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ARRYTHMIAS IN
CHILDREN
-Dr.Apoorva.E
PG,DCMS
ELECTRICAL ANATOMY OF
THE HEART
• The heart is a functional syncytium
• Network of myocytes connected to each other
by intercalated discs which have gap j...
• Sinoatrial (SA) node
• Interatrial tract (Bachmann’s bundle)
• Internodal tracts
• Atrioventricular (AV) node
• Bundle o...
CONDUCTION PATHWAY
PEDIATRIC ARRYTHMIAS
• An arrythmia is defined as an abnormality in heart rate
or rythm
• Classified as
Tachyarrythmias
Br...
Tachyarrhythmias - Symptoms
• General: palpitations,lightheadedness,
syncope,fatigue,SOB,chest pain
– Infants: poor feedin...
Tachyarrhythmias - Causes
• Primary: Underlying conduction abnormalities
• Secondary: Reversible Hs & Ts
– Hypovolemia – T...
Tachyarrhythmias - Originating in the
atria
1. SINUS ARRYTHMIA
• Normal physiologic variation in impulses
discharged from ...
Varied PP interval.No significant change in
P wave morphology/PR interval
2. SINUS TACHYCARDIA
• The sinus node sends out impulses faster than
usual >>HR
• In response to body’s need for >>CO :
ex...
P waves are present and normal , narrow
QRS, beat to beat variability
3. PREMATURE ATRIAL CONTRACTIONS
• Benign in the absence of underlying heart disease
• Common in newborn period
• Dependin...
Early p wave, sometimes with different morphology
than a sinus p wave
• Pacemaker shifts from sinus node to another
atrial site
• Normal variant
• Irregular rhythm
4.WANDERING ATRIAL PACEMAKER
5.SUPRA VENTRICULAR TACHYCARDIA
• Originating above the ventricles
• Most common abnormal tachycardia seen
in pediatric pr...
• Paroxysmal,sudden onset & offset
• Occuring at rest
• In infants,precipitated by infection and
in children by bronchodil...
• Older children present with palpitations
• Younger children – Basal HR higher for that age,HR
>> greatly with crying
• P...
• ECG similar to sinus tachycardia
• Differentiating features :
HR>230bpm,unvarying HR,abnormal P wave
axis if seen
• 3 major types
- re-entrant tachycardia with an accessory pathway
- Re-entrant tachycardia without an accessory pathway
-...
ATRIOVENTRICULAR RECIPROCATING
TACHYCARDIA (AVRT)
• Most common mechanism of SVT in infants
• Re-entrant tachycardia with ...
• Wolff-Parkinson-White syndrome :
- Characterized by the presence of a muscular bridge
connecting atria and ventricles on...
- Flow of impulses is antegrade through the
AV node and retrograde through the
accessory pathway towards the atrium
SVT in...
• Typical features of WPW are apparent when
tachycardia subsides
• Wide QRS complexes,delta waves,short PR interval
• Risk...
MANAGEMENT OF SVT
• Non pharmacological measures like
-placing an ice bag over the face
-Valsalva maneuver
-Straining
-Bre...
• If the child is hemodynamically stable,rapid iv
push of adenosine
(risk of AF)
•In older children,CCB like verapamil can...
• If the child is not stable,synchronized DC
cardioversion (1 J/kg)
• If the tachycardia is resistant, iv
procainamide,qui...
• Maintenance therapy
- When sinus rhythm is restored,
for long term maintenance,
DOC is beta blockers in both WPW and
Non...
AV NODAL RE-ENTRANT TACHYCARDIA
• Common form of SVT in adolescents
• Involves the use of 2 pathways within the AV
node
• ...
ATRIAL ECTOPIC TACHYCARDIA
• Uncommon in children
• Variable HR,usually >200bpm
• Due to a single focus of automaticity
• ...
