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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 postoperative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease. Heart Rhythm 2023; 20:1011-1017. [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] [MESH Headings] [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 postoperative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intraoperative treatment may improve outcomes, but patient selection remains a challenge. OBJECTIVES The purpose of this study was to describe contemporary outcomes of postoperative AJR/JET and develop a risk prediction score to identify patients at highest risk. METHODS This was a retrospective cohort study of children aged 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, whereas JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression. RESULTS Among 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 atrioventricular 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% confidence interval 0.70-0.75). Postoperative AJR and JET were associated with prolonged intensive care unit and hospital length of stay, but not with early mortality. CONCLUSION We describe a novel risk prediction score to estimate the risk of postoperative 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, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
| | - Khayri Shalhoub
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Iqbal El-Assaad
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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2
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Joye R, Beghetti M, Wacker J, Malaspinas I, Bouhabib M, Polito A, Bordessoule A, Shah DC. Early and Late Postoperative Tachyarrhythmias in Children and Young Adults Undergoing Congenital Heart Disease Surgery. Pediatr Cardiol 2023; 44:312-324. [PMID: 36517587 PMCID: PMC9894958 DOI: 10.1007/s00246-022-03074-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Raphael Joye
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland.
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Julie Wacker
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Iliona Malaspinas
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Maya Bouhabib
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Angelo Polito
- Pediatric Intensive Care Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Alice Bordessoule
- Pediatric Intensive Care Unit, Department of Woman, Child, and Adolescent Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Dipen C Shah
- Electrophysiology Unit, Cardiology Division, Geneva University Hospital, Geneva, Switzerland
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3
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Thibault C, Pelletier É, Nguyen C, Trottier ED, Doré-Bergeron MJ, DeKoven K, Roy AM, Piché N, Delisle JF, Morin C, Paquette J, Kleiber N. The Three W's of Acetaminophen In Children: Who, Why, and Which Administration Mode. J Pediatr Pharmacol Ther 2023; 28:20-28. [PMID: 36777982 PMCID: PMC9901322 DOI: 10.5863/1551-6776-28.1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/25/2022] [Indexed: 02/05/2023]
Abstract
Acetaminophen is one of the oldest medications commonly administered in children. Its efficacy in treating fever and pain is well accepted among clinicians. However, the available evidence supporting the use of acetaminophen's different modes of administration remains relatively scarce and poorly known. This short report summarizes the available evidence and provides a framework to guide clinicians regarding a rational use of acetaminophen in children.
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Affiliation(s)
- Céline Thibault
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Élaine Pelletier
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Christina Nguyen
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Evelyne D. Trottier
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pediatric Emergency Medicine (EDT), CHU Sainte Justine, Montreal, QC, Canada
| | - Marie-Joëlle Doré-Bergeron
- Department of Pediatrics (CT, MJDB, NK), CHU Sainte-Justine, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Kathryn DeKoven
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Anesthesiology (KD), CHU Sainte-Justine, Montreal, QC, Canada
| | - Anne-Marie Roy
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Nelson Piché
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada
| | - Jean-Francois Delisle
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Caroline Morin
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Pharmacy (EP, CN, JFD, CM), CHU Sainte-Justine, Montreal, QC, Canada
| | - Julie Paquette
- Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Nursing (AMR, JP), CHU Sainte-Justine, Montreal, QC, Canada
| | - Niina Kleiber
- Department of Pharmacology and Physiology (CT, NK), Université de Montreal, Montreal, QC, Canada,Research Center (CT, NK), CHU Sainte-Justine, Université de Montreal, Montreal, QC, Canada,Groupe de Gouvernance des Analgésiques (CT, EP, CN, EDT, MJDB, KD, AMR, NP, JFD, CM, JP, NK), Pharmacology Committee, CHU Sainte-Justine, Montreal, QC, Canada,Department of Surgery (NP), CHU Sainte-Justine, Montreal, QC, Canada
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Paluszek C, Brenner P, Pichlmaier M, Haas NA, Dalla-Pozza R, Hagl C, Hakami L. Risk Factors and Outcome of Post Fallot Repair Junctional Ectopic Tachycardia (JET). World J Pediatr Congenit Heart Surg 2019; 10:50-57. [PMID: 30799715 DOI: 10.1177/2150135118813124] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) is a common arrhythmia causing hemodynamic impairment following corrective cardiac surgery such as tetralogy of Fallot (TOF) repair. METHODS We report our experience with postoperative JET following surgical repair of TOF. The retrospective study was done from 2003 to 2012 with a total of 105 patients who underwent TOF repair. These patients' clinical and electrocardiographic data (pre-, intra-, and postoperative) were monitored to identify risk factors for the occurrence of JET and to evaluate the outcome of the affected patients. RESULTS Incidence-Fourteen patients developed JET, with only four patients going directly from sinus rhythm to JET. In all others, either a transient atrioventricular (AV) block or a junctional rhythm preceded JET, mostly intraoperatively, showing a significant relation ( P = .010). Age-Patients with JET were of younger age ( P = .025) and had longer cardiopulmonary bypass ( P = .044) and aortic cross-clamping times ( P = .038). Increased cost and care-The occurrence of JET was associated with a longer stay in the intensive care unit (ICU) and a prolonged need for inotropic support and mechanical ventilation. Time to rate control correlated with length of ICU and hospital stay. MORTALITY All JET patients converted into sinus rhythm, one of them died shortly after cessation of JET and two patients subsequently developed a first-degree AV block. CONCLUSION The occurrence of JET remains an important complication during the initial postoperative period by increasing mechanical ventilation time, the need for inotropic support, and prolonging the length of ICU and hospital stay. Risk factors are younger age, longer aortic cross-clamping/bypass times, and intraoperative arrhythmias.
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Affiliation(s)
- Corinna Paluszek
- 1 Department of Pediatric and Congenital Heart Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany.,2 Department of Cardiac Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany.,3 Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Paolo Brenner
- 2 Department of Cardiac Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Maximilian Pichlmaier
- 2 Department of Cardiac Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Nikolaus A Haas
- 3 Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Robert Dalla-Pozza
- 3 Department of Pediatric Cardiology and Intensive Care, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Christian Hagl
- 2 Department of Cardiac Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
| | - Lale Hakami
- 1 Department of Pediatric and Congenital Heart Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany.,2 Department of Cardiac Surgery, Medical Hospital of the University of Munich, Ludwig-Maximilian-University of Munich, Munich, Germany
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5
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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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