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Kim ME, Baskar S, Janson CM, Chandler SF, Whitehill RD, Dionne A, Law MA, Domnina Y, Smith-Parrish MN, Bird GL, Banerjee M, Zhang W, Reichle G, Schumacher KR, Czosek RJ, Morales DLS, Alten JA. Epidemiology of Postoperative Junctional Ectopic Tachycardia in Infants Undergoing Cardiac Surgery. Ann Thorac Surg 2024; 117:1178-1185. [PMID: 38484909 DOI: 10.1016/j.athoracsur.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/28/2024] [Accepted: 03/04/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) complicates congenital heart surgery in 2% to 8.3% of cases. JET is associated with postoperative morbidity in single-center studies. We used the Pediatric Cardiac Critical Care Consortium data registry to provide a multicenter epidemiologic description of treated JET. METHODS This is a retrospective study (February 2019-August 2022) of patients with treated JET. Inclusion criteria were (1) <12 months old at the index operation, and (2) treated for JET <72 hours after surgery. Diagnosis was defined by receiving treatment (pacing, cooling, and medications). A multilevel logistic regression analysis with hospital random effect identified JET risk factors. Impact of JET on outcomes was estimated by margins/attributable risk analysis using previous risk-adjustment models. RESULTS Among 24,073 patients from 63 centers, 1436 (6.0%) were treated for JET with significant center variability (0% to 17.9%). Median time to onset was 3.4 hours, with 34% present on admission. Median duration was 2 days (interquartile range, 1-4 days). Tetralogy of Fallot, atrioventricular canal, and ventricular septal defect repair represented >50% of JET. Patient characteristics independently associated with JET included neonatal age, Asian race, cardiopulmonary bypass time, open sternum, and early postoperative inotropic agents. JET was associated with increased risk-adjusted durations of mechanical ventilation (incidence rate ratio, 1.6; 95% CI, 1.5-1.7) and intensive care unit length of stay (incidence rate ratio, 1.3; 95% CI, 1.2-1.3), but not mortality. CONCLUSIONS JET is treated in 6% of patients with substantial center variability. JET contributes to increased use of postoperative resources. High center variability warrants further study to identify potential modifiable factors that could serve as targets for improvement efforts to ameliorate deleterious outcomes.
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Affiliation(s)
- Michael E Kim
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Shankar Baskar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher M Janson
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Robert D Whitehill
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Law
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yuliya Domnina
- Department of Cardiac Critical Care, Children's National Hospital, Washington, DC
| | - Melissa N Smith-Parrish
- Department of Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Geoffrey L Bird
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mousumi Banerjee
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Wenying Zhang
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Garrett Reichle
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Department of Cardiology, C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
| | - Richard J Czosek
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey A Alten
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Yang Q, Tadros HJ, Sun B, Bidzimou MT, Ezekian JE, Li F, Ludwig A, Wehrens XH, Landstrom AP. Junctional Ectopic Tachycardia Caused by Junctophilin-2 Expression Silencing Is Selectively Sensitive to Ryanodine Receptor Blockade. JACC Basic Transl Sci 2023; 8:1577-1588. [PMID: 38205351 PMCID: PMC10774596 DOI: 10.1016/j.jacbts.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 01/12/2024]
Abstract
Junctional ectopic tachycardia (JET) is a potentially fatal cardiac arrhythmia. Hcn4:shJph2 mice serve as a model of nodal arrhythmias driven by ryanodine type 2 receptor (RyR2)-mediated Ca2+ leak. EL20 is a small molecule that blocks RyR2 Ca2+ leak. In a novel in vivo model of JET, Hcn4:shJph2 mice demonstrated rapid conversion of JET to sinus rhythm with infusion of EL20. Primary atrioventricular nodal cells demonstrated increased Ca2+ transient oscillation frequency and increased RyR2-mediated stored Ca2+ leak which was normalized by EL20. EL20 was found to be rapidly degraded in mouse and human plasma, making it a potential novel therapy for JET.
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Affiliation(s)
- Qixin Yang
- Division of Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hanna J. Tadros
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Bo Sun
- Division of Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Minu-Tshyeto Bidzimou
- Division of Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jordan E. Ezekian
- Division of Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Feng Li
- Center for Drug Discovery and Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Andreas Ludwig
- Institut für Experimentelle und Klinische Pharmakologie, und Toxikologie, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Xander H.T. Wehrens
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Cardiovascular Research Institute, Departments of Medicine (Cardiology), Molecular Physiology and Biophysics, and Neuroscience and Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew P. Landstrom
- Division of Cardiology, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Cell Biology, Duke University School of Medicine, Durham, North Carolina, USA
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3
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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 post-operative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease. Heart Rhythm 2023:S1547-5271(23)00221-7. [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] [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 post-operative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intra-operative treatment may improve outcomes, but patient selection remains a challenge. OBJECTIVES Our objective was to describe contemporary outcomes of post-operative AJR/JET and develop a risk-prediction score to identify patients at highest risk. METHODS Retrospective cohort study of children 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 while JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression. RESULTS From 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 atrio-ventricular 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% CI 0.70, 0.75]. Post-operative AJR and JET was associated with prolonged ICU and hospital length of stay, but not with early mortality. CONCLUSION We describe a novel risk prediction score to estimate the risk of post-operative 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, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Khairy Shalhoub
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Iqbal El-Assaad
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Edward O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Dumeny L, Chantra M, Langaee T, Duong BQ, Zambrano DH, Han F, Lopez‐Colon D, Humma JF, Dacosta J, Lovato T, Mei C, Duarte JD, Johnson JA, Peek GJ, Jacobs JP, Bleiweis MS, Cavallari LH. β1-receptor polymorphisms and junctional ectopic tachycardia in children after cardiac surgery. Clin Transl Sci 2022; 15:619-625. [PMID: 34713976 PMCID: PMC8932827 DOI: 10.1111/cts.13178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/13/2021] [Accepted: 10/13/2021] [Indexed: 01/22/2023] Open
Abstract
Junctional ectopic tachycardia (JET) is a potentially life-threatening postoperative arrhythmia in children with specific congenital heart defects and can contribute significantly to postoperative morbidity for at-risk populations. In adults, β1-adrenergic receptor (ADRB1) and β2-adrenergic receptor (ADRB2) genotypes have been associated with increased risk for arrhythmias. However, their association with arrhythmia risk in children is unknown. We aimed to test associations between ADRB1 and ADRB2 genotypes and postoperative JET in patients with congenital heart defects. Children who underwent cardiac surgery were genotyped for the ADRB1 p.Ser49Gly (rs1801252; c.145A>G), p.Arg389Gly (rs1801253; c.1165C>G), ADRB2 p.Arg16Gly (rs1042713; c.46A>G), and p.Glu27Gln (rs1042714; c.79G>C) polymorphisms. The occurrence of postoperative JET was assessed via cardiologist-interpreted electrocardiograms. Genotype associations with JET were analyzed via logistic regression, adjusted for clinical variables associated with JET, with separate analysis in patients not on a β-blocker. Of the 343 children included (median age 8 months, 53% boys, 69% European ancestry), 45 (13%) developed JET. The Arg389Arg genotype was not significantly associated with JET in the overall population (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 0.96-4.03, p = 0.064), but was nominally associated in patients not taking a β-blocker (n = 324, OR = 2.25, 95% CI = 1.05-4.80. p = 0.034). None of the other variants were associated with JET. These data suggest that the ADRB1 Arg389Arg genotype may predict risk for JET following cardiac surgery in pediatric patients in the absence of β-blockade. Whether treatment with a β-blocker ameliorates this association requires further research.
