Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia

Clinical course and treatment of children and adolescents with the preexcitation syndrome - own studies

INTRODUCTION

Essentially, preexcitation syndrome is the presence of an accessory pathway in the heart, which can lead to serious consequences, ranging from atrioventricular reentrant tachycardia to sudden cardiac death. Wolff-Parkinson-White syndrome is the most common preexcitation syndrome.

AIM OF THE STUDY

The aim of the study was to evaluate the clinical course of the disease, as well as the treatment of children and adolescents hospitalized in the Department of Pediatric Cardiology in the years 2008-2015.

MATERIALS AND METHODS

The study was carried out in 45 children (62 % male, 38% female; the mean age 11 years). During the study we analyzed 12-lead ECG, 24-hour Holter ECG, echocardiography and the cycloergometric exercise test. The results of treatment were also discussed.

RESULTS

Apart from the typical features of preexcitation, the most prevalent abnormality found in ECG was atrioventricular reentrant tachycardia. In 24-hour Holter ECG the most frequently detected disorders were premature ventricular beats and premature atrial contractions. Structural heart defects were detected in 8.9% of the children. The cycloergometric exercise test was positive in 8.9% of patients. The mean duration of symptoms before the diagnosis was 2.5 years. 25% of the patients were asymptomatic. 42.2% of the children needed antiarrhythmic therapy, while 44.4% had accessory pathways ablated.

CONCLUSIONS

The most common symptom of preexcitation in the study group were heart palpitations. The most frequent type of arrhythmia in children with preexcitation syndrome was orthodromic atrioventricular reentrant tachycardia. For the majority of older children ablation of the accessory pathway was a recommended form of treatment. In younger children the standard preventive pharmacological treatment was applied for 6 to 12 months.

Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia

BACKGROUND

People with the cardiac arrhythmia supraventricular tachycardia (SVT) frequently present to clinicians in the prehospital and emergency medicine settings. Restoring sinus rhythm by terminating the SVT involves increasing the refractoriness of atrioventricular nodal tissue within the myocardium by means of vagal manoeuvres, pharmacological agents, or electrical cardioversion. A commonly used first-line technique to restore the normal sinus rhythm (reversion) is the Valsalva Manoeuvre (VM). This is a non-invasive means of increasing myocardial refractoriness by increasing intrathoracic pressure for a brief period, thus stimulating baroreceptor activity in the aortic arch and carotid bodies, resulting in increased parasympathetic (vagus nerve) tone.

OBJECTIVES

To assess the evidence of effectiveness of the VM in terminating SVT.

SEARCH METHODS

We updated the electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 7); MEDLINE Ovid (1946 to August week 3, 2014); EMBASE Classic and EMBASE Ovid (1947 to 27 August 2014); Web of Science (1970 to 27 August 2014); and BIOSIS Previews (1969 to 22 August 2014). We also checked trials registries, the Index to Theses, and the bibliographies of all relevant publications identified by these strategies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that examined the effectiveness of VM in terminating SVT.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data using a standardised form. We assessed each trial for internal validity, resolving any differences by discussion. We then extracted and entered data into Review Manager 5.

MAIN RESULTS

In this update, we did not identify any new RCT studies for inclusion. We identified two RCT studies as ongoing that we are likely to include in future updates. Accordingly, our results are unchanged and include three RCTs with a total of 316 participants. All three studies compared the effectiveness of VM in reverting SVT with that of other vagal manoeuvres in a cross-over design. Two studies induced SVT within a controlled laboratory environment. Participants had ceased all medications prior to engaging in these studies. The third study reported on people presenting to a hospital emergency department with an episode of SVT. These participants were not controlled for medications or other factors prior to intervention.The two laboratory studies demonstrated reversion rates of 45.9% and 54.3%, whilst the clinical study demonstrated reversion success of 19.4%. This discrepancy may be due to methodological differences between studies, the effect of induced SVT versus spontaneous episodic SVT, and participant factors such as medications and comorbidities. We were unable to assess any of these factors, or adverse effects, further, since they were either not described in enough detail or not reported at all.Statistical pooling was not possible due to heterogeneity between the included studies.

AUTHORS' CONCLUSIONS

We did not find sufficient evidence to support or refute the effectiveness of VM for termination of SVT. Further research is needed, and this research should include a standardised approach to performance technique and methodology.

Modified Valsalva manoeuvre to treat recurrent supraventricular tachycardia: description of the technique and its successful use in a patient with a previous near fatal complication of DC cardioversion

Patients with attacks of re-entrant supraventricular tachycardia (SVT) frequently present to the emergency department (ED). The Valsalva manoeuvre (VM) is the most effective and safe vagal manoeuvre and advocated as the first-line treatment in stable patients but has a relatively low cardioversion success rate. Improving its efficacy would reduce patients' exposure to the side effects and complications of second-line treatments and has other potential benefits. We describe a modification to the VM, which is currently being studied, and present the case of a 23-year-old patient who was successfully treated with this modified VM after a previous near-fatal complication of direct current (DC) cardioversion.

Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study

INTRODUCTION

The Valsalva manoeuvre (VM) is a recommended first-line physical treatment for patients with re-entrant supraventricular tachycardia (SVT), but is often ineffective in standard practice. A failed VM is typically followed by treatment with intravenous adenosine, which patients often find unpleasant. VM effectiveness might be improved by a modification to posture which exaggerates the manoeuvre's vagal response and reduces the need for further emergency treatment.

METHODS AND ANALYSIS

This is a multicentre randomised controlled clinical trial in 10 UK emergency departments (EDs). It compares a standard VM with a modified VM incorporating leg elevation and a supine posture after a standardised strain in stable adult patients presenting to the ED with SVT. The primary outcome measure is return to sinus rhythm on a 12-lead ECG. Secondary outcome measures include the need for treatment with adenosine or other antiarrhythmic treatments and the time patients spend in the ED. We plan to recruit approximately 372 patients, with 80% power to demonstrate an absolute improvement in cardioversion rate of 12%. An improvement of this magnitude through the use of a modified VM would be of significant benefit to patients and healthcare providers, and justify a change to standard practice.

ETHICS AND DISSEMINATION

The study has been approved by the South West-Exeter Research Ethics Committee (REC reference 12/SW/0281). The trial will be published in an international peer reviewed journal. Study findings will be sent to the European and International resuscitation councils to inform future revisions of arrhythmia management guidelines.

RESULTS

The trial will also be disseminated at international conferences and to patients through the Arrhythmia Alliance, a patient support charity.

REGISTRATION

The study is registered with Current Controlled Trials (ISRCTN67937027) and has been adopted by the National Institute for Health Research (NIHR) Clinical Research Network.