Junctional ectopic tachycardia in infants and children

Successful treatment with ivabradine for haemodynamically unstable junctional ectopic tachycardia occurring early after ST-elevation myocardial infarction

Junctional ectopic tachycardia (JET) is a relatively uncommon arrhythmia predominantly observed in infancy, often occurring after congenital heart surgery. Although JET is rare in adults, it can occur in the presence of myocardial ischaemia. We describe a woman in her early 70s who presented with multivessel ST-segment elevation myocardial infarction and underwent percutaneous coronary intervention on left anterior descending artery and right coronary artery. She developed JET on the second day, resulting in haemodynamic compromise. Despite initial treatment attempts including amiodarone and beta-blocking agents proving insufficient in controlling JET, we successfully managed by administering ivabradine. Subsequently, she was discharged with recovered cardiac function without recurrence of JET. JET often proves refractory to multiple antiarrhythmic agents and can lead to unfavourable outcomes. Several case reports have demonstrated the effectiveness of ivabradine in treating JET during infancy, which can also be an effective therapeutic option for adult without adversely affecting haemodynamics.

Emerging concepts in heart failure management and treatment: focus on tachycardia-induced cardiomyopathy

Tachycardia-induced cardiomyopathy is an entity characterized by reversible dysfunction of the left ventricle, which can be induced by different types of arrhythmia such as atrial fibrillation, atrial flutter, incessant supraventricular tachycardia and ventricular arrhythmia (more frequent causes). Correct identification of the causative arrhythmia and normalization of the heart rate (e.g through medical treatment, electrical cardioversion, ablation) can lead to recovery of left ventricular function. Tachycardia-induced cardiomyopathy should be suspected in patients with tachycardia and left ventricular dysfunction (heart failure setting), especially when there is no history of previous heart disease. Its usual phenotype is that of non-ischaemic/non-valvular dilated cardiomyopathy and it can occur in both children (main cause: permanent junctional reciprocating tachycardia) and adults (main cause: atrial fibrillation). With proper treatment, most cases recover within a few months, though there is a risk of relapse, especially when the causal arrhythmia reappears or its control is lost. This is a narrative review that comprehensively addresses the pathophysiology, clinical manifestations, and therapeutic management of tachycardia-induced cardiomyopathy. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Randomized controlled trial to evaluate the effect of prophylactic amiodarone versus dexmedetomidine on reducing the incidence of postoperative junctional ectopic tachycardia after pediatric open heart surgery

Background

Junctional ectopic tachycardia (JET) is the most common arrhythmia after pediatric open-heart surgeries (OHS), causing high morbidity and mortality. As diagnosis is often missed in patients with minimal hemodynamic instability, its incidence depends on active surveillance. A prospective randomized trial evaluated the efficacy and safety of prophylactic amiodarone and dexmedetomidine to prevent and control postoperative JET.

Methods

Consecutive patients aged under 12 years were randomized into amiodarone, dexmedetomidine (initiated during anesthetic induction) and control groups. Outcome measures included incidence of JET, inotropic score, ventilation, and intensive care unit (ICU) duration and hospital stay, as well as adverse drug effects.

Results

Two hundred and twenty-five consecutive patients with a median age of 9 months (range 2 days-144 months) and a median weight of 6.3 kg (range 1.8 kg-38 kg) were randomized with 70 patients each to amiodarone and dexmedetomidine groups, and the rest were controls. Ventricular septal defect and Fallot's tetralogy were the common defects. The overall incidence of JET was 16.4%. Syndromic patients, hypokalemia, hypomagnesemia, longer bypass, and cross-clamp duration were the risk factors for JET. Patients with JET had significantly prolonged ventilation (P = 0.043), longer ICU (P = 0.004), and hospital stay (P = 0.034) than those without JET. JET was less frequent in amiodarone (8.5%) and dexmedetomidine (14.2%) groups compared to controls (24.7%) (P = 0.022). Patients receiving amiodarone and dexmedetomidine had significantly lower inotropic requirements, lower ventilation duration (P = 0.008), ICU (P = 0.006), and hospital stay (P = 0.05). Adverse effects such as bradycardia and hypotension after amiodarone and ventricular dysfunction after dexmedetomidine were not significantly different from controls.

Conclusion

Prophylactic amiodarone or dexmedetomidine started before OHS is effective and safe for the prevention of postoperative JET.