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Affiliation(s)
- Leanne Dumeny
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Marut Chantra
- Division of Pediatric Critical CareDepartments of PediatricsCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA,Present address:
Division of Pediatric Critical Care MedicineDepartment of PediatricsFaculty of Medicine Ramathibodi HospitalMahidol UniversityRatchatewi, BangkokThailand
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Benjamin Q. Duong
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA,Present address:
Precision MedicineNemours Children’s HealthWilmingtonDelawareUSA
| | - Daniel H. Zambrano
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Frank Han
- Division of Cardiovascular SurgeryDepartments of Surgery and PediatricsCongenital Heart CenterCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Dalia Lopez‐Colon
- Division of Cardiovascular SurgeryDepartments of Surgery and PediatricsCongenital Heart CenterCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - James F. Humma
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Jonathan Dacosta
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Tommie Lovato
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Connie Mei
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Julio D. Duarte
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Julie A. Johnson
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
| | - Giles J. Peek
- Division of Cardiovascular SurgeryDepartments of Surgery and PediatricsCongenital Heart CenterCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Jeffrey P. Jacobs
- Division of Cardiovascular SurgeryDepartments of Surgery and PediatricsCongenital Heart CenterCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Mark S. Bleiweis
- Division of Cardiovascular SurgeryDepartments of Surgery and PediatricsCongenital Heart CenterCollege of MedicineUniversity of FloridaGainesvilleFloridaUSA
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational ResearchCenter for Pharmacogenomics and Precision MedicineCollege of PharmacyUniversity of FloridaGainesvilleFloridaUSA
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5
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Johnsrude CL. Infant with 2:1 atrioventricular block after surgery for congenital heart disease: What’s the mechanism? HeartRhythm Case Rep 2022; 8:27-30. [PMID: 35070703 PMCID: PMC8767167 DOI: 10.1016/j.hrcr.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Christopher L. Johnsrude
- Address reprint requests and correspondence: Dr Christopher L. Johnsrude, Associate Professor, Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville School of Medicine, Suite 113, KCPC, 571 S. Floyd St., Louisville, KY 40202.
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Rochelson E, Valdés SO, Asadourian V, Patel R, Lemming K, Howard TS, Pham TDN, Miyake CY, Kim JJ. Sotalol versus amiodarone for postoperative junctional tachycardia after congenital heart surgery. Heart Rhythm 2021; 19:450-456. [PMID: 34801734 DOI: 10.1016/j.hrthm.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Junctional ectopic tachycardia (JET) is a common arrhythmia after congenital heart disease surgery. There is variability in the choice of antiarrhythmic therapy, with amiodarone used commonly. Intravenous (IV) sotalol is a newly available agent that may be useful for JET. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of IV sotalol for postoperative JET and compare outcomes with IV amiodarone. METHODS This is a retrospective single-center study of all patients who received IV sotalol or IV amiodarone for postoperative JET at Texas Children's Hospital from December 15, 2015, to December 15, 2020. Data included antiarrhythmic efficacy, hemodynamics, and adverse effects. Successful JET control was defined as a decrease in JET rate to <170 beats/min (or decrease by >20%), or conversion to sinus rhythm, with persistent control over 24 hours without requiring alternative antiarrhythmics or mechanical support. RESULTS A total of 32 patients (median age 71 days; interquartile range 17-221 days) received IV amiodarone (n = 20 [62%]) or IV sotalol (n = 12 [38%]) for postoperative JET. Amiodarone was successful in treating JET in 75% of cases; sotalol was successful in 83%. The JET rate decreased faster over the first 90 minutes after a sotalol bolus (25 beats/min per hour) than after an amiodarone bolus (8 beats/min per hour) (P < .01); no heart rate difference was seen after 24 hours. Amiodarone infusion was discontinued early because of hypotension/bradycardia in 2 patients; this was not required in any patients receiving sotalol. CONCLUSION For children with postoperative JET, both IV sotalol and amiodarone are safe and efficacious. IV sotalol may lead to a faster improvement in heart rate.
