Pediatric arrhythmia

3,237 views
2,897 views

Published on

0 Comments
12 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,237
On SlideShare
0
From Embeds
0
Number of Embeds
85
Actions
Shares
0
Downloads
0
Comments
0
Likes
12
Embeds 0
No embeds

No notes for slide
  • Onset at infant stage, disappear in 93%, but 31% recur at average 8 y/o. Onset age >5y/o, persist in 78%.
  • <10% of terminal rhythm is VT in pediatric pt.
  • <=1 low, 2~3 intermediate, >=4 high probability
  • RVOT origin, LBBB with inf axis, sensitive to beta-blocker
  • Mortality high when associate with CHD (5~8% vs. 29~40%) at previous reports (prior to NB pacemaker) V rate <55bpm, wide QRS associate with mortality
  • Risk factor DCM: Z score of average pacing rate (Z>0.4) p=0.02, and age of pacemaker requirement, DCM- LVEDD> 2SD or LVEF<45% Epicardial- previous <5y/o, <30kg , now <1y/o, <8kg, vein occlusion, lead problem
  • Pediatric arrhythmia

    1. 1. Pediatric Arrhythmia 台大醫院小兒部 邱舜南醫師
    2. 2. Newborn 1 week to 3 months 3 months to 2 years 2 years to 10 years 10 years to adult 100-180 100-220 80-170 70-110 55-90 80-160 80-200 70-120 60-90 50-90 Up to 220 Up to 220 Up to 200 Up to 200 Up to 200 Age Resting (awake) Resting (sleeping) Exercise, fever Heart Rate (beats per min) Normal heart rates for infants and children
    3. 3. Pediatric Arrhythmia Tachycardia: PSVT VT Bradycardia: Sinus bradycardia AV block
    4. 4. Paroxysmal supraventricular tachycardia
    5. 5. Supraventricular tachycardia in pediatric patients * HR 215-350 (mean 280) in infants * 98% narrow QRS * Atrial fibrillation 0.4% 1-4% in infants with preexcitation
    6. 6. Josephson Wu D Gillette Ko Wu M Naheed (adult) (adult) (Ped) (Ped) (Ped) (Fetal) AVNRT 51 72 24 13 18 - AVRT 34 13 33 73 72 73 Atrial 15 15 42 14 10 27
    7. 7. PSVT in children AVRT AVNRT EAT
    8. 8. AVRT in Pediatric Patients * Peak age: young infants 5- 8 yr >13 yr * The younger the onset age, the less the recurrences ~ JACC 16(5):1215-20, 1990
    9. 9. AVRT * Manifest (delta wave) 0.06-0.3% general population 0.3-1% congenital heart disease * Concealed 57% for all AP (68% for left AP, 42% for right AP) * Ebstein’s anomaly * l –TGA * ? Heterotaxy syndrome
    10. 10. WPW WPW ~ A Population Study of the Natural History of Wolff-Parkinson-White Syndrome in Olmsted Count, Minnesota, 1953-1989(Circulation 1993;87:866-873
    11. 11. Preexcitation and Wolff-Parkinson-White Syndrome <ul><li>Bundle branch block with short PR interval in healthy young people prone to paroxysmal tachycardia </li></ul><ul><ul><li>Wolff L, Parkinson J, White PD. Am Heart J 1930:5:686-692. </li></ul></ul>
    12. 12. Preexcitation Syndrome <ul><li>Pre-excitation : an anomalous atrioventricular connection capable of antegrade and usually retrograde conduction. </li></ul><ul><li>WPW syndrome : patients with both pre-excitation in the surface ECG and symptoms caused by arrhythmias, either regular (circus movement tachycardias) or irregular (atrial fibrillation). </li></ul>
    13. 13. Tachycardia in WPW syndrome
    14. 14. Clinical manifestation of AVRT in infants & children <ul><li>Risk of Af (Vf): 1.5/1000 patient years, increases in the 2 nd decade </li></ul><ul><li>42 cases with cardiac arrest due to WPW, median 10 yr, 1day to 21yrs, mortality 36%, sequalae 33% </li></ul><ul><li>Risk factor: shortest RR at Af < 250 (220) ms, multiple AC </li></ul><ul><li>, </li></ul>
