In patients with pre-excitation, a short PR interval and a delta wave are not always clearly seen, particularly if the pre-excitation is mild. Absent septal Q waves have been used as additional ...evidence suggestive of pre-excitation. The purpose of the present study was to determine the incidence of normalization of septal Q waves after successful ablation of a manifest accessory pathway in pediatric patients with normal hearts. We performed a retrospective review of electrocardiograms (ECGs) obtained before and after successful catheter ablation of a single manifest accessory pathway in patients <21 years old (84 pairs of ECGs). The ECGs obtained in patients before ablation for atrioventricular nodal re-entry tachycardia were used as controls (n = 62). The absence of Q waves in the lateral leads (V5 to V7 ) and inferior leads (II, III, aVF) were determined. p Values <0.05 were considered significant. Before the ablation, 72 ECGs (85%) demonstrated absent Q waves in the lateral leads, and only 17 (20%) did not show evidence of Q waves after successful ablation of the accessory pathway (p <0.001). On the inferior leads, 37 ECGs (44%) showed no evidence of Q waves before ablation compared to 24 (29%) after ablation (p <0.05). The findings on the postablation ECG were not statistically different from the findings on the ECGs of the control patients. In conclusion, Q waves in the lateral and inferior leads are often absent in patients with manifest pre-excitation. Absent septal Q waves in the lateral and inferior leads frequently normalize after successful ablation of an accessory pathway.
Background
The clinical course of children with advanced heart block secondary to Lyme disease has not been well characterized.
Objective
To review the presentation, management, and time to ...resolution of heart block due to Lyme disease in previously healthy children.
Methods
An IRB approved single-center retrospective study was conducted of all patients < 21 years old with confirmed Lyme disease and advanced second or third degree heart block between 2007 and 2017.
Results
Twelve patients (100% male) with a mean age of 15.9 years (range 13.2–18.1) were identified. Six patients (50%) had mild to moderate atrioventricular valve regurgitation and all had normal biventricular function. Five patients had advanced second degree heart block and 7 had complete heart block with an escape rate of 20–57 bpm. Isoproterenol was used in 4 patients for 3–4 days and one patient required transvenous pacing for 2 days. Patients were treated with 21 days (
n
= 6, 50%) or 28 days (
n
= 6, 50%) of antibiotics. Three patients received steroids for 3–4 days. Advanced heart block resolved in all patients within 2–5 days, and all had a normal PR interval within 3 days to 16 months from hospital discharge.
Conclusion
Symptomatic children who present with new high-grade heart block from an endemic area should be tested for Lyme disease. Antibiotic therapy provides quick and complete resolution of advanced heart block within 5 days, while steroids did not appear to shorten the time course in this case series. Importantly, no patients required a permanent pacemaker.
Background: First‐line therapy for children with attention‐deficit–hyperactivity disorder (ADHD) is stimulant medication, which may have potential cardiovascular side‐effects. In patients with ...supraventricular tachycardia or Wolf‐Parkinson‐White syndrome (WPW), therapy for ADHD could become challenging. The purpose of the present study was to review the authors' experience of performing electrophysiologic study (EPS) with or without ablation to determine how it affected ADHD therapy.
Methods: Retrospective chart review of patients who underwent EPS between 2002 and 2009 was carried out. All patients under 21 years of age who had prior diagnosis of ADHD were included.
Results: Twenty patients met the inclusion criteria. The mean age was 12.1 ± 2.7 years (range: 5.6–16.8 years). The patients were diagnosed with ADHD on average 3.9 ± 2.7 years (range: 6 months–9 years) prior to the EPS. All patients had a structurally normal heart. Sixteen patients had cardiac symptoms. Seventeen patients underwent ablation of the arrhythmia substrate (16/17, 94% successful). Three patients with asymptomatic WPW were at low risk for life‐threatening arrhythmias and did not have ablation. After the EPS, two patients had increased doses of their ADHD medications, and two patients whose health‐care providers stopped the stimulant medication prior to EPS because of recurrent tachycardia were restarted on medications. All other patients on ADHD medications continued therapy.
Conclusions: EPS for risk stratification and ablation of arrhythmia substrate is safe and effective, allowing more liberal therapy in patients with ADHD and supraventricular tachycardia or WPW.
