A Low-Cost Simulation Model for R-Wave Synchronized Atrial Pacing in Pediatric Patients with Postoperative Junctional Ectopic Tachycardia

Standardized training for AVT pacing in paediatric patients with postoperative junctional ectopic tachycardia

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.

R-wave synchronised atrial pacing in pediatric patients with postoperative junctional ectopic tachycardia: the atrioventricular interval investigated by computational analysis and clinical evaluation

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.

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.