    15. 15. AV Nodal Reentrant Tachycardia (AVNRT) <ul><li>Dual AV nodal pathway (AH jump for 50 ms), but may be innocent </li></ul><ul><li>Rare in children younger than 5 years of age </li></ul><ul><li>Slow-fast AVNRT </li></ul>
    16. 18. Atrial Tachycardia (AT) <ul><li>Warm-up & cool-down in ectopic AT, but reentry in postop intra-atrial reentry tachycardia </li></ul><ul><li>May associated variable AV conduction or BBB </li></ul><ul><li>A propensity to secondary cardiomyopathy </li></ul>
    17. 19. Management of SVT <ul><li>Vagal maneuver </li></ul><ul><li>Adenosine </li></ul><ul><ul><li>Rapid flush from IV cath nearest to heart </li></ul></ul><ul><ul><li>0.1 then 0.2mg/kg (max. 6 then 12mg) </li></ul></ul><ul><li>Verapamil : 0.1 mg/kg, contraindicate in infant, use careful in young child, not use in manifest WPW </li></ul><ul><li>Digoxin, ß-blocker, Procainamide, Amiodarone </li></ul><ul><li>Cardioversion if hemodaynamically unstable </li></ul>
    18. 21. Treatment strategies of SVT in pediatric patients: medical or ablation <ul><li>* Natural history- </li></ul><ul><ul><li>prefer medication at age <6y/o </li></ul></ul><ul><li>* Complications- </li></ul><ul><ul><li>Potential lesion growth, coronary injury, AV block, vessel injury, … </li></ul></ul><ul><li>* Ablation efficacy and safety </li></ul>
    19. 22. Initial Success of RFCA of SVT in Children Without CHD AVRT 91% (2816/3110) AVNRT 96% (885/920) 98% (60/61) 100% (15/15) PRCAR NTUH-P Favor able factors left lateral AP(95%) experience (> 20 cases) Unfavorable factors Right free wall AP(86%) Septal AP (87%) decreased BW
    20. 23. Probability of supraventricular tachycardia recurrence in pediatric patients Wu et al. Cardiology. 85(5):284-9, 1994. <ul><li>90 patients with initial SVT episode before 15 yr (f/u 2-228; median, 215 months). </li></ul><ul><li>Mobidity: CHF 14 (16%), CVA 1. </li></ul><ul><li>SVT recurrence were associated with an older age at initial SVT episodes (p < 0.001). Even though, about 40% of the patients whose initial attacks occurred during infancy had recurrences 5 years later. </li></ul>
    21. 24. Complications of RFCA of SVT in Children Without CHD AV block 0.68% (25) 1% (1) Perforation 0.66% (10) 0 (0) brachial palsy 0.27% (10) 2% (2, transient) emboli 0.22% (8) 0 (0) pneumothorax 0.19% (7) 0 (0) death 0.11% (4) 0 (0) Risk factors : BW <15 kg, left free AP, experience AV block risk factors : anteroseptal AP, AVNRT, BW < 15 kg PRCAR NTUH-P 3.2% (118) 3 (3)
    22. 25. RFCA of SVT in Children Without CHD Recurrences AVRT 23 % 12 % AVNRT 29 % 7 % Unfavorable factors right free wall septal pathway PRCAR NTUH-P
    23. 26. Result of PSVT ≦ 5y/o <ul><li>Final success rate of RFCA for all diagnoses was 94%. </li></ul><ul><li>Total recurrence rate was 13%. </li></ul><ul><li>Atrial tachycardia in postoperative CHD was associated with the lowest success rate (57%) and highest recurrence rate (25%). </li></ul><ul><li>RFCA of SVT in those less than 6 years-old has comparable success and recurrence rate. But for AVNRT or paraHisian accessory pathway, conservative treatment is still suggested </li></ul>Int J Cardiol 72 (2000) 221–227
    24. 27. Ventricular Tachycardia
    25. 28. Etiology <ul><li>Relative rare in pediatric patients. </li></ul><ul><li>Congenital- </li></ul><ul><ul><li>congenital long QT syndrome, Brugada syndrome?, </li></ul></ul><ul><ul><li>Arrhythmogenic RV dysplasia </li></ul></ul><ul><ul><li>Idiopathic VT </li></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Myocarditis, HCM, DCM </li></ul></ul><ul><ul><li>hypoxemia, acidosis, e- imbalance, toxin </li></ul></ul><ul><ul><li>CHD postoperatively as TOF s/p </li></ul></ul><ul><ul><li>Myocardial tumor </li></ul></ul>
