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Hassan PF, El Haddad AM. Dexmedetomidine and magnesium sulfate in preventing junctional ectopic tachycardia after pediatric cardiac surgery. Paediatr Anaesth 2024; 34:459-466. [PMID: 38269418 DOI: 10.1111/pan.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) is a serious tachyarrhythmia following pediatric cardiac surgery. It isn't easy to treat and better to be prevented. This study aimed to examine the prophylactic effects of dexmedetomidine, MgSO4, or their combination in reducing JET following pediatric open cardiac surgery. METHODS Hundred and twenty children under 5 years, weighing more than 5 kg, who were scheduled for corrective acyanotic cardiac surgeries were randomized into three groups. Group MD (Dexmedetomidine-MgSO4 group): received dexmedetomidine 0.5 μg/kg IV over 20 min after induction, then infusion 0.5 μg/kg/h for 72 h, and 50 mg/kg bolus of MgSO4 with aortic cross-clamp release, then continued administration for 72 h postoperatively at a dose of 30 mg/kg/day. Group D (the dexmedetomidine group) received the same dexmedetomidine as the MD group in addition to normal saline instead of MgSO4. Group C (control group): received normal saline instead of dexmedetomidine and MgSO4. The primary outcome was the detection of JET incidence; the secondary outcomes were hemodynamic parameters, ionized Mg, vasoactive-inotropic score, extubation time, PCCU and hospital stay, and perioperative complications. RESULTS The incidence of JET was significantly reduced in Group MD and Group D (p = .007) compared to Group C. Ionized Mg was significantly higher in Group MD than in Groups D and C during rewarming and in the ICU (p < .001). Better hemodynamic profile in Group MD compared to Group D and Group C throughout surgery and in the ICU, the predictive indexes were significantly better in Group MD than in Groups D and C (p < .001). Including the extubation time, PCCU, and hospital stay. CONCLUSION Dexmedetomidine alone or combined with MgSO4 had a therapeutic role in the prevention of JET in children after congenital heart surgery.
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Affiliation(s)
- Passaint Fahim Hassan
- Intensive Care, and Pain Management, Kasr Al Aini Hospital, Cairo University, Cairo, Egypt
| | - Ahmed M El Haddad
- Intensive Care, and Pain Management, Kasr Al Aini Hospital, Cairo University, Cairo, Egypt
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Yarlagadda C, Abutineh MA, Datir RR, Travis LM, Dureja R, Reddy AJ, Packard JM, Patel R. Navigating the Incidence of Postoperative Arrhythmia and Hospitalization Length: The Role of Amiodarone and Other Antiarrhythmics in Prophylaxis. Cureus 2024; 16:e57963. [PMID: 38738095 PMCID: PMC11086606 DOI: 10.7759/cureus.57963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/14/2024] Open
Abstract
Antiarrhythmic drugs play a pivotal role in managing and preventing arrhythmias. Amiodarone, classified as a class III antiarrhythmic, has been used prophylactically to effectively prevent atrial fibrillation postoperatively in cardiac surgeries. However, there is a lack of consensus on the use of amiodarone and other antiarrhythmic drugs as prophylaxis to reduce the occurrence of all types of postoperative arrhythmias in cardiac and non-cardiac surgeries. A comprehensive PubMed query yielded 614 relevant papers, of which 52 clinical trials were analyzed. The data collection included the class of antiarrhythmics, timing or method of drug administration, surgery type, type of arrhythmia and its incidence, and hospitalization length. Statistical analyses focused on prophylactic antiarrhythmics and their respective reductions in postoperative arrhythmias and hospitalization length. Prophylactic amiodarone alone compared to placebo demonstrated a significant reduction in postoperative arrhythmia incidence in cardiac and non-cardiac surgeries (24.01%, p<0.0001), and it was the only treatment group to significantly reduce hospitalization length versus placebo (p = 0.0441). Prophylactic use of class 4 antiarrhythmics versus placebo also demonstrated a significant reduction in postoperative arrhythmia incidence (28.01%, p<0.0001), and while there was no significant statistical reduction compared to amiodarone (4%, p=0.9941), a lack of abundant data provides a case for further research on the prophylactic use of class 4 antiarrhythmics for this indication. Amiodarone prophylaxis remains a prime cornerstone of therapy in reducing postoperative arrhythmia incidence and hospitalization length. Emerging data suggests a need for a broader exploration of alternative antiarrhythmic agents and combination therapies, particularly class 4 antiarrhythmics, in both cardiac and non-cardiac surgeries. This meta-analysis depicts the effectiveness of amiodarone, among other antiarrhythmics, in postoperative arrhythmia incidence and hospitalization length reduction in cardiac and non-cardiac surgeries.
