Cardiac Performance: A Longitudinal Strain Analysis Study. J Cardiovasc Echogr, 2014. 24(1): p. 10-17. DISCLOSURES: No relevant relationships by Hana Bakalli, source=Web Response No relevant relationships by Aron Bender, source=Web Response No relevant relationships by Jessica Channick, source=Web Response Advisory Committee Member relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Consultant relationship with Actelion Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Arena Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Bayer Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: $5001 - $20000 by Richard Channick, source=Web Response, value=Consulting fee No relevant relationships by Sonia Jasuja, source=Web Response No relevant relationships by Rajan Saggar, source=Web Response No relevant relationships by Alexander Sherman, source=Web Response