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Moore EF, Pak J, Jefferis-Kirk C, Armatage A, Kronmal RA, Salerno JC, Files MD. Development and Implementation of a Standardized Heparin Protocol for Left-Sided Pediatric Electrophysiology Procedures. Pediatr Cardiol 2018; 39:941-947. [PMID: 29500504 DOI: 10.1007/s00246-018-1843-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 02/23/2018] [Indexed: 11/29/2022]
Abstract
Heparin is used to decrease the risk of thromboembolic complications during electrophysiology studies (EPS); however, there is wide practice variation and minimal evidence to guide heparin dosing, particularly in pediatric patients. This study retrospectively analyzed heparin dosing and response, measured via activated clotting time (ACT), in patients undergoing EPS and used these data (pre-protocol cohort, n = 40), as well as guidance from available literature to implement a standardized heparin protocol (phase 1, n = 43). We utilized quality improvement methodology to refine this protocol (phase 2, n = 40) to improve therapeutic heparin response. Prior to the protocol, patients achieved therapeutic ACT levels (250-350 s) only 35% of the time which improved to 60% during phase 1 (p < 0.05) and to 73% during phase 2 (p < 0.001 compared to pre-protocol). There were no thromboses or significant adverse events in any group. These results demonstrate the effectiveness of a standardized heparin protocol in achieving effective antithrombotic therapy during left-sided pediatric EPS.
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Affiliation(s)
- Emily F Moore
- Division of Cardiology and Cardiac Surgery, Heart Center at Seattle Children's Hospital, 4800 Sand Point way NE Mail Stop RC 2.820, Seattle, WA, 98105, USA.
| | - Jennifer Pak
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sand Point Way NE, Mail stop BM.5.420, Seattle, WA, 98105, USA
| | - Christa Jefferis-Kirk
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sand Point Way NE, Mail stop BM.5.420, Seattle, WA, 98105, USA
| | - Arlene Armatage
- Division of Cardiology and Cardiac Surgery, Heart Center at Seattle Children's Hospital, 4800 Sand Point way NE Mail Stop RC 2.820, Seattle, WA, 98105, USA
| | - Richard A Kronmal
- Department of Biostatistics, Collaborative Health Studies Coordinating Center, University of Washington, Bldg. 29, 6200 NE 74th St., Seattle, WA, 98115, USA
| | - Jack C Salerno
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, 1959 NE Pacific St., Health Sciences Bldg., Seattle, WA, 98195, USA
| | - Matthew D Files
- Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, 1959 NE Pacific St., Health Sciences Bldg., Seattle, WA, 98195, USA
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Can J Cardiol 2014; 30:e1-e63. [PMID: 25262867 DOI: 10.1016/j.cjca.2014.09.002] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: Executive Summary. Heart Rhythm 2014. [DOI: 10.1016/j.hrthm.2014.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102-65. [PMID: 24814377 DOI: 10.1016/j.hrthm.2014.05.009] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 02/07/2023]
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Risk factors of recurrence and complication in radiofrequency catheter ablation of atrioventricular reentrant tachycardia in children and adolescents. Cardiol Young 2013; 23:682-91. [PMID: 23328409 DOI: 10.1017/s1047951112001655] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND To compare potential risk factors for complications and recurrence after radiofrequency catheter ablation in symptomatic atrioventricular reentrant tachycardia in children and adolescents. METHODS We retrospectively reviewed the data of 213 consecutive patients with symptomatic atrioventricular reentrant tachycardia who underwent both electrophysiological study and radiofrequency catheter ablation, divided these patients into two groups, children (age < 12 years) and adolescents (12 < or = rage, 18 years), and compared the location of the accessory pathway, success rate, recurrence rate, complications, presence of congenital heart disease, presence of intermittent ventricular pre-excitation, and presence of Wolff–Parkinson–White syndrome in the two groups. RESULTS The position of the accessory pathway was mostly right sided in children (61.3%) and left sided in adolescents (61.5%). Children had significantly more congenital heart disease than adolescents (6.4% versus 0.8%). Univariate analysis showed children or adolescents with right-sided accessory pathways to be 6.84 times and those with accessory pathways on both sides of the septum 25 times more likely to relapse than those with a single accessory pathway. Multivariate analysis indicated that children or adolescents with two accessory pathways were six times, and those with intermittent ventricular pre-excitation nine times more at risk of relapsing following radiofrequency ablation than those with single accessory pathways. All five complications occurred in children. CONCLUSIONS The findings suggest that the position and number of accessory pathways and presence of intermittent ventricular pre-excitation are related to risks of recurrence of atrioventricular reentrant tachycardia in children and adolescents.