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Affiliation(s)
- Ellis Rochelson
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Santiago O Valdés
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | | | - Katherine Lemming
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Taylor S Howard
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Tam Dan N Pham
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Christina Y Miyake
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jeffrey J Kim
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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7
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Janson CM, Clancy CE. Ivabradine for Postoperative JET: Clear for Take-Off? JACC Clin Electrophysiol 2021; 7:1061-1063. [PMID: 34412869 DOI: 10.1016/j.jacep.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Christopher M Janson
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Colleen E Clancy
- Department of Physiology and Membrane Biology and Department of Pharmacology, School of Medicine, University of California-Davis, Davis, California, USA
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Arvind B, Kothari SS, Juneja R, Saxena A, Ramakrishnan S, Gupta SK, Chowdhury UK, Devagourou V, Talwar S, Hote MP, Rajashekar P, Sahu MK, Singh SP. Ivabradine Versus Amiodarone in the Management of Postoperative Junctional Ectopic Tachycardia: A Randomized, Open-Label, Noninferiority Study. JACC Clin Electrophysiol 2021; 7:1052-1060. [PMID: 33812837 DOI: 10.1016/j.jacep.2021.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to compare the efficacy of ivabradine and amiodarone in the management of postoperative junctional ectopic tachycardia (JET) after cardiac surgery in children. BACKGROUND JET is a serious arrhythmia occurring in children after cardiac surgery and requires aggressive management. Amiodarone has been conventionally used in its treatment. Recent studies have reported the utility of ivabradine in this regard. METHODS In this open-label randomized controlled trial, 94 children (age ≤18 years) who developed postoperative JET were allocated to receive either amiodarone or ivabradine. The primary endpoint was restoration of normal sinus rhythm. RESULTS Sinus rhythm was achieved in 43 out of the 46 patients (93.5%) in the amiodarone group and 46 out of the 48 patients (95.8%) in the ivabradine group (mean difference of treatment effect: 2.3%; 95% confidence interval: -6.7% to 11.5%). The median (interquartile range) time taken to achieve sinus rhythm conversion was similar in both the groups: 21.5 (17-30.2) hours versus 22 (13.4-38.5) hours (p = 0.36)]. The time taken to rate control of JET was significantly less in the amiodarone group: median 7.0 (5.5-9.5) hours versus 8.0 (5.8-10.8) hours (p = 0.02)]. No drug-related adverse events were observed in the ivabradine group. CONCLUSIONS Oral ivabradine is not inferior to intravenous amiodarone in converting postoperative JET to sinus rhythm. There was no difference in time taken to sinus rhythm conversion between the groups, although the rate control was earlier in patients who received amiodarone. Monotherapy with ivabradine may be considered as an alternative to amiodarone in the management of postoperative JET. (Comparison of Two Drugs, Ivabradine and Amiodarone, in the Management of Junctional Ectopic Tachycardia, an Abnormality in Cardiac Rhythm in Patients Under 18 years Who Undergo Cardiac Surgery: CTRI/2018/08/015182).
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Affiliation(s)
- Balaji Arvind
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shyam S Kothari
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Rajnish Juneja
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Saurabh Kumar Gupta
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal K Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Velayoudam Devagourou
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Milind P Hote
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajashekar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj Kumar Sahu
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sarvesh Pal Singh
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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Early postoperative arrhythmias in patients undergoing congenital heart surgery. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:27-35. [PMID: 33768978 PMCID: PMC7970075 DOI: 10.5606/tgkdc.dergisi.2021.20366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/27/2020] [Indexed: 11/21/2022]
Abstract
Background This study aims to evaluate early postoperative arrhythmias in children undergoing congenital cardiac surgery. Methods A total of 670 pediatric patients (355 males, 315 females; median age: 4 months; range, 1 day to 18 years) who underwent cardiac surgery due to congenital heart defects between December 2018 and November 2019 were included. The rate of postoperative arrhythmias, diagnosis, potential risk factors, and management strategies were evaluated. Multivariate regression analysis was used to identify significant factors of development of postoperative arrhythmias. Results Tachyarrhythmia was detected in 54 patients (8.1%), and the most common tachyarrhythmia was junctional ectopic tachycardia. Medical treatment was required in 25/38 (66%) of junctional ectopic tachycardia patients. Amiodarone was initiated in 18, dexmedetomidine in five, and flecainide + amiodarone in two of the patients. Different degrees of atrioventricular block were observed in 30 patients (4.5%). In 12 patients, permanent pacemakers were implanted during hospitalization. Age at the time of surgery under one-year-old, high inotropic scores, prolonged operation time, and high Aristotele"s scores were independent risk factors associated with early postoperative arrhythmia (p<0.05). The most common operations associated with early postoperative arrhythmia were left ventricular outflow tract, (6/20, 30%), complete atrioventricular septal defect (13/53, 24%), and tetralogy of Fallot (20/134, 14%) surgeries. Conclusion Cardiac arrhythmias are common in the early period after congenital heart surgery in children. The diagnosis and frequency of arrhythmias may vary according to different surgical procedures.
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Catton KG, Peterson JK. Junctional Ectopic Tachycardia: Recognition and Modern Management Strategies. Crit Care Nurse 2020; 40:46-55. [PMID: 32006036 DOI: 10.4037/ccn2020793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Kirsti G Catton
- Kirsti G. Catton is a CVICU pediatric nurse practitioner at Lucile Packard Children's Hospital, Palo Alto, California
| | - Jennifer K Peterson
- Jennifer K. Peterson is Clinical Program Director, Children's Heart Institute, Miller Children's and Women's Hospital, Long Beach, California
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11
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Alasti M, Mirzaee S, Machado C, Healy S, Bittinger L, Adam D, Kotschet E, Krafchek J, Alison J. Junctional ectopic tachycardia (JET). J Arrhythm 2020; 36:837-844. [PMID: 33024461 PMCID: PMC7532275 DOI: 10.1002/joa3.12410] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 12/26/2022] Open
Abstract
Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.