MULTIFOCAL ATRIAL TACHYCARDIA
• More common in infants than in older
children
• Characterized by 3 or more ectopic P
waves...
Chaotic ECG pattern with multiple ectopic P
waves with abnormal axes
JUNCTIONAL ECTOPIC TACHYCARDIA
• Due to an abnormal focus of automaticity
• The focus being a conducting tissue very close...
• Occurs in early post op period or may be
congenital
• IV amiodarone is the DOC for post-op JET
• Congenital JET requires...
ATRIAL FLUTTER
• Also called intra-atrial re-entrant tachycardia
• HR > 400-600 bpm in neonates
>250-300 bpm in children
•...
• Occurs in neonates with normal hearts and in
children with CHD (with large stretched atria)
and post-op
Rapid and regula...
• Temporary slowing of HR by vagal
maneuvres/adenosine/CCB
• Synchronized DC cardioversion is the TOC
• Patients with chro...
ATRIAL FIBRILLATION
• Uncommon in infants and children
• HR > 400-700 bpm
• Irregularly irregular rhythm on ECG and pulse
...
• If stable,CCB iv procainamide/amiodarone
• If unstable,DC cardioversion
Absence of clear P waves and an irregularly irre...
Tachyarrythmias-Originating in the
ventricles
1.PREMATURE VENTRICULAR CONTRACTIONS –
• Uncommon in children
• Unifocal/mul...
• Early, wide QRS complexes
• T waves in opposite direction of QRS
• Bigeminy, sinus beat followed by PVC,this
repeating a...
2. VENTRICULAR TACHYCARDIA
• Defined as atleast 3 PVC s at >120 bpm
• Paroxysmal/incessant
• Associated with myocarditis,a...
• If stable,treat with IV
amiodarone/lidocaine/procainamide and
correct the cause
• If unstable,DC cardioversion
Wide QRS ...
3. VENTRICULAR FIBRILLATION
• Seen in children with long QT syndrome or
Brugada syndrome
• Associated with cardiomyopathie...
• Treatment: immediate DC defibrillation, CPR
• If ineffective,give IV amiodarone,lidocaine and
repeat defibrillation
• Tr...
LONG Q-T SYNDROMES
• Include genetic abnormalities of ventricular
repolarization
• Long QT – interval on ECG
• Associated ...
• Precipitated by exercise
• LQT1 events are stress induced
• LQT3 occur during sleep
• LQT2 have an intermediate pattern
...
• Diagnostic criteria
Present with syncope,seizures,palpitations
Corrected QT interval >0.47sec or a QT
interval >0.44se...
• Treatment - Beta blockers which blunt the
HR s response to exercise
• If drug induced profound bradycardia –
pacemaker
•...
Bradyarrhythmias - Symptoms
• General: altered
consciousness,fatigue,dizziness,syncope
• Hemodynamic instability: hypotens...
Bradyarrhythmias - Causes
• Primary : Abnormal pacemaker/conduction system
(congenital or postsurgical injury), cardiomyop...
Bradyarrhythmias - Types
• Sinus bradycardia
– Physiological (ie: sleep, athletes)
– pathologic al(ie: abnormal electrolyt...
• SINUS ARREST
- Failure of impulse formation within SA node
• SINOATRIAL BLOCK
- Block between SA node and surrounding at...
• SICK SINUS SYNDROME
- Due to abnormalities in either the SA node /
atrial conduction pathways / both
- Post surgery for ...
• AV BLOCKS
Type EKG Findings Causes & Clinical Significance
1st
degree
Prolonged PR interval Causes include AV nodal dise...
CONGENITAL COMPLETE AV BLOCK
• Autoimmune injury to the fetal conduction system
by maternally derived anti-SSA/Ro,anti-SSB...
• May lead to hydrops fetalis
• Present with tiredness,frequent
naps,irritability,symptoms and signs of heart
failure
• Pr...
