Congenital EP Featured Articles of June 2017

 

Congenital and Pediatric Cardiac EP Reviews of June 2017 Manuscripts

 

Prospective Study of Adenosine on Atrioventricular Nodal Conduction in Pediatric and Young Adult Patients After Heart Transplantation.

Flyer JN, Zuckerman WA, Richmond ME, Anderson BR, Mendelsberg TG, McAllister JM, Liberman L, Addonizio LJ, Silver ES.

Circulation. 2017 Jun 20;135(25):2485-2493. doi: 10.1161/CIRCULATIONAHA.117.028087. Epub 2017 Apr 27.

PMID: 28450351

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Take Home Points:

  • Supraventricular tachycardia can be seen in up to 50% of children and adults after heart transplantation.
  • Adenosine, a endogenous nucleoside that results in sinus slowing and AV block, has been considered relatively contraindicated in heart transplant recipients due to post-transplant denervation
  • Adenosine use at low doses of 25 μg/kg or 1.5 mg were found to be effective in causing AV block in healthy heart transplant patients in sinus rhythm
  • AV block was seen in 96% of patients with escalating adenosine administration up to maximal dose of 200 μg/kg or 12 mg
  • There were no adverse events seen after adenosine administration including no clinically significant asystole (≥ 12 seconds) requiring rescue ventricular pacing
  • The use of adenosine during supraventricular tachycardia in post-heart transplants patients was not evaluated and therefore, the dosing, response and safety of adenosine in that scenario cannot be commented on based on this study.

 

A PatelComment from Dr. Akash Patel (San Francisco), section editor of Congenital Electrophysiology Journal Watch:  Previous limited data has suggested heart transplant patients are at adverse risk to adenosine in the setting of cardiac denervation after transplantation. In particular, adenosine exposure in this setting has been thought to lead to excessive AV block and bradycardia. Due to this concern, adenosine is relatively contraindicated in post-heart transplant patients and thus uncommonly used. However, up to 50% of children and adults with heart transplantation can be affected by supraventricular tachycardia with adenosine potentially providing a therapeutic and/or diagnostic option.  This single center prospective study from New York Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center aimed to improve our understanding of the safety and efficacy of adenosine in pediatric and young adult patients who have undergone heart transplantation with hopes to reconsider its use in this population.

 

All healthy patients ≥ 2 weeks post-cardiac transplantation were included if they agreed to consent and were excluded if there was evidence of rejection (clinical/humeral/cellular), graft vasculopathy, concurrent use of intravenous inotropic medication, concurrent treatment for rejection, conduction disease (first-, second-, or third-degree AV block, preexisting sinus node dysfunction), or systolic ventricular dysfunction. At the time of routine post-cardiac transplant catheterization, eligible patients underwent adenosine testing.

The study group included 80 patients (55% male) with a median age of 13.6 years (Range: 1.1 – 24 year). The median weight was 50.4 kg (Range: 7.8 – 120 kg). The indications for transplantation included cardiomyopathy (60%), congenital heart disease (30%), retransplantation (7.5%), and other (2.5%). The most common type of transplantation was bicaval (71%) followed by biatrial (28%). Prior history of rejection was seen in 49%. There was use of dipyridamole in 53% which is a medication known to effect adenosine metabolism. This medication was stopped 3 days before catheterization in all patients. There was use of antiarrhythmic drugs – beta-blocker (24%) and digoxin (2.5%)- but no data on indications or prior arrhythmia status. The cardiac catheterization procedures were done under general anesthesia in 64%.

After catheterization and biopsy were complete but before the removal of central access, a 4F quadripolar pacing catheter was introduced into the right ventricle with pacing thresholds tested and outputs set appropriately. Adenosine was given via central access in serial escalating doses based on weight until AV block or clinically significant asystole (either a sinus pause or AV block ≥ 12 seconds which were the predetermined criterion to initiate ventricular pacing) were seen. If patients weighed <60 kg, patients were given 12.5, 25, 50, 100, and 200 μg/kg of adenosine. If patients weighed ≥ 60 kg, patients were given 0.8, 1.5, 3, 6, and 12 mg.  See below.  The median maximal dose of adenosine given was 3.6 mg (IQR: 2.0 – 6.0 mg).

June EP v1

The primary outcome of the study was to assess the safety of adenosine.  There were no patients (0%) who had clinically significant asystole requiring rescue ventricular pacing after adenosine administration during the escalating adenosine protocol. See below.

