The Efficacy of Anti-Arrhythmic Drugs in Children With Idiopathic Frequent Symptomatic or Asymptomatic Premature Ventricular Complexes With or Without Asymptomatic Ventricular Tachycardia: a Retrospective Multi-Center Study

ECTOPIC trial: The efficacy of flEcainide Compared To metOprolol in reducing Premature ventrIcular Contractions: A randomized open-label crossover study in pediatric patients

BACKGROUND

Frequent premature ventricular contractions (PVCs) in children are usually considered benign. Symptoms and left ventricular dysfunction are indications for treatment with antiarrhythmic drugs.

OBJECTIVE

This study aimed to evaluate the efficacy of flecainide vs metoprolol in reducing PVCs in children.

METHODS

A randomized open-label crossover trial was conducted of children with a PVC burden of >15% on Holter monitoring successively treated with metoprolol and flecainide, or vice versa, with a drug-free interval of at least 2 weeks. Holter measurements were repeated before and after the start of the antiarrhythmic drug.

RESULTS

Sixty patients were screened; 19 patients could be included. Median age was 13.9 years (interquartile range, 5.5 years). Mean baseline PVC burden was 21.7% (n = 18; SD ± 14.0) before the start of flecainide and 21.2% (n = 17; SD ± 11.5) before the start of metoprolol. In a mixed model analysis, the estimated mean reduction in PVC burden was 10.6 percentage points (95% CI, 5.8-15.3) for flecainide and 2.4 percentage points (95% CI,2.7-7.5) for metoprolol, with a significant difference of 8.2 percentage points (95% CI, 0.86-15.46; P = .031). Exploratory analysis revealed that 9 of 18 patients treated with flecainide and 1 of 17 patients treated with metoprolol had a reduction to a PVC burden below 5%. No discriminating factors between flecainide responders and nonresponders were found; the mean plasma level was not significantly different (0.34 mg/L vs 0.52 mg/L; P = .277).

CONCLUSION

In children with frequent PVCs, flecainide led to a significantly greater reduction of PVC burden compared with metoprolol. Flecainide was effective in only a subgroup of patients, which appears to be unrelated to the plasma level.

The Relationship between Depression Symptoms and Physical Activity in Children with Idiopathic Ventricular Extrasystoles

Background and Objectives: Depression in childhood often co-occurs with anxiety disorders and a range of somatic symptoms. Recent studies have identified physical activity as a target for preventing the onset of depression. However, idiopathic ventricular extrasystoles (VEs) in children are sometimes associated with somatic symptoms and limitations in physical activity. The occurrence of arrhythmia can also be distressing for children and their parents. This study was conducted to determine the relationship between symptoms of depression, physical activity, and somatic symptoms in children with idiopathic VE. Materials and Methods: This study of children with structurally normal hearts and VE was approved by the local ethics committee (no. 2021/10-1383-859(1). The authors designed a questionnaire to assess symptoms, physical activity, and general well-being. As part of that, symptoms of depression were evaluated with a modified pediatric PHQ-9 (MP-PHQ-9) questionnaire, with scores ≤4 for no, 5-9 for mild, 10-14 for moderate, and ≥15 for severe depression. Children aged ≥12 years and parents who assessed their children's condition completed the questionnaires. All children also underwent 24-h electrocardiography and echocardiography to evaluate arrhythmia frequency and cardiac condition. Results: Questionnaires were completed by 60 children's parents and 39 children (≥12 years old). The median children's age was 13 years. Palpitations were experienced by 26 (43.3%), chest pain by 13 (21.7%), and exercise intolerance by 15 (25%) children. All patients had normal ventricular function and hemodynamically normal hearts. The median score of the MP-PHQ-9 completed by parents was 2, and by children was 4. The median VE frequency was 4.77 (0.1-32.77) % per 24 h. We found that 31 (51.7%) children engaged in extra-sports participation with a median time of 3.75 h per week. Eleven of the children were suspended from sports. There was no significant difference between VE frequency and MP-PHQ-9 scores. Higher MP-PHQ-9 scores were noted for symptomatic children who engaged in <5 h per week of physical activity. Conclusions: Higher depression scores were found for children with somatic symptoms than those without symptoms. Children who were physically active for less than 5 h per week also had higher depression risk scores than those who were more active. Our research has shown that parents underestimate the signs of depression in their children.

Ventricular tachycardia ablation in children

INTRODUCTION

The ablation of ventricular tachycardia, including premature ventricular contractions, is an approved, albeit infrequent procedure in pediatric patients. Data are scarce regarding the outcomes of this procedure. The purpose of this study was to share a high-volume center experience and patient outcomes for catheter ablation of ventricular ectopy and ventricular tachycardia in pediatric population.

METHODS

Data were retrieved from the institutional data bank. Outcomes over time were evaluated, and procedural details were compared.

RESULTS

A total of 116 procedures were performed on 102 pediatric patients between July 2009 and May 2021 at the Rajaie Cardiovascular Medical and Research Center in Tehran, Iran. Ablation was not performed in 4 procedures (3.4%) due to high-risk substrates. Of the remaining 112 ablations performed, 99 (88.4%) were successful. However, one patient died due to a coronary complication. There were no significant differences observed in early ablation results based on patients' age, sex, cardiac anatomy, or ablation substrates (P > 0.05). Follow-up records were available for 80 procedures, and 13 (16.3%) of those experienced recurrence. During long-term follow-up, none of the variables mentioned above were statistically different between patients with or without arrhythmia recurrence.

CONCLUSION

The overall success rate of pediatric ventricular arrhythmia ablation is favorable. We found no significant predictor for the procedural success rate concerning acute and late outcomes. Larger multicenter studies are needed to elucidate the predictors and outcomes of the procedure.

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.