Natural history of isolated atrial flutter in infancy

The diagnostic and therapeutic challenge of atrial flutter in children: a case report

BACKGROUND

Palpitations represent a common cause for consultation in the pediatric Emergency Department (ED). Unlike adults, palpitations in children are less frequently dependent from the heart, recognizing other causes.

CASE PRESENTATION

A 11-year-old male came to our pediatric ED for epigastric pain, vomiting and palpitations. During the previous 6 month the patient was affected by SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus). Electrocardiogram (ECG) revealed supraventricular tachycardia. Therefore, adenosine was administered unsuccessfully. The administration of adenosine, however, allowed us to make diagnosis of atypical atrial flutter. Multiple attempts at both electrical cardioversion, transesophageal atrial overdrive, and drug monotherapy were unsuccessful in our patient. Consequently, a triple therapy with amiodarone, flecainide, and beta-blocker was gradually designed to control the arrhythmic pattern with the restoration of a left upper atrial rhythm. There was not any evidence of sinus rhythm in the patient clinical history.

CONCLUSIONS

The present study underlines the rarity of this type of dysrhythmia in childhood and the difficulties in diagnosis and management, above all in a patient who has never showed sinus rhythm. Raising awareness of all available treatment options is essential for a better management of dysrhythmia in children.

Clinical characteristics and outcomes of atrial flutter in neonates

BACKGROUND

Atrial flutter is an uncommon arrhythmia that can cause severe morbidity, including heart failure and even death in refractory cases. This study investigated the clinical characteristics, treatment, and long-term outcomes of patients with neonatal atrial flutter and its association with heart failure.

METHODS

We retrospectively reviewed atrial flutter cases observed in our center between 1999 and 2021 and analyzed the clinical characteristics, treatment, and recurrence according to the presence of heart failure.

RESULTS

The study comprised 15 patients with atrial flutter, with median bodyweight and gestational age of 2.7 kg, 37+4 weeks, respectively. Twelve patients were diagnosed with atrial flutter on the first day of life. The median atrial and ventricular rates were 440/min, 220/min, respectively. Four patients exhibited congestive heart failure. Episodic recurrence was noted in five patients and occurred at a higher rate in patients with congestive heart failure (p = 0.004). Antiarrhythmic drugs for maintenance treatment were administered more often in patients with heart failure (p = 0.011). Initial treatment included direct current cardioversion (n = 9), digoxin (n = 4), and observation (n = 2). Four patients treated with cardioversion experienced recurrence during the neonatal period, and none of those treated with digoxin experienced recurrence. The median follow-up duration was 7 years, during which no atrial flutter recurrence was evident.

CONCLUSION

Neonates with congestive heart failure had a higher recurrence of atrial flutter. Direct current cardioversion is the most reliable treatment for neonatal atrial flutter, whereas digoxin may be a viable treatment option in refractory and recurrent cases.

Impact of transesophageal electrophysiological study on midterm management of pediatric tachyarrhythmias

Background

Transesophageal electrophysiological study (TEEPS) is a minimally invasive procedure that helps in evaluating the risk of recurrence of supraventricular tachycardia based on the inducibility of the tachycardia. The purpose of this study was to evaluate the diagnostic capability, negative predictive value of noninducibility of tachycardia and safety of TEEPS among the Indian pediatric population.

Methods

It is a retrospective single-center observational study of all patients who underwent TEEPS from January 01, 2014, to December 31, 2020.

Results

Twenty-two TEEPS procedures were done in eighteen children with three children undergoing more than one procedure. The median duration of follow-up was 42.97 months (8.52-82.12 months). Out of the 22 procedures, four were conducted for acute tachycardia termination, two for tachycardia suppression assessment, and sixteen to assess tachycardia inducibility off medications. Tachycardia was noninducible in nine children and inducible in six children. Two children had clinical recurrence of tachycardia on follow-up. Out of these two children, one had noninducibility of tachycardia on TEEPS. The negative predictive value of TEEPS was 88.89% in this study. None of the children had any postprocedure complication.

Conclusions

TEEPS is a safe procedure. It is used to assess the efficacy of medication in the suppression of arrhythmia. The noninducibility of tachycardia has a high negative predictive value and is a good indicator of nonrecurrence of clinical tachycardia on midterm follow-up.