 June EP V2

 

The secondary objective was to assess the efficacy of adenosine in the post-heart transplant patient. There was AV block seen in 77/80 (96%) of the cohort (see above).  There was sinus pause > 2 seconds seen in 4 (5%). The effect of AV nodal blockade was seen at doses as low as 25 μg/kg (< 60 kg) or 1.5 mg (≥ 60kg) in 12%. As expected, incremental escalations in dosing increased the percent of patients demonstrating AV nodal block. At up to initial standard dosing of 100 μg/kg (< 60 kg) or 6 mg (≥ 60kg), there was AV nodal blockade seen in 72%.  See Below.

June EP V3The AV nodal effects of adenosine varied in duration. The median longest R-R interval during AV block was 1.9 seconds (IQR: 1.4 – 3.2 seconds) (Example See Figure Below (A)) The mean total adenosine effect was 4.3 seconds (SD: ±2.0 seconds)  (Example: See Figure Below (B)). The absolute longest R-R interval and total adenosine effect in any patient was 8.4 seconds. The median consecutive non-conducted P waves during the longest pause were 2 (IQR, 1–3). The authors stated no variable predicted adenosine effect including prior rejection, maximal dose, weight, or time from transplant.

June EP v6

The use of adenosine was well tolerated with typical symptoms reported in the non-anesthetized group including shortness of breath, discomfort, chest pain, headache, and flushing. There were no adverse symptoms that resulted in premature termination of the protocol.

This study demonstrates the safety of adenosine use in a large healthy pediatric and young adult post-cardiac transplant cohort with no adverse effects including no clinically significant asystole requiring rescue ventricular pacing.  The authors conclude that adenosine is effective in causing AV node blockade at much lower doses – 25 μg/kg (< 60kg) or 1.5mg (≥ 60 kg) –  than PALS or ACLS standard dosing. As the effect is dose-dependent, gradual dose escalation can be considered up to maximal doses of 200 μg/kg (< the 60kg) or 12 mg (≥60kg) until AV blockade is achieved.

This study however does not address if and why lower doses are required and if there is an exaggerated response with adenosine use in post-transplant patients. In particular, it is unclear if the same lower doses given centrally in healthy age-based controls would have resulted in the same effect. In addition, in 1990 Ellenbogen et al (Circulation 1990;81: 821-828  PMID: 2306833) demonstrated there was evidence of a supersensitivity effect in adult patients. Since the dose escalation was terminated once AV block was seen, it is unclear if maximal dosing in all 80 patients would have resulted in an exaggerated response. The study design did not allow for answering these important questions but did show safety with their adenosine dose escalation protocol.  The authors discuss the roles of cardiac denervation and reinnervation as it may play a factor in these issues, but interesting the study showed safe adenosine effect as early as 25 days post-transplant and overall no correlation between time of transplant and effective adenosine dose suggesting other factors may play a role.

Clearly there are limitations to this study with the most notable being that patients are known to be healthy, were not in supraventricular tachycardia at the time of adenosine administration, and the route of adenosine administration was via central access. From a practical standpoint, adenosine is often given peripherally and used in an acute setting. Therefore, the effect of adenosine in the “healthy patient” is a less likely scenario as their rejection status and function may not be known and they may be on antiarrhythmics or other medications that may affect the response to adenosine. Nevertheless, this study demonstrates that adenosine may be used safely in this population but a cautious approach using low doses should be undertaken.

 

Additional EP Articles Worth Reading.

 

Intraoperative arrhythmias in children with congenital heart disease: transient, innocent events? Houck CA, Ramdjan TTTK, Yaksh A, Teuwen CP, Lanters EAH, Bogers AJJC, de Groot NMS.Europace. 2017 Jun 28. doi: 10.1093/europace/eux072. [Epub ahead of print]

PMID: 28666343

 

Cardiac Fibroblast Transcriptome Analyses Support a Role for Interferogenic, Profibrotic and Inflammatory Genes in Anti-SSA/Ro-Associated Congenital Heart Block.

Clancy RM, Markham AJ, Jackson T, Rasmussen SE, Blumenberg M, Buyon JP.

Am J Physiol Heart Circ Physiol. 2017 Jun 16:ajpheart.00256.2017. doi: 10.1152/ajpheart.00256.2017. [Epub ahead of print]

PMID: 28626076

 

Cardiac Arrhythmias in Adults with Congenital Heart Disease.

Balaji S, Mandapati R, Shivkumar K.

Card Electrophysiol Clin. 2017 Jun;9(2):xv-xvi. doi: 10.1016/j.ccep.2017.04.001. No abstract available.

PMID: 28457248

 

Genotype-Phenotype Correlation of SCN5A Mutation for the Clinical and Electrocardiographic Characteristics of Probands With Brugada Syndrome: A Japanese Multicenter Registry.