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Affiliation(s)
- Chetan Yarlagadda
- Medicine, Miller School of Medicine, University of Miami, Miami, USA
| | | | - Rohan R Datir
- Medicine, California University of Science and Medicine, Colton, USA
| | - Levi M Travis
- Medicine, Miller School of Medicine, University of Miami, Miami, USA
| | - Rohan Dureja
- Medicine, Miller School of Medicine, University of Miami, Miami, USA
| | - Akshay J Reddy
- Medicine, California University of Science and Medicine, Colton, USA
| | | | - Rakesh Patel
- Internal Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, USA
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3
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Dasgupta S, Shalhoub K, El-Assaad I, O'Leary E, Feins EN, Triedman JK, Walsh EP, Kheir JN, Dionne A. Clinical risk prediction score for post-operative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease. Heart Rhythm 2023:S1547-5271(23)00221-7. [PMID: 36898471 DOI: 10.1016/j.hrthm.2023.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Accelerated junctional rhythm (AJR) and Junctional ectopic tachycardia (JET) are common post-operative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intra-operative treatment may improve outcomes, but patient selection remains a challenge. OBJECTIVES Our objective was to describe contemporary outcomes of post-operative AJR/JET and develop a risk-prediction score to identify patients at highest risk. METHODS Retrospective cohort study of children 0-18 years undergoing cardiac surgery (2011-2018). AJR was defined as usual complex tachycardia with ≥1:1 ventricular-atrial association and junctional rate >25th percentile of sinus rate for age but < 170 bpm while JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression. RESULTS From 6364 surgeries, AJR occurred in 215 (3.4%) and JET in 59 (0.9%). Age, heterotaxy syndrome, aortic cross-clamp time, ventricular septal defect closure and atrio-ventricular canal repair were independent predictors of AJR/JET on multivariate analysis and included in the risk prediction score. The model accurately predicted the risk of AJR/JET with a C-index of 0.72 [95% CI 0.70, 0.75]. Post-operative AJR and JET was associated with prolonged ICU and hospital length of stay, but not with early mortality. CONCLUSION We describe a novel risk prediction score to estimate the risk of post-operative AJR/JET permitting early identification of at-risk patients who may benefit from prophylactic treatment.
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Affiliation(s)
- Soham Dasgupta
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Khairy Shalhoub
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Iqbal El-Assaad
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Edward O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Wadile S, Sivakumar K, Murmu UC, Ganesan S, Dhandayuthapani GG, Agarwal R, Sheriff EA, Varghese R. 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. Ann Pediatr Cardiol 2023; 16:4-10. [PMID: 37287843 PMCID: PMC10243657 DOI: 10.4103/apc.apc_150_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 06/09/2023] Open
Abstract
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.
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Affiliation(s)
- Santosh Wadile
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Kothandam Sivakumar
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Udaya Charan Murmu
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Selvakumar Ganesan
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Giridhar Gopal Dhandayuthapani
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Ravi Agarwal
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Ejaz Ahamed Sheriff
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
| | - Roy Varghese
- Department of Pediatric Cardiology, Institute of Cardio Vascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
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Izumi G, Takeda A, Yamazawa H, Kato N, Kato H, Tachibana T, Sagae O, Yahagi R, Maeno M, Hoshino K, Saito H. Perioperative junctional ectopic tachycardia associated with congenital heart disease: risk factors and appropriate interventions. Heart Vessels 2022; 37:1792-1800. [PMID: 35469049 DOI: 10.1007/s00380-022-02074-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/08/2022] [Indexed: 11/28/2022]
Abstract
The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3 years, range 0.0-53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18-10.07], ACC time exceeding 90 min (OR 1.90; CI 1.27-2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02-5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes.