Atrial Flutter in Pediatric Patients

Atrial flutter (AFL) in pediatric patients is a rare condition as the physical dimensions of the immature heart are inadequate to support the arrhythmia. This low incidence makes it difficult for patients in this particular setting to be studied. AFL accounts for 30% of fetal tachyarrhythmias, 11% to 18% of neonatal tachyarrhythmias, and 8% of supraventricular tachyarrhythmias in children older than 1 year of age. Transesophageal overdrive pacing can be used, instead, with lower success rate (60%-70%). The recommended drugs are digoxin which can decrease the ventricular rate until the spontaneous interruption of the AFL. Digoxin can be combined with flecainide or amiodarone in case of failure.

Outcomes of sustained fetal tachyarrhythmias after transplacental treatment

Background

Fetal tachyarrhythmia is a condition that may lead to cardiac dysfunction, hydrops, and death. Despite a transplacental treatment, failure to obtain or maintain sinus rhythm may occur.

Objective

We aimed to analyze the perinatal outcomes of sustained fetal tachyarrhythmias after in utero treatment.

Methods

We performed a retrospective evaluation of 69 cases with sustained fetal tachyarrhythmia. We compared the perinatal and long-term outcomes of prenatally converted and drug-resistant fetuses. Tachyarrhythmia subtypes were also evaluated.

Results

Conversion to sinus rhythm was obtained in 74% of cases; 26% of cases were drug-resistant and delivered arrhythmic. Three perinatal deaths occurred in both groups (6.7% vs 17%, P = .34). Neonates delivered arrhythmic were more frequently admitted to neonatal intensive care units (75% vs 31%, P < .01), and their hospital stay was longer (20.9 vs 6.64 days, P < .001). Multiple neonatal recurrences (81% vs 11%, P < .001), temporary hemodynamic dysfunction or heart failure (50% vs 6.7%, P < .001), and postnatal use of a combination treatment (44% vs 13%, P = .028) were also more frequent in this population. Beyond the neonatal period, rates of recurrences within the first 16 months were higher in drug-resistant fetuses (HR = 16.14, CI 95% [4.485; 193.8], P < .001). In this population, postnatal electrocardiogram revealed an overrepresentation of rare mechanisms, especially permanent junctional reciprocating tachycardia (PJRT) (31%).

Conclusion

Prenatal conversion to stable sinus rhythm is a major determinant of perinatal and long-term outcomes in fetal tachyarrhythmias. The underlying electrophysiological mechanisms have a major role in predicting these differential outcomes with an overrepresentation of PJRT in the drug-resistant population.

Successful treatment of neonatal atrial flutter by synchronized cardioversion: case report and literature review

BACKGROUND

Atrial flutter (AFL) is a supraventricular tachyarrhythmia. In the ECG tracing, it is marked by a fast, irregular atrial activity of 280-500 beats per minute. AFL is known to be a rare and also life-threatening rhythm disorder both at the fetus and neonatal period. AFL may result in circulatory failure, and in a more severe form, it may lead to a non-immune fetal hydrops. However, with early prenatal diagnosis and proper treatment, the majority of AFL cases show a good prognosis.

CASE PRESENTATION

We report a case of a neonate who was born at 34 weeks of gestational age by C-section because of risk for birth asphyxia, based on abnormal CTG tracing, which had no characteristic rhythms for fetal decelerations. A third day his heart rate was 220/bpm. ECG has shown supraventricular tachycardia with narrow QRS. The administration of adenosine resulted in the obvious appearance of "sawtooth wave" typical for AFL. Arrhythmia was resistant to the therapy of amiodaron. Then cardioversion was performed and the rhythm converted to normal.

CONCLUSIONS

As neonatal AFL might be resistant to conventional pharmacotherapy, one needs to remember about the possibility of electrical cardioversion in the pediatric cardiology referral center. Moreover, CTG monitoring is of limited use because it does not record fetal heart rhythms > 200/min and echocardiography at the reference center is practically the only method to monitor the condition of the fetus with abnormal rapid heart rhythm.