Yamagata K, Horie M, Aiba T, Ogawa S, Aizawa Y, Ohe T, Yamagishi M, Makita N, Sakurada H, Tanaka T, Shimizu A, Hagiwara N, Kishi R, Nakano Y, Takagi M, Makiyama T, Ohno S, Fukuda K, Watanabe H, Morita H, Hayashi K, Kusano K, Kamakura S, Yasuda S, Ogawa H, Miyamoto Y, Kapplinger JD, Ackerman MJ, Shimizu W.

Circulation. 2017 Jun 6;135(23):2255-2270. doi: 10.1161/CIRCULATIONAHA.117.027983. Epub 2017 Mar 24.

PMID: 28341781

 

 

CHD EP June 2017

 

  1. Intraoperative arrhythmias in children with congenital heart disease: transient, innocent events?

Houck CA, Ramdjan TTTK, Yaksh A, Teuwen CP, Lanters EAH, Bogers AJJC, de Groot NMS.

Europace. 2017 Jun 28. doi: 10.1093/europace/eux072. [Epub ahead of print]

PMID: 28666343

 

Select item 28660303

 

  1. Cardiac Fibroblast Transcriptome Analyses Support a Role for Interferogenic, Profibrotic and Inflammatory Genes in Anti-SSA/Ro-Associated Congenital Heart Block.

Clancy RM, Markham AJ, Jackson T, Rasmussen SE, Blumenberg M, Buyon JP.

Am J Physiol Heart Circ Physiol. 2017 Jun 16:ajpheart.00256.2017. doi: 10.1152/ajpheart.00256.2017. [Epub ahead of print]

PMID: 28626076

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  1. Sudden cardiac death in the young: Epidemiology and overview.

Link MS.

Congenit Heart Dis. 2017 Jun 15. doi: 10.1111/chd.12494. [Epub ahead of print]

PMID: 28618149

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  1. Sudden death in athletes.

Corrado D, Zorzi A.

Int J Cardiol. 2017 Jun 15;237:67-70. doi: 10.1016/j.ijcard.2017.03.034. Epub 2017 Mar 10.

PMID: 28318658

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  1. <i>Nkx2.5</i> is Essential to Establish Normal Heart Rate Variability in the Zebrafish Embryo.

Harrington JK, Sorabella R, Tercek A, Isler JR, Targoff KL.

Am J Physiol Regul Integr Comp Physiol. 2017 Jun 14:ajpregu.00223.2016. doi: 10.1152/ajpregu.00223.2016. [Epub ahead of print]

PMID: 28615160

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  1. Calcium Signaling and Cardiac Arrhythmias.

Landstrom AP, Dobrev D, Wehrens XHT.

Circ Res. 2017 Jun 9;120(12):1969-1993. doi: 10.1161/CIRCRESAHA.117.310083. Review.

PMID: 28596175

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  1. Permanent chronotropic impairment after closure of atrial or ventricular septal defect.

Heiberg J, Nyboe C, Hjortdal VE.

Scand Cardiovasc J. 2017 Jun 8:1-6. doi: 10.1080/14017431.2017.1337216. [Epub ahead of print]

PMID: 28592193

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  1. Cardiac Arrhythmias in Adults with Congenital Heart Disease.

Balaji S, Mandapati R, Shivkumar K.

Card Electrophysiol Clin. 2017 Jun;9(2):xv-xvi. doi: 10.1016/j.ccep.2017.04.001. No abstract available.

PMID: 28457248

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  1. Arrhythmia Surgery for Adults with Congenital Heart Disease.

Deal BJ, Mavroudis C.

Card Electrophysiol Clin. 2017 Jun;9(2):329-340. doi: 10.1016/j.ccep.2017.02.014. Review.

PMID: 28457246

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  1. Cardiac Arrhythmias in Adults with Congenital Heart Disease: Pacemakers, Implantable Cardiac Defibrillators, and Cardiac Resynchronization Therapy Devices.

Cecchin F, Halpern DG.

Card Electrophysiol Clin. 2017 Jun;9(2):319-328. doi: 10.1016/j.ccep.2017.02.013. Epub 2017 Mar 31. Review.

PMID: 28457245

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  1. Catheter Ablation: General Principles and Advances.

Ernst S.

Card Electrophysiol Clin. 2017 Jun;9(2):311-317. doi: 10.1016/j.ccep.2017.02.012. Epub 2017 Mar 14. Review.

PMID: 28457244

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  1. Drug Therapy in Adult Congenital Heart Disease.

Contractor T, Levin V, Mandapati R.

Card Electrophysiol Clin. 2017 Jun;9(2):295-309. doi: 10.1016/j.ccep.2017.02.011. Review.

PMID: 28457243

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  1. Sudden Cardiac Death in Adult Congenital Heart Disease.

Ávila P, Chaix MA, Mondésert B, Khairy P.