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Affiliation(s)
- Gaku Izumi
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan.
| | - Atsuhito Takeda
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hirokuni Yamazawa
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Nobuyasu Kato
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hiroki Kato
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North-15 West-7, Sapporo, 060-8638, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Kanagawa, 232-8555, Japan
| | - Osamu Sagae
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Ryogo Yahagi
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Motoki Maeno
- Division of Medical Engineering Center, Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Koji Hoshino
- Department of Anesthesiology and Critical Care Medicine, Faculty of Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Faculty of Hokkaido University Hospital, North-15 West-7, Sapporo, 060-8638, Japan
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George M, Goenka L. Alirocumab in Post ACS Patients - Saving Lives at a Premium. Curr Cardiol Rev 2022; 18:e030621193814. [PMID: 34082687 PMCID: PMC9241115 DOI: 10.2174/1573403x17666210603111158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 01/22/2021] [Accepted: 02/16/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Melvin George
- Department of Clinical Pharmacology, SRM MCH & RC, Kattankulathur, Chennai, Tamil Nadu, 603203, India
| | - Luxitaa Goenka
- Department of Clinical Pharmacology, SRM MCH & RC, Kattankulathur, Chennai, Tamil Nadu, 603203, India
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Mendel B, Christianto C, Setiawan M, Prakoso R, Siagian SN. A Comparative Effectiveness Systematic Review and Meta-analysis of Drugs for the Prophylaxis of Junctional Ectopic Tachycardia. Curr Cardiol Rev 2022; 18:e030621193817. [PMID: 34082685 PMCID: PMC9241111 DOI: 10.2174/1573403x17666210603113430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/22/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Brian Mendel
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Moira Setiawan
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Radityo Prakoso
- Pediatric Cardiology and Congenital Heart Defect Division, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Sisca Natalia Siagian
- Pediatric Cardiology and Congenital Heart Defect Division, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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8
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Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2021; 41:655-720. [PMID: 31504425 DOI: 10.1093/eurheartj/ehz467] [Citation(s) in RCA: 504] [Impact Index Per Article: 168.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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9
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Abstract
BACKGROUND Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. METHODS We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. RESULTS We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. CONCLUSION In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.
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10
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Ahmed A, Prodhan P, Spray BJ, Bolin EH. Impact of Perioperative Tachydysrhythmias on Mortality and Length of Stay in Complete Repair of Tetralogy of Fallot: A Multicenter Retrospective Cohort Study from the Pediatric Health Information System. Cardiology 2021; 146:368-374. [PMID: 33735878 DOI: 10.1159/000512777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Tachydysrhythmias (TDS) frequently occur after complete repair of tetralogy of Fallot (TOF). However, not much is known about the effect of TDS on morbidity and mortality after TOF repair. We sought to assess the associations between TDS and mortality and morbidity after repair of TOF using a multicentre database. MATERIALS AND METHODS We identified all children aged 0-5 years in the Pediatric Health Information System who underwent TOF repair between 2004 and 2015. Codes for TDS were used to identify cases. Outcome variables were inpatient mortality and total length of stay (LOS). Univariate and multiple logistic and linear regression analyses were used to identify the effects of multiple risk factors, including TDS, on mortality and LOS. RESULTS A total of 7,749 patients met inclusion criteria, of which 1,493 (19%) had codes for TDS. There was no association between TDS and inpatient mortality. However, TDS were associated with 1.1 days longer LOS and accounted for 2% of the variation observed in LOS. CONCLUSION After complete repair of TOF, TDS were not associated with mortality and appeared to have only a modest effect on LOS.