Clinically significant bradycardia is an uncommon problem in children, but one that can cause significant morbidity and sometimes necessitates implantation of a pacemaker. The most common causes of ...bradycardia are complete heart block (CHB), which can be congenital or acquired, and sinus node dysfunction, which is rare in children with structurally normal hearts. Pacemaker is indicated as therapy for the majority of children with CHB, and while early mortality is lower in postnatally diagnosed CHB than in fetal CHB, it is still up to 16%. In young children, less invasive transvenous pacemaker systems can be technically challenging to place and carry a high risk of complications, often necessitating surgical epicardial pacemaker placement, which usually entails a median sternotomy. We report three cases of pediatric patients referred for pacemaker implantation for different types of bradycardia, treated at our institution with oral albuterol with therapeutic results that avoided the need for surgical pacemaker implantation at that time.
Definitive treatment of supraventricular tachycardia (SVT) substrate involves catheter ablation. While objective success rates have been well established, long-term subjective patient experiences ...have not been well described. We quantify a subjective cure rate and characterize long-term patient experience after acutely successful ablation. A cross-sectional survey of pediatric patients with accessory pathways or atrioventricular nodal reentrant tachycardia who underwent acutely successful ablation from 2008 to 2012 was performed. Data were obtained from medical records and patient surveys. Patients with congenital heart disease other than patent ductus arteriosus, patent foramen ovale, or coronary artery abnormalities were excluded. Statistical analyses included Student’s
t
-test and
χ
2
analysis for continuous and categorical variables, respectively. Surveys were sent to 153 patients of which 147 responded with median follow-up of 7.2 (IQR 6.1–8.5) years. Of the 147 responders, 124 (84%) patients reported cure with a male predominance. Symptoms were present in 130/147 (88%) patients pre-ablation and in 53/147 (36%) post-ablation. Among those with post-ablation symptoms, 50/53 (94%) reported symptomatic improvement. Recurrence occurred in 23/147 (16%) patients and was more prevalent following cryoablation. Ablation of SVT substrate can be curative with excellent long-term results and patient satisfaction. Long-term subjective cure rate is high and there is a substantial decrease in symptoms post-ablation. Many patients continue to have symptoms following ablation; however, the majority of these patients consider themselves cured and symptoms can be attributed to other etiologies. Recurrence is uncommon and occurs more frequently following cryoablation.
Objectives
We aimed to measure the frequency and factors associated with anodal stimulation in a pediatric population with epicardial pacing leads.
Background
In bipolar pacemakers, capture of the ...myocardium typically occurs at the cathode. However, AS with capture at the anode has been described. This has not been described in epicardial pacemakers.
Methods
Retrospective data were collected from patients ≤ 21 years of age with permanent bipolar epicardial ventricular pacemakers from 1/2017 to 1/2018. AS was defined as a clear change on surface ECG in at least one of the 12 leads assessed by two blinded pediatric electrophysiologists.
Results
Twenty‐four bipolar leads in 23 patients were included in the study. One patient had both biventricular leads tested. Median age was 7.1 years (IQR 5.0–10.9), weight was 20.9 kg (IQR 16.5–33.5), and 65% were male. Testing was performed at a median of 2.8 years (IQR 1.6–6.1) after implant. Congenital heart disease was present in 57%. Complete heart block was the pacemaker indication in 78%. AS was identified in 16/24 (67%) of leads tested. Identification of AS was associated with presence of congenital heart disease (p = 0.004) and 3DD between electrodes (p = 0.04).
Conclusions
AS is common in pediatric patients and was associated with a history of congenital heart disease and greater estimated 3DD between electrodes. The prevalent nature of AS may allow clinicians to utilize existing pacemakers as multisite pacing systems.