•If HR is 50bpm or less,signs of heart failure +,CHD+,
pacemaker placement required
VAUGHAN WILLIAMS CLASSIFICATION
Class 1a – sodium fast channel blockers,prolong
repolarization
(quinidine,procainamide,dis...
Class 2 – beta blockers
(propranolol,atenolol)
Class 3 – potassium channel openers,prolong
repolarization
(amiodarone)
Cla...
THAT’S ALL
FOLKS !
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
Arrhythmias in children
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Arrhythmias in children

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Arrythmias in children , Nelson , Textbook of pediatrics , Pediatrics

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Arrhythmias in children

  1. 1. ARRYTHMIAS IN CHILDREN -Dr.Apoorva.E PG,DCMS
  2. 2. ELECTRICAL ANATOMY OF THE HEART
  3. 3. • The heart is a functional syncytium • Network of myocytes connected to each other by intercalated discs which have gap junctions • Through which electrical impulses propagate allowing rapid,synchronous depolarization of the myocardium
  4. 4. • Sinoatrial (SA) node • Interatrial tract (Bachmann’s bundle) • Internodal tracts • Atrioventricular (AV) node • Bundle of His • Right and left bundle branches • Purkinje fibers ELECTRICAL CONDUCTION COMPONENTS
  5. 5. CONDUCTION PATHWAY
  6. 6. PEDIATRIC ARRYTHMIAS • An arrythmia is defined as an abnormality in heart rate or rythm • Classified as Tachyarrythmias Bradyarrythmias Atrial Junctional Ventricular Heart blocks
  7. 7. Tachyarrhythmias - Symptoms • General: palpitations,lightheadedness, syncope,fatigue,SOB,chest pain – Infants: poor feeding, tachypnoea, irritability, sleepiness, pallor, vomiting • Hemodynamic instability: respiratory distress/failure,hypotension,poor end-organ perfusion,LOC,sudden collapse
  8. 8. Tachyarrhythmias - Causes • Primary: Underlying conduction abnormalities • Secondary: Reversible Hs & Ts – Hypovolemia – Toxins – Hypoxia – Tamponade – H+ ions (acidosis) – Tension pneumothorax – Hypoglycemia – Thrombosis (coronary, pulmonary) – Hypothermia – Trauma – Hypo/Hyperkalemia
  9. 9. Tachyarrhythmias - Originating in the atria 1. SINUS ARRYTHMIA • Normal physiologic variation in impulses discharged from SA node in relation to respiration • HR slows during expiration,increases during inspiration • Drugs like digoxin exaggerate it • Abolished by exercise
  10. 10. Varied PP interval.No significant change in P wave morphology/PR interval
  11. 11. 2. SINUS TACHYCARDIA • The sinus node sends out impulses faster than usual >>HR • In response to body’s need for >>CO : exercise,anxiety, fever, hypovolemia or circulatory shock, anemia, CHF, administration of catecholamines, thyrotoxicosis & myocardial disease.
