1
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Rodríguez NA, Patel N, Dariolli R, Ng S, Aleman AG, Gong JQ, Lin HM, Rodríguez M, Josowitz R, Sol-Church K, Gripp KW, Lin X, Song SC, Fishman GI, Sobie EA, Gelb BD. HRAS-Mutant Cardiomyocyte Model of Multifocal Atrial Tachycardia. Circ Arrhythm Electrophysiol 2024; 17:e012022. [PMID: 38415356 PMCID: PMC11021157 DOI: 10.1161/circep.123.012022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Germline HRAS gain-of-function pathogenic variants cause Costello syndrome (CS). During early childhood, 50% of patients develop multifocal atrial tachycardia, a treatment-resistant tachyarrhythmia of unknown pathogenesis. This study investigated how overactive HRAS activity triggers arrhythmogenesis in atrial-like cardiomyocytes (ACMs) derived from human-induced pluripotent stem cells bearing CS-associated HRAS variants. METHODS HRAS Gly12 mutations were introduced into a human-induced pluripotent stem cells-ACM reporter line. Human-induced pluripotent stem cells were generated from patients with CS exhibiting tachyarrhythmia. Calcium transients and action potentials were assessed in induced pluripotent stem cell-derived ACMs. Automated patch clamping assessed funny currents. HCN inhibitors targeted pacemaker-like activity in mutant ACMs. Transcriptomic data were analyzed via differential gene expression and gene ontology. Immunoblotting evaluated protein expression associated with calcium handling and pacemaker-nodal expression. RESULTS ACMs harboring HRAS variants displayed higher beating rates compared with healthy controls. The hyperpolarization activated cyclic nucleotide gated potassium channel inhibitor ivabradine and the Nav1.5 blocker flecainide significantly decreased beating rates in mutant ACMs, whereas voltage-gated calcium channel 1.2 blocker verapamil attenuated their irregularity. Electrophysiological assessment revealed an increased number of pacemaker-like cells with elevated funny current densities among mutant ACMs. Mutant ACMs demonstrated elevated gene expression (ie, ISL1, TBX3, TBX18) related to intracellular calcium homeostasis, heart rate, RAS signaling, and induction of pacemaker-nodal-like transcriptional programming. Immunoblotting confirmed increased protein levels for genes of interest and suppressed MAPK (mitogen-activated protein kinase) activity in mutant ACMs. CONCLUSIONS CS-associated gain-of-function HRASG12 mutations in induced pluripotent stem cells-derived ACMs trigger transcriptional changes associated with enhanced automaticity and arrhythmic activity consistent with multifocal atrial tachycardia. This is the first human-induced pluripotent stem cell model establishing the mechanistic basis for multifocal atrial tachycardia in CS.
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Affiliation(s)
- Nelson A. Rodríguez
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nihir Patel
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rafael Dariolli
- Dept of Pharmacological Sciences & Systems Biology Ctr New York, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Simon Ng
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Angelika G. Aleman
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jingqi Q.X. Gong
- Dept of Pharmacological Sciences & Systems Biology Ctr New York, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hung-Mo Lin
- Yale Center for Analytical Sciences (YCAS), New Haven, CT
| | - Matthew Rodríguez
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rebecca Josowitz
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Katia Sol-Church
- Dept of Pathology, Univ of Virginia School of Medicine, Charlottesville, VA
| | - Karen W. Gripp
- Division of Medical Genetics; Al duPont Hospital for Children/Nemours, Wilmington, DE
| | - Xianming Lin
- Leon H. Charney Division of Cardiology; New York Univ School of Medicine
| | - Soomin C. Song
- Ion Lab, Dept of Pathology, NYU Langone Health, New York, NY
| | - Glenn I. Fishman
- Leon H. Charney Division of Cardiology; New York Univ School of Medicine
| | - Eric A. Sobie
- Dept of Pharmacological Sciences & Systems Biology Ctr New York, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bruce D. Gelb
- Mindich Child Health & Development Inst, Icahn School of Medicine at Mount Sinai, New York, NY