Card Electrophysiol Clin. 2017 Jun;9(2):225-234. doi: 10.1016/j.ccep.2017.02.003. Epub 2017 Mar 18. Review.

PMID: 28457237

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  1. Ventricular Arrhythmias in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects.

Sathananthan G, Harris L, Nair K.

Card Electrophysiol Clin. 2017 Jun;9(2):213-223. doi: 10.1016/j.ccep.2017.02.004. Epub 2017 Mar 18. Review.

PMID: 28457236

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  1. Supraventricular Tachycardia in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects.

Janson CM, Shah MJ.

Card Electrophysiol Clin. 2017 Jun;9(2):189-211. doi: 10.1016/j.ccep.2017.02.005. Review.

PMID: 28457235

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  1. Bradyarrhythmias in Congenital Heart Disease.

Carlson SK, Patel AR, Chang PM.

Card Electrophysiol Clin. 2017 Jun;9(2):177-187. doi: 10.1016/j.ccep.2017.02.002. Epub 2017 Mar 22. Review.

PMID: 28457234

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  1. Introduction to the Congenital Heart Defects: Anatomy of the Conduction System.

Moore JP, Aboulhosn JA.

Card Electrophysiol Clin. 2017 Jun;9(2):167-175. doi: 10.1016/j.ccep.2017.02.001. Epub 2017 Mar 14. Review.

PMID: 28457233

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  1. Ventricular pacing in single ventricles-A bad combination.

Bulic A, Zimmerman FJ, Ceresnak SR, Shetty I, Motonaga KS, Freter A, Trela AV, Hanisch D, Russo L, Avasarala K, Dubin AM.

Heart Rhythm. 2017 Jun;14(6):853-857. doi: 10.1016/j.hrthm.2017.03.035.

PMID: 28528723

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  1. Postmortem therapy from a subcutaneous ICD: What is the mechanism?

Wiles BM, Fitzsimmons SJ, Roberts PR.

Pacing Clin Electrophysiol. 2017 Jun;40(6):735-737. doi: 10.1111/pace.13089. Epub 2017 May 16. No abstract available.

PMID: 28374449

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  1. Lone Pediatric Atrial Fibrillation in the United States: Analysis of Over 1500 Cases.

El-Assaad I, Al-Kindi SG, Saarel EV, Aziz PF.

Pediatr Cardiol. 2017 Jun;38(5):1004-1009. doi: 10.1007/s00246-017-1608-7. Epub 2017 Apr 3.

PMID: 28374048

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  1. Measures of and changes in heart rate variability in pediatric heart transplant recipients.

Williams T, Tang X, Gilmore G, Gossett J, Knecht KR.

Pediatr Transplant. 2017 Jun;21(4). doi: 10.1111/petr.12894. Epub 2017 Feb 8.

PMID: 28181355

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  1. [News techniques of pacing in congenital heart diseases].

Le Bloa M, Thambo JB.

Presse Med. 2017 Jun;46(6 Pt 1):594-605. doi: 10.1016/j.lpm.2017.05.015. Epub 2017 Jun 5. French.

PMID: 28595994

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  1. Postnatal Outcomes of Fetal Supraventricular Tachycardia: a Multicenter Study.

Hinkle KA, Peyvandi S, Stiver C, Killen SAS, Weng HY, Etheridge SP, Puchalski MD.

Pediatr Cardiol. 2017 Jun 29. doi: 10.1007/s00246-017-1662-1. [Epub ahead of print]

PMID: 28664446

 

Select item 28664445

 

  1. Prospective Study of Adenosine on Atrioventricular Nodal Conduction in Pediatric and Young Adult Patients After Heart Transplantation.

Flyer JN, Zuckerman WA, Richmond ME, Anderson BR, Mendelsberg TG, McAllister JM, Liberman L, Addonizio LJ, Silver ES.

Circulation. 2017 Jun 20;135(25):2485-2493. doi: 10.1161/CIRCULATIONAHA.117.028087. Epub 2017 Apr 27.

PMID: 28450351

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  1. Right Atrial Diverticulosis and Early-onset Arrhythmia: Rare Cause of Incessant Neonatal Arrhythmia.

Aggarwal N, Joshi R, Joshi RK, Agarwal M.

Indian Pediatr. 2017 Jun 15;54(6):503-504.

PMID: 28667725

 

Select item 28620681

 

  1. Variation in Pediatric Post-Ablation Care: A Survey of the Pediatric and Congenital Electrophysiology Society (PACES).

Dechert BE, Dick M 2nd, Bradley DJ, LaPage MJ.

