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European Heart Journal Advance Access originally published online on June 8, 2006
European Heart Journal 2006 27(17):2069-2073; doi:10.1093/eurheartj/ehl080
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© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Chronotropic incompetence in young patients with late postoperative atrial flutter: a case–control study

Nitasha Anand1, Brian W. McCrindle1,2,3, Christine C. Chiu1, Robert M. Hamilton1,2,3, Joel A. Kirsh1,2, Elizabeth A. Stephenson1,2 and Gil J. Gross1,2,3,4,*

1 Cardiology Division, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8
2 Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
3 Cardiovascular Research Programme, Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
4 Heart & Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada

Received 3 November 2005; revised 12 April 2006; accepted 19 May 2006; online publish-ahead-of-print 8 June 2006.

* Corresponding author. Tel: +1 416 813 7418; fax: +1 416 813 7547. E-mail address: ggross{at}sickkids.ca

See page 2036 for the editorial comment on this article (doi:10.1093/eurheartj/ehl150)

Aims Atrial flutter causes late postoperative morbidity in congenital heart disease (CHD). Sinoatrial node dysfunction is associated with late postoperative atrial flutter, but pacing interventions driven by minimum heart rates (HR) have yielded mixed results.

Methods and results A retrospective case–control study was used to test the hypothesis that late postoperative atrial flutter is associated with chronotropic incompetence in active young CHD patients. Control CHD patients aged ≤18 years without documented supraventricular ectopy (n=42) were matched with 42 patients (cases) having atrial flutter onset ≥6 months postoperatively. Minimum, average, and maximum non-flutter HRs were obtained from outpatient ambulatory 24 h ECG (Holter) recordings and graded exercise tests. Chronotropic competence was assessed using percentage of age-specific predicted maximum HR achieved, and calculated chronotropic index. Effects of rate-adaptive programming and maximum atrial pacing rates were analysed in 19 permanently paced cases. Least square estimates of minimum HRs were similar in cases and controls (54±2 vs. x52±2 bpm). Average HRs were lower in cases (75±2 vs. 81±2 bpm, P=0.02). Cases and controls differed most significantly with respect to percentage of predicted maximum HR achieved (67±2 vs. 80±2%, P<0.001). This difference remained highly significant when the data were adjusted for age, sex, permanent pacing, and negatively chronotropic medication usage at the time of testing. Among paced patients, atrial flutter was significantly less likely to be observed in the setting of rate-adaptive pacing [odds ratio (OR)=0.36; P<0.05], and the likelihood of detecting atrial flutter decreased relative to the maximum programmed atrial pacing rate (OR 0.87 for every 5% increment in maximum pacing rate relative to maximum predicted HR for age; P<0.05).

Conclusion Late postoperative atrial flutter is associated with chronotropic incompetence in paediatric CHD patients.

Key Words: Congenital heart disease • Postoperative atrial arrhythmias • Sinoatrial node dysfunction


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