- Depts of Pediatrics & Genetics and Genomic Sciences; Icahn School of Medicine at Mount Sinai, New York, NY
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Pamukcu O, Citli R. Ivabradine for congenital ectopic tachycardia in newborn. Cardiol Young 2024; 34:445-447. [PMID: 38105572 DOI: 10.1017/s1047951123003669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Congenital junctional ectopic tachycardia is a rare arrhythmia that occurs in patients without previous cardiac surgery. In this report, we wanted to present a 6-hour-old newborn with congenital junctional ectopic tachycardia resistant to conventional anti-arrhythmic medications, who was successfully treated with ivabradine and amiadarone combination. CASE A six-hour-old newborn girl was hospitalised in neonatal ICU because transient tachypnoea of the newborn. She was tachycardic, and supraventricular tachycardia was noticed. There was no answer to the adenosine esmolol treatment; even synchronised direct cardioversion intravenous amiodarone was started. Junctional ectopic tachycardia was diagnosed. We have added propranolol to the treatment and followed patient for 2 days. On the fourth day, junctional ectopic tachycardia rhythm still persisted; therefore, ivabradine treatment was added to the treatment. On the following day, the heart rhythm was slowed to 110/min, and propranolol was stopped; intravenous amiodarone treatment was changed to the oral form. The rhythm turned into sinus; two days after starting ivabradine and oral amiodarone. CONCLUSION Tachyarrhythmia originating in the atrioventricular node and atrioventricular junction including the bundle of His complex are junctional ectopic tachycardia. Congenital junctional ectopic tachycardia is rare, and it is mostly resistant to the conventional treatment.Ivabradine is a new anti-arrhythmic agent, used extensively to decrease sinus rate in the treatment of cardiac failure. Ivabradine may be an option for the resistant congenital ectopic tachycardia.
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Affiliation(s)
- Ozge Pamukcu
- Pediatric Cardiology, Kahramanmaras Necip Fazıl Şehir Hastanesi, Kahramanmaras, Turkey
| | - Rümeysa Citli
- Neonatology, Kahramanmaraş Necip Fazıl City Hospital, Kahramanmaras, Turkey
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3
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Gul O, Kafali HC, Ergul Y. Successful treatment of the focal ectopic atrial tachycardia in an infant with a single dose of ivabradin. Cardiol Young 2023; 33:1750-1752. [PMID: 36959114 DOI: 10.1017/s1047951123000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
We report on a 12-month-old boy with an ectopic atrial tachycardia successfully treated with the ivabradine that acts on cardiac pacemaker cells by selectively inhibiting the If channel. The patient was diagnosed with supraventricular tachycardia in another centre, and multi-drug therapy was unsuccessful to restore sinus ryhthm, so he was sent to our hospital for catheter ablation. We stopped the medications the patient was taking and started using ivabradine. Sinus rhythm was restored 2 hours after ivabradine treatment was started.
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Affiliation(s)
- Oguzhan Gul
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Research and Education Hospital, Istanbul, Turkey
| | - Hasan Candas Kafali
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Research and Education Hospital, Istanbul, Turkey
| | - Yakup Ergul
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Research and Education Hospital, Istanbul, Turkey
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4
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Tasci O, Karadeniz C. Ivabradine in a 15-day-old male neonate with refractory focal atrial tachycardia. Pacing Clin Electrophysiol 2023; 46:924-927. [PMID: 37428945 DOI: 10.1111/pace.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 07/12/2023]
Abstract
Ivabradine is used to reduce heart rate in children with chronic heart failure and dilated cardiomyopathy, it has recently been used off-label to treat tachyarrhythmias such as ectopic atrial tachycardia and junctional ectopic tachycardia (JET) in children. We report a successful ivabradine experience in a male neonate with refractory focal atrial tachycardia (FAT).
