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Unrepaired Primum Atrial Septal Defect With Atrial Fibrillation and Broad Complex Tachycardia: Submitted by J.P. Bokma, MD, PhD

Case Synopsis A 67-year-old man was referred to our hospital because of recurrent episodes of palpitations for the previous 3 years, which he described as irregular and fast. These episodes occurred several times per year. The palpitations usually started when he was at rest after a longer period of work or with stress. The diagnosis of atrial fibrillation was established and electric cardioversion was performed. A…

Atrial Flutter in a Repaired Tetralogy of Fallot Patient With Unusual Venous Anatomy: Submitted by Reza Ashrafi, MBBS, BSc, MD, MRCP and A.G. Stuart, MBChB, PgCert (Genomics), MSc, FRCP, FRCPCH, FESC

Case Synopsis History A 51-year-old male underwent primary repair of tetralogy of Fallot (ToF) in 1974 at the age of 9 years. The repair included a Dacron patch to close the ventricular septal defect and a pericardial patch in the right ventricular outflow tract. He remained well throughout childhood and early adult life with regular, but infrequent, outpatient follow-up. By the age of 48 he had…

Complex Transposition With the Risk of Sudden Death While Awaiting Transplant: Case Report by Berardo Sarubbi, MD, PhD

Case Synopsis Case Description A 27-year-old male was admitted to our cardiac tertiary center because of increasing dyspnea and progressive exercise intolerance. He had been followed up by different hospitals during his life. At birth, he was diagnosed with transposition of great arteries with ventricular septal defect and pulmonary outflow tract obstruction. At the age of 9 months, he underwent the Blalock-Hanlon atrial septectomy and at…

Sudden Death Risk in Congenitally Corrected Transposition With Ventricular Dysfunction: Patient case submitted by Matthias Greutmann, MD, FESC

Case Synopsis We report the case of a patient diagnosed with congenitally corrected transposition of the great arteries (ccTGA) at the age of 1 year. He developed severe systemic tricuspid valve regurgitation at the age of 6 years when it was decided to perform a double switch operation to prevent systemic right ventricular (RV) failure. As preparation for the double switch procedure, to “train” the subpulmonic…

Management of Arrhythmias in Pregnancy

During pregnancy, preexisting arrhythmias may or may not increase. Hemodynamic changes, particularly during the third trimester, may predispose to some arrhythmias. Palpitations due to higher plasma volumes or ectopy are common and benign; noninvasive ambulatory monitoring may be considered if symptoms suggest sustained or symptomatic tachyarrhythmias. Compression of abdominal venous or arterial vessels can cause supine hypotension, associated symptoms, and exacerbation of neurocardiogenic syncope. Management includes…

Treatment of Arrhythmias

Pharmacologic therapy for clinical arrhythmias Antiarrhythmic Agents Adenosine Adenosine is an intravenous (IV) purinergic blocker that inhibits sinus node and atrioventricular (AV) node automaticity and conduction, similar to high parasympathetic activity. Adenosine binds to the adenosine A1 receptor and activates a potassium current in the atrium (I KAdo ) with clinical transient effects of sinus node slowing, AV node block, and atrial refractory period shortening. Indications…

Evaluation of the Patient with Suspected Arrhythmias

Outpatient approach to arrhythmia monitoring Proper and effective monitoring is required to assess and manage arrhythmias and to document and diagnose the etiology of the problem. Many individuals have symptoms that might appear to be arrhythmic in origin but are not. Many arrhythmias may be of prognostic importance but are not easily diagnosed by symptoms alone. It is not uncommon for individuals to be completely asymptomatic…

Drug Effects and Electrolyte Disorders

Antiarrhythmic drugs By several mechanisms, some drugs, particularly antiarrhythmic drugs, can cause serious rhythm disturbances in susceptible individuals. This is termed proarrhythmia . Proarrhythmia encompasses an extensive list of arrhythmia types, including increase in premature ventricular contractions (PVCs), nonsustained ventricular tachycardia, sustained monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, and ventricular fibrillation. Some drugs increase the risk of bradycardia or atrioventricular (AV) block, another form of proarrhythmia.…

