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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Chronotropic incompetence in young patients with late postoperative atrial flutter: a case–control study
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)
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Abstract |
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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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Introduction |
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Atrial flutter is an important cause of late postoperative morbidity and mortality in patients with congenital heart disease (CHD). Among 380 paediatric flutter cases included in a multicenter collaborative study, 75% had undergone CHD reparative or palliative surgery.1 Atrial flutter is a recognized late sequela of surgical procedures addressing various congenital heart lesions including repair of atrial septal defects2 and tetralogy of Fallot;3 Mustard's4 or Senning's5 procedure for transposition of the great arteries; and the Fontan operation for complex univentricular CHD.6–11
Sinoatrial node dysfunction (SAND), and associated chronic bradycardia, has repeatedly been identified as a correlate and presumptive predisposing factor for atrial flutter in these patients,4,9,12,13 but the results of anti-bradycardia pacing have been equivocal in terms of reducing flutter frequency or severity.14,15 Most pacing interventions have focused on reduction or elimination of baseline bradycardia rather than on maintenance of appropriate chronotropic reserve for these typically active young patients.
Chronotropic incompetence predisposes to recurrent atrial fibrillation (AF) in some adults, and pacing strategies aimed at accelerating heart rate (HR) in appropriate settings can effectively reduce frequency of paroxysmal AF episodes in such patients.16,17 We hypothesized that chronotropic incompetence, defined as an impaired HR response to physiologic accelerants such as exercise, could predispose young CHD patients to develop atrial flutter. We performed a retrospective case–control study comparing baseline and maximal HRs in young postoperative CHD patients with and without documented atrial flutter to evaluate the role of chronotropic incompetence as a readily identifiable and potentially manageable risk factor for late postoperative atrial flutter.
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Methods |
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This investigation was approved by the Research Ethics Board at The Hospital for Sick Children, Toronto. A retrospective, single-centre case–control design was employed.
Cases
The Hospital for Sick Children cardiology database was searched for patients coded as having undergone any of the cardiac surgical procedures listed in Table 1, as well as other procedures associated with late postoperative atrial flutter such as tetralogy of Fallot repair. Procedural diagnoses included in the search strategy that did not yield suitable case–control pairings are omitted from Table 1. Each of these patients additionally had a coded diagnosis consistent with atrial flutter. Electrocardiographic documentation of at least one episode of atrial flutter occurring at least 6 months postoperatively was required for case inclusion. Atrial flutter was defined as atrial tachycardia with variable atrioventricular conduction and with re-entrant features including abrupt onset and termination, minimal rate variation, fixed P-wave axis and morphology, and conversion with pacing manoeuvres or synchronized direct current cardioversion.
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Subsequent detailed review of available records resulted in exclusion of those who: (i) had no clear electrocardiographic documentation of atrial flutter; (ii) experienced flutter perioperatively, defined as <1 month after any of the surgical procedures listed in Table 1, unless they subsequently experienced recurrence after a flutter-free hiatus of at least 6 months; (iii) experienced onset of atrial flutter 1–6 months postoperatively; and/or (iv) had any other significant rhythm disturbance documented, apart from transient perioperative dysrhythmias. In addition, case inclusion required the availability of graded exercise test (GXT) and/or outpatient ambulatory ECG monitoring (Holter) results obtained at least 6 months postoperatively.
Controls
Control patients were selected from among those meeting the same diagnostic criteria as for cases, but with exclusion of those bearing a coded diagnosis of any supraventricular tachydysrhythmia other than isolated atrial premature beats. Records were then reviewed in detail to identify one suitably matched control patient for each case based on the following criteria: (i) at least one identical surgical procedure from among those listed in Table 1; (ii) birth year within three of that of the matching case, to control for a possible era effect; (iii) follow-up duration to a postoperative time point at least as late as that of the onset of atrial flutter in the corresponding case, based on most recent available GXT and/or outpatient ambulatory ECG monitoring results. In situations where more than one potential control subject met all matching criteria for a given case, selection was based on proximity of the patients' birthdates.