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Affiliation(s)
- Aziez Ahmed
- Children's Heart Center, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, Connecticut, USA,
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Critical Care, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, Little Rock, Arkansas, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
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11
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Catton KG, Peterson JK. Junctional Ectopic Tachycardia: Recognition and Modern Management Strategies. Crit Care Nurse 2020; 40:46-55. [PMID: 32006036 DOI: 10.4037/ccn2020793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Junctional ectopic tachycardia is a common dysrhythmia after congenital heart surgery that is associated with increased perioperative morbidity and mortality. Risk factors for development of junctional ectopic tachycardia include young age (neonatal and infant age groups); hypomagnesemia; higher-complexity surgical procedure, especially near the atrioventricular node or His bundle; and use of exogenous catecholamines such as dopamine and epinephrine. Critical care nurses play a vital role in early recognition of dysrhythmias after congenital heart surgery, assessment of hemodynamics affecting cardiac output, and monitoring the effects of antiarrhythmic therapy. This article reviews the underlying mechanisms of junctional ectopic tachycardia, incidence and risk factors, and treatment options. Currently, amiodarone is the pharmacological treatment of choice, with dexmedetomidine increasingly used because of its anti-arrhythmic properties and sedative effect.
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Affiliation(s)
- Kirsti G Catton
- Kirsti G. Catton is a CVICU pediatric nurse practitioner at Lucile Packard Children's Hospital, Palo Alto, California
| | - Jennifer K Peterson
- Jennifer K. Peterson is Clinical Program Director, Children's Heart Institute, Miller Children's and Women's Hospital, Long Beach, California
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12
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Kumar V, Kumar G, Tiwari N, Joshi S, Sharma V, Ramamurthy R. Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study. World J Pediatr Congenit Heart Surg 2019; 10:709-714. [DOI: 10.1177/2150135119876600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol. Methods: A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone. Results: All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine. Conclusion: Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.
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Affiliation(s)
- Vivek Kumar
- Army Hospital Research and Referral, New Delhi, India
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
| | - Gaurav Kumar
- Army Hospital Research and Referral, New Delhi, India
- Department of Cardiothoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Nikhil Tiwari
- Army Hospital Research and Referral, New Delhi, India
- Department of Cardiothoracic Surgery, Army Hospital Research and Referral, New Delhi, India
| | - Sajan Joshi
- Army Hospital Research and Referral, New Delhi, India
- Department of Cardiothoracic Anesthesiology, Army Hospital Research and Referral, New Delhi, India
| | - Vipul Sharma
- Army Hospital Research and Referral, New Delhi, India
- Department of Cardiothoracic Anesthesiology, Army Hospital Research and Referral, New Delhi, India
| | - Ravi Ramamurthy
- Army Hospital Research and Referral, New Delhi, India
- Department of Pediatric Cardiology, Army Hospital Research and Referral, New Delhi, India
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Li X, Zhang C, Dai D, Liu H, Ge S. Efficacy of dexmedetomidine in prevention of junctional ectopic tachycardia and acute kidney injury after pediatric cardiac surgery: A meta‐analysis. CONGENIT HEART DIS 2018; 13:799-807. [PMID: 30260073 DOI: 10.1111/chd.12674] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/14/2018] [Accepted: 08/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Xin Li
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Chengxin Zhang
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Di Dai
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Haiyuan Liu
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Shenglin Ge
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
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He D, Aggarwal N, Zurakowski D, Jonas RA, Berul CI, Hanumanthaiah S, Moak JP. Lower risk of postoperative arrhythmias in congenital heart surgery following intraoperative administration of magnesium. J Thorac Cardiovasc Surg 2018; 156:763-770.e1. [DOI: 10.1016/j.jtcvs.2018.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/21/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