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Affiliation(s)
- Onur Tasci
- Department of Pediatric Cardiology, Sivas Numune Hospital, Sivas, Turkey
| | - Cem Karadeniz
- Department of Pediatric Cardiology, Izmir Katip Celebi University, Izmir, Turkey
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5
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Penslar J, Udupa S. Ivabradine in the Management of Pediatric Arrhythmias. Can J Cardiol 2023; 39:11-13. [PMID: 36336308 DOI: 10.1016/j.cjca.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 10/28/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joshua Penslar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.
| | - Sharmila Udupa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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6
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Hackl B, Lukacs P, Ebner J, Pesti K, Haechl N, Földi MC, Lilliu E, Schicker K, Kubista H, Stary-Weinzinger A, Hilber K, Mike A, Todt H, Koenig X. The Bradycardic Agent Ivabradine Acts as an Atypical Inhibitor of Voltage-Gated Sodium Channels. Front Pharmacol 2022; 13:809802. [PMID: 35586063 PMCID: PMC9108390 DOI: 10.3389/fphar.2022.809802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/24/2022] [Indexed: 12/19/2022] Open
Abstract
Background and purpose: Ivabradine is clinically administered to lower the heart rate, proposedly by inhibiting hyperpolarization-activated cyclic nucleotide-gated cation channels in the sinoatrial node. Recent evidence suggests that voltage-gated sodium channels (VGSC) are inhibited within the same concentration range. VGSCs are expressed within the sinoatrial node and throughout the conduction system of the heart. A block of these channels thus likely contributes to the established and newly raised clinical indications of ivabradine. We, therefore, investigated the pharmacological action of ivabradine on VGSCs in sufficient detail in order to gain a better understanding of the pro- and anti-arrhythmic effects associated with the administration of this drug. Experimental Approach: Ivabradine was tested on VGSCs in native cardiomyocytes isolated from mouse ventricles and the His-Purkinje system and on human Nav1.5 in a heterologous expression system. We investigated the mechanism of channel inhibition by determining its voltage-, frequency-, state-, and temperature-dependence, complemented by a molecular drug docking to the recent Nav1.5 cryoEM structure. Automated patch-clamp experiments were used to investigate ivabradine-mediated changes in Nav1.5 inactivation parameters and inhibition of different VGSC isoforms. Key results: Ivabradine inhibited VGSCs in a voltage- and frequency-dependent manner, but did not alter voltage-dependence of activation and fast inactivation, nor recovery from fast inactivation. Cardiac (Nav1.5), neuronal (Nav1.2), and skeletal muscle (Nav1.4) VGSC isoforms were inhibited by ivabradine within the same concentration range, as were sodium currents in native cardiomyocytes isolated from the ventricles and the His-Purkinje system. Molecular drug docking suggested an interaction of ivabradine with the classical local anesthetic binding site. Conclusion and Implications: Ivabradine acts as an atypical inhibitor of VGSCs. Inhibition of VGSCs likely contributes to the heart rate lowering effect of ivabradine, in particular at higher stimulation frequencies and depolarized membrane potentials, and to the observed slowing of intra-cardiac conduction. Inhibition of VGSCs in native cardiomyocytes and across channel isoforms may provide a potential basis for the anti-arrhythmic potential as observed upon administration of ivabradine.
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Affiliation(s)
- Benjamin Hackl
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Lukacs
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
| | - Janine Ebner
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Pesti
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
- Semmelweis University, School of Ph.D. Studies, Budapest, Hungary
| | - Nicholas Haechl
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Mátyás C Földi
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Elena Lilliu
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Klaus Schicker
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Helmut Kubista
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Karlheinz Hilber
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Arpad Mike
- ELKH, Plant Protection Institute, Centre for Agricultural Research, Martonvásár, Hungary
- Department of Biochemistry, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Hannes Todt
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Xaver Koenig
- Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Xaver Koenig,
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7
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Hackett G, Lin TK, Imundo JR. Use of Ivabradine in a Critically-Ill Pediatric Patient with Recalcitrant Ectopic Atrial Tachycardia and Complex Congenital Heart Disease. HeartRhythm Case Rep 2022; 8:415-419. [PMID: 35774211 PMCID: PMC9237372 DOI: 10.1016/j.hrcr.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Memon D, Larkin E, Varghese M. Congenital junctional ectopic tachycardia in the paediatric emergency department. Cardiol Young 2022; 32:1-3. [PMID: 35027094 DOI: 10.1017/s1047951121005187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Congenital junctional ectopic tachycardia is a rare but serious cardiac arrhythmia seen in neonates and young infants. It is frequently resistant and refractory to first-line treatment options such as cardioversion with adenosine and direct current shock, and it carries a high morbidity and mortality rate. The aim of this article is to present the case of congenital junctional ectopic tachycardia observed in a 14-day-old neonate, highlighting the role of ivabradine in the management, followed by a discussion about current approaches to treatment.
