Prophylactic amiodarone reduces junctional ectopic tachycardia after tetralogy of Fallot repair

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

Background

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

Methods

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

Results

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

Conclusion

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

Routine Perioperative Esmolol After Infant Tetralogy of Fallot Repair: Single-Center Retrospective Study of Hemodynamics

OBJECTIVES

Currently, surgical repair of tetralogy of Fallot (TOF) is associated with an 1.1% 30-day mortality rate. Those with junctional ectopic tachycardia (JET) and restrictive right ventricular physiology have poorer outcomes. Routine postoperative adrenergic or inodilator therapy has been reported, while beta-blockade following cardiopulmonary bypass has not. This study evaluated routine perioperative treatment with esmolol in infants undergoing TOF repair.

DESIGN

Retrospective chart review of the perioperative course following TOF repair.

SETTING

Single-center case series describing perioperative management of TOF in a cardiac ICU.

PATIENTS

This study reviewed all patients less than 18 months old who underwent TOF repair, excluding cases of TOF with absent pulmonary valve or atrioventricular septal defect, at our institution from June 2018 to April 2021.

INTERVENTIONS

This review investigates the hemodynamic effects of esmolol following cardiopulmonary bypass for TOF repair.

MEASUREMENTS AND MAIN RESULTS

Preoperative clinical characteristics and perioperative course were extracted from the medical record. Descriptive statistics were used. Twenty-six patients receiving perioperative esmolol after TOF repair were identified and included. Postoperative hemodynamic parameters were within a narrow range with minimal vasoactive support in most patients. Three of 26 patients experienced JET, and one of 26 of whom had a brief cardiac arrest. Median and interquartile range (IQR) for hospital and postoperative length of stay was 7 days (IQR, 6-9 d) and 6 days (IQR, 5-8 d), respectively. There were no 30-day or 1-year mortalities.

CONCLUSIONS

In this infant cohort, our experience is that the routine use of postoperative esmolol is associated with good cardiac output with minimal requirement for vasoactive support in most patients. We believe optimal postoperative management of infant TOF repair requires a meticulous multidisciplinary approach, which in our experience is enhanced with routine postoperative esmolol treatment.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of the evidence supporting post-operative medication use in congenital heart disease

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.

Junctional Ectopic Tachycardia: Recognition and Modern Management Strategies

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.

Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study

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.

Association Between Postoperative Dexmedetomidine Use and Arrhythmias in Infants After Cardiac Surgery

BACKGROUND

Dexmedetomidine has been suggested as an arrhythmia prophylactic agent after surgery for congenital heart disease due to its heart rate lowering effect, though studies are conflicting. We sought to study the effect of dexmedetomidine in infants that are at highest risk for arrhythmias.

METHODS

Retrospective cohort study of infants less than six months of age undergoing cardiopulmonary bypass for congenital heart disease. The arrhythmia incidence in the first 48 hours after surgery in infants receiving dexmedetomidine for sedation was compared to those that did not receive dexmedetomidine.

RESULTS

A total of 309 patients were included, 206 patients who did not receive dexmedetomidine and 103 patients who did. The incidence of tachyarrhythmias was similar between the non-DEX group and the DEX group (19% vs 15%, P = .34). When adjusted for baseline differences, the non-DEX group did not have an increased risk of postoperative tachyarrhythmias (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 0.5-3.8). The non-DEX group had an increased need for treatment for arrhythmias (18% vs 8%, P = .012). The three lesions with baseline higher risk for arrhythmias (tetralogy of Fallot, transposition of the great arteries, and complete atrioventricular canal) had an increased incidence of tachyarrhythmias in the non-DEX group (34% vs 6%, P = .027). This risk was not significant in multivariate analysis (OR: 2.5, 95% CI: 0.4-15.5).

CONCLUSIONS

High-risk infants had decreased incidence of tachyarrhythmias when receiving dexmedetomidine, though this was not significant after accounting for baseline differences between groups.

