The diagnosis and management of supraventricular tachycardia in infants part ii management options
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The diagnosis and management of supraventricular tachycardia in infants Part II: Management options. Leonard Steinberg, MD Timothy Knilans, MD The Heart Center Children’s Hospital Medical Center Cincinnati, OH. Overview. Commonly available pharmacotherapies Acute management

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The diagnosis and management of supraventricular tachycardia in infants part ii management options

The diagnosis and management of supraventricular tachycardia in infantsPart II: Management options

Leonard Steinberg, MD

Timothy Knilans, MD

The Heart Center

Children’s Hospital Medical Center

Cincinnati, OH


Overview
Overview in infants

  • Commonly available pharmacotherapies

  • Acute management

  • Subacute management

  • Chronic management

  • Radiofrequency ablation


Therapy commonly used drugs

Class I: sodium channel blockers in infants

procainamide

flecainide

Class II: ß-blockers

propranolol

esmolol

Class III

amiodarone

sotalol

Class IV: Ca channel blockers

verapamil

Miscellaneous

digoxin

adenosine

Therapy: commonly used drugs


Drugs class ia procainamide
Drugs: class IA (procainamide) in infants

  • Action:

    • slows conduction and prolongs refractoriness in muscle, specialized conduction tissue, and accessory pathways

  • Indications

    • atrial re-entry: atrial fibrillation, atrial flutter

    • accessory pathway tachycardia, particularly if short RP

  • Considerations

    • rapid metabolism > frequent dosing

    • serum concentrations and ECG’s

    • faster ventricular rates

    • negative inotropy


Drugs class ic flecainide
Drugs: class IC (flecainide) in infants

  • Action

    • slows conduction in muscle, conduction tissue, and AP’s

    • suppresses automaticity

  • Indications

    • primary atrial tachycardias (reentrant and automatic)

    • accessory pathway tachycardia, particularly if short RP

  • Considerations

    • negative inotropy

    • faster ventricular rates

    • proarrhythmia

    • serum concentrations and ECG’s

      ensure proper dosing

      avoid in structural heart defects


Drugs class ii propranolol
Drugs: class II (propranolol) in infants

  • Action

    • suppresses automaticity (and ectopy)

    • slows AV node conduction and prolongs refractoriness

  • Indications

    • automatic atrial tachycardia

    • all reentrant tachycardias (reduces inciting events)

  • Considerations

    • QID dosing

    • negative inotropy

    • systemic effects


Drugs class ii esmolol
Drugs: class II (esmolol) in infants

  • Action

    • suppresses automaticity (and ectopy)

    • slows AV node conduction and prolongs refractoriness

  • Indications

    • automatic atrial tachycardia

    • all reentrant tachycardias (reduces inciting events)

  • Considerations

    • very short half life

    • negative inotropy

    • systemic effects


Drugs class iii amiodarone
Drugs: class III (amiodarone) in infants

  • Action

    • slows conduction and prolongs refractoriness in all cardiac tissues

    • suppresses automaticity

  • Indications

    • second choice therapy for many arrhythmias

    • primary choice under special circumstances

  • Considerations

    • no negative inotropy – proarrhythmia

    • multiple systemic effects – long half life


Drugs class iii sotalol
Drugs: class III (sotalol) in infants

  • Action

    • prolongs conduction and refractoriness in all cardiac tissues

    • suppresses automaticity

  • Indications

    • second (and possibly 1st) choice for many arrhythmias

  • Considerations

    • proarrhythmia


Drugs class iv verapamil
Drugs: class IV (verapamil) in infants

  • Action

    • Prolongs conduction and recovery in AV node

  • Indications

    • ? AV node reentry tachycardia

  • Considerations

    • Circulatory collapse in infants


Drugs digoxin
Drugs: digoxin in infants

  • Action

    • prolongs conduction of AV node

    • shortens conduction and refractoriness of muscle and accessory pathways

  • Indications

    • reentrant tachycardias involving the AV node

    • rate control in primary atrial tachycardia

  • Considerations

    • avoid in WPW

    • positive inotropy


Drugs adenosine
Drugs: adenosine in infants

  • Action

    • impairs conduction in AV node (and some accessory pathways)

  • Indications

    • acute termination of AV node dependent reentrant tachycardia

    • diagnosis of SVT

  • Considerations

    • very short half life

    • use with caution in patients on bronchodilators

    • atrial fibrillation


Acute therapy

Vagal maneuvers in infants

Adenosine

Atrial pacing

D/C cardioversion

Chronic (or sub-acute) therapy

Address underlying metabolic and hemodynamic derangements

Always perform with continuous rhythm recording

Acute therapy


Acute therapy adenosine and vagal maneuvers
Acute therapy: adenosine and vagal maneuvers in infants

