Cardiovascular Collapse with Intravenous Amiodarone in Children: A Multi-Center Retrospective Cohort Study

Hemodynamic profile effects of PM101 amiodarone formulation in patients with post-operative tachyarrhythmias

Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.

Effectiveness of pharmacological cardioversion of new-onset atrial fibrillation during thoracic surgery operations: a single-centre experience

OBJECTIVE

Prophylactic pharmacological conversion agents could reduce the incidence of postoperative atrial fibrillation (AF) in patients undergoing thoracic operations. The current study examined whether the use of pharmacological conversion agents could help to restore sinus rhythm in patients with AF newly developed during thoracic operations.

METHODS

Medical records of 18,605 patients from January 1, 2015 to December 31, 2019, at the Shanghai Chest Hospital were reviewed. Patients with non-sinus rhythm prior to the surgery (n = 128) were excluded from data analysis. The final analysis included 18,477 patients (n = 16,292 undergoing lung operations; n = 2,185 undergoing esophageal operations).

RESULTS

Intraoperative AF (defined as AF lasting for at least 5 min) occurred in 646 out of a total of 18,477 subjects (3.49%). Within the 646 subjects, 258 received pharmacological conversion agents during the surgery. sinus rhythm was restored in 20.15% (52/248) of patients treated with pharmacological cardioversion and in 20.87% (81/399) patients not receiving pharmacological intervention. In a subgroup analysis of the 258 patients receiving pharmacological conversion agents, recovery of sinus rhythm was highest in beta-blocker group (35.59%, 21/59 vs. 15.78%, 15/95 in amiodarone group, p = 0.008, 5.55%, and 1/18 in amiodarone plus beta-blockers group, p = 0.016). The incidence of hypotension was higher in pharmacological conversion (27.5% vs. 9.3% in patients not receiving pharmacological intervention, p < 0.001). In subjects not recovering to sinus rhythm during the surgery (n = 513), electrical cardioversion in post-anesthesia care unit (PACU) restored sinus rhythm in > 98% of the cases (155/158 vs. 63/355 in subjects not receiving cardioversion; p < 0.001).

CONCLUSIONS

Our experience shows that pharmacological conversion, in general, failed to show better treatment effectiveness on intraoperative new-onset AF within period of surgery except for beta-blockers. Patients with AF persisting beyond the surgery could be effectively managed with electrical cardioversion.

IV Sotalol Use in Pediatric and Congenital Heart Patients: A Multicenter Registry Study

Background

There is limited information regarding the clinical use and effectiveness of IV sotalol in pediatric patients and patients with congenital heart disease, including those with severe myocardial dysfunction. A multicenter registry study was designed to evaluate the safety, efficacy, and dosing of IV sotalol.

Methods and Results

A total of 85 patients (age 1 day–36 years) received IV sotalol, of whom 45 (53%) had additional congenital cardiac diagnoses and 4 (5%) were greater than 18 years of age. In 79 patients (93%), IV sotalol was used to treat supraventricular tachycardia and 4 (5%) received it to treat ventricular arrhythmias. Severely decreased cardiac function by echocardiography was seen before IV sotalol in 7 (9%). The average dose was 1 mg/kg (range 0.5–1.8 mg/kg/dose) over a median of 60 minutes (range 30–300 minutes). Successful arrhythmia termination occurred in 31 patients (49%, 95% CI [37%–62%]) with improvement in rhythm control defined as rate reduction permitting overdrive pacing in an additional 18 patients (30%, 95% CI [19%–41%]). Eleven patients (16%) had significant QTc prolongation to >465 milliseconds after the infusion, with 3 (4%) to >500 milliseconds. There were 2 patients (2%) for whom the infusion was terminated early.

Conclusions

IV sotalol was safe and effective for termination or improvement of tachyarrhythmias in 79% of pediatric patients and patients with congenital heart disease, including those with severely depressed cardiac function. The most common dose, for both acute and maintenance dosing, was 1 mg/kg over ~60 minutes with rare serious complications.

Sotalol versus amiodarone for postoperative junctional tachycardia after congenital heart surgery

BACKGROUND

Junctional ectopic tachycardia (JET) is a common arrhythmia after congenital heart disease surgery. There is variability in the choice of antiarrhythmic therapy, with amiodarone used commonly. Intravenous (IV) sotalol is a newly available agent that may be useful for JET.

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of IV sotalol for postoperative JET and compare outcomes with IV amiodarone.

METHODS

This is a retrospective single-center study of all patients who received IV sotalol or IV amiodarone for postoperative JET at Texas Children's Hospital from December 15, 2015, to December 15, 2020. Data included antiarrhythmic efficacy, hemodynamics, and adverse effects. Successful JET control was defined as a decrease in JET rate to <170 beats/min (or decrease by >20%), or conversion to sinus rhythm, with persistent control over 24 hours without requiring alternative antiarrhythmics or mechanical support.

RESULTS

A total of 32 patients (median age 71 days; interquartile range 17-221 days) received IV amiodarone (n = 20 [62%]) or IV sotalol (n = 12 [38%]) for postoperative JET. Amiodarone was successful in treating JET in 75% of cases; sotalol was successful in 83%. The JET rate decreased faster over the first 90 minutes after a sotalol bolus (25 beats/min per hour) than after an amiodarone bolus (8 beats/min per hour) (P < .01); no heart rate difference was seen after 24 hours. Amiodarone infusion was discontinued early because of hypotension/bradycardia in 2 patients; this was not required in any patients receiving sotalol.