Data collection
Birth date, sex, underlying cardiac diagnoses, and operative procedures were abstracted from the clinical records. Dysrhythmia types and dates of onset were documented. Pacemaker types and dates of implantation were recorded where applicable, with notation made of programmed pacing parameters at the time of graded exercise testing, Holter recording, and flutter episodes.
Results of GXT and outpatient Holter recordings were reviewed for each patient, focusing on baseline (non-flutter) rhythm with minimum, average, and maximum HR recorded. Note was made of all medications being taken at the time of each test (Table 2). Inpatient Holter recordings were excluded.
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Echocardiographic reports from studies performed within 14 days of any of the Holter and exercise tests used were reviewed for documentation of ventricular dysfunction and atrioventricular (AV) valvar insufficiency. For each informative echocardiographic report, the most significant degree of ventricular dysfunction or AV valvar insufficiency was scored on a scale of 0–3 based on qualitative characterizations of absent, mild, moderate, or severe.
Among patients who underwent implantation of a permanent pacing system, records were examined from all pacemaker clinic visits. Data abstracted included pacing mode, programmed rates, documentation of high-rate episodes stored in device counters, and real-time cardiac rhythm recorded at the clinic visit. Stored events were presumptively attributed to atrial flutter when rates were comparable with those seen in electrocardiographically documented flutter, especially when available recorded atrial electrograms resembled those in documented flutter. For purposes of data analysis, tachydysrhythmias documented at any given visit were referred to programming information entered at the previous visit, based on the assumption that programming changes would have their effect during the interval leading up to the next visit rather than immediately.
Data analysis
Predicted maximum HR were based on the widely used formula.
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Data are described as frequencies, medians, and means with standard deviation (SD) as appropriate. Mixed linear regression for repeated measures analysis was used to determine significant differences between cases and controls while adjusting for the fact that cases were matched to controls and therefore not independent, and that some subjects had more than one measurement. A compound symmetry covariance structure was selected for the models based on fit characteristics. The matched pair was entered as the subject variable, and case vs. control status for the measurement variables from serial Holter monitoring and GXT was entered as a fixed effect, as were the variables gender, age, pacing, and medication. The same regression analysis was repeated for each variable with adjustment for subject, gender and for age, permanent pacing, and medication use (amiodarone and/or any known ß-adrenergic receptor blocking agent including sotalol) at the time of measurement by entering these variables into the complete regression model. This technique adjusted for these potential confounders and allowed the determination of the independent difference between cases and control subjects while further adjusting for the matching. All tests were two-sided.
Among cases with permanent atrial pacemakers, possible associations between episodes of atrial flutter and rate-adaptive vs. non-rate-adaptive pacing mode, and between episodes of atrial flutter and maximum programmed pacing rate as a percentage of the predicted maximum HR for age, were explored with general estimating equations for repeated measures, using an autoregressive covariance structure.
The Wilcoxon signed rank test was used for pairwise comparison of echocardiographic data.
All data analysis was performed with SAS statistical software Version 8 (SAS Institute Inc., Cary, NC USA) or with Sigma Stat Version 2.0 (SPSS Inc.) using default settings. A P-value <0.05 was considered significant.
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Results |
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There was 81% concordance for 124 open heart operations in 42 case–control pairs meeting inclusion and matching criteria, with surgical diagnoses as listed in Table 1. Each pair had at least one matching surgical diagnosis. There was no significant difference in the degree of ventricular dysfunction or AV valve insufficiency between cases and controls in 39 pairs for which comparative echocardiographic data were available.
Case characteristics
The database search strategy yielded 121 potential cases with electrocardiographically documented atrial flutter. Of these, 51 were excluded because they did not meet flutter onset timing criteria as defined in the Methods; 22 were excluded because they had other significant rhythm disturbances; two did not have sufficient Holter or exercise testing results available for analysis; and four did not have appropriately matching controls.