Pediatr Cardiol. 2017 Jun 15. doi: 10.1007/s00246-017-1654-1. [Epub ahead of print]

PMID: 28620754

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  1. Comparison of 6-mm Versus 8-mm-Tip Cryoablation Catheter for the Treatment of Atrioventricular Nodal Reentrant Tachycardia in Children: A Prospective Study.

Tuzcu V, Gul EE, Karacan M, Kamali H, Celik N, Akdeniz C.

Pediatr Cardiol. 2017 Jun 13. doi: 10.1007/s00246-017-1648-z. [Epub ahead of print]

PMID: 28612086

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  1. Genotype-Phenotype Correlation of SCN5A Mutation for the Clinical and Electrocardiographic Characteristics of Probands With Brugada Syndrome: A Japanese Multicenter Registry.

Yamagata K, Horie M, Aiba T, Ogawa S, Aizawa Y, Ohe T, Yamagishi M, Makita N, Sakurada H, Tanaka T, Shimizu A, Hagiwara N, Kishi R, Nakano Y, Takagi M, Makiyama T, Ohno S, Fukuda K, Watanabe H, Morita H, Hayashi K, Kusano K, Kamakura S, Yasuda S, Ogawa H, Miyamoto Y, Kapplinger JD, Ackerman MJ, Shimizu W.

Circulation. 2017 Jun 6;135(23):2255-2270. doi: 10.1161/CIRCULATIONAHA.117.027983. Epub 2017 Mar 24.

PMID: 28341781

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  1. “Chaotic Arrhythmia” During Successful Resuscitation After Ingestion of Yew (Taxus baccata) Needles.

Zutter A, Hauri K, Evers KS, Uhde S, Fassl J, Reuthebuch OT, Berset A, Kühne M, Donner BC.

Pediatr Emerg Care. 2017 Jun 6. doi: 10.1097/PEC.0000000000001196. [Epub ahead of print]

PMID: 28590987

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  1. Evaluation of QTc in Rett syndrome: Correlation with age, severity, and genotype.

Crosson J, Srivastava S, Bibat GM, Gupta S, Kantipuly A, Smith-Hicks C, Myers SM, Sanyal A, Yenokyan G, Brenner J, Naidu SR.

Am J Med Genet A. 2017 Jun;173(6):1495-1501. doi: 10.1002/ajmg.a.38191. Epub 2017 Apr 10.

PMID: 28394409

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  1. Cost Analysis of Patients Referred for Inherited Heart Rhythm Disorder Evaluation.

Janzen ML, Cheung C, Sanatani S, Cunningham T, Kerr C, Steinberg C, Sherwin E, Arbour L, Deyell MW, Andrade JG, Lehman AM, Gula LJ, Krahn AD.

Can J Cardiol. 2017 Jun;33(6):814-821. doi: 10.1016/j.cjca.2016.12.009. Epub 2016 Dec 20.

PMID: 28347582

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  1. Exome sequencing identifies primary carnitine deficiency in a family with cardiomyopathy and sudden death.

Lahrouchi N, Lodder EM, Mansouri M, Tadros R, Zniber L, Adadi N, Clur SB, van Spaendonck-Zwarts KY, Postma AV, Sefiani A, Ratbi I, Bezzina CR.

Eur J Hum Genet. 2017 Jun;25(6):783-787. doi: 10.1038/ejhg.2017.22. Epub 2017 Mar 15.

PMID: 28295041

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  1. Vectorcardiography identifies patients with electrocardiographically concealed long QT syndrome.

Cortez D, Bos JM, Ackerman MJ.

Heart Rhythm. 2017 Jun;14(6):894-899. doi: 10.1016/j.hrthm.2017.03.003. Epub 2017 Mar 6.

PMID: 28279743

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  1. Single-incision percutaneous pericardial ICD lead placement in a piglet model.

Clark BC, Opfermann JD, Davis TD, Krieger A, Berul CI.

J Cardiovasc Electrophysiol. 2017 Jun 1. doi: 10.1111/jce.13263. [Epub ahead of print]

PMID: 28569424

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  1. KCNQ1 p.L353L affects splicing and modifies the phenotype in a founder population with long QT syndrome type 1.

Kapplinger JD, Erickson A, Asuri S, Tester DJ, McIntosh S, Kerr CR, Morrison J, Tang A, Sanatani S, Arbour L, Ackerman MJ.

J Med Genet. 2017 Jun;54(6):390-398. doi: 10.1136/jmedgenet-2016-104153. Epub 2017 Mar 6.

PMID: 28264985 Free Article

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  1. Tachycardia cycle and atrioventricular nodal conduction properties in children with supraventricular tachycardia.

Mills M, Dubin AM, Motonaga KS, Ceresnak SR.

Pacing Clin Electrophysiol. 2017 Jun;40(6):745-747. doi: 10.1111/pace.13083. Epub 2017 May 16. No abstract available.