  • Indicated in AV nodal dependent tachycardias

  • Adenosine may terminate reentrant atrial tachycardias

  • No therapeutic benefit in automatic tachycardias

  • Save vagal maneuvers for known diagnosis

  • Adenosine response  accessory pathway

  • Watch for adenosine side effects


Acute therapy atrial pacing
Acute therapy: atrial pacing in infants

  • Esophageal or post op atrial pacing wires

  • Termination of reentrant SVT

  • Diagnostic tool

  • No termination of automatic tachycardia

  • Overdrive pacing of automatic junctional tachycardia

  • Equipment

  • Arrhythmias


Acute therapy d c cardioversion
Acute therapy: in infantsD/C cardioversion

  • Indicated for conversion of all reentrant tachycardias

  • First choice for hemodynamically unstable patient

  • 0.5 Joules/kg for most SVT

  • 1 Joule/kg for atrial fibrillation

  • Use previously required energy for repeat cardioversion

  • Anterior posterior orientation


Sub acute therapy iv drugs
Sub-acute therapy: IV drugs in infants

  • Esmolol

    • automatic atrial tachycardia

  • Procainamide

    • atrial and AV reentrant tachycardia

  • Digoxin

    • primary atrial tachycardias (rate control)

    • occasionally for AV node dependent tachycardias

  • Amiodarone

    • tachycardias traditionally difficult to treat

    • second line therapy

    • severely depressed function


Chronic therapy who to treat
Chronic therapy: who to treat in infants

ALL patients require close follow- up

  • Well tolerated

  • Normal function

  • No recurrences

  • Social

  • Poor function

  • Recurrent tachycardia

  • Hemodynamic compromise

  • Structural heart disease

  • Social

Don’t treat

Treat

No predictors of recurrence


Automatic atrial tachycardia

Suppress automaticity in infants

Control ventricular rate

Propranolol

Flecainide

Sotalol

Special circumstances

Amiodarone

+/– Digoxin

Automatic atrial tachycardia

Goals

Drugs

Consideration

“Reasonable” control may be a satisfactory endpoint


Reentrant atrial tachycardia

Suppress ectopy in infants

Prevent reentry

Control ventricular rate

Propranolol

Flecainide

Procainamide

Sotalol

Special circumstances

Amiodarone

+/– Digoxin

Reentrant atrial tachycardia

Goals

Drugs


Av reentry tachycardia

Suppress ectopy in infants

Attack pathway limb

Propranolol

Digoxin

Flecainide (short RP)

Procainamide (short RP)

Sotalol

Special circumstances

Amiodarone

AV reentry tachycardia

Goals

Drugs

Drugs

Goals

Consideration

Avoid digoxin when accessory pathway conducts antegrade


Pjrt permanent form of junctional reciprocating tachycardia

Suppress ectopy in infants

Prevent reentry

Propranolol

Digoxin

Flecainide

Sotalol

Amiodarone

PJRT(permanent form of junctional reciprocating tachycardia)

Goals

Drugs

Drugs

Goals

Consideration

May be refractory to multiple therapies


Av node reentry tachycardia

Suppress automaticity in infants

Attack AV node

Propranolol

Digoxin

Sotalol

Special circumstances

?? Verapamil

Amiodarone

AV node reentry tachycardia

Goals

Drugs


Automatic junctional tachycardia

Restore AV synchrony in infants

Suppress automaticity

drugs

reduce fever (post op)

reduce catecholamine state (post op)

Amiodarone

Flecainide

Sotalol

Procainamide

+hypothermia

Automatic junctional tachycardia

Goals

Drugs

Considerations

Considerations

Life threatening tachycardia

Very difficult to treat

Post op option: ECMO

Congenital option: RFA


Atrial fibrillation

Prevent re-entry in infants

Control ventricular rate

Evaluate for congenital heart disease

Treat metabolic and hemodynamic derangements

Amiodarone

+/- Digoxin

Atrial fibrillation

Goals

Drugs

Considerations

Look for structural heart disease


Chaotic atrial tachycardia

Digoxin in infants

Propranolol

caution with lung disease

Chaotic atrial tachycardia

Goals

Drugs

Goals

Suppress automaticity

Control ventricular rate

Considerations

  • Evaluate for respiratory illnesses, esp RSV

  • Tachycardia unlikely to recur once respiratory illness resolves


Choosing a drug other considerations

Use what works in infants

Low threshold for in-patient monitoring

Digoxin & amiodarone do not depress function

START SAFE

Choosing a drug: other considerations


Length of therapy

Indications ?? in infants

Most would treat through the first year of life

Holter and event monitors helpful

Inducibility ??

Natural history favors discontinuing therapy

Length of therapy


Therapy radiofrequency ablation
Therapy: in infantsradiofrequency ablation

No definitive indications established

  • Refractory tachycardia

  • Hemodynamic compromise

  • Hemodynamic catheterization

  • Impending loss of catheter

  • access

  • Expanding lesions

  • Higher complication rate

  • Natural history

Proceed

Wait

No long term data in humans


Summary

Therapy for SVT in infants can be divided into acute, sub-acute, chronic, and RF ablation

Acute interventions should be performed with continuous rhythm monitoring to assist in diagnosis

Use sub acute therapy when acute therapies fail

Individualize chronic therapy to the infant and the tachycardia mechanism

RF ablation rarely indicated

Summary


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