There were 42 cases included (57% male) with birth years ranging between 1975 and 1997 (median 1983). Follow-up duration was 15.1±3.7 (mean ± SD) years. Age at diagnosis of late postoperative atrial flutter was 9.4±5.0 years, with 20 cases having experienced perioperative flutter. Cases had a median of two GXT results available, obtained at age 14.3±2.8 years. They also had a median of two Holter reports available, obtained at age 13.3±3.6 years. Atrial or dual chamber pacing was instituted in 19 cases at age 8.8±4.6 years. An additional three cases underwent permanent ventricular pacemaker implantation at ages 0.6, 4.0, and 12.0 years. Documented mortality occurred in two cases, one with complications of cardiac transplantation and the second due to an apparent sudden cardiovascular collapse of presumed dysrhythmic aetiology during athletic participation.
Control characteristics
Among 42 control patients (57% male), birth years ranged between 1975 and 1997 with a median of 1984. Follow-up duration in controls was 14.5±4.0 years. By definition, there were no supraventricular tachydysrhythmias documented at any time. Controls had a median of two GXT results available, obtained at age 13.6±3.1 years. They had a median of one Holter report available, obtained at age 13.1±3.8 years. Three of the controls had atrial pacing instituted at 2.7, 3.5, and 8.8 years of age, whereas a ventricular pacemaker was implanted in one control patient aged 6.5 years. Sudden death was documented in one control patient.
Baseline HR data and chronotropic competence
Minimum and average HRs were abstracted from Holter reports, whereas maximum HRs were obtained from GXT results as well as from Holter studies. As shown in Table 3, minimum HRs were similar between the two groups. Cases did have significantly lower average HRs than control patients. However, the differences between atrial flutter patients and flutter-free controls were most pronounced with respect to maximum HRs achieved, expressed as age-specific percentage of predicted maximum to correct for variation attributable solely to maturation.
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The chronotropic index proposed by Elhendy et al.18 is a measure of chronotropic reserve obtained by relating maximum HR performance during exercise to the pre-exercise resting HR. We applied this analytical tool to GXT results among non-paced patients to further assess the evidence of chronotropic incompetence in our atrial flutter cases implicit in their significantly reduced percentage of predicted maximum HR values relative to those of controls. The chronotropic index values calculated for atrial flutter patients were lower than those of controls (Table 3).
Adjustment for confounding variables
While cases and controls were well matched for most variables considered in this study, there was a clear difference between the groups with respect to presence of permanent pacing (22 cases vs. 4 controls). We considered this, along with the use of negatively chronotropic medications, sex, and age at data acquisition as potentially confounding variables in the apparent association between atrial flutter and chronotropic incompetence. When the analysis was repeated with incorporation of these variables into the regression model, the key findings remained essentially unchanged (Table 3). Specifically, chronotropic incompetence correlated strongly with the presence of atrial flutter, whereas resting bradycardia did not.
Relationship between pacing strategy and atrial flutter in cases
Rhythm data were available from 228 pacemaker clinic encounters in the 19 cases subjected to permanent atrial or dual-chamber pacing. The presence of atrial flutter was ascertained by real-time documentation as well as by interpretation of high-rate episode information stored in device memory. We evaluated the apparent effect of pacing mode and of maximum programmed atrial pacing rate on flutter detection at individual encounters.
Pacing modes were grouped as either rate-adaptive (AAIR, DDIR, DDDR; 34 encounters) or as providing only default minimum atrial rate support (AAI, AAIM, AAIT, DVI, DDI, DDD; 194 encounters). Atrial flutter was significantly less likely to be observed in the setting of rate-adaptive pacing (odds ratio (OR)=0.36; P<0.05).
We also assessed the presence or absence of atrial flutter relative to the maximum programmed atrial pacing rate, irrespective of pacing mode, expressed as the percentage of maximum predicted HR for age. The likelihood of detecting atrial flutter decreased relative to the maximum programmed atrial pacing rate (OR 0.87 for every 5 percentage point increment in maximum pacing rate relative to maximum predicted HR for age; P<0.05).
