Association of atrial fibrillation and atrial flutter with sick sinus syndrome: a review of the issue based on examples of clinical observations

Authors

DOI:

https://doi.org/10.14739/2310-1210.2022.2.248102

Keywords:

atrial fibrillation, atrial flutter, sick sinus syndrome, radiofrequency ablation

Abstract

Despite significant progress in the treatment of patients with cardiac arrhythmias, atrial fibrillation (AF) remains one of the leading causes of serious cardiovascular events around the world. Currently, radiofrequency ablation (RFA) is the first-line method in the treatment of patients with AF. However, signs of sick sinus syndrome (SSS) are found in some AF patients after RFA, which requires urgent or planned pacemaker implantation.

Aim. To review current therapies for AF and sick sinus syndrome (SSS) and analyze peculiarities of the SSS development after RFA for AF.

Materials and methods. The analysis of the world literature data was carried out along with the analysis of our own clinical observations of patients with AF who underwent RFA.

Results. As a result of the data analysis, it was proposed to identify three possible groups of causes why AF patients may develop SSS after RFA: 1) organic (associated with degenerative fibrosis of the sinus node tissue that occurs during aging, or with other underlying organic changes in the sinus node), 2) functional (associated with the remodeling of the sinus node tissue and the surrounding tissue of the atrial myocardium caused by prolonged AF persistence), 3) iatrogenic (associated with the effects of antiarrhythmic drugs on the sinus node or caused by the RFA itself). Each group of causes identified was illustrated by a clinical case with the following analysis of long-term results of RFA.

Conclusions. It was proposed to develop a scale for SSS prediction in patients after RFA for AF evaluating a patient’s medical history, resting electrocardiography, 24-hour electrocardiographic monitoring, and, in some cases, coronary angiography to assess the peculiarities of the sinus node blood supply. The use of the above predictors could reduce the percentage of possible complications such as development of SSS in patients after RFA and also help to identify patients who may need a pacemaker implantation in the future.

Author Biographies

O. Yu. Schmidt, V. N. Karazin Kharkiv National University, Ukraine

MD, Assistant of the Department of Propaedeutics of Internal Medicine and Physical Rehabilitation

D. Ye. Volkov, SI “Zaitsev V. T. Institute of General and Emergency Surgery of the National Academy of Medical Sciences of Ukraine”, Kharkiv

MD, PhD, Head of the Department of Ultrasound and Clinical Instrumental Diagnostics and Minimally Invasive Interventions

M. S. Brynza, V. N. Karazin Kharkiv National University, Ukraine

MD, PhD, Associate Professor, Head of the Department of Propaedeutics of Internal Medicine and Physical Rehabilitation

К. H. Uvarova, V. N. Karazin Kharkiv National University, Ukraine

MD, Assistant of the Department of Propaedeutics of Internal Medicine and Physical Rehabilitation

D. Yu. Pavlova, V. N. Karazin Kharkiv National University, Ukraine

MD, Assistant of the Department of Propaedeutics of Internal Medicine and Physical Rehabilitation