CONCLUSION

For children with postoperative JET, both IV sotalol and amiodarone are safe and efficacious. IV sotalol may lead to a faster improvement in heart rate.

Tachycardia-induced cardiomyopathy secondary to incessant ectopic atrial tachycardia in two infants: Potential new indication for early initiation of enteral ivabradine

This report describes two cases of tachycardia-induced cardiomyopathy secondary to incessant ectopic atrial tachycardia (EAT) in an infant presenting with severe left ventricular dysfunction and hemodynamic instability. The two cases were managed differently. The first required mechanical ventilation and was resistant to conventional antiarrhythmic drugs. After the initiation of enteral ivabradine (0.15mg/kg) the heart rate slowed with significant improvement in hemodynamics, peripheral perfusion and sinus rhythm was restored after 12 hours. Ivabradine was continued and the patient was discharged home after 10 days of hospitalization. The second case was managed by early initiation of ivabradine and resulted in restoration of sinus rhythm within 4 hours, thus avoiding trials of conventional anti-arrhythmic drugs with unstable hemodynamic profile. The infant was discharged after 5 days of hospitalization on ivabradine..

Care of Children with Supraventricular Tachycardia in the Emergency Department

Prior studies have characterized children with supraventricular tachycardia (SVT) in inpatient settings, however there is a paucity of data regarding pediatric SVT in the Emergency Department (ED) setting. We sought to describe pediatric ED visits for SVT and assess whether variability exists in care. We performed a cross-sectional study of ED visits for SVT among children < 18 years old from 2010 to 2017 at 33 pediatric hospitals. Visits were included if made for a primary International Disease Classification Ninth or Tenth Revision diagnosis code for SVT and intravenous (IV) adenosine was given on the initial or 2nd hospital day. We evaluated factors associated with hospital admission using multivariate logistic regression and described variability in frequency of rate of hospitalization, second-line IV antiarrhythmic medication usage, and diagnostic testing across sites. We included 2329 ED visits made by 1738 children and the median patient age was 6.3 years (IQR 1.5-11.9). There were 2 deaths (0.1% of visits). Marked variability existed between centers in rates of admission to the hospital (range 17-85%) and ICU (range 4-60%). Factors associated with admission included: younger age, male sex and presence of comorbid conditions. A second IV antiarrhythmic agent was used in 17% of visits (range 4-41% across hospitals). There was variability in rates of diagnostic testing between centers [chest x-ray (range 10-47%), complete blood count (range 10-72%), electrolytes (range 22-86%), echocardiography (range 3-68%)]. Management of SVT is variable across pediatric hospitals, suggesting an opportunity for standardization in care.

Treatment of Permanent Junctional Reciprocating Tachycardia in a Preterm Neonate: Case Report

Permanent junctional reciprocating tachycardia (PJRT) is most often observed in infants and children and can lead to incessant tachycardia. PJRT is usually refractory to medical treatment. Tachycardia may infrequently occur in the fetus in which case fetal tachycardia transplacental treatment should be started immediately. Term delivery is recommended for fetuses with tachycardia in the absence of significant clinical compromise to avoid complications of preterm birth. Herein, a 36-week preterm neonate presented with PJRT. He had tachycardia in the fetal period and was treated with digoxin, amiodaron, and esmolol therapy after birth without undergoing the catheter ablation procedure.

Intravenous Sotalol in the Young: Safe and Effective Treatment With Standardized Protocols

OBJECTIVES

This study assessed the safety and efficacy of novel and standardized protocols for the use of intravenous (IV) sotalol in pediatric patients.

BACKGROUND

Acute arrhythmia treatments in children remain limited. IV sotalol is a new option but pediatric experience is limited. There is no standardized protocol for rapid infusion during acute arrhythmias. This study assessed a single center's initial experience with IV sotalol in young patients, describing a protocol for rapid infusion for acute treatment, and reviewed the safety and efficacy of maintenance dosing.

METHODS

This is a retrospective study of all patients who received IV sotalol at Rady Children's Hospital. Demographics, arrhythmia, hemodynamics, and effects of IV sotalol were assessed.

RESULTS

Thirty-seven patients received IV sotalol from December 2015 to December 2018. Group 1 (n = 26) received sotalol for acute therapy and group 2 (n = 11) received a maintenance dose of sotalol after successful cardioversion with alternate therapies. The groups had similar demographics. Group 1 included patients with atrial flutter (n = 16), patients with supraventricular tachycardia (SVT) (n = 9), and patients with atrial ectopic tachycardia (AET) (n = 1). All 9 patients with SVT (100%) converted to sinus rhythm after failure to convert using adenosine. Median administration time was 15 min, the median dose was 30 mg/m², and mean time to cardioversion was 14 min. Group 2 median infusion time was 120 min, the median dose was 54 mg/m²/day, and all patients maintained sinus rhythm. No patients required cessation for adverse effects previously described for IV sotalol.

CONCLUSIONS

IV sotalol was safe and effective for acute and maintenance therapy in young patients. In acute patients, 30 mg/m² over 15 min converted most patients. IV sotalol adds a valuable option to IV therapies in the young.