Early and Late Postoperative Tachyarrhythmias in Children and Young Adults Undergoing Congenital Heart Disease Surgery

The population of patients with congenital heart disease is constantly growing with an increasing number of individuals reaching adulthood. A significant proportion of these children and young adults will suffer from tachyarrhythmias due to the abnormal anatomy, the hemodynamic burden, or as a sequela of surgical treatment. Depending on the underlying mechanism, arrhythmias may arise in the early postoperative period (hours to days after surgery) or in the late postoperative period (usually years after surgery). A good understanding of the electrophysiological characteristics and pathophysiological mechanisms is therefore crucial to guide the therapeutic approach. Here, we synthesize the current state of knowledge on epidemiological features, risk factors, pathophysiological insights, electrophysiological features, and therapy regarding tachyarrhythmias in children and young adults undergoing reparative surgery for congenital heart disease. The evolution and latest data on treatment options, including pharmacological therapy, ablation procedures, device therapy decision, and thromboprophylaxis, are summarized. Finally, throughout this comprehensive review, knowledge gaps and areas for future research are also identified.

Incidence of non-benign arrhythmia in neonatal intensive care unit: 18 years experience from a single center

Background

Non-benign arrhythmias, which require urgent recognition and care in neonatal intensive care unit (NICU) settings, are rare but can severely impact neonates. We aimed to clarify the epidemiology and characteristics of non-benign arrhythmias and their influence on neonates.

Methods

This single-center retrospective study included patients admitted to the NICU at Kurashiki Central Hospital between January 2001 and December 2019. Only patients with structurally normal hearts were included. The use of direct cardioversion (DC), antiarrhythmic agents, and the presence of risk factors was reviewed from medical records.

Results

Of the 8082 admissions, 2919 patients (36.1%) were low birth weight infants (LBWI) weighing less than 1500 g. There were 23 patients with arrhythmias (nine of them were LBWIs) with an incidence of 0.28%. There were 16 patients with tachyarrhythmia (eight supraventricular tachycardia [SVT] cases, three atrial flutters [AFL] cases, three ventricular tachycardia cases, two junctional ectopic tachycardia cases), and seven with bradyarrhythmia (all with complete atrioventricular [AV] block). For tachyarrhythmia cases, seven patients required DC, and eight were on antiarrhythmic agents at the time of discharge. Two patients (28.5%) with complete AV block required pacemaker implantation before discharge. The treatment strategy was dependent on the type of arrhythmia. All patients were discharged without significant morbidities.

Conclusions

The incidence of non-benign arrhythmias was as low as 0.28%. Arrhythmias can be managed successfully in neonates, yet risk factors related to mortality warrant further study.

Successful cryoablation of junctional ectopic tachycardia is feasible in a 13.4kg, 18-month-old toddler

JET (junctional ectopic tachycardia) is a complicated and rare form of supraventricular tachycardia that is associated with a high rate of morbidity and mortality. Pharmaceutical management can be insufficient, and cryoablation has been described for congenital JET management. We describe cryoablation for congenital JET in an prior 32-week gestational aged, 18-month-old (corrected 16-month-old) with no JET post-ablation with normal Holter and follow-up within 6 months following cryoablation. This report demonstrates the safety and feasibility of cryoablation in patients as young as 18 months old.

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Cryoablation of congenital JET was safe for an 18-month-old (corrected gestational age 14 months) infant.

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Follow-up of 6 months demonstrated no recurrence of JET.

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The 4mm Cryo-catheter was a safe tool for JET ablation.

Atypical fetal junctional ectopic tachycardia: a case report and literature review

Background

Junctional ectopic tachycardia (JET) is caused by ectopic rhythms, originating in the atrioventricular node, typically with heart rate between 200 and 250 bpm. Herein, we present a case of fetal JET with normal fetal heart rate and a review of nine cases.

Case presentation

A 32-year-old, gravida 2, para 1, woman in whom fetal JET could not be diagnosed prenatally because the fetal heart rate was within the normal range. The fetus was diagnosed with premature restriction of the foramen ovale, and a cesarean section was performed, owing to the right heart overload that was characterized by fetal ascites and abnormal fetal Doppler velocity. Postnatally, the female neonate was diagnosed with JET on a 12-lead electrocardiogram, which revealed a neonatal heart rate of 158 bpm with narrow QRS and atrioventricular dissociation. After failure to respond to amiodarone therapy, she was treated with flecainide, which controlled the JET rate from 120 to 150 bpm. Fetal tachycardia with ventriculo-atrial (VA) dissociation or 1:1 VA conduction with a shorter VA interval than that of atrioventricular reentrant tachycardia confirmed the diagnosis of fetal JET.

Conclusions

JET should be suspected even in the absence of tachycardia in patients with ductus venosus and pulmonary vein retrograde flow or tricuspid and mitral regurgitation without a cardiac anomaly, as tachycardia might sometimes be intermittent in cases of JET.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04655-6.