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Affiliation(s)
- Mohammad Alasti
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Sam Mirzaee
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Colin Machado
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Stewart Healy
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Logan Bittinger
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - David Adam
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Emily Kotschet
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Jack Krafchek
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
| | - Jeffrey Alison
- Monash Cardiac Rhythm Management Department MonashHEART Monash Medical Centre Melbourne Vic. Australia
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12
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Kylat RI, Samson RA. Junctional ectopic tachycardia in infants and children. J Arrhythm 2020; 36:59-66. [PMID: 32071621 PMCID: PMC7011855 DOI: 10.1002/joa3.12282] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/02/2019] [Accepted: 11/11/2019] [Indexed: 02/01/2023] Open
Abstract
Tachyarrhythmias originating in the atrioventricular (AV) node and AV junction including the bundle of His complex (BH) are called junctional tachycardia (JT) or junctional ectopic tachycardia (JET). Congenital JET (CJET) is a rare arrhythmia that occurs in patients without a preceding cardiac surgery and can be refractory to medical therapy and associated with high morbidity and mortality. CJET has a high rate of morbidity and mortality with death occurring in 35% of cases. JET occurring within 72 hours after cardiac surgery is referred to as postoperative JET (POJET) and caused by direct trauma, ischemic, or stretch injury to the AV conduction tissues during surgical repair of congenital heart defects. Focal junctional tachycardia (FJT) is also known as automatic junctional tachycardia and includes paroxysmal or non-paroxysmal forms. We discuss a staged approach to therapy with improved pharmacological therapies and the use of catheter-based therapies.
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Affiliation(s)
- Ranjit I. Kylat
- Department of PediatricsCollege of MedicineUniversity of ArizonaTucsonAZUSA
| | - Ricardo A. Samson
- Children's Heart Center of NevadaLas VegasNVUSA
- Department of PediatricsDivision of CardiologyUniversity of Nevada‐Las Vegas School of MedicineLas VegasNVUSA
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13
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Yasuhara J, Kuno T, Taki M, Toda K, Kumamoto T, Kojima T, Shimizu H, Yoshiba S, Kobayashi T, Sumitomo N. Predictors of Early Postoperative Supraventricular Tachyarrhythmias in Children After the Fontan Procedure. Int Heart J 2019; 60:1358-1365. [PMID: 31735772 DOI: 10.1536/ihj.19-099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Postoperative arrhythmias are a frequent and fatal complication after the Fontan operation. However, clinical evidence demonstrating early postoperative arrhythmias in children undergoing the Fontan operation is limited. This study aimed to evaluate the prevalence of arrhythmias and identify the predictors of early postoperative supraventricular tachyarrhythmias (SVTs) after the Fontan procedure.Data were analyzed from 80 pediatric patients who underwent Fontan procedures between April 2000 and December 2017 in a single-center retrospective study. Early postoperative SVTs were defined as arrhythmias within 30 days after the Fontan procedure. We divided the patients into two groups, with or without early postoperative arrhythmias, and the predictors of early postoperative arrhythmias were analyzed. A multivariate logistic regression analysis was performed to determine independent predictors of early postoperative SVTs after the Fontan procedure.Early postoperative SVTs were observed in 21 patients (26.3%). The most common arrhythmia was junctional ectopic tachycardia. After an adjustment, an atrioventricular valve regurgitation (AVVR) grade of ≥2 (odds ratio 10.54, 95% confidence interval 2.52 to 44.17, P = 0.001) and preoperative arrhythmias (odds ratio 26.49, 95% confidence interval 1.64 to 428.62, P = 0.021) were significant predictors of early postoperative SVTs after the Fontan operation.An AVVR grade ≥2 and preoperative arrhythmia were significant predictors associated with early postoperative SVTs. Intervention for AVVR may provide clinical benefit for preventing early postoperative arrhythmias after the Fontan operation.
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Affiliation(s)
- Jun Yasuhara
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center.,Center for Cardiovascular Research and Heart Center, Nationwide Children's Hospital
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center
| | - Moe Taki
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Koichi Toda
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Takashi Kumamoto
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center.,Department of Pediatrics, Saga University Hospital
| | - Takuro Kojima
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Hiroyuki Shimizu
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center.,Department of Intensive Care, Kanagawa Children's Medical Center
| | - Shigeki Yoshiba
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Toshiki Kobayashi
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
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14
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Li X, Zhang C, Dai D, Liu H, Ge S. Efficacy of dexmedetomidine in prevention of junctional ectopic tachycardia and acute kidney injury after pediatric cardiac surgery: A meta‐analysis. CONGENIT HEART DIS 2018; 13:799-807. [PMID: 30260073 DOI: 10.1111/chd.12674] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/14/2018] [Accepted: 08/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Xin Li
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Chengxin Zhang
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Di Dai
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Haiyuan Liu
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Shenglin Ge
- Department of Cardiovascular Surgery The First Affiliated Hospital of Anhui Medical University Hefei China
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15
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He D, Aggarwal N, Zurakowski D, Jonas RA, Berul CI, Hanumanthaiah S, Moak JP. Lower risk of postoperative arrhythmias in congenital heart surgery following intraoperative administration of magnesium. J Thorac Cardiovasc Surg 2018; 156:763-770.e1. [DOI: 10.1016/j.jtcvs.2018.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/21/2018] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
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16
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Ghimire LV, Chou FS. Efficacy of prophylactic dexmedetomidine in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery patients: A systematic review and meta-analysis. Paediatr Anaesth 2018; 28:597-606. [PMID: 29882346 DOI: 10.1111/pan.13405] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Junctional ectopic tachycardia is a serious tachyarrhythmic complication following pediatric cardiac surgery. It is difficult to manage and is associated with significant morbidity and mortality. Conventional nonpharmacological and pharmacological measures have shown limited effects. Dexmedetomidine is an α2 agonist which has recently been shown in multiple studies to be effective. AIMS The aim of this systematic review with meta-analysis was to evaluate the efficacy of prophylactic dexmedetomidine administration in the prevention of junctional ectopic tachycardia in pediatric patients following cardiac surgeries. METHODS We searched MEDLINE, EMBASE, Cochrane, Web of Science, and relevant references published in English before December 20, 2017 and performed meta-analysis on the selected studies, with one group receiving prophylactic perioperative dexmedetomidine administration and another group receiving placebo. The primary outcome was the incidence of junctional ectopic tachycardia, secondary outcomes included bradycardia, hypotension, intensive care unit stay, total hospital stay, inotropic scores, and total mechanical ventilation time. Odds ratio or mean difference with 95% confidence intervals were calculated using a random effect model. RESULTS Seven studies (5 prospective randomized studies and 2 retrospective case-controlled studies) with a total of 1616 patients were analyzed. The incidence of junctional ectopic tachycardia in the dexmedetomidine group was significantly reduced compared to placebo. Similarly, intensive care unit stay, inotropic scores, and total mechanical ventilation time were also significantly decreased in the dexmedetomidine group. No significant increases in adverse events were found. Mortality was low in both groups. CONCLUSION Prophylactic dexmedetomidine is effective in reducing the incidence of postoperative junctional ectopic tachycardia without significant increases in adverse events in pediatric patients undergoing surgery for congenital heart diseases.
