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      Sinus node dysfunction in patients with Fontan circulation: could heart rate variability be a predictor for pacemaker implantation?


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          Sinus node dysfunction (SND) causes significant morbidity in patients after Fontan surgery. Heart rate variability (HRV) reflects the autonomic regulation of the heart, and changes in HRV have been associated with SND in adults. We aimed to study whether changes in HRV could be detected in 24-h electrocardiographic (ECG) recordings in Fontan patients with SND. We compared HRV results from two patient groups; patients with Fontan circulation who later required a pacemaker due to severe SND ( n = 12) and patients with Fontan circulation and SND, without indication for pacemaker treatment ( n = 11), with two control groups; patients with Fontan circulation without SND ( n = 90) and healthy controls ( n = 66). The Poincaré plot index SD2 (representing changes in heart rate over 24-h) and the very low-frequency (VLF) HRV component were significantly higher in both SND groups, both compared with healthy controls and patients with Fontan circulation without SND. In SND patients with pacemakers, SD2 and VLF were slightly reduced compared to SND patients without pacemaker ( p = 0.06). In conclusion, in Fontan patients with SND the HRV is significantly higher compared to healthy controls and Fontan patients without SND. However, in patients with severe SND requiring pacemaker, SD2 and VLF tended to be lower than in patients with SND without pacemaker, which could indicate a reduced diurnal HRV in addition to the severe bradycardia. This is a small study, but our results indicate that HRV analysis might be a useful method in the follow-up of Fontan patients regarding development of SND.

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          Advances in heart rate variability signal analysis: joint position statement by the e-Cardiology ESC Working Group and the European Heart Rhythm Association co-endorsed by the Asia Pacific Heart Rhythm Society.

          Following the publication of the Task Force document on heart rate variability (HRV) in 1996, a number of articles have been published to describe new HRV methodologies and their application in different physiological and clinical studies. This document presents a critical review of the new methods. A particular attention has been paid to methodologies that have not been reported in the 1996 standardization document but have been more recently tested in sufficiently sized populations. The following methods were considered: Long-range correlation and fractal analysis; Short-term complexity; Entropy and regularity; and Nonlinear dynamical systems and chaotic behaviour. For each of these methods, technical aspects, clinical achievements, and suggestions for clinical application were reviewed. While the novel approaches have contributed in the technical understanding of the signal character of HRV, their success in developing new clinical tools, such as those for the identification of high-risk patients, has been rather limited. Available results obtained in selected populations of patients by specialized laboratories are nevertheless of interest but new prospective studies are needed. The investigation of new parameters, descriptive of the complex regulation mechanisms of heart rate, has to be encouraged because not all information in the HRV signal is captured by traditional methods. The new technologies thus could provide after proper validation, additional physiological, and clinical meaning. Multidisciplinary dialogue and specialized courses in the combination of clinical cardiology and complex signal processing methods seem warranted for further advances in studies of cardiac oscillations and in the understanding normal and abnormal cardiac control processes.
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            2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.

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              The Fontan circulation: who controls cardiac output?

              In a Fontan circuit the mechanisms involved in control of cardiac output at rest and during exercise differ significantly from normal. The classical model presumes an unlimited preload which is not available in the Fontan circuit. This review critically analyses the role of contractility, heart rate, and afterload and highlights the importance of pulmonary vascular resistance (PVR) in determining adequate preload and, therefore, cardiac output in these patients. A conceptual model of the determinants of cardiac output in Fontan patients is presented.

                Author and article information

                +46 90 7852124 , jenny.alenius@umu.se
                Pediatr Cardiol
                Pediatr Cardiol
                Pediatric Cardiology
                Springer US (New York )
                27 March 2019
                27 March 2019
                : 40
                : 4
                : 685-693
                [1 ]ISNI 0000 0001 1034 3451, GRID grid.12650.30, Department of Clinical Sciences, Pediatrics, , Umeå University, ; 901 85 Umeå, Sweden
                [2 ]ISNI 0000 0001 1034 3451, GRID grid.12650.30, Department of Radiation Sciences, Biomedical Engineering, , Umeå University, ; Umeå, Sweden
                [3 ]ISNI 0000 0001 0930 2361, GRID grid.4514.4, Department of Clinical Sciences Lund, Children Heart Centre, Skåne University Hospital, , Lund University, ; Lund, Sweden
                [4 ]ISNI 0000 0000 9919 9582, GRID grid.8761.8, Department of Cardiology, The Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Institute of Clinical Sciences, , Gothenburg University, ; Gothenburg, Sweden
                [5 ]ISNI 0000 0000 9241 5705, GRID grid.24381.3c, Department of Women’s and Children’s Health, Karolinska Institutet, , Karolinska University Hospital, ; Stockholm, Sweden
                © The Author(s) 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                Funded by: FundRef http://dx.doi.org/10.13039/501100003793, Hjärt-Lungfonden;
                Award ID: 20090146
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100008352, Stiftelsen Samariten;
                Award ID: 2015-0000
                Award Recipient :
                Funded by: Oskarsfonden (SE)
                Award ID: 20150204
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100002960, Västerbotten Läns Landsting;
                Award ID: VLL-645531
                Award Recipient :
                Original Article
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                © Springer Science+Business Media, LLC, part of Springer Nature 2019

                Cardiovascular Medicine
                congenital heart disease,fontan circulation,pacemaker,sinus node dysfunction,heart rate variability,poincaré analysis


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