Neonatal supraventricular tachycardia

Supraventricular tachycardia (SVT) is one of the most common conditions requiring emergency cardiac care in neonates. Atrioventricular reentrant tachycardia utilizing an atrioventricular bypass tract is the most common form of SVT presenting in the neonatal period. There is high likelihood for spontaneous resolution for most of the common arrhythmia substrates in infancy. Pharmacological agents remain as the primary therapy for neonates.

Cost-effectiveness of digoxin, pacing, and direct current cardioversion for conversion of atrial flutter in neonates

IntroductionNewborn atrial flutter can be treated by medications, pacing, or direct current cardioversion. The purpose is to compare the cost-effectiveness of digoxin, pacing, and direct current cardioversion for the treatment of atrial flutter in neonates.Materials and methodsA decision tree model was developed comparing the efficacy and cost of digoxin, pacing, and direct current cardioversion based on a meta-analysis of published studies of success rates of cardioversion of neonatal atrial flutter (age<2 months). Patients who failed initial attempt at cardioversion progressed to the next methodology until successful. Data were analysed to assess the cost-effectiveness of these methods with cost estimates obtained from 2015 Medicare reimbursement rates.

RESULTS

The cost analysis for cardioversion of atrial flutter found the most efficient method to be direct current cardioversion at a cost of $10 304, pacing was next at $11 086, and the least cost-effective was digoxin at $14 374. The majority of additional cost, regardless of method, was from additional neonatal ICU day either owing to digoxin loading or failure to covert. Direct current cardioversion remains the most cost-effective strategy by sensitivity analyses performed on pacing conversion rate and the cost of the neonatal ICU/day. Direct current cardioversion remains cost-effective until the assumed conversion rate is below 64.6%.

CONCLUSION

The most cost-efficient method of cardioverting a neonate with atrial flutter is direct current cardioversion. It has the highest success rates based on the meta-analysis, shorter length of stay in the neonatal ICU owing to its success, and results in cost-savings ranging from $800 to $4000 when compared with alternative approaches.

Neonatal atrial flutter after insertion of an intracardiac umbilical venous catheter

Objective:

To describe a case of neonatal atrial flutter after the insertion of an intracardiac umbilical venous catheter, reporting the clinical presentation and reviewing the literature on this subject.

Case description:

A late-preterm newborn, born at 35 weeks of gestational age to a diabetic mother and large for gestational age, with respiratory distress and rule-out sepsis, required an umbilical venous access. After the insertion of the umbilical venous catheter, the patient presented with tachycardia. Chest radiography showed that the catheter was placed in the position that corresponds to the left atrium, and traction was applied. The patient persisted with tachycardia, and an electrocardiogram showed atrial flutter. As the patient was hemodynamically unstable, electric cardioversion was successfully applied.

Comments:

The association between atrial arrhythmias and misplaced umbilical catheters has been described in the literature, but in this case, it is noteworthy that the patient was an infant born to a diabetic mother, which consists in another risk factor for heart arrhythmias. Isolated atrial flutter is a rare tachyarrhythmia in the neonatal period and its identification is essential to establish early treatment and prevent systemic complications and even death.

Fetal-Maternal Hemorrhage Detected by Sudden Disappearance of Rh Immune Globulin-Related Anti-D

BACKGROUND

Fetal-maternal hemorrhage is usually spontaneous and goes undetected but can be associated with adverse perinatal outcomes.

CASE

We describe the detection of a fetal-maternal hemorrhage by abrupt disappearance of prophylactic anti-D on antibody screen in an Rh-negative mother with dichorionic twins admitted for atrial flutter of one twin. Both rosette and Kleihauer-Betke tests were positive. The diagnosis was confirmed by anemia in one twin at birth.

CONCLUSION

Fetal-maternal hemorrhage requires a high index of suspicion for diagnosis. An unexpected sudden decline in Rh immune globulin-related anti-D may be an indication of fetal-maternal hemorrhage.

Multiple external electrical cardioversions for refractory neonatal atrial flutter

This report describes a case of atrial flutter in a fetal/neonatal patient who did not respond to adenosine, a propafenone bolus, and three electrical external cardioversions. A fourth direct current cardioversion after propafenone premedication resolved the atrial flutter. The arrhythmia did not recur with propafenone therapy during a 12-month follow-up period.

