Abstract: Abstrakt. Supraventrikulárne arytmie sú pri pľúcnej artériovej hypertenzii (PAH) časté a spôsobujú závažné klinické a hemodynamické zhoršenie. Ich manažment je zložitý a využíva konzervatívne i intervenčné postupy. Uvádzame prípad pacientky s idiopatickou PAH s viacerými recidivujúcimi supraventrikulárnymi tachyarytmiami. U pacientky narodenej v roku 1978 sa stanovila diagnóza idiopatickej PAH v roku 2006. V roku 2007 bol do liečby zaradený sildenafil. Kvôli progresii ochorenia sa v roku 2012 iniciovalo subkutánne podávanie treprostinilu a v roku 2013 sa pridal bosentan. V apríli 2014 bola prijatá do nemocnice pre náhle zhoršenie dýchavice a hypotenziu. Na elektrokardiograme (EKG) bola prítomná pravidelná tachykardia s úzkym komplexom QRS s frekvenciou 150/min, ktorú sa podarilo ukončiť i. v. adenozínom. Pri elektrofyziologickom vyšetrení sa potvrdila atrioventrikulárna nodálna reentry tachykardia a realizovala sa úspešná rádiofrekvenčná modulácia pomalej dráhy. Okrem toho sa izoprenalínom dali indukovať viaceré pravidelné a nepravidelné atriálne tachykardie, ktoré neboli vhodné na intervenčné riešenie. Do liečby bol zaradený betablokátor v malej dávke a pacientka bola v klinicky stabilnom stave a so sínusovým rytmom prepustená domov. O šesť týždňov po intervencii bola rehospitalizovaná kvôli pokojovej dýchavici a veľkoobehovej kongescii s nálezom perzistujúcej symptomatickej atriálnej tachykardie. Vykonala sa elektrická kardioverzia s nastolením sínusového rytmu. Do liečby sa pridal amiodarón. Atriálna tachykardia recidivovala a stav pacientky sa napriek terapeutickým opatreniam ďalej zhoršoval. Bola zaradená na zoznam čakateľov na transplantáciu pľúc. Atriálna tachykardia s primeraným prevodom na komory pretrvávala dlhodobo. Pacientka zomrela na zlyhanie srdca včasne po transplantácii pľúc. Obr. 4, Tab. 3, Lit. 18, on-line full text (Free, PDF) www.cardiologyletters.sk Abstract. Supraventricular arrhythmias in pulmonary arterial hypertension (PAH) are common and often result in severe clinical and hemodynamic deterioration. The management is complex and involves conservative and interventional approaches. We present a case of a patient with idiopathic PAH with multiple recurrent supraventricular arrhythmias. The female patient (b. 1978) was diagnosed with idiopathic PAH in 2006 and sildenafil treatment was initiated in 2007. Due to disease progression, SQ treprostinil was started in 2012 and bosentan was added in 2013. In April, 2014, she was admitted to hospital due to abrupt worsening of dyspnea and hypotension. Regular tachycardia with the rate of 150/min was detected and terminated by intravenous adenosine. On electrophysiology study (EPS), atrio-ventricular nodal re-entrant tachycardia (AVNRT) was confirmed and a successful slow pathway modulation by radio frequency (RF) ablation was performed. In addition, several regular and irregular atrial tachycardias other than typical atrial flutter were inducible by isoprenaline at EPS. A small dose of short-acting beta-blocker (metoprolol) was initiated and the patient was discharged from hospital in a clinically stable status and in sinus rhythm. However, she was re-admitted to hospital due to dyspnea at rest, signs of right ventricular failure, and persisting atrial tachycardia 6 weeks later. Electric cardioversion was performed and sinus rhythm was restored. Amiodarone was added. Further interventional treatment was not indicated due to high risk and low probability of success of the procedure in context of multiple foci of arrhythmia. Atrial tachycardia recurred soon and persisted. Unfortunately, the patient´s status further deteriorated in spite of treatment escalation and she was listed for lung transplant. Atrial tachycardia with adequate ventricular rate persisted in the long-term. The patient died of heart failure early after lung transplant. Conclusion: SV arrhythmia can result in an abrupt destabilization of the patient´s status. We believe it is of the utmost importance to aim for reconstitution of the sinus rhythm using all available conservative and interventional approaches. On the other side, it is also possible that SV arrhythmia represents one of the signals of disease progression and a marker of unfavourable outcome. We therefore presume that on the occurrence of SV arrhythmia, pulmonary hypertension specific treatment escalation should be considered to minimize further PAH progression. Fig. 4, Tab. 3, Ref. 18, on-line full text (Free, PDF) www.cardiologyletters.sk
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