This document discusses supraventricular tachycardia (SVT) in pediatric patients. SVT is the most common abnormal heart rhythm seen in children and the most common arrhythmia requiring treatment. It is usually caused by re-entry mechanisms involving an accessory pathway or the atrioventricular node. Diagnosis involves obtaining an electrocardiogram during episodes to identify P wave patterns. Treatment options include vagal maneuvers, medications like adenosine, calcium channel blockers, or beta blockers, and cardioversion. Radiofrequency ablation can provide a cure for refractory or recurrent cases. Proper diagnosis of the underlying SVT mechanism guides selection of the most appropriate treatment approach.

1. SupraventricularSupraventricular
Tachycardia inTachycardia in
PediatricPediatric

2. Cardiac arrhythmia
• is a abnormal electrical activity in the heart
• too fast or too slow
• regular or irregular.
DefinationDefination

3. OverviewOverview

4. Sinus tachycardia
SVT
VF
VT
Atrial fib
Atrial flutter
Sinus bradycardia
Heart block
Sinus arrhythmia
PAC
PVC
Tachycardia Bradycardia
Irregular

5. In structurally normal/
abnormal heart
Congenital metabolic
disorders of
mitochondria
SLE
Rheumatic fever
Myocarditis
Toxin (diphtheria)
Pro-arrhythmic or
anti-arrhythmic
drugs
Surgical correction
of CHD
CongenitalCongenital AcquiredAcquired

6. Normal Heart RateNormal Heart Rate
Age Heart Rate
Newborn 120-160
Infant 80- 140
Toddler 1-3 yrs 80- 130
Pre School 3-5yrs 80- 120
School Age 6-12 yrs 70- 110
Adolescent 13+ 60- 100

7. Range from
Completely asymptomatic
Loss of consciousness
Sudden cardiac death
In infants
Lethargy
Poor feeding
Irritability
Cardiac failure
Underlying congenital
heart disease
In children
Palpitation
Syncope
Dizziness
Chronic fatigue
Shortness of breath
Chest discomfort

8. History
Symptoms
Frequency and length of episode
Onset and triggers
Any underlying disease
Medications
o Triggering factor
o Used for underlying cardiac disease
Evaluation Child withEvaluation Child with
ArrhythmiaArrhythmia

9. DiagnosisDiagnosis
Always do-
12 Lead ECG!!!!!
-During tachycardia
-In sinus rhythm

10. Diagnostic methodsDiagnostic methods
• Always
• Always
• Always record a rhythm
strip during any
intervention (adenosine,
cardioversion, Valsalva,
etc.)

11. Diagnostic methodsDiagnostic methods
• Holter
• Event recorder
• Exercise ECG
• Post-op atrial/ventricular pacing wires
• Esophageal pacing leads
• Adenosine can be diagnostic
• Invasive electrophysiology study

12. Sinus RhythmSinus Rhythm
Every QRS complex is preceded by a P wave
and every P wave must be followed by a QRS
The P wave morphology and axis must be
normal and
PR interval will usually be normal for that age

14. Sinus ArrhythmiaSinus Arrhythmia
Most common irregularity of heart rhythm seen
in children
Normal variant
Heart rate increases during inspiration and
decreases during expiration

15. Sinus ArrhythmiaSinus Arrhythmia
Normal phasic variation of heart rate with respiration
Variable P-P intervals
No treatment needed

16. TachyarrhythmiaTachyarrhythmia
• Supraventricular Tachycardia
• Ventricular Tachycardia

17. Basic Mechanism ofBasic Mechanism of
TachycardiaTachycardia
1. Re- entry – most common
2. Automaticity
3. Triggered activity - rare

18. Re – entry TachycardiaRe – entry Tachycardia

19. AutomaticityAutomaticity

20. SVTSVT
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 and in adolescence

21. SVTSVT
Commonest mechanism – re-entry
- Accessory pathway – 80%
-AV nodal re-entry – 20%
-Younger age – accessory pathway
-Older age - AVNRT

22. SVT - classificationSVT - classification
AV node Dependent Tachycardia AV Node independent Tachycardia
AVRT
- concealed pathway
- manifest pathway -WPW syndrome
Sinus node reentrant Tachycardia
AVNRT
- Typical ( slow-fast)
- Atypical (Fast-slow)
Atrial Tachycardia
- Focal atrial tachycardia
- Multifocal atrial tachycardia
Juctional Ectopic Tachycardia ( JET) Atrial Flutter
Permanent Juctional Reciprocating
Tachycardia ( PJRT)
Atrial Fibrillation