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Affiliation(s)
- Danyal Memon
- Department of Paediatrics, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Elizabeth Larkin
- Department of Paediatrics, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Mathew Varghese
- Department of Paediatrics, Our Lady of Lourdes Hospital, Drogheda, Ireland
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9
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Di Marco GM, De Nigris A, Pepe A, Pagano A, Di Nardo G, Tipo V. Ivabradine-Flecainide as Breakthrough Drug Combination for Congenital Junctional Ectopic Tachycardia: A Case Report and Literature Review. Pediatr Rep 2021; 13:624-631. [PMID: 34842781 PMCID: PMC8629013 DOI: 10.3390/pediatric13040074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/04/2021] [Accepted: 11/19/2021] [Indexed: 11/23/2022] Open
Abstract
Congenital junctional ectopic tachycardia (CJET) is a rare tachyarrhythmia that remains difficult to manage, with suboptimal control in most cases. Here, we report literature research on the use of ivabradine in the treatment of pediatric junctional ectopic tachycardia (JET), both congenital and postoperative, and describe the successful use of ivabradine-flecainide association for CJET therapy resistant to other antiarrhythmic agents. This new drug combination was effective in completely suppressing JET. Ivabradine-flecainide combination may be considered a new therapeutic strategy of CJET with a satisfactory efficacy/tolerability ratio in patients resistant to conventional drug combinations.
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Affiliation(s)
- Giovanni Maria Di Marco
- Division of Cardiology, Department of Pediatrics, Santobono- Pausilipon Children Medical Hospital, 80129 Naples, Italy; (G.M.D.M.); (G.D.N.)
| | - Angelica De Nigris
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
- Correspondence: ; Tel.: +39-388-175-3749
| | - Angela Pepe
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Pediatrics Section, University of Salerno, 84081 Baronissi, Italy;
| | - Annamaria Pagano
- Department of Translational Medical Science, Pediatrics Section, University of Naples “Federico II”, 80126 Naples, Italy;
| | - Giangiacomo Di Nardo
- Division of Cardiology, Department of Pediatrics, Santobono- Pausilipon Children Medical Hospital, 80129 Naples, Italy; (G.M.D.M.); (G.D.N.)
| | - Vincenzo Tipo
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, 80129 Naples, Italy;
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10
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Karmegaraj B, Balaji S, Raju PN, Subramanian P, Subramanian R, Ibrahim S, Razeen M, Krishnakumar R. Tachycardia-induced cardiomyopathy secondary to incessant ectopic atrial tachycardia in two infants: Potential new indication for early initiation of enteral ivabradine. Ann Pediatr Cardiol 2021; 14:422-427. [PMID: 34667421 PMCID: PMC8457284 DOI: 10.4103/apc.apc_37_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/26/2021] [Accepted: 06/05/2021] [Indexed: 11/04/2022] Open
Abstract
This report describes two cases of tachycardia-induced cardiomyopathy secondary to incessant ectopic atrial tachycardia (EAT) in an infant presenting with severe left ventricular dysfunction and hemodynamic instability. The two cases were managed differently. The first required mechanical ventilation and was resistant to conventional antiarrhythmic drugs. After the initiation of enteral ivabradine (0.15mg/kg) the heart rate slowed with significant improvement in hemodynamics, peripheral perfusion and sinus rhythm was restored after 12 hours. Ivabradine was continued and the patient was discharged home after 10 days of hospitalization. The second case was managed by early initiation of ivabradine and resulted in restoration of sinus rhythm within 4 hours, thus avoiding trials of conventional anti-arrhythmic drugs with unstable hemodynamic profile. The infant was discharged after 5 days of hospitalization on ivabradine..
