Management of ventricular fibrillation or unstable ventricular tachycardia in patients with congenital long-QT syndrome: a suggested modification to ACLS guidelines

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Tachyarrhythmias and defibrillation

Although cardiac arrhythmias less commonly cause hemodynamic compromise in children than in adults, prompt recognition and treatment of arrhythmias remain an important part of pediatric resuscitation because of the availability of specific, effective therapies. This article summarizes the 2005 American Heart Association Guidelines for Pediatric Advanced Life Support regarding tachyarrhythmias, including treatment with antiarrhythmics and direct current countershock therapy, and provides an update of recent literature since the guidelines were published.

Dental treatment of patients with long QT syndrome

BACKGROUND

Long QT syndrome (LQTS) is associated with life-threatening cardiac arrhythmias causing syncope and sudden cardiac death, frequently precipitated by physical or psychological stress.

TYPES OF STUDIES REVIEWED

The authors did a literature review of data published in peer-reviewed medical and dental journals. They also extracted epidemiologic information, correlations between genetic mutations and disease onset and progression, and data regarding outcomes of therapy from published peer-reviewed studies and the cohort population belonging to the International Long QT Syndrome Registry.

RESULTS

LQTS is diagnosed after an unexpected cardiac event or through QT interval prolongation on an electrocardiogram. Gene mutation identification in LQTS provides insight into respective proarrhythmogenic factors and indicated therapeutic regimens. beta-blockers are the initial treatment for two of the three major forms of LQTS. Patients refractory to beta-antiadrenergic therapy may benefit from one or more of the following: cardiac pacemakers, implanted cardioverter defibrillators and left cardiac sympathetic denervation.

CONCLUSIONS

Clinical studies are needed to investigate the safety of treating patients in an ambulatory setting.

CLINICAL IMPLICATIONS

Preventive measures are recommended, including evaluation by a cardiac specialist before any dental intervention, use of anxiolytic protocols, avoidance of drugs that prolong the QT interval, and provision of treatment in a setting in which medical emergencies can be managed expeditiously. Dental treatment in a hospital and use of a general anesthetic administered by anesthesiologists are recommended for procedures in which anxiety and adrenergic stimulation would not be suppressed sufficiently in an ambulatory environment.

Acquired long QT syndrome and elective anesthesia in children

We present the case of a child who had had a previous episode of torsades de pointes (TdP) and who was scheduled for elective surgery under general anesthesia. The pathophysiology of this condition and the anesthesia concerns are discussed. An 8-year-old male with a history of osteogenic sarcoma had undergone an uneventful limb salvage procedure 2 years earlier. During a subsequent admission to the hospital, he had had a cardiopulmonary arrest with complete recovery. Telemetry electrocardiogram (ECG) rhythm recordings obtained during the event showed TdP that degenerated into ventricular fibrillation, which then terminated spontaneously. On a subsequent ECG, the QTc interval was 694 ms. The prolonged QT interval was attributed to homeopathic use of cesium chloride supplements and the QT interval normalized after cesium was stopped. He presented for an elective procedure and, with an anesthetic plan that emphasized medications without known effect on the QT interval, had an uneventful perioperative course. The optimal anesthesia plan for patients with prolonged QT or those suspected to be at risk for prolongation of the QT interval has not been well described. Available evidence suggests that using total intravenous anesthesia with propofol may be the safest and was used uneventfully in this case. Additionally, this case emphasizes the need to inquire about the use of supplements and naturopathic medications, even in children, that may have life-threatening side effects or interactions with anesthetic agents.