Echocardiography predictors of sustained sinus rhythm after cardioversion of supraventricular arrhythmia in patients with septic shock

Abstract

Background Supraventricular arrhythmias (SVA) are associated with two to five times worse survival in septic shock. The objective of the study was to propose echocardiography parameters that could predict the maintenance of sinus rhythm and the feasibility of the rhythm control approach. Methods Patients in septic shock with an onset of an SVA, a normal to moderately reduced LV systolic function (EF_LV˃̳35%) and on a continuous noradrenaline of less than 1.0 ug/kg.min were included. Echocardiography was performed at the arrhythmia onset, 1h and 4h post cardioversion on an infusion of propafenone or amiodarone. There were no limits to electric cardioversions. Arrhythmia recurrences were analysed in relation to a complex of echocardiography parameters. Results Out of the 209 patients enrolled into the trial, 173 were analysed in sinus rhythm at 1h and 187 at 4h post cardioversion. Heart rate decreased from a median of 130(111;147)/min to 85(78;96)/min at 1h, p˂0.001, accompanied by an increase of stroke volume from 50(42;60)ml to 66(58;78)ml at 1h,p˂0.001. The left atrial end-systolic diameter (LA_ESD 40(35;45)mm) and indexed biplanar volume (LAVI 31(26;39)ml/m2) did not change, the left atrial emptying fraction (36 (29;45)% at 4h, p = 0.005), trans-mitral A-wave (p = 0.002) and the A-wave velocity-time integral (Avti 7.7(6.1;9.4)cm at 4h,p˂0.001) were gradually increased. Pulmonary artery systolic pressure (PAPs) did not change, while the right ventricular systolic function parameters increased with cardioversion (all p˂0.001). Vasopressor dosage at the start of arrhythmia, at 1h and 4h post cardioversion showed significant reductions for noradrenaline (p < 0.001) and vasopressin (p < 0.001). The feasible predictors of arrhythmia recurrence were LA_EF at 4h with the cut- off 38.4%, AUC 0.69, p˂0.001, and Avti at 4h with the cut-off 6.8cm, AUC 0.65, p = 0.001. The elevated PAPs at 4h (p = 0.007) and enlarged LA_ESD at arrhythmia onset (p = 0.04) predicted only multiple recurrences (˃3). LAVI (p = 0.06) and arrhythmia history (p = 0.09) were not useful. Conclusion There is a period of atrial functional recovery after restoration of electrical sinus rhythm in patients with septic shock complicated by an SVA. The associations of LA_EF and Avti at 4 hours post-cardioversion with sustained sinus rhythm suggest potential parameters to guide the choice between rhythm and rate control strategies. Trial registration : ClinicalTrials.gov Identifier: NCT03029169