References

  1. Hindricks, G., Potpara, T., Dagres, N., Arbelo, E., Bax, J. J., Blomström-Lundqvist, C., Boriani, G., Castella, M., Dan, G. A., Dilaveris, P. E., Fauchier, L., Filippatos, G., Kalman, J. M., La Meir, M., Lane, D. A., Lebeau, J. P., Lettino, M., Lip, G., Pinto, F. J., Thomas, G. N., … ESC Scientific Document Group. (2021). 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal, 42(5), 373-498. https://doi.org/10.1093/eurheartj/ehaa612
  2. Aggarwal, N., Selvendran, S., Raphael, C. E., & Vassiliou, V. (2015). Atrial Fibrillation in the Young: A Neurologist's Nightmare. Neurology Research International, 2015, Article 374352. https://doi.org/10.1155/2015/374352
  3. Staerk, L., Sherer, J. A., Ko, D., Benjamin, E. J., & Helm, R. H. (2017). Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circulation Research, 120(9), 1501-1517. https://doi.org/10.1161/CIRCRESAHA.117.309732
  4. Markides, V., & Schilling, R. J. (2003). Atrial fibrillation: classification, pathophysiology, mechanisms and drug treatment. Heart, 89(8), 939-943. https://doi.org/10.1136/heart.89.8.939
  5. Fuster, V., Rydén, L. E., Asinger, R. W., Cannom, D. S., Crijns, H. J., Frye, R. L., Halperin, J. L., Kay, G. N., Klein, W. W., Lévy, S., McNamara, R. L., Prystowsky, E. N., Wann, L. S., Wyse, D. G., Gibbons, R. J., Antman, E. M., Alpert, J. S., Faxon, D. P., Fuster, V., & Gregoratos, G. (2001). ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation, 104(17), 2118-2150. https://doi.org/10.1161/circ.104.17.2118
  6. Nesheiwat, Z., Goyal, A., & Jagtap, M. (2021). Atrial Fibrillation. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526072/#_NBK526072_pubdet_
  7. Proietti, R., Hadjis, A., AlTurki, A., Thanassoulis, G., Roux, J. F., Verma, A., Healey, J. S., Bernier, M. L., Birnie, D., Nattel, S., & Essebag, V. (2015). A Systematic Review on the Progression of Paroxysmal to Persistent Atrial Fibrillation: Shedding New Light on the Effects of Catheter Ablation. JACC: Clinical Electrophysiology, 1(3), 105-115. https://doi.org/10.1016/j.jacep.2015.04.010
  8. Heidt, S. T., Kratz, A., Najarian, K., Hassett, A. L., Oral, H., Gonzalez, R., Nallamothu, B. K., Clauw, D., & Ghanbari, H. (2016). Symptoms In Atrial Fibrillation: A Contemporary Review And Future Directions. Journal of Atrial Fibrillation, 9(1), Article 1422. https://doi.org/10.4022/jafib.1422
  9. January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Jr, Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., & Yancy, C. W. (2019). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 74(1), 104-132. https://doi.org/10.1016/j.jacc.2019.01.011
  10. Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B., Castella, M., Diener, H. C., Heidbuchel, H., Hendriks, J., Hindricks, G., Manolis, A. S., Oldgren, J., Popescu, B. A., Schotten, U., Van Putte, B., Vardas, P., & ESC Scientific Document Group. (2016). 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal, 37(38), 2893-2962. https://doi.org/10.1093/eurheartj/ehw210
  11. Kerr, C. R., Humphries, K. H., Talajic, M., Klein, G. J., Connolly, S. J., Green, M., Boone, J., Sheldon, R., Dorian, P., & Newman, D. (2005). Progression to chronic atrial fibrillation after the initial diagnosis of paroxysmal atrial fibrillation: results from the Canadian Registry of Atrial Fibrillation. American Heart Journal, 149(3), 489-496. https://doi.org/10.1016/j.ahj.2004.09.053