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Affiliation(s)
- Laxmi V Ghimire
- Section of Pediatrics and Section of Cardiology, Department of Medicine, Lakes Region General Hospital, Laconia, NH, USA.,Department of Clinical Pediatrics, University of New England, Biddeford, ME, USA
| | - Fu-Sheng Chou
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA.,Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
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17
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Entenmann A, Dittrich S, Hessling V, Niederwanger C, Cortina G, Michel M. Standardized training for AVT pacing in paediatric patients with postoperative junctional ectopic tachycardia. Nurs Crit Care 2018; 23:192-197. [PMID: 29508526 DOI: 10.1111/nicc.12345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Junctional ectopic tachycardia is a serious complication of surgery for paediatric congenital heart disease. R-wave synchronized atrial (AVT) pacing, an innovative temporary pacing technique, restores atrioventricular synchrony in these patients. The method is highly effective but technically complex. A standardized training model exists for doctors but not for paediatric intensive care nurses. AIMS This study seeks to evaluate whether a standardized programme involving simulation and vignettes increases knowledge of AVT pacing and accuracy of its documentation, as well as recognition and management of specific complications. STUDY DESIGN This study was an experimental simulation test with before and after descriptive evaluation. METHODS A custom-made simulation model was used in combination with standardized training. Before and after training, 10 paediatric nurse specialists were asked to document pacing, to identify complications and to intervene as necessary. Four clinical scenarios were presented: effective AVT pacing, ineffective AVT pacing, pacing with narrow interval between atrial pacing and ventricular sensing and pacemaker-induced tachycardia. Identification and management of complications were evaluated using a 3-point scale. RESULTS Training improved the quality of documentation and complication management. At outset, documentation by 1 of 10 participants was completely correct, and after training, documentation by 8 of 10 participants was completely correct. Before training, 30% of interpretations of the four presented clinical scenarios were correct (12/40) versus 83% (33/40) after training. The decision to notify a doctor of a complication was correct in 83% (33/40) before versus 95% (38/40) after the training. CONCLUSION Standardized simulation training improves quality and safety in AVT pacing, with more accurate documentation of the pacing mode and better recognition and management of specific complications during pacing. RELEVANCE TO CLINICAL PRACTICE AVT pacing should be performed in conjunction with standardized simulation training in paediatric cardiac intensive care units.
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Affiliation(s)
- Andreas Entenmann
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Susann Dittrich
- Western Training Centre for Healthcare Professions, Innsbruck, Austria
| | - Vera Hessling
- Department for Congenital Heart Disease and Pediatric Cardiology, Schleswig-Holstein University Hospital, Kiel, Germany
| | | | - Gerard Cortina
- Department of Pediatrics, Innsbruck Medical University, Innsbruck, Austria
| | - Miriam Michel
- Department for Congenital Heart Disease and Pediatric Cardiology, Schleswig-Holstein University Hospital, Kiel, Germany
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18
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Ling X, Zhou H, Ni Y, Wu C, Zhang C, Zhu Z. Does dexmedetomidine have an antiarrhythmic effect on cardiac patients? A meta-analysis of randomized controlled trials. PLoS One 2018; 13:e0193303. [PMID: 29494685 PMCID: PMC5832237 DOI: 10.1371/journal.pone.0193303] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 02/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background Cardiac surgery patients often experience several types of tachyarrhythmias after admission to the intensive care unit (ICU), which increases mortality and morbidity. Dexmedetomidine (DEX) is a popular medicine used for sedation in the ICU, and its other pharmacological characteristics are gradually being uncovered. Purpose To determine whether DEX has an antiarrhythmic effect after cardiac surgery. Methods The three primary databases MEDLINE, Embase (OVID SP) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched, and all English-language and randomized control-designed clinical publications comparing DEX to control medicines for sedation after elective cardiac surgery were included. Two colleagues independently extracted the data and performed other quality assessments. A subgroup analysis was performed according to the different medicines used and whether cardiopulmonary bypass (CPB) was applied. All tachyarrhythmias that occurred in the atria and ventricles were analyzed. Results A total of 1295 patients in 9 studies met the selection criteria among 2587 studies that were screened. After quantitative synthesis, our results revealed that the DEX group was associated with a lower incidence of ventricular arrhythmia (VA, OR 0.24, 95% CI 0.09–0.64, I2 = 0%, P = 0.005) than the control group. Subgroup analysis did not reveal a significant difference between the DEX and propofol subgroups (OR 0.13, 95% CI 0.03–0.56, I2 = 0%, P = 0.007). Additionally, no difference in the incidence of atrial fibrillation (AF) was observed regardless of the different control medicines (OR 0.82, 95% CI 0.60–1.10, I2 = 25%, P = 0.19) or whether CPB was applied. Conclusions This meta-analysis revealed that DEX has an antiarrhythmic effect that decreases the incidence of VA compared to other drugs used for sedation following cardiac surgery. DEX may not have an effect on AF, but cautious interpretation should be exercised due to high heterogeneity.