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Discussion |
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Association between late postoperative atrial flutter and chronotropic incompetence
Our observations support the hypothesis that chronotropic incompetence as a specific functional manifestation of SAND correlates with late postoperative atrial flutter in children with surgically palliated CHD. HR acceleration in response to exercise and other physiologic stimuli was significantly more blunted in atrial flutter cases than in matched controls, whereas minimum HRs were essentially indistinguishable between the two groups. This key observation relates to the widespread consideration of minimum HR as a central criterion in clinical decision-making with respect to permanent pacemaker implantation in postoperative paediatric SAND.19
Among atrial flutter patients with permanent atrial or dual-chamber pacing systems, flutter was observed significantly more frequently in those treated without rate-adaptive pacing than in those paced in rate-adaptive modes. Moreover, there was a significant inverse correlation between the detection of atrial flutter at individual clinical encounters and the maximum programmed pacing rate, irrespective of pacing mode.
Bradycardia-mediated remodelling as a basis for atrial flutter predisposition
Chronic bradycardia induces ventricular electrical remodelling predisposing to episodic tachydysrhythmias in humans20 as well as in animal models.21 Consistent features include delayed action potential repolarization, QT interval prolongation, and increased susceptibility to spontaneous or induced torsades des pointes. A recent report from Sanders et al. indicates that similar atrial electrical remodelling takes place in the setting of SAND.22 Their study involved intracardiac electrophysiologic characterization of 16 adult SAND patients and an equal number of age-matched controls, and demonstrated that those with SAND had prolonged P-wave duration and atrial effective refractoriness as well as diffuse conduction abnormalities. Thus, bradycardic atrial remodelling likely increases susceptibility to late postoperative atrial flutter. However, the specific role of chronotropic incompetence in this process remains to be elucidated.
Diagnostic and therapeutic implications
Our findings have several potentially important implications for management of children with postoperative SAND. Firstly, the striking similarity between minimum HR values in the two patient groups indicates that minimum HR cannot be relied upon to identify patients at risk for late postoperative atrial flutter, and hence as candidates for pacemaker implantation as a flutter preventive manoeuvre.
Secondly, the chronotropic index calculated from GXT is a readily obtainable estimate of chronotropic competence that could be used to identify patients at risk for atrial flutter easily, safely, and inexpensively. The predictive value of the chronotropic index remains to be validated in a large-scale prospective study.
Finally, among patients selected for pacemaker implantation, pacing strategies aimed primarily at minimum HR support might not yield satisfactory flutter prevention or suppression. A prospective trial assessing late atrial flutter incidence in patients managed with conventional anti-bradycardia pacing strategies as compared with pacemaker programming aimed specifically at restoration of chronotropic competence would be of great interest in this regard.
Study limitations
Like most retrospective investigations, this study relies on the accuracy of recorded clinical data. Information with respect to medication dosage, compliance, or duration of use at the time of each individual test was not obtained. Results reported here should be viewed as preliminary and should be validated prospectively.
Our study was deliberately designed to isolate atrial rate parameters in order to assess their association with late postoperative atrial flutter. This approach precluded evaluation of links between atrial flutter and other suspected or established predisposing factors such as surgical technique, incisional scarring, and haemodynamic issues, which are considered elsewhere.3–5,7,8,11,13,15,23 It must be emphasized, however, that the careful matching strategy of our case–control study design mitigates any potentially confounding effects of these other putative predisposing factors.
Conclusions
Late postoperative atrial flutter is associated with chronotropic incompetence in paediatric CHD patients. Permanent pacing strategies based upon maximum achievable HR and chronotropic index data, and aimed at the restoration of chronotropic competence, could potentially offer improved prevention of late postoperative atrial flutter in this young and active patient population.
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Invaluable assistance provided by Shirley Wang and Laura Fenwick is gratefully acknowledged.
Conflict of interest: none declared.
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References |
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