Atrial Flutter in Infants

OBJECTIVES

We sought to characterize the clinical nature of atrial flutter (AFL) in a large cohort of infants.

BACKGROUND

There are no large studies describing the natural history of AFL in infants. Previous studies vary in the therapy used and expected prognosis.

METHODS

We reviewed the records of all children younger than 1 year of age who were diagnosed with AFL at our hospital during the past 25 years, excluding those with previous cardiac surgery.

RESULTS

We identified 50 infants with AFL. Most, 36 (72%), presented within the first 48 h of life. Congestive heart failure was evident in 10 infants, with 6 presenting at 1 day of age, and 4 presenting beyond 1 month of age. The remainder were asymptomatic. A large atrial septal defect was the only structural heart disease. Spontaneous conversion to sinus rhythm occurred in 13 (26%) infants. Sinus rhythm was restored in 20 of 23 (87%) attempts at direct current cardioversion and 7 of 22 (32%) attempts at transesophegeal pacing; 7 required antiarrhythmic therapy. An additional arrhythmia, all supraventricular, appeared in 11 (22%) infants. The recurrence of AFL developed in 6 infants; 5 of 6 of these incidents occurred within 24 h of the first episode. All patients with recurrence had an additional arrhythmia.

CONCLUSIONS

Infants with AFL usually present within the first 2 days of life. No association was found with structural heart disease. Direct current cardioversion appears to be most effective at establishing sinus rhythm. Chronic AFL has the potential to cause cardiovascular compromise. Atrial flutter in the absence of other arrhythmias has a low risk of recurrence. Once in sinus rhythm, infants with AFL have an excellent prognosis and may not require chronic antiarrhythmic therapy.

Neonatal intractable atrial flutter successfully treated with intravenous flecainide

We present a neonatal case with intractable atrial flutter that did not respond to digitalization and electrical cardioversion. Intravenous flecainide administration completely resolved the atrial flutter. Proarrhythmic effects were not induced by flecainide administration. Although the efficacy of flecainide for atrial flutter during the infantile or childhood period is low, intravenous flecainide is worth consideration as a treatment for atrial flutter, even in intractable cases as described here, during the neonatal period.

Electronic medical devices: a primer for pathologists

CONTEXT

Electronic medical devices (EMDs) with downloadable memories, such as implantable cardiac pacemakers, defibrillators, drug pumps, insulin pumps, and glucose monitors, are now an integral part of routine medical practice in the United States, and functional organ replacements, such as the artificial heart, pancreas, and retina, will most likely become commonplace in the near future. Often, EMDs end up in the hands of the pathologist as a surgical specimen or at autopsy. No established guidelines for systematic examination and reporting or comprehensive reviews of EMDs currently exist for the pathologist.

OBJECTIVE

To provide pathologists with a general overview of EMDs, including a brief history; epidemiology; essential technical aspects, indications, contraindications, and complications of selected devices; potential applications in pathology; relevant government regulations; and suggested examination and reporting guidelines.

DATA SOURCES

Articles indexed on PubMed of the National Library of Medicine, various medical and history of medicine textbooks, US Food and Drug Administration publications and product information, and specifications provided by device manufacturers.

STUDY SELECTION

Studies were selected on the basis of relevance to the study objectives.

DATA EXTRACTION

Descriptive data were selected by the author.

DATA SYNTHESIS

Suggested examination and reporting guidelines for EMDs received as surgical specimens and retrieved at autopsy.

CONCLUSIONS

Electronic medical devices received as surgical specimens and retrieved at autopsy are increasing in number and level of sophistication. They should be systematically examined and reported, should have electronic memories downloaded when indicated, will help pathologists answer more questions with greater certainty, and should become an integral part of the formal knowledge base, research focus, training, and practice of pathology.

[A case of atrial flutter after umbilical venous catheterization]

Isolated atrial flutter is an extremely rare form of supraventricular tachycardia in the neonatal period. It may be initiated by central venous catheterization.