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Affiliation(s)
- Xiaoyan Ling
- Outpatient Nursing Department, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
| | - Hongmei Zhou
- Department of Anesthesiology, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
| | - Yunjian Ni
- Department of Anesthesiology, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
| | - Cheng Wu
- Department of Anesthesiology, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
| | - Caijun Zhang
- Department of Anesthesiology, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
| | - Zhipeng Zhu
- Department of Anesthesiology, the Second Affiliated Hospital of Jiaxing University, Jiaxing City, Zhejiang Province, China
- * E-mail:
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19
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Risk Factors for Development of Ectopic Atrial Tachycardia in Post-operative Congenital Heart Disease. Pediatr Cardiol 2018; 39:459-465. [PMID: 29147786 DOI: 10.1007/s00246-017-1773-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
Ectopic atrial tachycardia (EAT) is common in surgically repaired congenital heart disease (CHD) and carries the potential for significant hemodynamic compromise. Our objective was to determine the incidence, and risk factors of EAT after CHD surgery. Prospective study of patients that underwent surgery for CHD from February to October 2016 was performed. Demographic, perioperative and electrophysiologic data were collected. Sustained EAT (> 30 s) was documented by telemetry or electrocardiogram and confirmed by a pediatric electrophysiologist. All patients were followed through index hospitalization. During the study period, 17/204 (8%) of patients developed EAT with median time-to-event of 14 days. 15/17 (88%) received anti-arrhythmic therapy for sustained EAT. By univariate analysis, younger age (5 vs. 284 days, P < .001), lower weight (3.2 vs. 7.5 kg, P < .001), single ventricle physiology (P = .05), longer cardiopulmonary bypass time (176 vs. 94 min, P < .001), need for delayed sternal closure (P < .001), and higher STAT category (P < .001) were associated with EAT. Incidence among single ventricle patients was 7/44 (16%), and of those 7/13 (54%) were < 30 days of age. Multivariable Cox regression analysis confirmed age at surgery < 30 days (hazard ratio = 11.7, P = .002) and use of milrinone (hazard ratio = 4.4, P = .007) as independent predictors of EAT. Post-operative EAT is frequent following surgery for CHD especially in neonates. Further study is warranted, specifically in the single ventricle population, given the high potential risk for arrhythmia-induced hemodynamic compromise in this vulnerable population.
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20
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Entenmann A, Michel M, Ismer B, Gebauer R. R-wave synchronised atrial pacing in pediatric patients with postoperative junctional ectopic tachycardia: the atrioventricular interval investigated by computational analysis and clinical evaluation. Biomed Eng Online 2017; 16:139. [PMID: 29258517 PMCID: PMC5735521 DOI: 10.1186/s12938-017-0430-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/12/2017] [Indexed: 11/26/2022] Open
Abstract
Background R-wave synchronised atrial pacing is an effective temporary pacing therapy in infants with postoperative junctional ectopic tachycardia. In the technique currently used, adverse short or long intervals between atrial pacing and ventricular sensing (AP–VS) may be observed during routine clinical practice. Objectives The aim of the study was to analyse outcomes of R-wave synchronised atrial pacing and the relationship between maximum tracking rates and AP–VS intervals. Methods Calculated AP–VS intervals were compared with those predicted by experienced pediatric cardiologist. Results A maximum tracking rate (MTR) set 10 bpm higher than the heart rate (HR) may result in undesirable short AP–VS intervals (minimum 83 ms). A MTR set 20 bpm above the HR is the hemodynamically better choice (minimum 96 ms). Effects of either setting on the AP–VS interval could not be predicted by experienced observers. In our newly proposed technique the AP–VS interval approaches 95 ms for HR > 210 bpm and 130 ms for HR < 130 bpm. The progression is linear and decreases strictly (− 0.4 ms/bpm) between the two extreme levels. Conclusions Adjusting the AP–VS interval in the currently used technique is complex and may imply unfavorable pacemaker settings. A new pacemaker design is advisable to allow direct control of the AP–VS interval.
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Affiliation(s)
- Andreas Entenmann
- Department of Pediatrics, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Miriam Michel
- Department for Congenital Heart Disease and Pediatric Cardiology, Schleswig-Holstein University Hospital, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Bruno Ismer
- Peter Osypka Institute for Pacing and Ablation, Offenburg University of Applied Sciences, Offenburg, Germany
| | - Roman Gebauer
- Department of Pediatric Cardiology, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany
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21
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Webster G. Aiming at a Blurry Target: Optimal Therapy for Postoperative JET. World J Pediatr Congenit Heart Surg 2017; 8:691-693. [DOI: 10.1177/2150135117738009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gregory Webster
- Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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22
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Selective autonomic stimulation of the AV node fat pad to control rapid post-operative atrial arrhythmias. PLoS One 2017; 12:e0183804. [PMID: 28902899 PMCID: PMC5597131 DOI: 10.1371/journal.pone.0183804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 08/13/2017] [Indexed: 11/24/2022] Open
Abstract
Junctional ectopic tachycardia (JET) and atrial fibrillation (AF) occur in patients recovering from open-heart surgery (OHS). Pharmacologic treatment is used for the control of post-operative atrial arrhythmias (POAA), but is associated with side effects. There is a need for a reversible, modulated solution to rate control. We propose a non-pharmacologic technique that can modulate AV nodal conduction in a selective fashion. Ten mongrel dogs underwent OHS. Stimulation of the anterior right (AR) and inferior right (IR) fat pad (FP) was done using a 7-pole electrode. The IR was more effective in slowing the ventricular rate (VR) to AF (52 +/- 20 vs. 15 +/- 10%, p = 0.003) and JET (12 +/- 7 vs. 0 +/- 0%, p = 0.02). Selective site stimulation within a FP region could augment the effect of stimulation during AF (57 +/- 20% (maximum effect) vs. 0 +/- 0% (minimum effect), p<0.001). FP stimulation at increasing stimulation voltage (SV) demonstrated a voltage-dependent effect (8 +/- 14% (low V) vs. 63 +/- 17 (high V) %, p<0.001). In summary, AV node fat pad stimulation had a selective effect on the AV node by decreasing AV nodal conduction, with little effect on atrial activity.
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23
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Janson CM, Shah MJ. Supraventricular Tachycardia in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects. Card Electrophysiol Clin 2017; 9:189-211. [PMID: 28457235 DOI: 10.1016/j.ccep.2017.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Supraventricular arrhythmias represent a major source of morbidity in adults with congenital heart disease (ACHD). Anatomic variants and post-operative changes contribute to a unique electrophysiologic milieu ripe for the development of supraventricular tachycardia. Intra-atrial reentrant tachycardia is the most prevalent mechanism. Atrioventricular reciprocating tachycardia is common in lesions associated with accessory pathways. Abnormal anatomy complicates the management of atrioventricular nodal reentrant tachycardia. Tachycardia mediated by twin atrioventricular nodes is rare. Focal tachycardias are considerations in the ACHD population. Each of these tachycardia mechanisms is reviewed, focusing on the inherent diagnostic and therapeutic challenges.
