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• INSIGHTS INTO INTRADIALYTIC ATRIAL FIBRILLATION ONSET MECHANISMS
  Simonetta Genovesi
  Published on: 23 November 2015

• Published on: 23 November 2015

  INSIGHTS INTO INTRADIALYTIC ATRIAL FIBRILLATION ONSET MECHANISMS

  • Simonetta Genovesi, MD
  • Other Contributors:
    • Antonio Vincenti and Stefano Severi

  It is with interest that we read the paper by Buiten et al. (1) in which the authors, using the implantable cardioverter defibrillator (ICD) remote monitoring function in patients enrolled in the ICD-2 trial, showed that hemodialysis (HD) is a trigger for atrial fibrillation (AF) episodes. The study of Buiten confirms some observations we made in the recent past. Few years ago we studied, by high frequency electrocardiograp...

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  It is with interest that we read the paper by Buiten et al. (1) in which the authors, using the implantable cardioverter defibrillator (ICD) remote monitoring function in patients enrolled in the ICD-2 trial, showed that hemodialysis (HD) is a trigger for atrial fibrillation (AF) episodes. The study of Buiten confirms some observations we made in the recent past. Few years ago we studied, by high frequency electrocardiography, the effects of the HD session on P-wave duration (Pwd), an expression of intra -atrial conduction velocity, demonstrating that the procedure induced a prolongation of Pwd closely related to the reduction of the plasma potassium concentration. When the pre-and post-dialysis values of electrolytes were put in a computational model that simulates the atrial action potential, the atrial potential upstroke was slowed down from the beginning towards the end of the HD session. Also we observed a reduction of the effective refractory period (2). It is well known that both phenomena are part of the electrical remodeling at the base of AF onset. These data were also confirmed by a multiscale computer model (3). Buiten et al. show that a lower concentration of potassium in the dialysis bath (which usually is associated to a high shift of the electrolytes during the dialysis session) is associated with a higher probability of occurrence of AF episodes intra and peri-HD session. This observation is concordant with our data. Recently, we reported a case of a patient in whom HD session constantly induced episodes of paroxysmal AF. The episodes were preceded by a reduction of the plasma potassium levels and an increase of supraventricular ectopic beats and of the vagal component of heart rate variability as evaluated by spectral analysis. The computational model, feeded with the data of each session, consistently showed an increase in atrial potential upstroke duration and a reduction in the effective refractory period. Both phenomena were enhanced when the IK,ACh current, sensitive to acetylcholine, was added to the model, suggesting that the vagal rather than adrenergic stimulation plays an important role in the genesis of intradialytic AF episodes (4). We think that it would be very interesting to test this hypothesis using data obtained from the remote monitoring of ICD-2 trial patients.

  References 1. Buiten MS, de Bie MK, Rotmans BA et al. The dialysis procedure as a trigger for atrial fibrillation: new insights in the development of atrial fibrillation in dialysis patients. Heart 2014; 100: 685-690 2. Severi S, Pogliani D, Fantini G et al. Alterations of atrial electrophysiology induced by electrolyte variations: combined computational and P-wave analysis. Europace 2010; 12: 842-849 3. Krueger MW, Severi S, Genovesi S et al. Alterations of atrial electrophysiology related to hemodialysis session: insights from a multiscale computer model. J Electrocardiol 2011; 44: 176-183 4. Vincenti A, Passini E, Fabbrini P et al. Recurrent intradialytic paroxysmal atrial fibrillation: hypotheses on onset mechanisms based on clinical data and computational analysis. Europace 2014; 16:396-404

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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