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Affiliation(s)
- Balaganesh Karmegaraj
- Department of Pediatrics, Krishna Maternity Home and Children Hospital, Tirunelveli, Tamil Nadu, India.,Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Seshadri Balaji
- Department of Pediatrics (Cardiology), Oregon Health and Science University, Portland, Oregon, USA
| | - Prasanna Narayanan Raju
- Department of Pediatrics, Krishna Maternity Home and Children Hospital, Tirunelveli, Tamil Nadu, India
| | - Pradheep Subramanian
- Department of Pediatrics, Krishna Maternity Home and Children Hospital, Tirunelveli, Tamil Nadu, India
| | - Raju Subramanian
- Department of Pediatrics, Krishna Maternity Home and Children Hospital, Tirunelveli, Tamil Nadu, India
| | - Syed Ibrahim
- Department of Pediatrics, Royal hospital, Tirunelveli, India
| | - Mohamed Razeen
- Department of Pediatrics, Royal hospital, Tirunelveli, India
| | - Raman Krishnakumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Oknińska M, Paterek A, Zambrowska Z, Mackiewicz U, Mączewski M. Effect of Ivabradine on Cardiac Ventricular Arrhythmias: Friend or Foe? J Clin Med 2021; 10:4732. [PMID: 34682854 PMCID: PMC8537674 DOI: 10.3390/jcm10204732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/24/2021] [Accepted: 10/08/2021] [Indexed: 12/12/2022] Open
Abstract
Life-threatening ventricular arrhythmias, such as ventricular tachycardia and ventricular fibrillation remain an ongoing clinical problem and their prevention and treatment require optimization. Conventional antiarrhythmic drugs are associated with significant proarrhythmic effects that often outweigh their benefits. Another option, the implantable cardioverter defibrillator, though clearly the primary therapy for patients at high risk of ventricular arrhythmias, is costly, invasive, and requires regular monitoring. Thus there is a clear need for new antiarrhythmic treatment strategies. Ivabradine, a heartrate-reducing agent, an inhibitor of HCN channels, may be one of such options. In this review we discuss emerging data from experimental studies that indicate new mechanism of action of this drug and further areas of investigation and potential use of ivabradine as an antiarrhythmic agent. However, clinical evidence is limited, and the jury is still out on effects of ivabradine on cardiac ventricular arrhythmias in the clinical setting.
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Affiliation(s)
| | | | | | | | - Michał Mączewski
- Centre of Postgraduate Medical Education, Department of Clinical Physiology, ul. Marymoncka 99/103, 01-813 Warsaw, Poland; (M.O.); (A.P.); (Z.Z.); (U.M.)
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12
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Younis NK, Abi-Saleh B, Al Amin F, El Sedawi O, Tayeh C, Bitar F, Arabi M. Ivabradine: A Potential Therapeutic for Children With Refractory SVT. Front Cardiovasc Med 2021; 8:660855. [PMID: 34414216 PMCID: PMC8368123 DOI: 10.3389/fcvm.2021.660855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: In April 2015, ivabradine was approved by the Food and Drug Administration for the treatment of patients with coronary artery disease and heart failure (HF). The use of this medication has been linked with improved clinical outcomes and reduced rates of hospitalization in patients with symptomatic HF and a baseline heart rate of 70 bpm and above. Nonetheless, little is known about the use of ivabradine in pediatric patients with supraventricular tachycardia (SVT). This use is not well-studied and is only endorsed by a few case reports and case series. Aim: This study discusses the off-label utilization of ivabradine in pediatric patients with SVT, and highlights its efficacy in treating treatment-resistant (refractory) SVT. Methods: We conducted a retrospective single-center observational study involving pediatric patients with SVT treated at our center between January 2016 and October 2020. We identified the total number of patients with SVT, and the number of patients with refractory SVT treated with Ivabradine. Similarly, we performed a thorough review of the databases of PubMed, Medline and Google Scholar to compare the clinical course of our patients to those described in the literature. Results: Between January 2016 and October 2020, 79 pediatric patients with SVT were seen and treated at our center. A treatment-resistant SVT was noted only in three patients (4%). Ivabradine was used in these patients as a single or combined therapy. The rest (96%) were successfully treated with conventional anti-arrhythmics such as β-blockers, flecainide, and other approved medications. In the ivabradine group, successful reversal to sinus rhythm was achieved in two of the three patients (66%), one patient was treated with a combination therapy of amiodarone and ivabradine, and the other patient was treated only with ivabradine. Conclusion: Overall, promissory results are associated with the use of ivabradine in pediatric patients with refractory SVT. Ivabradine appears to be a safe and well-tolerated medication that can induce adequate suppression of SVT, complete reversal to sinus rhythm, and effective enhancement of left ventricular function.