Tetralogy of Fallot: Everything you wanted to know but were afraid to ask

Tetralogy of Fallot (TOF) has four anatomic features: right ventricular hypertrophy (RVH), ventriculoseptal defect (VSD), overriding aorta and right ventricular outflow tract obstruction (RVOT) with an occurrence of 3.9 /10,000 births. The pathophysiologic effects in TOF are largely determined by the degree of RVOT and not the VSD. Intra-operative anesthetic management is also dependent on the degree of RVOT obstruction and influenced by the extent of surgical RVOT repair.

Landiolol Hydrochloride Rapidly Controls Junctional Ectopic Tachycardia After Pediatric Heart Surgery

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.

Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2 years

Background

Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age.

Methods

From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients (n = 96) had postoperative JET.

Results

JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca (p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn’t affect the duration of mechanical ventilation nor hospital stay (p = 0.12 and 0.2 respectively) but prolonged the ICU stay (p = 0.011). JET resolved in 39.5% (n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% (n = 30) of patients and its use was associated with longer ICU stay (p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn’t affect ICU (p = 0.43) or hospital stay (p = 0.14) however, long duration of JET increased ICU and hospital stay (p = 0.02 and 0.009; respectively).

Conclusion

JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential.

Management of postoperative junctional ectopic tachycardia in pediatric patients: a survey of 30 centers in Germany, Austria, and Switzerland

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.

The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery

OBJECTIVE

The objective of this study was to assess the effectiveness of pre-emptive dexmedetomidine versus amiodarone in preventing junctional ectopic tachycardia (JET) in pediatric cardiac surgery.

DESIGN

This is a prospective, controlled study.

SETTING

This study was carried out at a single university hospital.

SUBJECTS AND METHODS

Ninety patients of both sexes, American Society of Anesthesiologists Physical Status II and III, age range from 2 to 18 years, and scheduled for elective cardiac surgery for congenital and acquired heart diseases were selected as the study participants.

INTERVENTIONS

Patients were randomized into three groups (30 each). Group I received dexmedetomidine 1 mcg/kg diluted in 100 ml of normal saline intravenously (IV) over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 0.5 mcg/kg/h infusion for 72 h postoperative, Group II received amiodarone 5 mg/kg diluted in 100 ml of normal saline IV over a period of 20 min, and the infusion was completed 10 min before the induction followed by a 10-15 mcg/kg/h infusion for 72 h postoperative, and Group III received 100 ml of normal saline IV. Primary outcome was the incidence of postoperative JET. Secondary outcomes included vasoactive-inotropic score, ventilation time (VT), pediatric cardiac care unit stay, hospital length of stay, and perioperative mortality.

MEASUREMENTS AND MAIN RESULTS

The incidence of JET was significantly reduced in Group I and Group II (P = 0.004) compared to Group III. Heart rate while coming off from cardiopulmonary bypass (CPB) was significantly low in Group I compared to Group II and Group III (P = 0.000). Mean VT, mean duration of Intensive Care Unit stay, and length of hospital stay (day) were significantly short (P = 0.000) in Group I and Group II compared to Group III (P = 0.000).

CONCLUSION

Perioperative use of dexmedetomidine and amiodarone is associated with significantly decreased incidence of JET as compared to placebo without significant side effects.

Impact of Different Diagnostic Criteria on the Reported Prevalence of Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery

OBJECTIVES

Junctional ectopic tachycardia is a frequent complication after pediatric cardiac surgery. A uniform definition of postoperative junctional ectopic tachycardia has yet to be established in the literature. The objective of this study is to analyze differences in the general and age-related prevalence of postoperative junctional ectopic tachycardia according to different diagnostic definitions.

DESIGN

Data files and electrocardiograms of 743 patients (age, 1 d to 17.6 yr) who underwent surgery for congenital heart disease during a 3-year period were reviewed. The prevalence of postoperative junctional ectopic tachycardia in this cohort was determined according to six different definitions identified in the literature and one definition introduced for analytical purposes. Agreement between the definitions was analyzed according to Cohen κ coefficients. A receiver operating characteristic analysis was performed to determine the ability of different definitions to discriminate between patients with increased postoperative morbidity and without.

SETTING

A university-affiliated tertiary pediatric cardiac PICU.