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, R1, Bronx, NY 10467, USA.
| | - Maully J Shah
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA
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24
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Cunningham ME, Doroshow R, Olivieri L, Moak JP. Junctional ectopic tachycardia secondary to myocarditis associated with sudden cardiac arrest. HeartRhythm Case Rep 2016; 3:124-128. [PMID: 28491785 PMCID: PMC5420052 DOI: 10.1016/j.hrcr.2016.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | | | | | - Jeffrey P. Moak
- Address reprint requests and correspondence: Dr Jeffrey P. Moak, Division of Cardiology, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010.Division of Cardiology, Children’s National Health System, 111 Michigan Ave, NWWashingtonDC20010
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25
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Abstract
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.
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26
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Clark BC, Berul CI. Arrhythmia diagnosis and management throughout life in congenital heart disease. Expert Rev Cardiovasc Ther 2016; 14:301-20. [PMID: 26642231 DOI: 10.1586/14779072.2016.1128826] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Arrhythmias, covering bradycardia and tachycardia, occur in association with congenital heart disease (CHD) and as a consequence of surgical repair. Symptomatic bradycardia can occur due to sinus node dysfunction or atrioventricular block secondary to either unrepaired CHD or surgical repair in the area of the conduction system. Tachyarrhythmias are common in repaired CHD due to scar formation, chamber distension or increased chamber pressure, all potentially leading to abnormal automaticity and heterogeneous conduction properties as a substrate for re-entry. Atrial arrhythmias occur more frequently, but ventricular tachyarrhythmias may be associated with an increased risk of sudden cardiac death, notably in patients with repaired tetralogy of Fallot or aortic stenosis. Defibrillator implantation provides life-saving electrical therapy for hemodynamically unstable arrhythmias. Ablation procedures with 3D electroanatomic mapping technology offer a viable alternative to pharmacologic or device therapy. Advances in electrophysiology have allowed for successful management of arrhythmias in patients with congenital heart disease.
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Affiliation(s)
- Bradley C Clark
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
| | - Charles I Berul
- a Division of Cardiology , Children's National Health System , Washington , DC , USA.,b Department of Pediatrics , George Washington University School of Medicine , Washington , DC , USA
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27
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Abstract
Junctional ectopic tachycardia, after surgery for CHD, is a serious arrhythmia that can cause increased morbidity and mortality. We report a case of junctional ectopic tachycardia, preceded by sepsis, in a 4-year-old girl, 31 months after open-heart surgery. She was successfully treated using low-dose landiolol hydrochloride.
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Schmitt KRL, Fedarava K, Justus G, Redlin M, Böttcher W, Delmo Walter EM, Hetzer R, Berger F, Miera O. Hypothermia During Cardiopulmonary Bypass Increases Need for Inotropic Support but Does Not Impact Inflammation in Children Undergoing Surgical Ventricular Septal Defect Closure. Artif Organs 2015; 40:470-9. [DOI: 10.1111/aor.12587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | - Katsiaryna Fedarava
- Department of Congenital Heart Disease/Pediatric Cardiology; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Georgia Justus
- Department of Congenital Heart Disease/Pediatric Cardiology; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Mathias Redlin
- Department of Anesthesiology; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Wolfgang Böttcher
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Eva Maria Delmo Walter
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology; Deutsches Herzzentrum Berlin; Berlin Germany
- Department of Pediatrics; Division of Cardiology; Charité-Universitätsmedizin; Berlin Germany
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology; Deutsches Herzzentrum Berlin; Berlin Germany
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He D, Sznycer-Taub N, Cheng Y, McCarter R, Jonas RA, Hanumanthaiah S, Moak JP. Magnesium Lowers the Incidence of Postoperative Junctional Ectopic Tachycardia in Congenital Heart Surgical Patients: Is There a Relationship to Surgical Procedure Complexity? Pediatr Cardiol 2015; 36:1179-85. [PMID: 25762470 PMCID: PMC4561858 DOI: 10.1007/s00246-015-1141-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
Magnesium sulfate was given to pediatric cardiac surgical patients during cardiopulmonary bypass period in an attempt to reduce the occurrence of postoperative junctional ectopic tachycardia (PO JET). We reviewed our data to evaluate the effect of magnesium on the occurrence of JET and assess a possible relationship between PO JET and procedure complexity. A total of 1088 congenital heart surgeries (CHS), performed from 2005 to 2010, were reviewed. A total of 750 cases did not receive magnesium, and 338 cases received magnesium (25 mg/kg). All procedures were classified according to Aristotle score from 1 to 4. Overall, there was a statistically significant decrease in PO JET occurrence between the two groups regardless of the Aristotle score, 15.3 % (115/750) in non-magnesium group versus 7.1 % (24/338) in magnesium group, P < 0.001. In the absence of magnesium, the risk of JET increased with increasing Aristotle score, P = 0.01. Following magnesium administration and controlling for body weight, surgical and aortic cross-clamp times in the analyses, reduction in adjusted risk of JET was significantly greater with increasing Aristotle level of complexity (JET in non-magnesium vs. magnesium group, Aristotle level 1: 9.8 vs. 14.3 %, level 4: 11.5 vs. 3.2 %; odds ratio 0.54, 95 % CI 0.31-0.94, P = 0.028). Our data confirmed that intra-operative usage of magnesium reduced the occurrence of PO JET in a larger number and more diverse group of CHS patients than has previously been reported. Further, our data suggest that magnesium's effect on PO JET occurrence seemed more effective in CHS with higher levels of Aristotle complexity.