  12. Nieuwlaat, R., Prins, M. H., Le Heuzey, J. Y., Vardas, P. E., Aliot, E., Santini, M., Cobbe, S. M., Widdershoven, J. W., Baur, L. H., Lévy, S., & Crijns, H. J. (2008). Prognosis, disease progression, and treatment of atrial fibrillation patients during 1 year: follow-up of the Euro Heart Survey on atrial fibrillation. European Heart Journal, 29(9), 1181-1189. https://doi.org/10.1093/eurheartj/ehn139
  13. Blum, S., Aeschbacher, S., Meyre, P., Zwimpfer, L., Reichlin, T., Beer, J. H., Ammann, P., Auricchio, A., Kobza, R., Erne, P., Moschovitis, G., Di Valentino, M., Shah, D., Schläpfer, J., Henz, S., Meyer-Zürn, C., Roten, L., Schwenkglenks, M., Sticherling, C., Kühne, M., … Swiss‐AF Investigators. (2019). Incidence and Predictors of Atrial Fibrillation Progression. Journal of the American Heart Association, 8(20), Article e012554. https://doi.org/10.1161/JAHA.119.012554
  14. Iwasaki, Y. K., Nishida, K., Kato, T., & Nattel, S. (2011). Atrial Fibrillation Pathophysiology: Implications for Management. Circulation, 124(20), 2264-2274. https://doi.org/10.1161/CIRCULATIONAHA.111.019893
  15. Mareedu, R. K., Abdalrahman, I. B., Dharmashankar, K. C., Granada, J. F., Chyou, P. H., Sharma, P. P., Smith, P. N., Hayes, J. J., Greenlee, R. T., & Vidaillet, H. (2010). Atrial Flutter Versus Atrial Fibrillation in a General Population: Differences in Comorbidities Associated With Their Respective Onset. Clinical Medicine & Research, 8(1), 1-6. https://doi.org/10.3121/cmr.2009.851
  16. Shah, S. R., Luu, S. W., Calestino, M., David, J., & Christopher, B. (2018). Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence. Journal of Community Hospital Internal Medicine Perspectives, 8(5), 269-275. https://doi.org/10.1080/20009666.2018.1514932
  17. Raymond-Paquin, A., Andrade, J., & Macle, L. (2019). Catheter ablation: an ongoing revolution. Journal of Thoracic Disease, 11(Suppl. 3), S212-S215. https://doi.org/10.21037/jtd.2019.02.20
  18. Hong, K. L., Borges, J., & Glover, B. (2020). Catheter ablation for the management of atrial fibrillation: current technical perspectives. Open Heart, 7(1), Article e001207. https://doi.org/10.1136/openhrt-2019-001207
  19. Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., Calkins, H., Corrado, D., Deftereos, S. G., Diller, G. P., Gomez-Doblas, J. J., Gorenek, B., Grace, A., Ho, S. Y., Kaski, J. C., Kuck, K. H., Lambiase, P. D., Sacher, F., Sarquella-Brugada, G., Suwalski, P., … ESC Scientific Document Group. (2020). 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). European Heart Journal, 41(5), 655-720. https://doi.org/10.1093/eurheartj/ehz467
  20. Baman, T., Latchamsetty, R., & Oral, H. (2011). Complications of Radiofrequency Catheter Ablation for Atrial Fibrillation. Journal of Atrial Fibrillation, 4(3), Article 345.
  21. Kim, D. H., Choi, J. I., Lee, K. N., Ahn, J., Roh, S. Y., Lee, D. I., Shim, J., Kim, J. S., Lim, H. E., Park, S. W., & Kim, Y. H. (2018). Long-term clinical outcomes of catheter ablation in patients with atrial fibrillation predisposing to tachycardia-bradycardia syndrome: a long pause predicts implantation of a permanent pacemaker. BMC Cardiovascular Disorders, 18(1), Article 106. https://doi.org/10.1186/s12872-018-0834-0
  22. Song, C., Jin, M. N., Lee, J. H., Kim, I. S., Uhm, J. S., Pak, H. N., Lee, M. H., & Joung, B. (2015). Predictors of Sick Sinus Syndrome in Patients after Successful Radiofrequency Catheter Ablation of Atrial Flutter. Yonsei Medical Journal, 56(1), 31-37. https://doi.org/10.3349/ymj.2015.56.1.31