Congenital junctional ectopic tachycardia in the paediatric emergency department

Congenital junctional ectopic tachycardia is a rare but serious cardiac arrhythmia seen in neonates and young infants. It is frequently resistant and refractory to first-line treatment options such as cardioversion with adenosine and direct current shock, and it carries a high morbidity and mortality rate. The aim of this article is to present the case of congenital junctional ectopic tachycardia observed in a 14-day-old neonate, highlighting the role of ivabradine in the management, followed by a discussion about current approaches to treatment.

Ivabradine monotherapy in congenital junctional ectopic tachycardia

Congenital JET (junctional ectopic tachycardia) is a rare and often difficult to treat tachyarrhythmia in young infants. The addition of Ivabradine to standard Congenital JET therapy has been shown to improve arrhythmia control. However, Ivabradine has not been reported as a single drug in the control of congenital JET. We report a pre-term neonate in whom Ivabradine monotherapy was successful in treating congenital JET.

A Comparative Effectiveness Systematic Review and Meta-analysis of Drugs for the Prophylaxis of Junctional Ectopic Tachycardia

BACKGROUND

Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction.

OBJECTIVE

The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery.

METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

RESULTS

Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P<0.00001); 95% CI 0.21-0.52. Magnesium: risk ratio 0.50; I2= 24%; Z=5.08 (P<0.00001); 95% CI 0.39-0.66].

CONCLUSION

All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.

Ivabradine-Flecainide as Breakthrough Drug Combination for Congenital Junctional Ectopic Tachycardia: A Case Report and Literature Review

Congenital junctional ectopic tachycardia (CJET) is a rare tachyarrhythmia that remains difficult to manage, with suboptimal control in most cases. Here, we report literature research on the use of ivabradine in the treatment of pediatric junctional ectopic tachycardia (JET), both congenital and postoperative, and describe the successful use of ivabradine-flecainide association for CJET therapy resistant to other antiarrhythmic agents. This new drug combination was effective in completely suppressing JET. Ivabradine-flecainide combination may be considered a new therapeutic strategy of CJET with a satisfactory efficacy/tolerability ratio in patients resistant to conventional drug combinations.

Diagnosis and management of junctional ectopic tachycardia in children

Junctional ectopic tachycardia (JET) is more common in its postoperative form. A thorough understanding of its etiology, pathophysiology, and management strategies is essential. Classically, postoperative JET is considered to arise from surgical trauma. Genetic susceptibility and an intrinsic morphologic/functional defect in the conduction system inherent in congenital heart diseases likely play a significant role. The devastating effects on postoperative hemodynamics warrant prompt attention. A multipronged management approach with general measures, pharmacotherapy, and pacing has decreased morbidity and mortality. Amiodarone and procainamide remain the preferred drugs, while ivabradine appears promising. Carefully planned randomized trials can go a long way in developing a systematic management protocol for postoperative JET.

Timely Use of Venous-Arterial ECMO to Treat Congenital Pediatric Junctional Ectopic Tachycardia: A Case Report

Supraventricular tachycardia is the most common tachyarrhythmia in pediatrics. Although postoperative junctional ectopic tachycardia (JET) is a known complication of congenital heart surgery that is typically transient, congenital JET is rare and requires aggressive treatment to maintain hemodynamic stability. We describe the case of a 3-month-old, previously healthy female who presented with heart failure and cardiogenic shock secondary to congenital JET for whom extracorporeal membrane oxygenation (ECMO) provided time for selection of effective therapy. Adenosine, cardioversion, and transesophageal pacing were unsuccessful, and her echocardiogram demonstrated bilateral atrial dilation and severe left ventricular systolic dysfunction. Approximately 8 hours after presentation, venous-arterial ECMO was commenced allowing for successful treatment with amiodarone. Her electrocardiogram demonstrated atrioventricular dissociation consistent with JET. She was successfully decannulated from ECMO after 6 days. Her discharge echocardiogram showed normal ventricular function, and she had no significant ECMO sequelae. This case demonstrates the value of early ECMO initiation for cardiovascular support in pediatric patients with a life-threatening arrhythmia and in cardiogenic shock. ECMO support can allow for full diagnostic and therapeutic decisions to effectively reverse the consequences of uncontrolled arrhythmias unrelated to surgical complications.