PMID: 28383202

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  1. Clinical Application of the QRS-T Angle for the Prediction of Ventricular Arrhythmias in Patients with the Fontan Palliation.

Tran TV, Cortez D.

Pediatr Cardiol. 2017 Jun;38(5):1049-1056. doi: 10.1007/s00246-017-1618-5. Epub 2017 Apr 29.

PMID: 28456831

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  1. Low Iron Stores in Otherwise Healthy Children Affect Electrocardiographic Markers of Important Cardiac Events.

Karadeniz C, Özdemir R, Demirol M, Katipoğlu N, Yozgat Y, Meşe T, Ünal N.

Pediatr Cardiol. 2017 Jun;38(5):909-914. doi: 10.1007/s00246-017-1596-7. Epub 2017 Mar 7.

PMID: 28271153

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  1. Catecholaminergic Polymorphic Ventricular Tachycardia.

Wall JJ, Iyer RV.

Pediatr Emerg Care. 2017 Jun;33(6):427-431. doi: 10.1097/PEC.0000000000001156.

PMID: 28570361

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  1. High School Cardiac Emergency Response Plans and Sudden Cardiac Death in the Young.

White MJ, Loccoh EC, Goble MM, Yu S, Odetola FO, Russell MW.

Prehosp Disaster Med. 2017 Jun;32(3):269-272. doi: 10.1017/S1049023X17000048. Epub 2017 Feb 20.

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Congenital EP Featured Articles of April 2017

 

Pediatric Cardiac and EP Reviews of April 2017 Manuscripts

 

Pacemaker and Defibrillator Implantation in Patients with Transposition of the Great Arteries

Grubb AF, Shah G, Aziz PF, Krasuski RA

The Journal of Innovations in Cardiac Rhythm Management, 8 (2017), 2658-2664

 

Take Home Points:

 

  • Cardiac implantable device implantation in TGA substrates presents unique challenges both at implant and throughout follow-up.
  • This study does not apply to arterial switch patients.
  • Despite differences in indications for implantable devices and age at device implant between d- and l-TGA patients, both TGA groups unfortunately appear to have similar progressions in the development of heart failure with its associated morbidity and mortality.
  • Utilization of current published guidelines for primary prevention ICD implantation has shortcomings when applied to TGA substrates and would benefit from updated evidence and experience with ICDs in TGA patients to guide and individualize this treatment option in this unique patient population.

 

chang-philip-1780821827Commentary from Dr. Philip Chang (Los Angeles), section editor of Congenital Heart Surgery Journal Watch: Article summary:

Grubb et al presented a retrospective review of their single-center experience with cardiac implantable electronic devices (CIEDs) in d- and l-TGA patients with systemic RVs.  The study looked at all TGA patients with CIEDs cared for at their institution over an 18-year period.  All patients had systemic right ventricles and all patients had undergone biventricular repair approaches, with single-ventricle variants and those with repairs to restore systemic morphologic left ventricular circulation excluded from analysis.  In total, 63 patients were identified (34 d-TGA, 29 l-TGA).  The authors performed detailed chart review for each subject to determine initial device implant timing/age, development of heart failure, and variables associated with ICD follow-up including defibrillation thresholds and shocks.

 

EP1

 

EP3

 

EP4

 

Study limitations include single-center inclusivity and retrospective design.  The authors did not provide more in-depth detail pertaining to implant approaches, CIED pocket site (left vs. right chest for transvenous devices, which could have implications in ICD defibrillation function), or CIED-related complications.   Several patients reportedly had CRT devices, but no detail was provided in terms of the indications for CRT or implant approach.

 

Reviewer perspective and thoughts for pediatric/CHD EP:

While it is commonly recognized and even expected that TGA patients will require CIED implantation, primarily for pacing indications, it has been quite some time since the topic of CIED utilization and benefit in TGA patients has been studied.  As such, the authors are commended for reviewing their data and presenting their experience, which is quite valuable for our community.  The study definitely highlights the importance of considering multi-institutional pooling of data and experience.  Furthermore, while the growth of the atrial switched d-TGA population is diminishing, there is still a considerable population of these patients, along with a growing number of adult l-TGA patients that should motivate greater awareness of the use of CIEDs in these very unique ACHD subgroups.

