Variation in Antiarrhythmic Management of Infants Hospitalized with Supraventricular Tachycardia: A Multi-Institutional Analysis

Rediscover the predictive capacity of B-type natriuretic peptide applied to neonatal supraventricular tachycardia

BACKGROUND

Supraventricular tachycardia (SVT) is one of the most common non-benign arrhythmias in neonates, potentially leading to cardiac decompensation. This study investigated the early risk factors of acute heart failure (AHF) secondary to SVT in neonates, and explored their value in guiding the selection of effective anti-arrhythmic treatment.

METHODS

A total of 43 newborns diagnosed with and treated for SVT between January 2017 and December 2022 were analyzed. According to the presence of AHF after restoring sinus rhythm in newborns with SVT, they were divided into SVT with AHF group and SVT without AHF group. Clinical data and anti-arrhythmic therapies were analyzed. Risk factors of AHF secondary to SVT in neonates were determined using logistic regression. The cut-off value for predictors of AHF secondary to SVT and demanding of a second-line anti-arrhythmic treatment was determined through receiver operating characteristic (ROC) analysis.

RESULTS

Time to initial control of tachycardia > 24 h, hyperkalemia, anemia, and plasma B-type natriuretic peptide (BNP) were identified as risk factors of AHF secondary to SVT in neonates. BNP exhibited AUC of 0.80 in predicting AHF, and BNP > 2460.5pg/ml (OR 2.28, 95% CI 1.27 ~ 45.39, P = 0.03) was an independent predictor, yielding sensitivity of 70.6% and specificity of 84.6%. Neonates with BNP > 2460.5pg/ml (37.5% versus 7.4%, P = 0.04) had a higher demand for a second line anti-arrhythmic treatment to terminate SVT, with sensitivity and specificity for BNP in predicting at 75.0%, 71.4%, respectively.

CONCLUSIONS

BNP could be used to predict an incident of AHF secondary to SVT and a demand of second-line anti-arrhythmic treatment to promptly terminate SVT and prevent decompensation in neonates.

Outcomes of Infant Supraventricular Tachycardia Management Without Medication

Most infants presenting with supraventricular tachycardia (SVT) are treated with an antiarrhythmic, primarily to prevent unrecognized future episodes that could lead to tachycardia-induced cardiomyopathy. A common practice at our institution is to not treat after the first presentation of infant SVT and instead educate parents on heart rate monitoring and reasons to present to care. The goal of this study was to evaluate the outcomes of non-pharmacologic treatment of infant SVT at first presentation and compare to outcomes of infants treated with an antiarrhythmic. This was a retrospective single center study of all infants presenting with a first episode of SVT from 2014 to 2021. Excluded were patients with a non-reentry type tachyarrhythmia, atrial flutter, long-RP tachycardia, congenital heart disease, or abnormal ventricular function. Sixty-four infants were included in the study. Thirty-six were managed without an antiarrhythmic. SVT recurred in 28% of the non-treatment group vs 50% in those treated with antiarrhythmics, p = 0.12. Of the patients admitted to the hospital, those in the non-treatment group had a shorter length of stay, 1(IQR 1-1) vs 3(IQR 2-4) days, p < 0.01. Non-treated patients were less likely to present to the emergency department for recurrent SVT, 6% vs 32%, p < 0.01. Neither group had a patient develop tachycardia-induced cardiomyopathy. For infants with structurally and functionally normal hearts, non-treatment combined with parental education after the first episode of SVT does not lead to worse outcomes. This approach avoids the burden of medication administration in an infant and may have the added benefit of empowering parents to feel comfortable managing clinically insignificant tachycardia at home.

Transesophageal pacing studies reduce readmission but prolong initial admission in infants with supraventricular tachycardia: A cost-comparison analysis

Background

Supraventricular tachycardia (SVT) is a common arrhythmia. Infants with SVT are often admitted to initiate antiarrhythmics. Transesophageal pacing (TEP) studies can be used to guide therapy prior to discharge.

Objective

The objective of this study was to investigate the impact of TEP studies on length of stay (LOS), readmission, and cost in infants with SVT.

Methods

This was a 2-site retrospective review of infants with SVT. One site (Center TEPS) utilized TEP studies in all patients. The other (Center NOTEP) did not. Patients with structural heart disease, patients with gestational age <34 weeks, and patients diagnosed after 6 months were excluded. At Center TEPS, repeat TEP studies were performed after titration of medication until SVT was not inducible. Primary endpoints were LOS and readmission for breakthrough SVT within 31 days of discharge. Hospital reimbursement data were utilized for cost-effectiveness analysis.