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Affiliation(s)
- Nour K Younis
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bernard Abi-Saleh
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Internal Medicine Department, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Farah Al Amin
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Omar El Sedawi
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Christelle Tayeh
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
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13
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López Fernández E, Montañes Delmas E, Granados Ruiz MÁ, Oviedo Melgares L, Ramos Casado V. Uso de ivabradina en el tratamiento de la taquicardia ectópica de la unión tras cirugía cardiaca. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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14
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López Fernández E, Montañes Delmas E, Granados Ruiz MÁ, Oviedo Melgares L, Ramos Casado V. Use of ivabradine in pediatric post-operative junctional ectopic tachycardia. An Pediatr (Barc) 2021; 95:118-120. [PMID: 34294598 DOI: 10.1016/j.anpede.2020.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022] Open
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15
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Asfour SS, Al-Omran KA, Alodhaidan NA, Asfour RS, Khalil TM, Al-Mouqdad MM. Ivabradine Monotherapy for the Treatment of Congenital Junctional Ectopic Tachycardia in a Premature Neonate. J Pediatr Pharmacol Ther 2021; 26:414-417. [PMID: 34035688 DOI: 10.5863/1551-6776-26.4.414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/22/2020] [Indexed: 11/11/2022]
Abstract
Congenital junctional ectopic tachycardia is a rare and special type of supraventricular arrhythmia. Junctional ectopic tachycardia is characterized by persistently elevated heart rates that may cause an impairment in cardiac function. Junctional ectopic tachycardia is considered one of the most difficult-to-treat conditions even with a combination of antiarrhythmic medications. Ivabradine is a novel antiarrhythmic medication used to decrease the heart rate in adults with angina pectoris. We report a first case of a premature neonate with a normal heart structure who developed junctional ectopic tachycardia and was subsequently treated successfully with ivabradine.
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Effect of ivabradine on cardiac arrhythmias: Antiarrhythmic or proarrhythmic? Heart Rhythm 2021; 18:1230-1238. [PMID: 33737235 DOI: 10.1016/j.hrthm.2021.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/28/2022]
Abstract
Cardiac arrhythmias are a major source of mortality and morbidity. Unfortunately, their treatment remains suboptimal. Major classes of antiarrhythmic drugs pose a significant risk of proarrhythmia, and their side effects often outweigh their benefits. Therefore, implantable devices remain the only truly effective antiarrhythmic therapy, and new strategies of antiarrhythmic treatment are required. Ivabradine is a selective heart rate-reducing agent, an inhibitor of hyperpolarization-activated, cyclic nucleotide-gated (HCN) channels, currently approved for treatment of coronary artery disease and chronic heart failure. In this review, we focus on the clinical and basic science evidence for the antiarrhythmic and proarrhythmic effects of ivabradine. We attempt to dissect the mechanisms behind the effects of ivabradine and indicate the focus of future studies.