Sudden cardiac arrest in pediatric patients is a rare occurrence. Supraventricular tachycardia without the presence of ventricular preexcitation in pediatric patients with a structurally normal heart ...is generally considered benign. Previous literature in adults reported a subset of patients in whom SVT was suspected to be the primary trigger of sudden cardiac arrest. We performed a single-center, retrospective cohort study of pediatric patients without known heart disease, 1–21 years of age, presenting with aborted SCA between 2009 and 2019. We collected diagnostic studies in all patients to identify the etiology of the aborted SCA. Thirty patients met the inclusion criteria. The median age at the time of SCA was 15.2 years. The etiology of SCA was identified in 23 (77%) patients. Of the seven patients with unknown diagnosis after initial diagnostic studies, three patients subsequently developed fast SVT that was presumed to be the etiology of the initial SCA. These three patients had varying diagnoses of atrioventricular nodal reentry tachycardia, ectopic atrial tachycardia, and a concealed accessory pathway with atrioventricular reentrant tachycardia. After ablation or medical treatment of the SVT substrate, no further tachyarrhythmias were observed. Pediatric patients presenting with an aborted SCA of unknown etiology ought to be considered for electrophysiology testing to elicit occult SVT substrates that may lead to a malignant ventricular tachyarrhythmia.
The traditional first stage of palliation for functional single-ventricle lesions with transposition of the great vessels and systemic outflow tract obstruction has been either the Norwood or Sano ...procedure or the Damus-Kaye-Stansel procedure. There is limited literature on the use of an arterial switch procedure as the initial staged palliation for functional single ventricles in this setting. This study is an examination of our institutional experience with performing the palliative switch procedure with examination of suitability for Fontan completion and midterm outcome in these patients.
This is a retrospective review of our institutional experience from October 1991 through August 2006 on single-ventricle patients with transposition of the great vessels and systemic outflow tract obstruction who underwent a palliative arterial switch procedure.
Nine patients underwent an initial palliative switch procedure. Six of 9 patients underwent completion of palliation with the Fontan procedure and are alive and well. One patient is well and is awaiting the next stage of palliation (78%). There was 1 early operative death (11%) and 1 late death (11%). There was 1 case of recoarctation (11%).
The palliative switch procedure appears a reasonable surgical option for patients with functional single-ventricle lesions, transposition of the great vessels, and systemic outflow tract obstruction. Patients who have undergone a palliative switch procedure are suitable candidates for completion of palliation with the Fontan procedure.
•ST/T changes on exercise electrocardiography in pulmonary hypertension are predictive of outcomes.•Those with ST/T changes were more likely to die/need lung transplant within 8 years.•ST/T changes ...were associated with high pulmonary artery pressure on catheterization.•Exercise electrocardiography can be an early indicator of worsening pulmonary hypertension.
Cardiopulmonary exercise testing (CPET) is an important tool in assessing the functional status of patients with pulmonary arterial hypertension (PAH). During CPET, continuous electrocardiography (ECG) is used as a marker of exercise-induced ischemia or arrhythmia. We hypothesize that ECG changes with exercise may be an early indicator of clinical worsening in PAH and could predict adverse outcomes. Clinical, hemodynamic, and CPET data of 155 children and young adult patients with PAH who underwent CPET between 2012 and 2019 in our pulmonary hypertension (PH) center were included in this retrospective analysis. ECGs were analyzed for ST depressions and T-wave inversions, along with coincident hemodynamic data. These data were correlated with adverse outcomes divided into 2 categories: severe worsening (death or receiving lung transplant) and mild to moderate worsening (PAH medication escalation, hospitalization, shunt creation, or listing for lung transplant). The median age was 19 years (range 7 to 40 years), 69% were female, and the average follow-up time was 5 years (range 1 to 8 years). A total of 63 patients (41%) had at least 1 adverse outcome. A total of 39 patients (25%) demonstrated significant ST-T-wave changes with exercise. Patients with ST-T-wave changes were 20% more likely to die or need lung transplant than those without. The multiple linear regression found that ST-T-wave changes were a predictor of elevated mean pulmonary arterial pressure (mPAP) found on catheterization (R = 0.489, p = 0.003), although not of pulmonary vascular resistance index (R = −0.112, p = 0.484). An mPAP of 55 mm Hg was the most sensitive and specific point in identifying when ST-T-wave changes with exercise begin to appear. In conclusion, ST-T-wave changes on exercise ECG are significantly associated with adverse outcomes in PH in a medium-term follow-up study, and the presence of ST-T-wave changes correlates with higher mPAP. These ECG changes with exercise may be used as early indicators of clinical worsening in PH and predictors of adverse outcomes.
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