Results

The cohort included 131 patients, 59 in Center TEPS and 72 in Center NOTEP. One patient was readmitted in Center TEPS vs 17 in Center NOTEP (1.6% vs 23.6%; P ≤ .001). Median LOS was longer for Center TEPS at 118.0 (interquartile range [IQR] 74.0-189.5) hours vs Center NOTEP at 66.9 (IQR 45.5-118.3) hours (P = .001). Twenty-one patients had multiple TEP studies. Median length of readmission for Center NOTEP was 65 (IQR 41-101) hours. Including readmission costs, utilization of TEP studies resulted in a probability-weighted cost of $45,531 per patient compared with $31,087 per patient without TEP studies.

Conclusion

Utilization of TEP studies was associated with decreased readmission rates but longer LOS and greater cost compared with SVT management without TEP studies.

Antiarrhythmic Drug Dosing in Children-Review of the Literature

Antiarrhythmic drugs represent a mainstay of pediatric arrhythmia treatment. However, official guidelines and consensus documents on this topic remain scarce. There are rather uniform recommendations for some medications (including adenosine, amiodarone, and esmolol), while there are only very broad dosage recommendations for others (such as sotalol or digoxin). To prevent potential uncertainties and even mistakes with regard to dosing, we summarized the published dosage recommendations for antiarrhythmic drugs in children. Because of the wide variations in availability, regulatory approval, and experience, we encourage centers to develop their own specific protocols for pediatric antiarrhythmic drug therapy.

Outcomes in Infants with Supraventricular Tachycardia: Risk Factors for Readmission, Recurrence and Ablation

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants. Once diagnosed, infants are admitted for antiarrhythmic therapy and discharged after observation. There are limited data on risk factors for readmission and readmission rates, while on medication. The objective of this study was to investigate risk factors for readmission and outcomes in infants diagnosed with SVT. This is a single-center retrospective study over a 10-year period of infants under 6 months of age with documented SVT. Infants with congenital heart disease requiring surgical or catheter intervention, gestational age less than 32 weeks or diagnosis of atrial flutter or fibrillation were excluded. The primary outcome was readmission within 31 days of hospital discharge. Long term need for ablation and eventual discontinuation of medications were assessed. Ninety patients were included. Beta blockers were the initial therapy in 66 and 28 required a medication change. Nineteen were readmitted within 31 days of discharge. The only clinical factor associated with early readmission was presence of ventricular pre-excitation (6/19 vs. 8/71, p = 0.03). Patients who were readmitted within 31 days had a longer length of treatment (12 [11.5, 22.0] vs. 10 [7.5, 12.0] months, p = 0.007) and were more likely to undergo ablation (4/19 vs. 2/71, p = 0.017). In this cohort of infants with SVT, readmission was common and ventricular pre-excitation was identified as a risk factor for readmission. Infants who were readmitted within 31 days of discharge had longer length of antiarrhythmic therapy and were more likely to undergo catheter ablation.

Supraventricular Tachycardia in Infants With Congenital Diaphragmatic Hernia: Prevalence, Associations, and Outcomes

OBJECTIVES

To characterize the prevalence, associations, management, and outcomes of supraventricular tachycardia (SVT) in neonates with congenital diaphragmatic hernia (CDH).

DESIGN

Retrospective chart and cardiology code review within a cohort of patients with CDH was used to define a subpopulation with atrial arrhythmia. SVT mechanisms were confirmed by electrocardiogram analysis. Cox proportional hazard regression identified risk factors for SVT and association with clinical outcomes.

SETTING

Medical Surgical ICU in a single, tertiary center, Boston Children's Hospital.

PATIENTS

Eligible patients included neonates presenting with classic Bochdalek posterolateral CDH between 2005 and 2017, excluding newborns with Morgagni hernia or late diagnoses of CDH (>28 d).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

SVT arose in 25 of 232 neonates with CDH, (11%); 14 of 25 infants (56%) had recurrent SVT; atrioventricular node-dependent tachycardia was the most frequent mechanism (32%). The majority (71%) of SVT episodes received intervention. Nine patients (36%) received preventative antiarrhythmic medications. SVT was associated with lower Apgar score at 1 min, structural heart disease, larger defect size, extracorporeal membrane oxygenation (ECMO) support, and prostaglandin therapy for ductal patency as well as hospital stay greater than or equal to 8 weeks and use of supplemental oxygen at discharge.

