Tachyarrhythmias; When should I refer?

Hasri Samion MD, M.Med, FNHAM, FAsCC Consultant Paediatric Cardiologist Paediatric & Congenital Heart Centre Institut Jantung Negara

Supraventricular tachycardia
Heart rate >230 beats per minute
Narrow QRS complex Normal QRS axis p wave usually not seen

Supraventricular tachycardia

Supraventricular tachycardia
AVN as parts of the tachycardia circuit
AVN reentry tachycardia (60%) Accessory pathway reentry tachycardia

WPW syndrome (30%)

AVN not parts of the tachycardia circuit (8%)

Atrial flutter Atrial ectopic

Mechanism of SVT

Reentry AVN reentry AV reentry

Automaticity

Reentry Circuit
Two pathways with diff properties. Conduction vs recovery

Induced by ectopic beats, antegrade conduction through slow pathway (fast recovery) and retrograde through fast pathway (slow recovery).

Use of p wave timing to identify the cause of Tachycardia

A. B. C. D.

Atrial flutter Atrial ectopic tachycardia AVRT AVNRT

Supraventricular tachycardia
12 leads ECG during tachycardia if patient is stable
At least ECG strip during termination of tachycardia Repeat 12 leads ECG during sinus rhythm

AVNRT

AVRT

Acute Management of SVT

I/V Adenosine push

I/V Flecainide slow bolus

I/V Verapamil slow bolus (not suitable for

children less than 1 year) I/V Amiodarone infusion for children with underlying congenital heart disease D/C Cardioversion in unstable cases

Role of Adenosine
To terminate tachycardia
Unmasked atrial activity by blocking AVN;

identify the etiology/mechanism

NOT to treat SVT

Atrial Flutter

Antiarrhythmic Drugs for SVT

Digoxin: 10mcg/Kg/day
Propanolol: 1-4 mg/Kg/dose TID

Flecainide: 2-5 mg/Kg/dose BID

Amiodarone: 5-15 mg/Kg/day

Verapamil: 1-4 mg/Kg/dose TID

Management strategies for SVT in children

Majority successfully managed by

antiarrhythmic drugs
Ablation recommended for breakthrough

tachyarrhythmia in AVNRT, AVRT, AET, Atrial Flutter

Ablation success rate more than 95% Low risk of complete heart block

Ventricular Tachycardia
Broad QRS complex tachycardia

Rate more than 100 beats but usually less

than 180 beats/min LBBB or RBBB QRS morphology Atrioventricular dissociation. Premature ventricular beats during sinus rhythm.

Right Ventricular Outflow Tract Tachycardia in children

School going age group Non-sustained monomorphic/LBBB morphology

and normal axis

Multiple LBBB/polymorphis: ARVD is the likely

diagnosis
Sensitive to Adenosine and verapamil

Right ventricular outflow tract tachycardia

Idiopathic Left Ventricular Tachycardia

School going/young adult age group Sustained VT but rarely cause syncope RBBB morphology and superior axis Stress induced tachycardia Verapamil sensitive

Left ventricular fascicular tachycardia

Management strategies for VT in Children

RVOT Ventricular Tachycardia Does not cause sudden death Antiarrhythmis drugs if symptomatic Consider Ablation if frequent breakthrough and symptomatic while on antiarrhythmic drugs
ILV Ventricular Tachycardia Verapamil is effective in most cases Ablation is curative and may be offered

10 years old. Has been diagnosed to have Secundum ASD Complaint of Intermittent palpitation

Thank you