  12. 12. P waves are present and normal , narrow QRS, beat to beat variability
  13. 13. 3. PREMATURE ATRIAL CONTRACTIONS • Benign in the absence of underlying heart disease • Common in newborn period • Depending on prematurity of the beat,PAC’s may result in a normal/prolonged/absent QRS complex Conducted to ventricle with aberrant or widened QRS complex Not conducted to ventricle, apparent pause
  14. 14. Early p wave, sometimes with different morphology than a sinus p wave
  15. 15. • Pacemaker shifts from sinus node to another atrial site • Normal variant • Irregular rhythm 4.WANDERING ATRIAL PACEMAKER
  16. 16. 5.SUPRA VENTRICULAR TACHYCARDIA • Originating above the ventricles • Most common abnormal tachycardia seen in pediatric practice • Most common arrhythmia requiring treatment in pediatric population • Most frequent age presentation: 1st 3 months of life, 2nd peaks @ 8-10 yrs and in adolescents
  17. 17. • Paroxysmal,sudden onset & offset • Occuring at rest • In infants,precipitated by infection and in children by bronchodilators,decongestants • Rates of SVT vary with age (>180 bpm) • Short paroxysms usually are not dangerous • Prolonged attack lasting for 6-24hrs or HR > 300 bpm lead to heart failure
  18. 18. • Older children present with palpitations • Younger children – Basal HR higher for that age,HR >> greatly with crying • P waves difficult to define, but 1:1 with normal QRS
  19. 19. • ECG similar to sinus tachycardia • Differentiating features : HR>230bpm,unvarying HR,abnormal P wave axis if seen
  20. 20. • 3 major types - re-entrant tachycardia with an accessory pathway - Re-entrant tachycardia without an accessory pathway - Ectopic/automatic tachycardias AVRT AVNRT ATRIAL ECTOPICS JUNCTIONAL ECTOPICS ATRIAL FLUTTER ATRIAL FIBRILLATION
  21. 21. ATRIOVENTRICULAR RECIPROCATING TACHYCARDIA (AVRT) • Most common mechanism of SVT in infants • Re-entrant tachycardia with an accessory pathway • Flow of impulses may be bidirectional or retrograde only
  22. 22. • Wolff-Parkinson-White syndrome : - Characterized by the presence of a muscular bridge connecting atria and ventricles on either the right or left side of AV ring - Flow of impulses is bidirectional
  23. 23. - Flow of impulses is antegrade through the AV node and retrograde through the accessory pathway towards the atrium SVT in a child with WPW showing normal QRS complexes with P waves seen on upstroke of T waves
  24. 24. • Typical features of WPW are apparent when tachycardia subsides • Wide QRS complexes,delta waves,short PR interval • Risk of sudden death
  25. 25. MANAGEMENT OF SVT • Non pharmacological measures like -placing an ice bag over the face -Valsalva maneuver -Straining -Breath holding
  26. 26. • If the child is hemodynamically stable,rapid iv push of adenosine (risk of AF) •In older children,CCB like verapamil can be given iv (C/I in <1year)
  27. 27. • If the child is not stable,synchronized DC cardioversion (1 J/kg) • If the tachycardia is resistant, iv procainamide,quinidine,flecainide,sotalol, amiodarone can be tried • If SVT still persists,catheter ablation with success rate of 80-95% Radiofrequency Cryo Surgical
  28. 28. • Maintenance therapy - When sinus rhythm is restored, for long term maintenance, DOC is beta blockers in both WPW and Non WPW syndromes - Digoxin can be given in infants with no accessory pathway
  29. 29. AV NODAL RE-ENTRANT TACHYCARDIA • Common form of SVT in adolescents • Involves the use of 2 pathways within the AV node • Precipitated by exercise • Present with syncopal attacks • Good control on antiarrythmic therapy • Beta blockers remain the drug of choice for maintenance
  30. 30. ATRIAL ECTOPIC TACHYCARDIA • Uncommon in children • Variable HR,usually >200bpm • Due to a single focus of automaticity • On starting pharmacologic therapy,the tachycardia gradually slows down only to speed up again • ECG shows ectopic p waves with an abnormal axis
