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MANAGEMENT OF A PARTURIENT WITH INCESSANT ATRIAL TACHYCARDIA AND TACHYCARDIA INDUCED CARDIOMYOPATHY
Abstract Number: T3C-4
Abstract Type: Case Report/Case Series
INTRODUCTION: Arrhythmias are the most common cardiac complication encountered during pregnancy in women with and without structural heart disease. Atrial tachycardia (AT) is a regular atrial rhythm at a constant rate of >100 beats per minute originating outside of the sinus node. Focal ATs are usually paroxysmal and self-limited, although in some patients, focal AT may be present nearly continuously (ie, incessant AT). Incessant AT is important as it may be associated with left ventricular dysfunction (1).
CASE: a 36 year-old G5P3A1 at 32 weeks presented with decreased fetal movements. Her medical history was notable for past two admissions with AT in 2010 and 2012. The tachycardia resolved after being treated with calcium channel blocker and beta blocker during both admissions and her ECHO was unremarkable. At this admission, she was noted to be tachycardic in 150s and EKG showed septal atrial re-entrant focus and first degree AV block. Patient denied palpitation, short of breath, or chest pain, her only symptom was fatique. Cardiology was consulted and the patient was put on telemetry. Both metoprolol and diltiazem failed to bring her heart rate (HR) down and her systolic blood pressure (SBP) began to decrease to 80s. TTE showed severely depressed LV systolic function (LVEF decreased to 28% from 51% three months ago). After a multidisciplinary team discussion, urgent cesarean section (C/S) proceeded. Given her hemodynamic status, arterial line placed and epidural was dosed slowly with 2% lidocaine to achieve surgical level. During the surgery, patient's HR gradually climbed up to 170's and SBP decreased to 70s-80s. Phenylephrine infusion required to maintain SBP in 100's and HR in 150's. Following C/S, patient was admitted to CCU and was infused with amiodarone which slowed HR to 130s and increased BP to 120s/70s. After three days recovery, patient went a radiofrequency catheter ablation with great success and discharged home.
DISCUSSION: Focal atrial tachycardia is relatively rare during pregnancy and most without apparent structural heart disease. Atrial tachycardia is often persistent and be refractory to treatment. Antiarrhythmic agents (adenosine, digoxin, beta blockers, calcium channel blockers) may slow AV conduction, but not terminate the arrhythmia (2). Because it is difficult to treat AT and AT is generally well tolerate by mother and fetus, it is not recommend to cardioversion if the patient is hemodynamically stable. However, if tachycardia-induced cardiomyopathy is present, DC cardioversion maybe required, although atrial tachycardia can be resistant to cardioversion. Finally, for patient has incessant atrial tachycardia, radiofrequency catheter ablation should be considered (3). It is preferred to perform ablation after delivery due to concerns of ionizing radiation exposure to the fetus.
1.Medi et al. J Am Coll Cardiol 2009;53:1791
2.Murphy et al.Br Heart J 1992;68:342
3.Szumowski et al. J Cardiovasc Elec 2010;21:877