  23. Kawaji, T., Shizuta, S., Yamagami, S., Aizawa, T., Yoshizawa, T., Kato, M., Yokomatsu, T., Miki, S., Ono, K., & Kimura, T. (2018). Impact of Pre-Existing Bradycardia on Subsequent Need for Pacemaker Implantation After Radiofrequency Catheter Ablation for Atrial Fibrillation. Circulation Journal, 82(10), 2493-2499. https://doi.org/10.1253/circj.CJ-18-0214
  24. Kusumoto, F. M., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R., Goldschlager, N. F., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K. R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019). 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 140(8), e382-e482. https://doi.org/10.1161/CIR.0000000000000628
  25. Dakkak, W., & Doukky, R. (2020). Sick Sinus Syndrome. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470599/
  26. Jensen, P. N., Gronroos, N. N., Chen, L. Y., Folsom, A. R., deFilippi, C., Heckbert, S. R., & Alonso, A. (2014). Incidence of and Risk Factors for Sick Sinus Syndrome in the General Population. Journal of the American College of Cardiology, 64(6), 531-538. https://doi.org/10.1016/j.jacc.2014.03.056
  27. Boriani, G., & Padeletti, L. (2015). Management of atrial fibrillation in bradyarrhythmias. Nature Reviews Cardiology, 12(6), 337-349. https://doi.org/10.1038/nrcardio.2015.30
  28. Semmler, V., von Krogh, F., Haller, B., Reents, T., Bourier, F., Telishevska, M., Kottmaier, M., Kornmayer, M., Brooks, S., Koch-Büttner, K., Lennerz, C., Brkic, A., Grebmer, C., Blazek, P., Weigand, S., Hessling, G., Kolb, C., & Deisenhofer, I. (2019). The incidence, indications and predictors of acute pacemaker implantation after ablation of persistent atrial fibrillation. Clinical Research in Cardiology, 108(6), 651-659. https://doi.org/10.1007/s00392-018-1393-1
  29. Hada, M., Miyazaki, S., Kajiyama, T., Yamaguchi, M., Kusa, S., Nakamura, H., Hachiya, H., Tada, H., Hirao, K., & Iesaka, Y. (2019). Catheter ablation of paroxysmal atrial fibrillation in patients with sick sinus syndrome. Heart and Vessels, 34(3), 503-508. https://doi.org/10.1007/s00380-018-1256-8
  30. Semelka, M., Gera, J., & Usman, S. (2013). Sick sinus syndrome: a review. American family physician, 87(10), 691-696.
  31. John, R. M., & Kumar, S. (2016). Sinus Node and Atrial Arrhythmias. Circulation, 133(19), 1892-1900. https://doi.org/10.1161/CIRCULATIONAHA.116.018011
  32. Kezerashvili, A., Krumerman, A. K., & Fisher, J. D. (2008). Sinus Node Dysfunction in Atrial Fibrillation: Cause or Effect? Journal of Atrial Fibrillation, 1(3), Article 30.
  33. Knöll, R., Arras, M., Zimmermann, R., Schaper, J., & Schaper, W. (1994). Changes in gene expression following short coronary occlusions studied in porcine hearts with run-on assays. Cardiovascular Research, 28(7), 1062-1069. https://doi.org/10.1093/cvr/28.7.1062
  34. Morishima, I., Morita, Y., Takagi, K., Kanzaki, Y., Kobori, A., Kaitani, K., Inoue, K., Kurotobi, T., Nagai, H., Watanabe, N., Furui, K., Yoshioka, N., Yamauchi, R., Tsuboi, H., & Shizuta, S. (2019). P1038 Device implantation after catheter ablation of paroxysmal atrial fibrillation with coexisting sick sinus syndrome: Insights from the Kansai Plus Atrial Fibrillation (KPAF) study. European Heart Journal, 40(Suppl. 1), 631. https://doi.org/10.1093/eurheartj/ehz747.0629
