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J Thorac Cardiovasc Surg 2006;132:647-655
© 2006 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Impaired cardiac autonomic nervous activity predicts sudden cardiac death in patients with operated and unoperated congenital cardiac disease

Astrid Lammersa, Harald Kaemmerer, MD, PhDa,*, Regina Hollweck, Dipl Statb, Raphael Schneider, Dipl Ing (FH)c, Petra Barthel, MDc, Siegmund Braun, MDd, Annette Wacker, MDa, Silke Brodherr-Heberlein, MDa, Michael Hauser, MDa, Andreas Eicken, MDa, Georg Schmidt, MD, PhDc,1, John Hess, MD, PhDa

a Klinik für Kinderkardiologie und angeborene Herzfehler, Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Germany
b Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der TU, München, Germany
c Erste Medizinische Klinik der Technischen Universität München, Klinikum Rechts der Isar, München, Germany
d Institut für Laboratoriumsmedizin, Deutsches Herzzentrum, München, Germany

Received for publication December 14, 2005; revisions received February 26, 2006; accepted for publication March 6, 2006.

* Address for reprints: Harald Kaemmerer, MD, PhD, FESC, Deutsches Herzzentrum München, Lazarettstr. 36, D-80636 München, Germany (Email: kaemmerer{at}dhm.mhn.de).

OBJECTIVES: Sudden cardiac death is a leading cause of mortality in patients with congenital cardiac disease after surgical correction and is potentially preventable. The identification of patients at risk is therefore of major interest. We sought to assess the prognostic value of impaired cardiac autonomic nervous activity in patients with congenital cardiac disease.

METHODS: Forty-three consecutive patients with congenital cardiac disease were included in this prospective study. Parameters of heart rate turbulence and heart rate variability were calculated from Holter electrocardiograms. In addition, serum brain natriuretic peptide levels were measured. A combined end point of sudden cardiac death or nearly missed sudden cardiac death was used.

RESULTS: During a mean follow up of 27 ± 12.7 months, 5 patients died, and another 2 were successfully resuscitated. On univariate analysis, both brain natriuretic peptide levels and parameters of heart rate variability and heart rate turbulence were associated with impaired prognosis. On multivariate analysis, pathologic heart rate turbulence was found to be the strongest independent risk stratifier (hazard ratio, 61.5; P < .001).

CONCLUSIONS: Impaired cardiac autonomic nervous activity is associated with an increased risk of sudden cardiac death in congenital cardiac disease. Our results suggest that heart rate turbulence might be superior to established markers of cardiac autonomic dysfunction, such as heart rate variability. The combined use of heart rate turbulence, heart rate variability, and markers of neurohormonal activation, such as brain natriuretic peptide, might further improve the prognostic value.

Abbreviations and Acronyms BNP = B-type natriuretic peptide; CCD = congenital cardiac disease; CI = confidence interval; ECG = electrocardiography; HRT = heart rate turbulence; HRV = heart rate variability; HRVTI = heart rate variability triangular index; RMSSD = square root of the mean square differences of successive RR intervals; SDANN = standard deviation of mean values for all normal-to-normal intervals over 5 minutes; SDNN = standard deviation of all normal-to-normal intervals; TO = turbulence onset; TS = turbulence slope; VPB = ventricular premature beat




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