CONCLUSIONS

SVT can occur in neonates with CDH and frequently requires treatment. Odds of occurrence are increased with greater CDH disease severity, ECMO, and prostaglandin use. In unadjusted logistic regression analysis, SVT was associated with adverse hospital outcomes, underscoring the importance of recognition and management in this vulnerable population.

Evaluation of Clinical Course and Maintenance Drug Treatment of Supraventricular Tachycardia in Children During the First Years of Life. A Cohort Study from Eastern Germany

Supraventricular tachycardia (SVT) is considered the most common cause of arrhythmia in children and infants. Regarding the likelihood of a spontaneous resolution of SVTs during the first years of life, drug treatment aims to bridge the time until children 'grow out' out of the arrhythmia. The choice of antiarrhythmic agents and the planning of maintenance therapy are mainly based on clinical experience and retrospective single- and multi-institutional analyses and databases from all over the world approaching differently to this topic. The current study aimed to evaluate the clinical course, pharmacological treatment strategies, and constellations of risk for recurrences in the management of SVTs in children aged 3 < years. The database of the Heart Center Leipzig, Department of Pediatric cardiology, was searched for pediatric patients aged < 3 years with a clinically documented SVT between 2000 and 2019 that received pharmacologic treatment. Patients with complex congenital heart disease or arrhythmias following cardiac surgery were excluded. 69 patients were included. Pharmacologic treatment, follow-up schedule, recurrences, outcomes, and risk factors for complicated courses are reported. Drug therapy of SVTs in young children remains a controversial topic with heterogeneous treatment and follow-up strategies applied. Risk factors for recurrences and/or stubborn clinical courses are difficult rhythm control with 3 or more antiarrhythmic drugs, ectopic atrial tachycardias, and a first occurrence of the SVT in the fetal period. Prospective studies are needed to sufficiently evaluate optimal treatment strategies.

Essentials of Paroxysmal Supraventricular Tachycardia for the Pediatrician

Paroxysmal supraventricular tachycardia (SVT) is the most common clinical arrhythmia in young patients. With an estimated prevalence of roughly 1 in 500 children, a pediatrician may knowingly or unknowingly see several patients who are affected each year. SVT symptoms can sometimes be vague or conflated with common pediatric complaints. Different forms of SVT are predominant at different ages, sometimes complicating timely recognition and referral. Differing pathophysiology and age distribution impact risk of complications such as heart failure, or rarely, sudden death. Treatment choices continue to evolve as new medications, monitoring devices, and ablation technologies continue to mature. This review focuses on the most common types of paroxysmal SVT: atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and Wolff-Parkinson White syndrome. Atrial arrhythmia mechanisms are also briefly outlined. It is meant to provide practical guidelines for the diagnosis and management of patients with SVT from infancy through adolescence. [Pediatr Ann. 2021;50(3):e113-e120.].

Antiarrhythmic Treatment Duration and Tachycardia Recurrence in Infants with Supraventricular Tachycardia

We sought to assess the effect of a shorter medication treatment course (up to 4-6 months of age) on the recurrence of infantile supraventricular tachycardia (SVT). This was a retrospective review of infants with SVT diagnosed at age 0-12 months at Rady Children's Hospital (2010-2017). Infants with structural congenital heart disease, automatic tachycardias, atrial flutter, or lack of follow-up data were excluded. Seventy-four infants met criteria. Median age at diagnosis was 6 days (IQR 0-21 days); 28.4% presented with fetal tachycardia. Median gestational age was 38.4 weeks (IQR 36-40), 30% were preterm. Median age at medication discontinuation was 6.7 months (IQR 4.6-9.8). Therapy was stopped at younger age in patients managed by pediatric electrophysiologist (vs. general pediatric cardiologist): 4.9 vs. 8.6 months (p = 0.03). Thirty-eight patients (51.4%) were treated for < 6 months; 32.4% for 6-12 months, and 16.2% for > 12 months. SVT recurrence was similar for these groups: 13.2% vs. 16.7%, and 33.3%, respectively, (p = 0.27). Most patients with recurrence required emergency care, though none had significant adverse outcomes. Infants with SVT and structurally normal cardiac anatomy, who remain recurrence free on a single agent, have no increased risk of recurrence with shorter treatment courses of 4-6 months, compared to traditional treatment duration of 6-12 months.

Paroxysmal Supraventricular Tachycardia in Wolff–Parkinson–White Syndrome in a Newborn—Case Report and Mini-Review

Wolff–Parkinson–White (WPW) syndrome is a rare abnormal condition frequently associated with paroxysmal supraventricular tachycardia (PSVT) and is described as an arrhythmia under the form of increased heartbeat. Currently, there are various possible treatments going from medicines such as adenosine and beta-blockers to cardioversion. The unknown causes of this condition together with the different responses to treatment in each patient make it difficult to establish the best therapeutic approach. In this context, in the current paper, we were interested in reporting the therapeutic options and their efficiency in the case of associated heart or inflammatory conditions in a 13-day-old patient.