  35. You, B., Li, Z., Su, X., Liu, F., & Wang, B. (2016). Prediction of sinus node dysfunction in patients with paroxysmal atrial fibrillation and sinus pause. Cardiology Plus, 1(4), 6-11. https://doi.org/10.4103/2470-7511.248367
  36. Kim, D., Shim, C. Y., Hong, G. R., Cho, I. J., Lee, S. H., Chang, H. J., Lee, S., Ha, J. W., & Chang, B. C. (2018). Sinus node dysfunction after surgical atrial fibrillation ablation with concomitant mitral valve surgery: Determinants and clinical outcomes. PLOS ONE, 13(9), Article e0203828. https://doi.org/10.1371/journal.pone.0203828
  37. Hocini, M., Sanders, P., Deisenhofer, I., Jaïs, P., Hsu, L. F., Scavée, C., Weerasoriya, R., Raybaud, F., Macle, L., Shah, D. C., Garrigue, S., Le Metayer, P., Clémenty, J., & Haïssaguerre, M. (2003). Reverse Remodeling of Sinus Node Function After Catheter Ablation of Atrial Fibrillation in Patients With Prolonged Sinus Pauses. Circulation, 108(10), 1172-1175. https://doi.org/10.1161/01.CIR.0000090685.13169.07
  38. Kistler, P. M., Sanders, P., Fynn, S. P., Stevenson, I. H., Spence, S. J., Vohra, J. K., Sparks, P. B., & Kalman, J. M. (2004). Electrophysiologic and electroanatomic changes in the human atrium associated with age. Journal of the American College of Cardiology, 44(1), 109-116. https://doi.org/10.1016/j.jacc.2004.03.044
  39. Choudhury, M., Boyett, M. R., & Morris, G. M. (2015). Biology of the Sinus Node and its Disease. Arrhythmia & Electrophysiology Review, 4(1), 28-34. https://doi.org/10.15420/aer.2015.4.1.28
  40. Yilmazer, B., Sali, M., Cosan, F., & Cefle, A. (2015). Sinus node dysfunction in adult systemic lupus erythematosus flare: A case report. Modern Rheumatology, 25(3), 472-475. https://doi.org/10.3109/14397595.2013.843744
  41. Nakamura, T. (1990). A Clinical Study of Drug-Induced Sinus Node Dysfunction. Nippon Ronen Igakkai Zasshi. Japanese Journal of Geriatrics, 27(2), 193-200. https://doi.org/10.3143/geriatrics.27.193
  42. Ovsyshcher, I. E. (2006). Drug-Induced, Drug-Provoked and Drug-Associated Bradycardia. In A. Raviele (Ed.), Cardiac Arrhythmias 2005 (pp. 569-574). Springer. https://doi.org/10.1007/88-470-0371-7_69
  43. Doris, U., Kharche, S., Petkova, M., Borbas, B., Logantha, S., Fedorenko, O., Maczewski, M., Mackiewicz, U., Zhang, Y., Chahal, A., D'Souza, A., Atkinson, A. J., Dobrzynski, H., & Yanni, J. (2019). A sexy approach to pacemaking: differences in function and molecular make up of the sinoatrial node. Histology and Histopathology, 34(11), 1255-1268. https://doi.org/10.14670/HH-18-115
  44. Ferrer, M. I. (1968). The Sick Sinus Syndrome in Atrial Disease. JAMA, 206(3), 645-646. https://doi.org/10.1001/jama.1968.03150030101028
  45. Turitto, G., Saponieri, C., Onuora, A., & El-Sherif, N. (2007). Prolonged Transient Atrial Electrical Silence Following Termination of Chronic Atrial Tachyarrhythmias. PACE, 30(11), 1311-1315. https://doi.org/10.1111/j.1540-8159.2007.00863.x
  46. Lamas, G. A., Lee, K., Sweeney, M., Leon, A., Yee, R., Ellenbogen, K., Greer, S., Wilber, D., Silverman, R., Marinchak, R., Bernstein, R., Mittleman, R. S., Lieberman, E. H., Sullivan, C., Zorn, L., Flaker, G., Schron, E., Orav, E. J., & Goldman, L. (2000). The Mode Selection Trial (MOST) in sinus node dysfunction: Design, rationale, and baseline characteristics of the first 1000 patients. American Heart Journal, 140(4), 541-551. https://doi.org/10.1067/mhj.2000.109652