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Landiolol Hydrochloride Rapidly Controls Junctional Ectopic Tachycardia After Pediatric Heart Surgery. Pediatr Crit Care Med 2018; 19:713-717. [PMID: 29677032 DOI: 10.1097/pcc.0000000000001573] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Junctional ectopic tachycardia is a supraventricular tachyarrhythmia with atrioventricular dissociation that causes life-threatening postsurgical conditions in pediatric heart patients. This study evaluates the efficacy of landiolol hydrochloride for managing junctional ectopic tachycardia. DESIGN A single-center retrospective study. SETTING PICU at the university hospital. PATIENTS Of 561 pediatric patients who underwent open-heart surgery between 2006 and 2017, 10 patients developed sustained junctional ectopic tachycardia and were selected for landiolol treatment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Landiolol decreased mean heart rate significantly from 206.1 ± 14.5 to 158.0 ± 8.6 beats/min within 2 hours after administration (p < 0.01). Mean time to achieve 20% heart rate reduction was 2.1 ± 0.5 hours. Systolic blood pressure between pre and post landiolol administration did not change significantly (72.6 ± 5.9 to 79.7 ± 6.2 mm Hg). Once junctional heart rate was sufficiently suppressed, atrioventricular sequential pacing was introduced to stabilize hemodynamics. Nine of 10 cases (90%) had atrioventricular sequential pacing to maintain appropriate heart rate and restore atrioventricular synchronicity under suppressed junctional heart rate. Subsequently, eight of 10 cases (80%) were converted to regular sinus rhythm within 24 hours after starting landiolol administration. The average time to achieve sinus rhythm conversion was 7.9 ± 3.4 hours. CONCLUSIONS Landiolol rapidly suppresses junctional heart rate in junctional ectopic tachycardia after pediatric heart surgery without significant blood pressure compromises. Subsequent atrioventricular sequential pacing was effective at restoring atrioventricular synchronicity and stabilizing hemodynamics. Combining junctional rate control with landiolol and atrioventricular sequential pacing is therefore suggested as a promising option for prompt management of postoperative junctional ectopic tachycardia.
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Fritock MD, Ing RJ, Twite MD. Cardiac Arrest in 2 Neonates Receiving Amiodarone and Dexmedetomidine. J Cardiothorac Vasc Anesth 2017; 31:2135-2138. [DOI: 10.1053/j.jvca.2017.02.176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Indexed: 11/11/2022]
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17
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Entenmann A, Michel M, Herberg U, Haas N, Kumpf M, Gass M, Egender F, Gebauer R. Management of postoperative junctional ectopic tachycardia in pediatric patients: a survey of 30 centers in Germany, Austria, and Switzerland. Eur J Pediatr 2017; 176:1217-1226. [PMID: 28730319 DOI: 10.1007/s00431-017-2969-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/10/2017] [Accepted: 07/12/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED Postoperative junctional ectopic tachycardia (JET) is a frequent complication after pediatric cardiac surgery. Current recommendations on how and when to treat JET are inconsistent. We evaluated the management strategies of postoperative JET in German-speaking countries. We sent an online survey to 30 centers of pediatric cardiology that perform surgery for congenital heart defects in Germany (24), Austria (4), and Switzerland (2). The survey asked 18 questions about how and in what treatment sequence postoperative JET was managed. All 30 centers completed the survey (100% return rate). There was general agreement that the management of JET is based on administration of antiarrhythmic drugs, body surface cooling, and temporary pacing. Many centers presented treatment algorithms based on published literature, all centers named amiodarone as the first drug of choice. Significant disagreement was found concerning the timing and sequential order of additional therapeutic measures and particularly about the dosing of amiodarone and the role of R-wave synchronized atrial pacing. CONCLUSION This survey reveals that from center to center, the treatment of postoperative JET may vary substantially. Future work should focus on those treatment modalities where a high rate of variation is found. Such studies may be of value to achieve commonly adopted treatment recommendations. What is known: • Treatment of postoperative junctional ectopic tachycardia is predominantly based on administration of antiarrhythmic drugs, therapeutic cooling, and temporary pacing. • Amiodarone is the antiarrhythmic drug of choice in this context. What is new: • Dosing and duration of administration of amiodarone differ relevantly from center to center. • The sequential order of drug administration, therapeutic cooling, and pacing is not consistent.