Cardiac Pacing and Pacemaker Rhythms

Pacemaker rhythms Cardiac pacing systems are described by a three- or four-letter code. The first letter indicates the chamber in which pacing stimuli are delivered (atrium, A; ventricle, V; or both, D). The second letter indicates the chamber in which sensing of the intracardiac electrical signal is occurring (atrium, A; ventricle, V; or both, D). The third letter indicates the response of the device to a…

Ventricular Tachyarrhythmias

Nonsustained ventricular tachycardia Description Ventricular tachycardia (VT) is defined as three or more consecutive ventricular beats occurring at a rate of 100 beats or more per minute. Nonsustained ventricular tachycardia (NSVT) ( Fig. 6.1 ) is defined as VT lasting less than 30 seconds and that does not require intervention for termination. The QRS complex morphology may be either monomorphic (e.g., uniform in a given ECG…

Supraventricular Tachyarrhythmias

Supraventricular tachycardia Supraventricular tachycardia (SVT) is a rhythm disturbance with a rate greater than 100 that requires tissue from above the His-Purkinje system to perpetuate. SVT can be regular (e.g., atrioventricular [AV] node reentry), irregular (e.g., atrial flutter [AFL] with variable AV conduction), or irregularly irregular (e.g., multifocal atrial tachycardia [MAT], atrial fibrillation [AF]). SVT can be associated with a narrow QRS complex, a wide QRS…

Tachycardia

Tachycardia mechanisms Automaticity The rate at which the sinus node discharges usually is faster than other latent or subsidiary automatic cardiac pacemakers. Subsidiary pacemakers can become dominant in the settings of acidosis, ischemia, sympathetic stimulation, and use of certain drugs. Normal automaticity can be suppressed by pacing but generally resumes after pacing stops. Abnormal automaticity can be due to cell damage and abnormal depolarization. The partial…

Ectopic Complexes and Rhythms

Premature atrial complexes Description Premature atrial complexes (PACs) are supraventricular ectopic depolarizations originating in or near the atria or in the pulmonary veins that supersede activation from the sinus node. The most common sites of origin appear to be in or around the pulmonary vein ostia, especially in patients who are at risk for atrial fibrillation (AF). They may be isolated and unifocal or multiform in…

Bradyarrhythmias—Conduction System Abnormalities

Atrioventricular conduction abnormalities Atrioventricular (AV) block occurs when an atrial impulse either is not conducted to the ventricle or is conducted with delay. This assumes that the impulse occurs at a time that conduction would be expected to occur based on normal conduction and refractory period properties. Conduction block assumes that the rate of the atrial rhythm is in the normal physiological range and is regular.…

Sinus Node: Normal and Abnormal Rhythms

Normal sinus node Description Normal sinus rhythm (NSR) is an atrial rhythm caused by electrical activation that originates from the sinus node, a structure located in the area of the junction of the right atrium and superior vena cava. NSR P waves, representing atrial depolarization (but not sinus node activity itself), are upright in leads I and aVL and the inferior leads (II, III, aVF), indicating the…

Telemedicine in Pediatric Cardiology

Telemedicine now pervades almost every aspect of the practice of pediatric cardiology. Simply defined, telemedicine means using technology to practice medicine at a distance–and it is now used on a daily basis for clinical care, education, research, and administrative tasks. Use of the cloud to transfer images (echocardiogram, angiography, computed tomography [CT], or magnetic resonance imaging [MRI]), remote attendance at patient care conferences, home monitoring of…

Anesthetic Considerations for Cardiac and Noncardiac Surgery in the Child With Congenital Cardiac Disease

Introduction The complexity of congenital cardiac lesions and increased requirements for imaging studies and interventions in this growing patient population necessitate the specialized skills of the pediatric cardiac anesthesiologist. The great majority of these practitioners undergo primary training in anesthesiology, followed by a fellowship in pediatric anesthesia and additional training in pediatric cardiac anesthesia, most recently as a 1-year subspecialty fellowship. Moreover, specifically trained certified registered…

Screening in Pediatric and Congenital Cardiac Disease

Introduction “Screening” in the field of pediatric cardiology is currently implemented in many different areas. The interest and opportunities for screening have increased and evolved along with the increase in our knowledge base. Screening currently includes in utero screening for congenital heart disease (CHD), pulse oximetry after birth screening for CHD, screening for at-risk entities for sudden cardiac death, screening for neurodevelopmental issues, screening for familial…