There is little debate in the indications for and benefits of pacing in TGA substrates and the authors’ findings of more predominant pacing for sinus node disease in d-TGA and AV block in l-TGA isn’t novel.  It remains unclear as to the role of CRT for wide QRS, heart block, or dyssynchrony in TGA, and more specifically its feasibility and effectiveness in primary systemic RV resynchronization.  With the advent of and interest in His-bundle pacing, the feasibility of this method of pacing in d- vs. l-TGA would be interesting to explore in terms of technical considerations and long-term benefit.  The finding that no primary prevention ICD patients received appropriate shocks was interesting, but not entirely surprising.  This certainly raises the question of the appropriateness of applying standard guidelines for ICD implantation to the TGA population and while some published data exists for risk stratification in d-TGA, greater evidence is needed to guide ICD therapy, particularly for primary prevention indications, in these patients.   Finally, with the subcutaneous ICD as a contemporary implant option, it will also be interesting to see how the balance between implant indication and “ease” of device implant will change.

 

It is sobering to see that both d- and l-TGA patients with systemic RVs progress in very similar fashions to develop heart failure and its associated clinical sequelae and mortality.  This shared finding between d- and l-TGA patients highlights the unique and highly complex substrate in which CIEDs are being applied, as well as the multifactorial process involved in the near-universal fate of the systemic RV in these TGA patients.

 

 

 

Lone Pediatric Atrial Fibrillation in the United States: Analysis of Over 1500 Cases

El-Assaad I, Al-Kindi SG, Saarel EV, Aziz PF

Pediatr Cardiol April 2017 (DOI: 10.1007/s00246-017-1608-7)

 

Take home points:

  • Lone atrial fibrillation is a rare arrhythmia condition among pediatric patients.
  • Increasing age and obesity appear associated with higher incidence of lone atrial fibrillation though evidence indicating direct causality is lacking.
  • While complications such as thromboembolic events are rare in pediatric lone atrial fibrillation, their incidence is not ignorable. However, treatment recommendations and practice patterns are inconsistent.

 

Commentary from Dr. Philip Chang (Los Angeles, CA) section editor of Congenital Heart Surgery Journal WatchThere has been much recent interest in atrial fibrillation in pediatric and young adult patients, particularly as it pertains to risk factors for its development as well as treatment in patients with significant or symptomatic recurrences and in the setting of CHD.  Despite this interest, studies with large sample sizes are lacking in order to better understand its incidence, clinical sequelae, treatment options and response, and long-term outcomes, particularly in otherwise healthy individuals.  The current study from El-Assaad et al provides a descriptive analysis of the largest cohort of young patients with lone atrial fibrillation in the United States.

The authors sought to evaluate risk factors and short-term outcomes of pediatric lone atrial fibrillation, simply defined as atrial fibrillation occurring in the absence of cardiac and systemic diseases.  They utilized a privately managed national healthcare database, Explorys, from which they were able to query and determine an incidence of pediatric lone atrial fibrillation, other variables that may be associated with its diagnosis, and clinical sequelae over a 17-year period (1999-2016).  The database was created from de-identified data provided by 360 hospitals in all 50 US states and over 300,000 providers.

Results of querying the Explorys database yielded nearly 8 million children, with 1910 children linked to an atrial fibrillation diagnosis.  Of these patients, 1750 children met the definition of lone atrial fibrillation.  This resulted in a calculated pediatric lone AF incidence of 7.5 in 100,000 persons at risk.  Nearly 10% of these patients also had concomitant diagnosis of SVT but further characterization of this could not be determined from the dataset variables.  The authors found relatively low percentages of antiarrhythmic use (5%), aspirin or warfarin for anticoagulation (7% and 5%, respectively), and electrical cardioversion (3%).  Older patients tended to be prescribed aspirin or warfarin more frequently compared to younger aged cohorts.

EP5

Multivariate analysis showed increasing age, male gender, and obesity to be associated with risk of lone AF.  Increasing age was also associated with increased risk of AF recurrence within 1 month of initial episode.  Interestingly, among patients 15-19 years of age, nearly 20% experienced AF recurrence.  The authors also found that 2% of patients experienced a stroke within 1 year of lone AF diagnosis.  Following exclusion of other concomitant diagnoses including sepsis, hypertension, hypertensive crisis, drug abuse, stimulant use, cancer, renal impairment, sleep apena, respiratory failure, and bone marrow transplant, a total of 1580 patient remained.  Among these patients, a male predominance was noted (61%), and most episodes of lone AF occurred in the 15-19 years age group (58%).  Those in the oldest age cohort had recurrence rates spanning 15-22% from 1 month up to 1 year after the initial event.  In this lone AF subset, 1% of patients had a stroke within 1 year of lone AF diagnosis.