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Amstetter D, Badt F, Rubi L, Bittner RE, Ebner J, Uhrin P, Hilber K, Koenig X, Todt H. The bradycardic agent ivabradine decreases conduction velocity in the AV node and in the ventricles in-vivo. Eur J Pharmacol 2021; 893:173818. [PMID: 33345856 DOI: 10.1016/j.ejphar.2020.173818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Ivabradine blocks hyperpolarisation-activated cyclic nucleotide-gated (HCN) channels, thereby lowering the heart rate, an action that is used clinically for the treatment of heart failure and angina pectoris. We and others have shown previously that ivabradine, in addition to its HCN channel blocking activity, also inhibits voltage-gated Na channels in vitro at concentrations that may be clinically relevant. Such action may reduce conduction velocity in cardiac atria and ventricles. Here, we explore the effect of administration of ivabradine on parameters of ventricular conduction and repolarization in the surface ECG of anesthetized mice. We found that 5 min after i.p. administration of 10 mg/kg ivabradine spontaneous heart rate had declined by ~13%, which is within the range observed in human clinical studies. At the same time a significant increase in QRS duration by ~18% was observed, suggesting a reduction in ventricular conduction velocity. During transesophageal pacing at heart rates between 100 and 220 beats/min there was no obvious rate-dependence of ivabradine-induced QRS prolongation. On the other hand, ivabradine produced substantial rate-dependent slowing of AV nodal conduction. We conclude that ivabradine prolongs conduction in the AV-node and in the ventricles in vivo.
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Affiliation(s)
- Daniel Amstetter
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Florian Badt
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Lena Rubi
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Reginald E Bittner
- Neuromuscular Research Department, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Janine Ebner
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Pavel Uhrin
- Department of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Austria
| | - Karlheinz Hilber
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Xaver Koenig
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria
| | - Hannes Todt
- Center for Physiology and Pharmacology, Department of Neurophysiology and Neuropharmacology, Medical University of Vienna, Vienna, Austria.
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Khan N, Salvi P, Dharod D, Chokhandre M, Mandrekar A, Joshi S. Use of Ivabradine in the Treatment of Tachyarrhythmias After Surgery for Congenital Heart Diseases. J Cardiothorac Vasc Anesth 2020; 34:2395-2400. [DOI: 10.1053/j.jvca.2020.02.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/16/2020] [Accepted: 02/26/2020] [Indexed: 11/11/2022]
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Abstract
Multifocal atrial tachycardia has certain electrocardiographic similarities to atrial fibrillation. The mechanism of atrial fibrillation is heterogenous but in some cases may arise from a single ectopic driver with fibrillatory conduction to the rest of the atria. This has led to the speculation that multifocal atrial tachycardia may have a similar mechanistic unifocal site that disperses through the atrium in a fibrillatory pattern. Ivabradine has been reported to be efficacious in an adult with paroxysmal atrial fibrillation as well as in children with junctional or ectopic atrial tachycardias. This is the first report of successfully using ivabradine, a novel anti-arrhythmic If blocking agent, to convert multifocal atrial tachycardia in a 5-month-old critically ill infant to a pattern indicating a single ectopic atrial focus. This allowed the patient's single atrial focus to be ablated with return to sinus rhythm and decannulation from ventriculoarterial extracorporeal membrane oxygenation. This case suggests that multifocal atrial tachycardia may arise from a single automatic focus with downstream fibrillatory conduction to the atria.
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20
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Ivabradina para el control crónico de la frecuencia cardiaca en fibrilación auricular permanente. Diseño del proyecto BRAKE-AF. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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21
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Michel H, Heißenhuber F, Wellmann S, Melter M, Gerling S. Ectopic Atrial Tachycardia in a 12-Month-Old Girl Treated With Ivabradine and Beta-Blocker, a Case Report. Front Pediatr 2020; 8:313. [PMID: 32612966 PMCID: PMC7308433 DOI: 10.3389/fped.2020.00313] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 05/14/2020] [Indexed: 11/17/2022] Open
Abstract
We report on a 12-month-old girl with an ectopic atrial tachycardia successfully treated with the combination of a beta blocking agent and Ivabradine that acts on cardiac pacemaker cells by selectively inhibiting the If channel. Standard therapy had failed to control the tachycardia before. No side effects attributable to Ivabradine were noticed. Due to its mechanism of action Ivabradine is a promising novel agent for the therapy of tachycardia due to increased automaticity. Reports on the use of Ivabradine in young children or infants are rare, but show promising results for congenital junctional ectopic tachycardia. This report adds the second case of ectopic atrial tachycardia in this age group and novel treatment with Ivabradine to the literature.