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Affiliation(s)
- Andreas Entenmann
- Department of Pediatrics, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Miriam Michel
- Department of Pediatrics, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany
| | - Nikolaus Haas
- Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Ludwig-Maximilian University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, University Children's Hospital Tübingen, Hoppe-Seyler-Strasse 1, 72076, Tübingen, Germany
| | - Matthias Gass
- Department of Pediatric Cardiology, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
| | - Friedemann Egender
- Department for Congenital Heart Disease and Pediatric Cardiology, Schleswig-Holstein University Hospital, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Roman Gebauer
- Department of Pediatric Cardiology, University of Leipzig, Heart Center, Strümpellstrasse 39, 04289, Leipzig, Germany
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Abstract
Accelerated junctional rhythm has been reported in children in the setting of acute rheumatic fever; however, we describe a hitherto unreported case of isolated junctional tachycardia in a child with streptococcal pharyngitis, not meeting revised Jones criteria for rheumatic fever. A previously healthy, 9-year-old girl presented to the emergency department with complaints of sore throat, low-grade fever, and intermittent chest pain. She was found to have a positive rapid streptococcal antigen test. The initial electrocardiogram showed junctional tachycardia with atrioventricular dissociation in addition to prolonged and aberrant atrioventricular conduction. An echocardiogram revealed normal cardiac anatomy with normal biventricular function. The patient responded to treatment with amoxicillin for streptococcal pharyngitis. The junctional tachycardia and other electrocardiogram abnormalities resolved during follow-up.
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El Amrousy DM, Elshmaa NS, El-Kashlan M, Hassan S, Elsanosy M, Hablas N, Elrifaey S, El-Feky W. Efficacy of Prophylactic Dexmedetomidine in Preventing Postoperative Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery. J Am Heart Assoc 2017; 6:JAHA.116.004780. [PMID: 28249845 PMCID: PMC5524013 DOI: 10.1161/jaha.116.004780] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative junctional ectopic tachycardia is one of the most serious arrhythmias that occur after pediatric cardiac surgery, difficult to treat and better to be prevented. Our aim was to assess the efficacy of prophylactic dexmedetomidine in preventing junctional ectopic tachycardia after pediatric cardiac surgery. METHODS AND RESULTS A prospective controlled study was carried out on 90 children who underwent elective cardiac surgery for congenital heart diseases. Patients were randomized into 2 groups. Group I (dexmedetomidine group): 60 patients received dexmedetomidine; Group II (Placebo group): 30 patients received the same amount of normal saline intravenously. The primary outcome was the incidence of postoperative junctional ectopic tachycardia. Secondary outcomes included bradycardia, hypotension, vasoactive inotropic score, ventilation time, pediatric cardiac care unit stay, length of hospital stay, and perioperative mortality. The incidence of junctional ectopic tachycardia was significantly reduced in the dexmedetomidine group (3.3%) compared with the placebo group (16.7%) with P<0.005. Heart rate while coming off cardiopulmonary bypass was significantly lower in the dexmedetomidine group (130.6±9) than the placebo group (144±7.1) with P<0.001. Mean ventilation time, and mean duration of intensive care unit and hospital stay (days) were significantly shorter in the dexmedetomidine group than the placebo group (P<0.001). However, there was no significant difference between the 2 groups as regards mortality, bradycardia, or hypotension (P>0.005). CONCLUSION Prophylactic use of dexmedetomidine is associated with significantly decreased incidence of postoperative junctional ectopic tachycardia in children after congenital heart surgery without significant side effects.
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Affiliation(s)
| | - Nagat S Elshmaa
- Department of Anesthesia & Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed El-Kashlan
- Department of Anesthesia & Surgical ICU, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Samir Hassan
- Pediatric Department, Tanta University Hospital, Tanta, Egypt
| | | | - Nahed Hablas
- Pediatric Department, Tanta University Hospital, Tanta, Egypt
| | - Shimaa Elrifaey
- Pediatric Department, Tanta University Hospital, Tanta, Egypt
| | - Wael El-Feky
- Cardiothoracic Surgery Department, Tanta University Hospital, Tanta, Egypt
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