  31. 31. MULTIFOCAL ATRIAL TACHYCARDIA • More common in infants than in older children • Characterized by 3 or more ectopic P waves and varying PR intervals • Spontaneous resolution occurs usually by 3 years of age
  32. 32. Chaotic ECG pattern with multiple ectopic P waves with abnormal axes
  33. 33. JUNCTIONAL ECTOPIC TACHYCARDIA • Due to an abnormal focus of automaticity • The focus being a conducting tissue very close to the AV node (junctional) • Discharge of impulses from junctional tissue exceeds SA nodal discharge leading to AV dissociation
  34. 34. • Occurs in early post op period or may be congenital • IV amiodarone is the DOC for post-op JET • Congenital JET requires catheter ablation • Maintenance therapy with amiodarone/sotalol
  35. 35. ATRIAL FLUTTER • Also called intra-atrial re-entrant tachycardia • HR > 400-600 bpm in neonates >250-300 bpm in children • Due to re-entrant pathway located in the right atrium circling the tricuspid valve annulus • AV dissociation occurs and ventricles respond to 2nd - 4th atrial beat
  36. 36. • Occurs in neonates with normal hearts and in children with CHD (with large stretched atria) and post-op Rapid and regular saw-toothed flutter waves
  37. 37. • Temporary slowing of HR by vagal maneuvres/adenosine/CCB • Synchronized DC cardioversion is the TOC • Patients with chronic atrial fluttter are at >> risk for thromboembolism and stroke -require anticoagulants • Maintenance therapy with type 1 and type 3 agents
  38. 38. ATRIAL FIBRILLATION • Uncommon in infants and children • HR > 400-700 bpm • Irregularly irregular rhythm on ECG and pulse • Post op,in CHD with enlarged atria,thyrotoxicosis,pulmonary embolism,pericarditis,cardiomyopathy
  39. 39. • If stable,CCB iv procainamide/amiodarone • If unstable,DC cardioversion Absence of clear P waves and an irregularly irregular ventricular response (No two R-R intervals are the same)
  40. 40. Tachyarrythmias-Originating in the ventricles 1.PREMATURE VENTRICULAR CONTRACTIONS – • Uncommon in children • Unifocal/multifocal • Abolished on exercise • If unifocal/disappearing with exercise/ associated with normal heart,then considered benign,no therapy needed. • Advise patients to avoid caffeine and other stimulants
  41. 41. • Early, wide QRS complexes • T waves in opposite direction of QRS • Bigeminy, sinus beat followed by PVC,this repeating as a pattern also frequently seen
  42. 42. 2. VENTRICULAR TACHYCARDIA • Defined as atleast 3 PVC s at >120 bpm • Paroxysmal/incessant • Associated with myocarditis,anomalous LCA,MVP,primary cardiac tumors,cardiomyopathy / Post-op • Prompt treatment to prevent degeneration into VF
  43. 43. • If stable,treat with IV amiodarone/lidocaine/procainamide and correct the cause • If unstable,DC cardioversion Wide QRS (>0.08 sec), P waves may be unidentifiable or not related to QRS
  44. 44. 3. VENTRICULAR FIBRILLATION • Seen in children with long QT syndrome or Brugada syndrome • Associated with cardiomyopathies,structural heart diseases causing ventricular dysfunction • Sudden death occurs unless an effective ventricular beat is reestablished rapidly
  45. 45. • Treatment: immediate DC defibrillation, CPR • If ineffective,give IV amiodarone,lidocaine and repeat defibrillation • Treat the cause once sinus rhythm is established
  46. 46. LONG Q-T SYNDROMES • Include genetic abnormalities of ventricular repolarization • Long QT – interval on ECG • Associated with malignant ventricular arrythmias leading to sudden death • Atleast 50% are familial
  47. 47. • Precipitated by exercise • LQT1 events are stress induced • LQT3 occur during sleep • LQT2 have an intermediate pattern • LQT3 has highest probability of sudden death
  48. 48. • Diagnostic criteria Present with syncope,seizures,palpitations Corrected QT interval >0.47sec or a QT interval >0.44sec Notched T waves Low HR for age Familial history of LQTS/sudden death