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Affiliation(s)
- Holger Michel
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Frank Heißenhuber
- Clinic for Cardiology-Electrophysiology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Sven Wellmann
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Michael Melter
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
| | - Stephan Gerling
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
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22
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Fontenla A, López-Gil M, Tamargo-Menéndez J, Matía-Francés R, Salgado-Aranda R, Rey-Blas JR, Miracle-Blanco Á, Mejía-Martínez E, Pastor-Fuentes A, Toquero-Ramos J, Arias MÁ, Montilla I, Gómez de la Cámara A, Arribas F. Ivabradine for chronic heart rate control in persistent atrial fibrillation. Design of the BRAKE-AF project. ACTA ACUST UNITED AC 2019; 73:368-375. [PMID: 31631048 DOI: 10.1016/j.rec.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/11/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION AND OBJECTIVES Ivabradine is an inhibitor of the If channel, the main determinant of the pacemaker function of the sinus node. The drug has been approved for the treatment of angina and heart failure. There is some evidence of its role as an inhibitor of atrial-ventricular node (AVN) conduction. The aim of the BRAKE-AF project is to assess ivabradine use for rate control in atrial fibrillation (AF). METHODS A multicenter, randomized, parallel, open-label, noninferiority phase III clinical trial will be conducted to compare ivabradine vs digoxin in 232 patients with uncontrolled permanent AF despite beta-blockers or calcium channel blockers. The primary efficacy endpoint is the reduction in daytime heart rate measured by 24-hour Holter monitoring at 3 months. This clinical trial will be supported by an electrophysiological study of the effect of ivabradine on the action potential of the human AVN. To do this, an experimental model will be used with Chinese hamster ovarium cells transfected with the DNA encoding the expression of the t channels involved in this action potential and recording of the ionic currents with patch clamp techniques. RESULTS New data will be obtained on the effect of ivabradine on the human AVN and its safety and efficacy in patients with permanent AF. CONCLUSIONS The results of the BRAKE-AF project might allow inclusion of ivabradine within the limited arsenal of drugs currently available for rate control in AF. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov. Identifier: NCT03718273.
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Affiliation(s)
- Adolfo Fontenla
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - María López-Gil
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Tamargo-Menéndez
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | | | | | | | | | - Jorge Toquero-Ramos
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Isabel Montilla
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Agustín Gómez de la Cámara
- Unidad de Investigación Clínica en Ensayos Clínicos (UICEC), Hospital 12 de Octubre, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Arribas
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Janson CM, Tan RB, Iyer VR, Vogel RL, Vetter VL, Shah MJ. Ivabradine for treatment of tachyarrhythmias in children and young adults. HeartRhythm Case Rep 2019; 5:333-337. [PMID: 31285993 PMCID: PMC6587055 DOI: 10.1016/j.hrcr.2019.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Reina Bianca Tan
- Division of Pediatric Cardiology, NYU Langone School of Medicine, New York, New York
| | - V Ramesh Iyer
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - R Lee Vogel
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria L Vetter
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maully J Shah
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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24
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Ergul Y, Ozturk E. Ivabradine use as an antiarrhythmic therapy in congenital junctional ectopic tachycardias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1576. [DOI: 10.1111/pace.13478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Yakup Ergul
- Department of Pediatric Cardiology/Electrophysiology, Saglik Bilimleri University; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Center Hospital; Istanbul Turkey
| | - Erkut Ozturk
- Department of Pediatric Cardiology, Saglik Bilimleri University; Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Center Hospital; Istanbul Turkey
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25
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Mert KU, Şener E, Mert GÖ. Beneficial effects of ivabradine in atrial or ventricular arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1575. [DOI: 10.1111/pace.13480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Kadir Uğur Mert
- Department of Cardiology, Faculty of Medicine; Eskişehir Osmangazi University; Eskişehir Turkey
| | - Emre Şener
- Department of Cardiology, Faculty of Medicine; Eskişehir Osmangazi University; Eskişehir Turkey
| | - Gurbet Özge Mert
- Department of Cardiology; Yunus Emre State Hospital; Eskişehir Turkey
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