    26. 29. Congenital Long QT Syndromes <ul><li>Romano-Ward (1963) & Jerwell-Lange-Nelson (1957) </li></ul><ul><li>Ion channel defects </li></ul>
    27. 30. <ul><li>ß-blocker therapy </li></ul><ul><li>Left cardiac sympathetic denervation </li></ul><ul><li>ICD implantation </li></ul>
    28. 31. Idiopathic VT <ul><li>Idiopathic RV VT vs. Idiopathic LV VT </li></ul><ul><li>The younger onset age, more spontaneous resolution </li></ul><ul><li>Syncope, heart failure (cardiomyopathy) 15% </li></ul><ul><li>Medication, RFCA </li></ul>~ JACC 33(7): 2062-72, 1999
    29. 32. 86 VT patients in our institution (M/F 49/37) Infant Child(1-10yr) Adolescent p value VT spon. resolution 4/5(80%) 0/10(0%) 1/20(5%) <0.05(I. vs C.) <0.05(I. vs A.) Ablation 0/0(0%) 4/10(40%) 16/20(80%) 0.11(I. vs C.) <0.05(I vs A.) Recur After Ablation 1/4(25%) 3/16(18%) 0.79 Idiopathic LV RV P-value Initial success 17/18(94%) 2/3(67%) 0.271 Recurrence 3/17(17%) 2/2(100%) 0.058
    30. 33. Management of VT <ul><li>Amiodarone : 5 mg/kg over 20-60 min, max 15mg/kg </li></ul><ul><ul><li>Prolong QT, hypotension </li></ul></ul><ul><li>Procainamide : 15 mg/kg over 30-60 min. </li></ul><ul><ul><li>Prolong QT, induce polymorphic VT, AV block, myocardial suppression </li></ul></ul><ul><li>Lidocaine : 1mg/kg then 20-50ug/kg/min </li></ul><ul><ul><li>Most effective in VT caused by myocardial ischemia </li></ul></ul><ul><li>Vasopressin : 0.4-1U/kg/dose then 0.005-0.1 U/kg/hr </li></ul><ul><ul><li>No more recommend in child </li></ul></ul><ul><li>DC cardioversion : 0.5~1 J/kg then 2 J/kg. </li></ul>
    31. 36. Bradyarrhythmia <ul><li>Sinus bradycardia </li></ul><ul><ul><li>Sinus node dysfunction (SSS) rare in children except CHD postoperatively (Senning, TCPC) </li></ul></ul><ul><ul><li>Hypoxemia, hypothermia, acidosis, e- imbalance, toxin, … </li></ul></ul><ul><li>AV block </li></ul>
    32. 37. Atrioventricular block Acquired: surgery (VSD, LVOTO, L-TGA), myocarditis Congenital: transplacental autoimmune injury l -TGA
    33. 38. CAVB associated with myocarditis <ul><li>Return of AV conduction in 67% of young myocarditis with advanced AV block patients. </li></ul><ul><li>The average time of recovery is 3.3 ± 2.8 days. </li></ul><ul><li>persistent AV block > 1 week indicates the need for permanent cardiac pacing. </li></ul><ul><ul><li>~ Pediatr Cardiol 24:495–497, 2003 </li></ul></ul>
    34. 39. Congenital AV block <ul><li>1/15,000 –20,000 live birth </li></ul><ul><li>Maternal SLE with SSA/anti-Ro, SSB/anti-La (+) </li></ul><ul><li>May associated with LQTS </li></ul><ul><li>Usually irreversible and need a pacemaker </li></ul>Pacemaker free survival rate
    35. 40. Congenital AV block Epicardial VVI® pacemaker Transvenous VDD pacemaker
    36. 41. F/U of congenital CAVB <ul><li>Lead problems- fracture </li></ul><ul><li>SCD due to prolonged QT </li></ul><ul><li>DCM </li></ul>
    37. 42. Bradyarrhythmias – treatment <ul><li>Atropine </li></ul><ul><ul><li>0.02 mg/kg IV (IO or ET) </li></ul></ul><ul><ul><li>Minimum: 0.1 mg </li></ul></ul><ul><ul><li>Maximum: 0.5 mg in children; 1 mg in adolescent. May repeat once. </li></ul></ul><ul><li>Epinephrine </li></ul><ul><li>Isoprotenolol </li></ul><ul><li>Transcutaneous pacing </li></ul>
    38. 44. Thanks for your attention!

    ×