  49. 49. • Treatment - Beta blockers which blunt the HR s response to exercise • If drug induced profound bradycardia – pacemaker • If drug resistant,LQT3- implantable cardiac defibrillator
  50. 50. Bradyarrhythmias - Symptoms • General: altered consciousness,fatigue,dizziness,syncope • Hemodynamic instability: hypotension, poor end-organ perfusion, respiratory distress/failure, sudden collapse
  51. 51. Bradyarrhythmias - Causes • Primary : Abnormal pacemaker/conduction system (congenital or postsurgical injury), cardiomyopathy, myocarditis • Secondary : Reversible Hs & Ts: – Hypoxia – Hypotension – H+ ions (acidosis) – Heart block – Hypothermia – Hyperkalemia – Trauma (head) – Toxins/drugs (cholinesterase inhibitors, Ca++ channel blockers, β blockers, digoxin, α2 agonists, opioids)
  52. 52. Bradyarrhythmias - Types • Sinus bradycardia – Physiological (ie: sleep, athletes) – pathologic al(ie: abnormal electrolytes, infection, drugs, hypoglycemia, hypothyroidism, ↑ICP)
  53. 53. • SINUS ARREST - Failure of impulse formation within SA node • SINOATRIAL BLOCK - Block between SA node and surrounding atrium preventing conduction of impulses Rare in children Digoxin toxicity,extensive atrial surgery
  54. 54. • SICK SINUS SYNDROME - Due to abnormalities in either the SA node / atrial conduction pathways / both - Post surgery for CHD (fontan,mustard,senning procedures) or even in patients with normal heart - Usually asymptomatic and don’t require treatment - Periods of marked sinus slowing present with dizziness and syncope pacemaker if symptoms recur
  55. 55. • AV BLOCKS Type EKG Findings Causes & Clinical Significance 1st degree Prolonged PR interval Causes include AV nodal disease,myocarditis,↑K+, drugs (ie: Ca++ channel blockers, β-blockers, digoxin), acute rheumatic fever. Usually asymptomatic. 2nd degree Mobitz type I Wenchebach Progressive prolongation of PR interval until a P wave is not conducted.After this dropped beat cycle starts again with a short PR interval Usually due to block within AV node. Caused by drugs (ie: Ca++ channel blockers, β-blockers, digoxin). Can cause dizziness. Typically transient and benign; Rarely progresses to 3rd degree heart block. 2nd Degree Mobitz type II Prolonged constant PR interval, inhibition of a set proportion of atrial impulses Usually caused by defect in conduction pathway or acute coronary syndrome, leading to block below AV node & His bundle. Symptoms include palpitations, presyncope, syncope. Can progress to 3rd degree heart block; often requires pacemaker. 3rd Degree complete AV dissociation. No atrial impulses are conducted to the ventricle Congenital or caused by conduction system disease(myocardial tumors/abscess/myocarditis) or injury (surgery for vsd). Most symptomatic form of heart block: fatigue, presyncope, syncope. Usually requires pacemaker
  56. 56. CONGENITAL COMPLETE AV BLOCK • Autoimmune injury to the fetal conduction system by maternally derived anti-SSA/Ro,anti-SSB/La antibodies • Maternal SLE or sjogren syndrome • NKX2-5 gene mutation has congenital complete av block with asd • High fetal loss rate
  57. 57. • May lead to hydrops fetalis • Present with tiredness,frequent naps,irritability,symptoms and signs of heart failure • Prominent peripheral pulses due to compensatory >> in stroke volume • Murmur + • ECG shows P waves and QRS complexes having no constant relationship
  58. 58. •If HR is 50bpm or less,signs of heart failure +,CHD+, pacemaker placement required
  59. 59. VAUGHAN WILLIAMS CLASSIFICATION Class 1a – sodium fast channel blockers,prolong repolarization (quinidine,procainamide,disopyramide) Class1b – sodium fast channel blockers,shorten repolarization (lidocaine,mexiletine,phenytoin) Class 1c – sodium channel blockers (flecainide,propafenone)
  60. 60. Class 2 – beta blockers (propranolol,atenolol) Class 3 – potassium channel openers,prolong repolarization (amiodarone) Class 4 – miscellaneous (verapamil,adenosine,digoxin)
  61. 61. THAT’S ALL FOLKS !

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