Propafenone is associated with fewer recurrences of supraventricular arrhythmias in mechanically ventilated patients with septic shock and right ventricular dysfunction.

Introduction: Supraventricular arrhythmias (SVA) are common in mechanically ventilated patients with septic shock and may be aggravated by right ventricular (RV) dysfunction. Optimal rhythm-control strategies in this setting remain uncertain. We explored whether propafenone differs from amiodarone in maintaining sinus rhythm in patients with RV dysfunction. Methods: This exploratory sub-analysis of the randomized double-blind PRASE trial included patients with septic shock who developed new-onset SVA, had preserved to moderately reduced left ventricular systolic function (ejection fraction >35%), and received continuous norepinephrine at doses <1.0 µg/kg/min. Patients were classified according to the presence or absence of RV dysfunction using comprehensive echocardiographic criteria. Outcomes included cardioversion at 24 h, arrhythmia recurrence, multiple recurrences, and 12-month survival. Results: Among 162 patients with sufficient echocardiographic data, 73 (45%) met criteria for RV dysfunction. Of these, 42 received propafenone and 31 amiodarone; 89 patients without RV dysfunction served as controls. Cardioversion at 24 h did not differ significantly between propafenone and amiodarone in patients with RV dysfunction (69% vs. 56.7%, Conclusions: In mechanically ventilated patients with septic shock and RV dysfunction, propafenone was associated with fewer arrhythmia recurrences compared with amiodarone, despite similar short-term cardioversion rates. These findings are hypothesis-generating and suggest that propafenone may represent a promising alternative to amiodarone for rhythm control in critically ill patients with right ventricular dysfunction, warranting further prospective evaluation. Trial registration: ClinicalTrials.gov Identifier: NCT03029169.