  47. Ishikawa, T., Tsuji, Y., & Makita, N. (2016). Inherited bradyarrhythmia: A diverse genetic background. Journal of Arrhythmia, 32(5), 352-358. https://doi.org/10.1016/j.joa.2015.09.009
  48. Ishikawa, T., Ohno, S., Murakami, T., Yoshida, K., Mishima, H., Fukuoka, T., Kimoto, H., Sakamoto, R., Ohkusa, T., Aiba, T., Nogami, A., Sumitomo, N., Shimizu, W., Yoshiura, K. I., Horigome, H., Horie, M., & Makita, N. (2017). Sick sinus syndrome with HCN4 mutations shows early onset and frequent association with atrial fibrillation and left ventricular noncompaction. Heart Rhythm, 14(5), 717-724. https://doi.org/10.1016/j.hrthm.2017.01.020
  49. Chang, H. Y., Lin, Y. J., Lo, L. W., Chang, S. L., Hu, Y. F., Li, C. H., Chao, T. F., Yin, W. H., & Chen, S. A. (2013). Sinus node dysfunction in atrial fibrillation patients: the evidence of regional atrial substrate remodelling. EP Europace, 15(2), 205-211. https://doi.org/10.1093/europace/eus219
  50. Thorolfsdottir, R. B., Sveinbjornsson, G., Aegisdottir, H. M., Benonisdottir, S., Stefansdottir, L., Ivarsdottir, E. V., Halldorsson, G. H., Sigurdsson, J. K., Torp-Pedersen, C., Weeke, P. E., Brunak, S., Westergaard, D., Pedersen, O. B., Sorensen, E., Nielsen, K. R., Burgdorf, K. S., Banasik, K., Brumpton, B., Zhou, W., Oddsson, A., … DBDS Genomic Consortium. (2021). Genetic insight into sick sinus syndrome. European Heart Journal, 42(20), 1959-1971. https://doi.org/10.1093/eurheartj/ehaa1108
  51. Kitamura, T., Fukamizu, S., Arai, K., Hojo, R., Aoyama, Y., Komiyama, K., Sakurada, H., & Hiraoka, M. (2016). Transient sinus node dysfunction following sinus node artery occlusion due to radiofrequency catheter ablation of the septal superior vena cava-right atrium junction. Journal of Electrocardiology, 49(1), 18-22. https://doi.org/10.1016/j.jelectrocard.2015.11.001
  52. Chugh, A., Makkar, A., Yen Ho, S., Yokokawa, M., Sundaram, B., Pelosi, F., Jongnarangsin, K., Oral, H., & Morady, F. (2013). Manifestations of coronary arterial injury during catheter ablation of atrial fibrillation and related arrhythmias. Heart Rhythm, 10(11), 1638-1645. https://doi.org/10.1016/j.hrthm.2013.09.001
  53. Hayashi, T., Mizukami, A., Kuroda, S., Matsumura, A., Goya, M., & Sasano, T. (2020). Sinus node dysfunction characterized by reduction only in maximum heart rate during exercise after superior vena cava isolation in atrial fibrillation catheter ablation - A potential complication. HeartRhythm Case Reports, 6(4), 206-209. https://doi.org/10.1016/j.hrcr.2019.12.012
  54. Barra, S., Gopalan, D., Baran, J., Fynn, S., Heck, P., & Agarwal, S. (2018). Acute and sub-acute sinus node dysfunction following pulmonary vein isolation: a case series. European Heart Journal - Case Reports, 2(1), Article ytx020. https://doi.org/10.1093/ehjcr/ytx020

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2022-04-04

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1.
Schmidt OY, Volkov DY, Brynza MS, Uvarova КH, Pavlova DY. Association of atrial fibrillation and atrial flutter with sick sinus syndrome: a review of the issue based on examples of clinical observations. Zaporozhye Medical Journal [Internet]. 2022Apr.4 [cited 2026May13];24(2):240-7. Available from: https://zmj.zsmu.edu.ua/article/view/248102

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Vol. 24 No. 2 (2022)

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Review

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