PATIENTS

Infants and children who underwent heart surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The prevalence of postoperative junctional ectopic tachycardia ranged from 2.0% to 8.3% according to the seven different definitions. Even among definitions for which the general prevalence was almost equal, the distribution according to age varied. Most definitions used a frequency criterion to define postoperative junctional ectopic tachycardia. Definitions based on a fixed frequency criterion did not identify cases of postoperative junctional ectopic tachycardia in patients older than 12 months. The grade of agreement was moderate or poor between definitions using a fixed or dynamic frequency criterion and those not based on a critical heart rate (κ = 0.37-0.66). In the receiver operating characteristic analysis, the definition with a fixed frequency criterion of 180 beats/min or an age-related frequency criterion according to the 95th percentile showed the optimal cut-off value to determine increased postoperative morbidity.

CONCLUSIONS

Different definitions of junctional ectopic tachycardia after pediatric cardiac surgery lead to relevant differences in the reported prevalence and age distribution pattern. A uniform definition of postoperative junctional ectopic tachycardia is needed to provide comparable study results and to improve the diagnosis of junctional ectopic tachycardia in pediatric patients.

Arrhythmias in Cardiac Critical Care

OBJECTIVES

Here, we characterize the frequency, mechanisms, clinical impact, and potential treatment options for several arrhythmias commonly encountered in pediatric cardiac critical care.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSIONS

Arrhythmias among children in the cardiac critical care setting are common and clinically important, associated independently with prolonged mechanical ventilation, critical care unit stay, and an increase in mortality. The precise characterization of an arrhythmia may provide clues as to an underlying mechanism as well as serve to guide treatment. Arrhythmia therapy, pharmacologic or otherwise, is directed toward addressing the underlying mechanism, and as such may be applicable to the treatment of more than one specific rhythm disturbance. Decisions concerning therapy must call into consideration an arrhythmia's underlying etiology, mechanism, and associated hemodynamic embarrassment, along with the potential for adverse effects of treatment.

Safety and Efficacy of Prophylactic Amiodarone in Preventing Early Junctional Ectopic Tachycardia (JET) in Children After Cardiac Surgery and Determination of Its Risk Factor

Postoperative arrhythmia is a common complication after open heart surgery in children. JET is the most common and dangerous arrhythmia. We aimed to assess safety and efficacy of prophylactic amiodarone in preventing JET in children underwent cardiac surgery and to assess risk factors for JET among our patients. In total, 117 children who underwent cardiac surgery for CHD at Tanta University Hospital from October 2011 to April 2015 were divided in two groups; amiodarone group (65 patients) was given prophylactic amiodarone intraoperatively and placebo group (52 patients). Amiodarone is started as loading dose of 5 mg/kg IV in the operating room after induction of anesthesia and continued for 3 days as continuous infusion 10-15 μg/kg/min. Primary outcome and secondary outcomes of amiodarone administration were reported. We studied pre-, intra- and postoperative factors to determine risk factors for occurrence of JET among these children. Prophylactic amiodarone was found to significantly decrease incidence of postoperative JET from 28.9 % in placebo group to 9.2 % in amiodarone group, and symptomatic JET from 11.5 % in placebo group to 3.1 % in amiodarone group, and shorten postoperative intensive care unit and hospital stay without significant side effects. Risk factors for occurrence of JET were younger age, lower body weight, longer cardiopulmonary bypass, aortic cross-clamp time, hypokalemia, hypomagnesemia, acidosis and high dose of inotropes. JET was more associated with surgical repair of right ventricular outlet obstruction as in case of tetralogy of Fallot and pulmonary stenosis. Most of JET 15/21 (71.4 %) occurred in the first day postoperatively, and 6/21 occurred in the second day (28.6 %). Prophylactic amiodarone is safe and effective in preventing early JET in children after open heart surgery.