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Affiliation(s)
- Dingchao He
- Division of Cardiovascular Surgery, Children’s National Medical Center, Washington, DC, USA
| | | | - Yao Cheng
- Division of Biostatistics and Study Methodology, Children’s National Medical Center, Washington, DC, USA
| | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children’s National Medical Center, Washington, DC, USA
| | - Richard A. Jonas
- Division of Cardiovascular Surgery, Children’s National Medical Center, Washington, DC, USA
| | - Sridhar Hanumanthaiah
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Jeffrey P. Moak
- Division of Cardiology, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010, USA
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Shuplock JM, Smith AH, Owen J, Van Driest SL, Marshall M, Saville B, Xu M, Radbill AE, Fish FA, Kannankeril PJ. Association between perioperative dexmedetomidine and arrhythmias after surgery for congenital heart disease. Circ Arrhythm Electrophysiol 2015; 8:643-50. [PMID: 25878324 DOI: 10.1161/circep.114.002301] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 04/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dexmedetomidine is commonly used after congenital heart surgery and may be associated with a decreased incidence of postoperative tachyarrhythmias. Using a large cohort of patients undergoing congenital heart surgery, we examined for an association between dexmedetomidine use in the immediate postoperative period and subsequent arrhythmia development. METHODS AND RESULTS A total of 1593 surgical procedures for congenital heart disease were performed. Dexmedetomidine was administered in the immediate postoperative period after 468 (29%) surgical procedures. When compared with 1125 controls, the group receiving dexmedetomidine demonstrated significantly fewer tachyarrhythmias (29% versus 38%; P<0.001), tachyarrhythmias receiving intervention (14% versus 23%; P<0.001), bradyarrhythmias (18% versus 22%; P=0.03), and bradyarrhythmias receiving intervention (12% versus 16%; P=0.04). After propensity score matching with 468 controls, the arrhythmia incidence between groups became similar: tachyarrhythmias (29% versus 31%; P=0.66), tachyarrhythmias receiving intervention (14% versus 17%; P=0.16), bradyarrhythmias (18% versus 15%; P=0.44), and bradyarrhythmias receiving intervention (12% versus 9%; P=0.17). After excluding controls exposed to dexmedetomidine at a later time in the hospitalization, dexmedetomidine was associated with increased odds of bradyarrhythmias receiving intervention (odds ratio, 2.18; 95% confidence interval, 1.02-4.65). Furthermore, there was a dose-dependent increase in the odds of bradyarrhythmias (odds ratio, 1.04; 95% confidence interval, 1.01-1.07) and bradyarrhythmias receiving intervention (odds ratio, 1.05; 95% confidence interval, 1.01-1.08). CONCLUSIONS Although dexmedetomidine exposure in the immediate postoperative period is not associated with a clinically meaningful difference in the incidence of tachyarrhythmias after congenital heart surgery, it may be associated with increased odds of bradyarrhythmias.
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Affiliation(s)
- Jacqueline M Shuplock
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.).
| | - Andrew H Smith
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Jill Owen
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Sara L Van Driest
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Matt Marshall
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Benjamin Saville
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Meng Xu
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Andrew E Radbill
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Frank A Fish
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
| | - Prince J Kannankeril
- From the Thomas P. Graham Jr. Division of Pediatric Cardiology (J.M.S., A.H.S., J.O., A.E.R., F.A.F., P.J.K.), Division of Pediatric Critical Care Medicine (A.H.S.), and Division of General Pediatrics (S.L.V.D.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN; Department of Pharmaceutical Services at Vanderbilt University Medical Center, Nashville, TN (M.M.); and Department of Biostatistics at Vanderbilt University School of Medicine, Nashville, TN (B.S., M.X.)
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Avedillo L, Martín-Alguacil N, Salazar I. Anatomical Variations of the Blood Vascular System in Veterinary Medicine: The Internal Iliac Artery of the Dog: Part One. Anat Histol Embryol 2014; 44:299-307. [PMID: 25196254 DOI: 10.1111/ahe.12142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 07/18/2014] [Indexed: 11/30/2022]
Abstract
Traditional veterinary anatomical models describe the branches of the caudal gluteal artery as the iliolumbar, cranial gluteal, lateral caudal, satellite of the ischiatic nerve and dorsal perineal arteries. However, some classical veterinary anatomy textbooks often indicate variations the general organization of the arterial tree, without giving any pattern of origin or illustrations of the different branching. The aim of this study was to investigate the presumptive variability of the caudal gluteal artery. Two hundred and thirty-two pelvic halves from 116 adult dogs were examined. Twelve anatomical variations were found, nine occurring in more than 5% of the dogs, and three in <5%. A 'long-type' internal iliac artery, which means short caudal gluteal and internal pudendal arteries, was identified, while a 'perineal trunk' was observed as an interesting arterial variation. If the caudal segment alone is taken into consideration, identical vascular patterns in both hemi-pelvises are found in 17% of the dogs. Significant statistical correlation was found for four different types of anatomic variations and gender, two types of variations and body size, one type of variation for body side and one type of variation for head shape.
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Affiliation(s)
- L Avedillo
- Clínica Veterinaria Villaluenga, Villaluenga de la Sagra, Toledo, Spain
| | - N Martín-Alguacil
- Department of Anatomy and Embryology, School of Veterinary Medicine, Universidad Complutense de Madrid, Avda. Puerta de Hierro s/n, Madrid, 28040, Spain
| | - I Salazar
- Unit of Anatomy and Embryology, Department of Anatomy and Animal Production, Veterinary School, University of Santiago de Compostela, Lugo, Spain
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Tharakan JA, Sukulal K. Post cardiac surgery junctional ectopic tachycardia: A 'Hit and Run' tachyarrhythmia as yet unchecked. Ann Pediatr Cardiol 2014; 7:25-8. [PMID: 24701081 PMCID: PMC3959056 DOI: 10.4103/0974-2069.126545] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jaganmohan A Tharakan
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Kiron Sukulal
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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Smith AH, Flack EC, Borgman KY, Owen JP, Fish FA, Bichell DP, Kannankeril PJ. A common angiotensin-converting enzyme polymorphism and preoperative angiotensin-converting enzyme inhibition modify risk of tachyarrhythmias after congenital heart surgery. Heart Rhythm 2014; 11:637-43. [PMID: 24389577 DOI: 10.1016/j.hrthm.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Andrew H Smith
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - English C Flack
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kristie Y Borgman
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jill P Owen
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank A Fish
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David P Bichell
- Department of Pediatric Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Prince J Kannankeril
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
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