23. P wave in TachycardiaP wave in Tachycardia
- Important to identify p wave during the tachycardia
- Helps to guide types of SVT
- No p wave
- Short RP tachycardia
- Long RP tachycardia

24. P wave in TachycardiaP wave in Tachycardia
No visible p Wave, narrow complex
- AVNRT

25. P wave in Tachycardia –P wave in Tachycardia –
Short RPShort RP
- AVRT
- Typical AVNRT

26. P wave in Tachycardia –P wave in Tachycardia –
Short RPShort RP

27. P wave in Tachycardia –P wave in Tachycardia –
Long RPLong RP
- Atypical AVNRT
- PJRT
- Atrial tachycardia
- Sinus tachycardia
- sinus node tachycardia

28. P wave in Tachycardia –P wave in Tachycardia –
Long RPLong RP

29. What's Next?What's Next?
LOOK FOR THE R-R interval
- regular
- irregular
Gives clues on types of SVT

31. ANRT - P wave on STANRT - P wave on ST
segmentsegment
Regular R-R intervalRegular R-R interval

32. AVNRT - p wave absent orAVNRT - p wave absent or
pseudo r wave on VIpseudo r wave on VI
Regular R-R intervalRegular R-R interval

33. AET - Long RP tachycardiaAET - Long RP tachycardia
with abnormal p wavewith abnormal p wave
morphologymorphology
Regular R-R intervalRegular R-R interval

34. PJRT -Long RP tachycardiaPJRT -Long RP tachycardia
with abnormal p wavewith abnormal p wave
inverted lead II,III,aVFinverted lead II,III,aVF
Regular R-R intervalRegular R-R interval

35. Atrial flutter – saw toothAtrial flutter – saw tooth
baselinebaseline

36. MET – Irregular TachycardiaMET – Irregular Tachycardia
Long RPLong RP
different p wavedifferent p wave
morphologymorphology

37. JET – Irregular R-R intervalJET – Irregular R-R interval
p wave with VA dissociationp wave with VA dissociation

38. ManagementManagement
Treatment Option SVT Termination
1.Vagal maneuvers
2.Anti arrhythmic drugs ( IV or Oral )
3.Electrical Termination
- DC cardioversion
- Endocardial pacing
- Trans Esophageal pacing

39. ManagementManagement

40. ManagementManagement
Vagal Maneuvers
1.Smaller childrens and infants
- Ice cold facecloth to the face
- Stimulate the vagal response
1.Older childrens
- carotid massage
- Valsalva technique

41. Management - IVManagement - IV
AdenosineAdenosine
• Diagnostic and therapeutic
• Given via central line better than peripheral
• Short half life
• 100-500mcg/kg given rapid IV push
• ALWAYS!!! Record rhythm strip during adenosine

42. Adenosine ResponseAdenosine Response

43. Adenosine responseAdenosine response

44. Adenosine ResponseAdenosine Response

45. SVT TreatmentSVT Treatment
1. IV Verapamil – older childrens 0.1mg/kg
- Contraindicated in < 4 yrs old and in WPW
syndrome
1. Digoxin – useful in infants
- Contraindicated in WPW
1. IV propranolol 0.1mg/kg
2. IV Flecanaide 0.5-2mg/kg
3. IV amiodarone 5mg/kg in 30min and 5-
15mcg/kg/min
4. Cardioversion 0.5-2J/kg

46. Management- PreventionManagement- Prevention
1.No treatment
2.Anti Arrhythmic drug
3.Radiofrequency ablation

47. Management - PreventionManagement - Prevention
No Treatment
-Infrequent eposides
-Explain
-Educate on valsalva
-PRN treatment in ED

48. Management - PreventionManagement - Prevention

49. Management - PreventionManagement - Prevention

50. Treatment OptionsTreatment Options
1. AV node
- Digoxin
- Class II – beta blockers
- Class III – Amiodarone
- Class IV – Verapamil
1. Accessory pathway
- Class 1C – Flecanaide
- Class III – Amiodarone
- WPW- No Verapamil or Digoxin

51. Management - PreventionManagement - Prevention
Radiofrequency Ablation
– invasive procedure
- Curative
-Older children's
-Incessant SVT- PJRT
-Symptomatic SVT
-Drug refractory SVT
-WPW with symptomatic

52. SummarySummary
• SVT generally well tolerated, life threatening is
uncommon
• Record 12 lead ECG during arrhythmia
• Record rhythm strip during any intervention
• ECG clue for diagnosis – wide or narrow complex, p
wave relationship to QRS and regular or irregular
rhythm
• Proper diagnosis can guide appropriate Tx

53. THANK YOUTHANK YOU