Low incidence of arrhythmias in the right ventricular infundibulum sparing approach to tetralogy of Fallot repair

To improve outcomes, including arrhythmia incidence, for patients with tetralogy of Fallot (TOF), the authors' institution adopted an approach that minimizes or avoids transmural incision of the right ventricular outflow tract. When pulmonary blood flow is insufficient during the neonatal period, placement of an aortopulmonary artery shunt is preferred, followed by complete repair later in infancy. This study reviewed the perioperative and mid-term arrhythmia outcomes at the authors' institution using this approach. Patients who underwent TOF repair from 1995 to 2008 were included in the study. Patient demographics and surgical history were collected. The primary end points of the study included documented perioperative arrhythmias and arrhythmias at the 10-year follow-up assessment. Of the 298 patients who underwent TOF repair, 50 (17 %) had undergone prior placement of a systemic-to-pulmonary artery shunt. The median age at repair was 9.7 months (interquartile range, 6.3-16.2 months). Clinically significant perioperative arrhythmias were found in 12 patients (4 %) including 6 junctional tachycardias, 4 atrial tachycardias, and 1 temporary complete heart block. No patients were receiving antiarrhythmic medications more than 24 months after surgery. Of the 298 patients, 86 (29 %) had a follow-up period of 10 years or longer (median, 12.2 years). No patients experienced new arrhythmias, received antiarrhythmic therapy, experienced post-discharge ventricular tachycardia, had atrioventricular block, or required a pacemaker or defibrillator. The right ventricular infundibulum sparing approach is associated with an extremely low incidence of perioperative and midterm arrhythmias. The perioperative and mid-term outcomes compare favorably with existing data from programs favoring neonatal repair. Long-term follow-up evaluation is essential to determine whether this strategy can effectively alter late pathophysiology and minimize late-term arrhythmias and associated mortality.

A common angiotensin-converting enzyme polymorphism and preoperative angiotensin-converting enzyme inhibition modify risk of tachyarrhythmias after congenital heart surgery

BACKGROUND

The angiotensin-converting enzyme insertion/deletion (ACE I/D) polymorphism is described in association with numerous phenotypes, including arrhythmias, and may provide predictive value among pediatric patients undergoing congenital heart surgery.

OBJECTIVE

The purpose of this study was to examine the role of a common polymorphism on postoperative tachyarrhythmias in a large cohort of pediatric patients undergoing congenital heart surgery with cardiopulmonary bypass (CPB).

METHODS

Subjects undergoing congenital heart surgery with CPB at our institution were consecutively enrolled from September 2007 to December 2012. In addition to DNA, perioperative clinical data were obtained from subjects.

RESULTS

Postoperative tachyarrhythmias were documented in 45% of 886 enrollees and were associated with prolonged mechanical ventilation (P <.001) and intensive care unit length of stay (P <.001). ACE I/D was in Hardy-Weinberg equilibrium (19% I/I, 49% I/D, 32% D/D). I/D or D/D genotypes were independently associated with a 60% increase in odds of new tachyarrhythmia (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3, P = .02). Preoperative ACE inhibitor administration was independently associated with a 47% reduction in odds of postoperative tachyarrhythmia in the entire cohort (OR 0.53, 95% CI 0.32-0.88, P = .01), driven by a 5-fold reduction in tachyarrhythmias among I/I genotype patients (OR 0.19, 95% CI 0.04-0.88, P = .02).

CONCLUSION

The risk of tachyarrhythmias after congenital heart surgery is independently affected by the ACE I/D polymorphism. Preoperative ACE inhibition is associated with a lower risk of postoperative tachyarrhythmias, an antiarrhythmic effect that appears genotype dependent. An understanding of genotype variation may play an important role in the perioperative management of congenital heart surgery.

Pediatric postoperative cardiac care

Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.

Tetralogy of Fallot: perioperative anesthetic management of children and adults

Tetralogy of Fallot (TOF) is a common congenital heart defect in children. Perioperative considerations include preoperative preparation for surgery, intraoperative anesthetic management, and common postoperative issues in the intensive care unit. Surgical debates have shifted away from 2-stage versus single-stage repairs to debates of how surgery to limit pulmonary insufficiency (PI) may have significant long-term impact as the child grows. There are many adult survivors of TOF repair in infancy who now present with a unique set of problems related to PI and right ventricular dysfunction. These adults provide new insights into congenital heart disease (CHD) and how management strategies early in life may have significant implications much later in life. Patients with complex CHD should have lifelong follow-up, so our knowledge will continue to improve, and the best possible care can be provided for these patients.