Detection of Junctional Ectopic Tachycardia by Central Venous Pressure

Central venous pressure (CVP) is the blood pressure in the venae cavae, near the right atrium of the heart. This signal waveform is commonly collected in clinical settings, and yet there has been limited discussion of using this data for detecting arrhythmia and other cardiac events. In this paper, we develop a signal processing and feature engineering pipeline for CVP waveform analysis. Through a case study on pediatric junctional ectopic tachycardia (JET), we show that our extracted CVP features reliably detect JET with comparable results to the more commonly used electrocardiogram (ECG) features. This machine learning pipeline can thus improve the clinical diagnosis and ICU monitoring of arrhythmia. It also corroborates and complements the ECG-based diagnosis, especially when the ECG measurements are unavailable or corrupted.

Early postoperative arrhythmias in patients undergoing congenital heart surgery

Background

This study aims to evaluate early postoperative arrhythmias in children undergoing congenital cardiac surgery.

Methods

A total of 670 pediatric patients (355 males, 315 females; median age: 4 months; range, 1 day to 18 years) who underwent cardiac surgery due to congenital heart defects between December 2018 and November 2019 were included. The rate of postoperative arrhythmias, diagnosis, potential risk factors, and management strategies were evaluated. Multivariate regression analysis was used to identify significant factors of development of postoperative arrhythmias.

Results

Tachyarrhythmia was detected in 54 patients (8.1%), and the most common tachyarrhythmia was junctional ectopic tachycardia. Medical treatment was required in 25/38 (66%) of junctional ectopic tachycardia patients. Amiodarone was initiated in 18, dexmedetomidine in five, and flecainide + amiodarone in two of the patients. Different degrees of atrioventricular block were observed in 30 patients (4.5%). In 12 patients, permanent pacemakers were implanted during hospitalization. Age at the time of surgery under one-year-old, high inotropic scores, prolonged operation time, and high Aristotele"s scores were independent risk factors associated with early postoperative arrhythmia (p<0.05). The most common operations associated with early postoperative arrhythmia were left ventricular outflow tract, (6/20, 30%), complete atrioventricular septal defect (13/53, 24%), and tetralogy of Fallot (20/134, 14%) surgeries.

Conclusion

Cardiac arrhythmias are common in the early period after congenital heart surgery in children. The diagnosis and frequency of arrhythmias may vary according to different surgical procedures.

Infective endocarditis of an aortic bioprosthesis causing life-threatening incessant junctional tachycardia: a case report

Background 

Infective endocarditis with paravalvular abscess can be complicated by atrioventricular block (AVB), but junctional ectopic tachycardia (JET) has as yet never been described.

Case summary 

A 68-year-old male recently admitted with Staphylococcal aureus endocarditis of his aortic valve bioprosthesis, presented with a regular tachycardia at 240 b.p.m. with a pre-existent right bundle branch block pattern. Haemodynamic collapse necessitated electrical cardioversion, following which high-grade AVB was observed. Multiple recurrences of the same tachycardia required repeated electrical cardioversions and emergent electrophysiological study, which indicated JET. The tachycardia was unresponsive to overdrive pacing, adenosine and intravenous amiodarone, and external cardioversions. Radiofrequency catheter ablation of the atrioventricular node was performed emergently with interruption of the tachycardia. A temporary external pacemaker was implanted via a jugular route. The tachycardia recurred after 48 h at a slower rate, and the patient underwent redo ablation. Transoesophageal echocardiography revealed a pseudoaneurysm of the right sinus of Valsalva probably corresponding to an evacuated abscess. A permanent pacemaker was implanted after active infection had been ruled out. At 3 months of follow-up, the patient had complete AVB, without arrhythmia recurrence.

Discussion 

This is the first case report of JET complicating a paravalvular abscess of the aortic valve with concomitant AVB. Junctional ectopic tachycardia is very rare arrhythmia which is usually seen in children as a congenital arrhythmia or following surgical correction of paediatric heart disease. The differential diagnosis is discussed in detail in the article.

Use of ivabradine for treatment of junctional ectopic tachycardia in post congenital heart surgery

Cardiac surgeries especially involving crux of the heart as performed in tetralogy of Fallot (TOF) and pulmonary stenosis are mainly responsible for junctional ectopic tachycardia (JET). Diversified antiarrhythmic agents have been used in an impressive way to treat JET but showed suboptimal efficacy and varied associated adverse effects. But, ivabradine has proved as final crusader for its treatment. We report our initial experience of 4 cases in last 6 months with ivabradine in the management of postoperative JET. Encouraged by various reports and our increasing experience with ivabradine in heart failure population, we have moved to ivabradine as the first drug of choice for postoperative JET. Bradycardia was the only significant adverse effect in our series. The availability of atrial and ventricular pacing wires or at least transvenous temporary pacing should be ensured before starting ivabradine.