Neonatal supraventricular tachycardia

Supraventricular tachycardia (SVT) is one of the most common conditions requiring emergency cardiac care in neonates. Atrioventricular reentrant tachycardia utilizing an atrioventricular bypass tract is the most common form of SVT presenting in the neonatal period. There is high likelihood for spontaneous resolution for most of the common arrhythmia substrates in infancy. Pharmacological agents remain as the primary therapy for neonates.

Sustained tachyarrhythmia in children younger than 1 year of age: Six year single-center experience

BACKGROUND

The aim of this study was to evaluate the results of non-operational sustained tachyarrhythmia in patients <1 year of age at the present center.

METHODS

Between November 2010 and November 2016, the demographic characteristics, type and localization of the tachyarrhythmia, echocardiographic findings, and medical and/or ablation therapy for patients <1 year of age with sustained tachyarrhythmia were evaluated.

RESULTS

Of 99 patients, 91 had sustained supraventricular tachycardia, and eight had sustained ventricular tachycardia. The median age was 30 days (range, 1-350 days), and the median weight was 4.2 kg (range, 2-13 kg). The common symptoms were palpitation and restlessness (n = 49, 49.5%), or the tachycardia was detected during routine inspection (n = 25, 25.3%) or fetal echocardiography (n = 11, 11.1%). Nineteen individuals (19%) had left ventricular (LV) dysfunction on first echocardiography. Twenty individuals had congenital heart disease. Common diagnoses were Wolff-Parkinson-White syndrome (n = 27), focal atrial tachycardia (n = 10), permanent junctional reciprocating tachycardia(n = 6), and atrial flutter (n = 6). Seventeen patients underwent medical therapy combined with cardioversion. The most commonly used abortive and acute therapy agents were adenosine, esmolol, and amiodarone. The most common combination therapy was propranolol and amiodarone, followed by a propranolol and propafenone combination. Nine individuals were treated with catheter ablation due to either resistance to medical therapy or LV dysfunction.

CONCLUSIONS

Tachyarrhythmias in children <1 year of age are mostly caused by accessory pathways and require multidrug therapy. Catheter ablation is an effective alternative therapy in the case of resistance to medical therapy and/or LV dysfunction.

Management of Supraventricular Tachycardia in Infants

Supraventricular tachycardia is the most common tachyarrhythmia encountered in infants. In older children and adults, definitive treatment of the supraventricular tachycardia substrate with catheter ablation is a common approach to management. However, in infants, the risks of catheter ablation are significantly higher, and the patients often outgrow the potential to experience episodes. Therefore, antiarrhythmic medications are often utilized to minimize the likelihood of experiencing episodes. This article reviews the common arrhythmia mechanisms encountered in infants and the medications used to treat these patients.

Propranolol Versus Digoxin in the Neonate for Supraventricular Tachycardia (from the Pediatric Health Information System)

Conflicting data exist for the appropriate management of a neonate with supraventricular tachycardia (SVT). We sought to assess postnatal prescribing trends for neonates with SVT and to evaluate if there were therapy-specific mortality and resource utilization benefits. Nationally distributed data from 44 pediatric hospitals in the 2004 to 2015 Pediatric Health Information System database were used to identify patients admitted at ≤2 days of age with structurally normal hearts and treated with an antiarrhythmic medication. Outcome variables were mortality, cost, and length of stay (LOS). Multivariable models and propensity score matching were used. There were 2,657 neonates identified with a median gestational age of 37 weeks (interquartile range 34 to 39). Digoxin and propranolol were most commonly prescribed; digoxin use steadily decreased to 23% of antiarrhythmic medication administrations over the study period, whereas propranolol increased to 77%. Multivariable comparisons revealed that the odds of mortality for neonates on propranolol were 0.32 times those on digoxin (95% confidence interval 0.17 to 0.59; p <0.001); hospital costs were $16,549 lower for propranolol versus digoxin (95% confidence interval $5,502 to $27,596, p = 0.003). No difference was found for LOS. Propensity score matching and subset analyses of patients with only arrhythmia diagnostic codes confirmed mortality benefits for propranolol, although longer LOS was observed. In conclusion, propranolol use for the neonate with SVT is associated with lower in-hospital mortality and hospital costs compared with digoxin.