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Zachariah JP, Walsh EP, Triedman JK, Berul CI, Cecchin F, Alexander ME, Bevilacqua LM. Multiple accessory pathways in the young: the impact of structural heart disease. Am Heart J 2013; 165:87-92. [PMID: 23237138 DOI: 10.1016/j.ahj.2012.10.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 10/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The presence of multiple accessory pathways (MultAP) is described in structural heart disease (SHD) such as Ebstein's anomaly and cardiomyopathies. Structural defects can impact the tolerability of tachyarrhythmia and can complicate both medical management and ablation. In a large cohort of pediatric patients with and without SHD undergoing invasive electrophysiology study, we examined the prevalence of MultAP and the effect of both MultAP and SHD on ablation outcomes. METHODS Accessory pathway number and location, presence of SHD, ablation success, and recurrence were analyzed in consecutive patients from our center over a 16-year period. RESULTS In 1088 patients, 1228 pathways (36% retrograde only) were mapped to the right side (TV) in 18%, septum (S) in 39%, and left side (MV) in 43%. MultAP were present in 111 pts (10%), involving 250 distinct pathways. SHD tripled the risk of MultAP (26% SHD vs 8% no SHD, P < .001). Multivariable adjusted risk factors for MultAP included Ebstein's (OR 8.7[4.4-17.5], P < .001) and cardiomyopathy (OR 13.3[5.1-34.5], P < .001). Of 1306 ablation attempts, 94% were acutely successful with an 8% recurrence rate. Ablation success was affected by SHD (85% vs 95% for no SHD, P < .01) but not by MultAP (91% vs 94% for single, P = .24). Recurrence rate was higher for SHD (17% SHD vs 8% no SHD, P < .05) and MultAP (19% MultAP vs 8% single, P < .001). CONCLUSIONS MultAP are found in 10% of pediatric patients, and are more common in SHD compared to those with normal hearts. Both the presence of MultAP and SHD negatively influence ablation outcomes.
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Kim YH, Park HS, Hyun MC, Kim YN. Pediatric tachyarrhythmia and radiofrequency catheter ablation: results from 1993 to 2011. Korean Circ J 2012; 42:735-40. [PMID: 23236324 PMCID: PMC3518706 DOI: 10.4070/kcj.2012.42.11.735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/27/2012] [Accepted: 06/04/2012] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We performed a retrospective study to elucidate the frequency of tachycardia mechanisms and the characteristics of accessory pathways (APs), confirmed by radiofrequency catheter ablation (RFCA) in pediatric tachycardia. In addition, we analyzed the efficacy and safety of pediatric RFCA. SUBJECTS AND METHODS The authors retrospectively reviewed the records of a total of 260 patients (aged 2 to 18 years) who had undergone RFCA between August 1993 and July 2011 at two medical centers in Daegu. RESULTS Two hundred and sixty patients underwent 272 RFCAs at less than 18 years of age. Of these 260 patients, 9 patients (3%) were younger than 6 years, and 175 patients (67%) were older than 12 years. The tachycardia mechanisms observed were atrioventricular reentry tachycardia (AVRT) in 175 patients (65%), atrioventricular nodal reentry tachycardia (AVNRT) in 83 patients (30%), ventricular tachycardia in 12 patients (4%), and atrial tachycardia in 2 patients (0.7%). Among the patients with AVRT, there were 94 concealed APs and 81 manifest APs. Left-side APs were more common in concealed APs than in manifest APs (72/94, 77% vs. 33/81, 41%, p<0.001). Sixty-six percent (55/83) of AVNRT cases were located at the M1 and/or M2 sites. Four patients had multiple tachycardia mechanisms (AVNRT+AVRT) and 9 patients had multiple APs. The recurrence rate was 5% (13/272). Of these recurrent cases, 12 patients had AVRT. The overall success rate was 95%. CONCLUSION Pediatric RFCA provides a good success rate and an acceptable recurrence. In addition, we suggest that the APs location may be associated with concealed or manifest property of APs.
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Affiliation(s)
- Yeo Hyang Kim
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Daegu, Korea
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BUDDHE SUJATHA, SINGH HARINDER, DU WEI, KARPAWICH PETERP. Radiofrequency and Cryoablation Therapies for Supraventricular Arrhythmias in the Young: Five-Year Review of Efficacies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:711-7. [DOI: 10.1111/j.1540-8159.2012.03372.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Difficulties with ablation for arrhythmias in children. Indian Pacing Electrophysiol J 2008; 8:S55-74. [PMID: 18478062 PMCID: PMC2363723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Radiofrequency ablation procedures in children present unique challenges for the electrophysiologist. At times, obtaining vascular access to reach the heart is a problem. If this first step is accomplished, the small size of the child's heart, arrhythmias relatively unique to the pediatric population, and the presence of congenital heart disease add to the complexity.In this manuscript, a review of commonly encountered problems and suggested solutions based on practice are presented. Precise mapping of the arrhythmogenic substrate, techniques to access excluded portions of the atrium from prior surgery, and the basis for electrophysiology maneuvers important in pediatric ablation are highlighted.
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Chang YB, Lee SH, Kang EY, Rhee KS, Joo CU. Results of radiofrequency catheter ablation in children and adolescent with tachyarrhythmia. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.11.1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Young Beom Chang
- Department of Pediatrics, Institute of Cardiovascular Research, Chonbuk National University Medical School, Jeonju, Korea
| | - Seung Hyun Lee
- Department of Pediatrics, Institute of Cardiovascular Research, Chonbuk National University Medical School, Jeonju, Korea
| | - Eun Young Kang
- Department of Pediatrics, Institute of Cardiovascular Research, Chonbuk National University Medical School, Jeonju, Korea
| | - Kyoung-Suk Rhee
- Department of Internal Medicine, Institute of Cardiovascular Research, Chonbuk National University Medical School, Jeonju, Korea
| | - Chan Uhng Joo
- Department of Pediatrics, Institute of Cardiovascular Research, Chonbuk National University Medical School, Jeonju, Korea
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Affiliation(s)
- Eun-Jung Bae
- Department of Pediatrics, College of Medicine, Seoul National University, Seoul, Korea
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