CASE REPORT

A male infant was born at 35 weeks by cesarean section for placenta praevia. He was eutrophic. Apgar score was 10 at 1 and 5 minutes. He secondary developed a respiratory distress syndrome. He was then ventilated by nasal CPAP. Immediately after an umbilical venous catheterization, a tachycardia appeared without preexistent cardiac dysfunction. An intravenous dose of adenosine (Striadyne) showed a characteristic sawtooth pattern of P waves on inferior leads. The cardiac-US examination was normal. This atrial flutter was converted to normal sinus rhythm by transoesophageal pacing, without adjunction of antiarrhythmic drugs. The newborn was weaned from mechanical ventilation 48 hours later and discharged from hospital at seven days post natal age. His development and clinical examination were normal two months later.

CONCLUSION

The isolated atrial flutter is rare in the neonate. It may be triggered by a venous catheterization. Transoesophageal atrial pacing is safe and effective for conversion.

Pharmacologic management of supraventricular tachycardias in children. Part 2: Atrial flutter, atrial fibrillation, and junctional and atrial ectopic tachycardia

OBJECTIVE

To review the literature regarding the use of antiarrhythmic agents in the management of atrial flutter (AF), atrial fibrillation (Afib), junctional ectopic tachycardia (JET), and atrial ectopic tachycardia (AET) in infants and children. To discuss the advantages and disadvantages of specific agents in each type of arrhythmia in an effort to develop treatment guidelines.

DATA SOURCE

A MEDLINE search encompassing the years 1966-1996 was used to identify pertinent literature for discussion. Additional references were found in the articles, which were retrieved via MEDLINE.

STUDY SELECTION

Clinical trials that address the use of antiarrhythmic agents for the treatment of supraventricular tachycardia, AF, Afib, JET, and AET in children were selected. Literature pertaining to dosage, pharmacokinetics, efficacy, and toxicity of antiarrhythmic agents in children were considered for possible inclusion in the review; information judged to be pertinent by the authors was included in the discussion.

DATA EXTRACTION

Although there are numerous reports of antiarrhythmic use in children, there are very few large studies designed that evaluate the use of specific antiarrhythmic agents in the treatment of AF, Afib, JET, or AET. Ideally, controlled clinical trials are used to develop clinical guidelines; however, in this situation, most data and information must be obtained from case series of children treated. Although the results from these types of studies may be useful in developing guidelines for the optimal use of these agents for the treatment of AF, Afib, JET, and AET, controlled trials are required for establishing standard treatment guidelines for all patients.

DATA SYNTHESIS

Despite limited scientific evaluation of conventional agents in the treatment of AF, Afib, JET, or AET in children, they continue to be the standards of care. Most information regarding the use of conventional agents in children has been extrapolated from the adult literature. Little justification for the use of the agents or dosing in children is available. Controlled trials regarding the use of newer antiarrhythmic agents (propafenone, amiodarone, flecainide) are available; however, the variance in dosing schemes, presence of structural heart disease, and patient age may confound the results.

CONCLUSIONS

Because of greater clinical experience, conventional antiarrhythmic agents generally remain as first-line therapy in the management of most supraventricular tachycardias in children. Atrial pacing or cardioversion to reestablish sinus rhythm is indicated for initial episodes of AF in infants, followed by chronic prophylactic therapy in those with significant structural heart disease or in infants in whom AF recurs. Attempts to eliminate AF in children outside the neonatal or infancy period should begin with trials of traditional agents such as digoxin or procainamide, and if unsuccessful, subsequent trials of amiodarone. Digoxin and beta-blockers remain the mainstay of therapy for children with Afib, followed by procainamide for treatment failures. Intravenous amiodarone, the newest addition to our antiarrhythmic armamentarium, is the most promising agent in the treatment of postoperative JET. This arrhythmia has been traditionally managed with corporal cooling and/or digoxin therapy; however, intravenous amiodarone may now be a valuable option. Although relatively unsuccessful in the management of congenital JET and AET, conventional agents are typically used prior to the initiation of long-term therapy with potentially more toxic agents such as amiodarone or propafenone. Additional well-designed, controlled trials are needed to further evaluate the comparative efficacy of agents such as flecainide, sotalol, moricizine, propafenone, and amiodarone in the management of AF, Afib, JET, and AET in children, as well as to evaluate the dosing and toxicity in various age groups.