EP6

EP7

Study limitations include limited available variables in the database and inability to control for the quality and accuracy of the data provided.  For example, the authors noted that they were unable to review ECGs to confirm AF diagnosis or echocardiograms to evaluate chamber size and that some patients could have been misclassified as having AF in the first place.  Recurrence rates could have been overestimated if a single AF diagnosis reappeared on more than 1 occasion.  They also noted that the dataset itself has not been directly validated for pediatric studies, though adult studies have demonstrated its validity.  It is unclear as to why nearly 10% of the originally classified “lone AF” patients were excluded given other systemic diseases to come to the subgroup of 1580 patients that were further analyzed for lone AF incidence and recurrence.  By the authors’ definition, these patients would not have met a pure lone AF diagnosis given these concomitant conditions, many of which can certainly increase the risk of arrhythmias (AF being one of them).  If the subgroup patients were used to calculate incidence, the lone AF incidence would be even lower.  Finally, the authors did not have further details relating to concomitant SVT in the 10% of patients identified and there was no long-term data regarding treatment efficacy (antiarrhythmics or catheter ablation), prognosis, and outcomes.

 

Reviewer perspective and thoughts for pediatric/CHD EP:

This study is an excellent example of the use of large scale databases to evaluate otherwise rare conditions.  As such, it provides a faster, and perhaps more accurate, assessment of pediatric lone AF incidence, as well as general approaches to management, complications, and recurrence.  The study is obviously limited by the quality and accuracy of data entered into the database itself.

This study’s finding of the association between lone AF and obesity, male gender, and increasing age is helpful and consistent with previous publications noting these potential associations that had substantially smaller patient cohorts.  The association with obesity is likely multifactorial.  Obesity is frequently associated with other cardiovascular conditions including hypertension, diastolic dysfunction, and left atrial distension and pressure loading, though interestingly, the association between obesity and lone AF was apparently made in the study after excluding for these other systemic diseases.  It is possible that these other systemic diseases were under-reported in the dataset and echo data was not available to assess for evidence of diastolic dysfunction or left atrial abnormalities.  Obesity is also frequently associated with obstructive sleep apnea, which is increasingly recognized as having a strong association with arrhythmia risk including AF (though again, the study largely excluded patients with concomitant diagnoses of AF and sleep apnea).  The authors noted familial lone AF as a possible important contributor, and the genetics of AF remains an important area of ongoing research.

Several important findings from this study that are important for the pediatric EP community to be aware of is the low incidence of pediatric lone AF that is found and which is likely more reflective of its true incidence in the general pediatric population.  Furthermore, based on the study’s results, there appears to be a fairly high recurrence rate (up to 20% in the oldest age cohort) as well as a low but very concerning incidence of stroke.  Both of these appeared to be present in the setting of low utilization of antiarrhythmic agents and anticoagulation.  In fact, the stroke incidence that was noted in this study corresponded to an equivalent CHADS2VASc score that would qualify patients to receive anticoagulation with either warfarin or NOACs.  This study’s findings show that pediatric lone AF may not be as benign of a condition as some may think and that these patients require aggressive and close follow-up to address or prevent recurrences and to reduce AF-related complications.

CHD EP April 2017

 

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Prevention and Treatment in Utero of Autoimmune Associated Congenital Heart Block

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Saxena A, Izmirly PM, Mendez B, Buyon JP, Friedman DM.

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Comments: There are no specific guidelines or approaches for the prevention or treatment of cardiac neonatal lupus (NL), however several studies have provided evidence for a general approach to the disease.

  1. Maternal fluorinated steroids have been used to prevent cardiac NL onset or mortality has not been proven, their use in incomplete heart block, cardiomyopathy and hydrops fetalis has been associated with improved outcomes. β-agonists can increase fetal heart rates in those with congenital heart block, but their endurance and impact on mortality remain in question.
  2. Plasmapheresis: There are no controlled experiments so far.
  3. IVIG at a dose of 400 mg/kg did not prevent the recurrence of cardiac NL in mothers with a previously affected child, but it has shown promise in treating fetal cardiomyopathy.
  4. Hydroxychloroquine exposure during pregnancy has been associated with a decreased recurrence of cardiac NL, and an open label prospective trial is currently recruiting to further investigate this association.

Cardiac resynchronization therapy for pediatric patients with heart failure and congenital heart disease: a reappraisal of results

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Motonaga KS, Dubin AM.

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Comment: An excellent reappraisal of CRT results in the CHD population. The emerging disconnect of electrical from mechanical synchrony in the systemic LV’s, the poor response in systemic RV’s and the inconsistent response in single ventricles reflects the need for further understanding. The heterogeneity of this population may therefore need new innovative tools and somewhat individualized approaches to the selection process and pacing strategy for optimal CRT response.

PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease

PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease.

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 RK, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA.

Heart Rhythm. 2014 May 7. pii: S1547-5271(14)00513-X. doi: 10.1016/j.hrthm.2014.05.009. [Epub ahead of print] No abstract available.

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Comment: Long awaited guidelines; A must read and a must download article in your smart phone for a ready reference.