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Strasburger JF, Eckstein G, Butler M, Noffke P, Wacker‐Gussmann A. Fetal Arrhythmia Diagnosis and Pharmacologic Management. J Clin Pharmacol 2022; 62 Suppl 1:S53-S66. [PMID: 36106782 PMCID: PMC9543141 DOI: 10.1002/jcph.2129] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
One of the most successful achievements of fetal intervention is the pharmacologic management of fetal arrhythmias. This management usually takes place during the second or third trimester. While most arrhythmias in the fetus are benign, both tachy- and bradyarrhythmias can lead to fetal hydrops or cardiac dysfunction and require treatment under certain conditions. This review will highlight precise diagnosis by fetal echocardiography and magnetocardiography, the 2 primary means of diagnosing fetuses with arrhythmia. Additionally, transient or hidden arrhythmias such as bundle branch block, QT prolongation, and torsades de pointes, which can lead to cardiomyopathy and sudden unexplained death in the fetus, may also need pharmacologic treatment. The review will address the types of drug therapies; current knowledge of drug usage, efficacy, and precautions; and the transition to neonatal treatments when indicated. Finally, we will highlight new assessments, including the role of the nurse in the care of fetal arrhythmias. The prognosis for the human fetus with arrhythmias continues to improve as we expand our ability to provide intensive care unit-like monitoring, to better understand drug treatments, to optimize subsequent pregnancy monitoring, to effectively predict timing for delivery, and to follow up these conditions into the neonatal period and into childhood. Coordinated initiatives that facilitate clinical fetal research are needed to address gaps in knowledge and to facilitate fetal drug and device development.
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Affiliation(s)
- Janette F. Strasburger
- Division of CardiologyDepartments of Pediatrics and Biomedical EngineeringChildren's Wisconsin, Herma Heart Institute, and Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Gretchen Eckstein
- Division of CardiologyDepartments of Pediatrics and Biomedical EngineeringChildren's Wisconsin, Herma Heart Institute, and Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Mary Butler
- College of NursingUniversity of Wisconsin–OshkoshOshkoshWisconsinUSA
| | - Patrick Noffke
- Division of CardiologyDepartments of Pediatrics and Biomedical EngineeringChildren's Wisconsin, Herma Heart Institute, and Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Annette Wacker‐Gussmann
- German Heart CenterDepartment of Congenital Heart Disease and Pediatric Cardiology MunichMunchenBavariaGermany
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Escudero CA, Tan RBM, Beach CM, Dalal AS, LaPage MJ, Hill AC. Approach to Wide Complex Tachycardia in Paediatric Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:60-73. [PMID: 37969244 PMCID: PMC10642107 DOI: 10.1016/j.cjcpc.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2023]
Abstract
Wide complex tachycardia (WCT) is an infrequently encountered condition in paediatric patients and may be due to a variety of causes including supraventricular tachycardia with aberrant conduction, ventricular activation via an accessory pathway, ventricular pacing, or ventricular tachycardia. Immediate tachycardia termination is required in haemodynamically unstable patients. After stabilization or in those with haemodynamically tolerated WCT, a careful review of electrocardiographic tracings and diagnostic manoeuvres are essential to help elucidate the cause. Subacute and chronic management for WCT will depend on the underlying cause as well as features of the patient and the tachycardia presentation. This article will review the epidemiology, potential causes, and management of WCT in children. A detailed review of the pathophysiology, differential diagnosis, and diagnostic and treatment options is provided to enable the reader to develop a practical approach to managing this condition in young patients.
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Affiliation(s)
- Carolina A. Escudero
- Division of Cardiology, Department of Pediatrics, University of Alberta and Stollery Children’s Hospital, Edmonton, Alberta, Canada
| | - Reina Bianca M. Tan
- Division of Cardiology, Department of Pediatrics, NYU Langone Health and Hassenfeld Children’s Hospital, New York, New York, USA
| | - Cheyenne M. Beach
- Section of Cardiology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aarti S. Dalal
- Division of Cardiology, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Martin J. LaPage
- Division of Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison C. Hill
- Division of Cardiology, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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3
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Tadros HJ, Boggs R, Childress M, Chang PM. Case 3: An Unusual Rhythm in a 12-day-old Infant. Neoreviews 2020; 21:e622-e624. [PMID: 32873657 DOI: 10.1542/neo.21-9-e622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Hanna J Tadros
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Ryan Boggs
- Congenital Heart Center, University of Florida, Gainesville, FL
| | - Megan Childress
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Philip M Chang
- Congenital Heart Center, University of Florida, Gainesville, FL
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El Joueid N, Touma Boulos M, Abou Jaoude S, Daou L. Ventricular Tachycardia in an Infant Without Congenital Anomaly: A Case Report. Cardiol Res 2020; 11:61-65. [PMID: 32095198 PMCID: PMC7011923 DOI: 10.14740/cr1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/08/2020] [Indexed: 11/30/2022] Open
Abstract
Ventricular tachycardia (VT) is a serious form of arrhythmia that can be life-threatening; that’s why diagnosis and treatment are very important in order to avoid serious complications. We are reporting this case of VT which is a rare entity, especially, in healthy infants. This infant, without cardiac pathology known from birth, presented with poor food intake and grunting with hepatomegaly on clinical examination, and a heartbeat at 200/ min. The electrocardiogram (ECG) showed wide QRS complex tachycardia, and the echocardiogram showed a dilated and hypokinetic cardiomyopathy. The clinical signs and chest X-ray changes were consistent with mild cardiac failure. This presentation makes the diagnosis challenging, therefore, it is important to take a good history of the case with a complete clinical exam to achieve the correct diagnosis, and to avoid potential complications. VT of an infant may be benign but should not be diagnosed as such before eliminating serious causes.
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Affiliation(s)
- Nouhad El Joueid
- Pediatric Department, Hotel-Dieu de France University Hospital, Saint Joseph University, Medical School, Alfred Naccache Boulevard, Achrafieh, Beirut, Lebanon
| | - Marianne Touma Boulos
- Pediatric Department, Hotel-Dieu de France University Hospital, Saint Joseph University, Medical School, Alfred Naccache Boulevard, Achrafieh, Beirut, Lebanon
| | - Simon Abou Jaoude
- Cardiology Department, Hotel-Dieu de France University Hospital, Saint Joseph University, Medical School, Alfred Naccache Boulevard, Achrafieh, Beirut, Lebanon
| | - Linda Daou
- Pediatric Cardiology Department, Hotel-Dieu de France University Hospital, Saint Joseph University, Medical School, Alfred Naccache Boulevard, Achrafieh, Beirut,Lebanon
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Ban JE. Neonatal arrhythmias: diagnosis, treatment, and clinical outcome. KOREAN JOURNAL OF PEDIATRICS 2017; 60:344-352. [PMID: 29234357 PMCID: PMC5725339 DOI: 10.3345/kjp.2017.60.11.344] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 08/31/2017] [Accepted: 09/04/2017] [Indexed: 11/27/2022]
Abstract
Arrhythmias in the neonatal period are not uncommon, and may occur in neonates with a normal heart or in those with structural heart disease. Neonatal arrhythmias are classified as either benign or nonbenign. Benign arrhythmias include sinus arrhythmia, premature atrial contraction, premature ventricular contraction, and junctional rhythm; these arrhythmias have no clinical significance and do not need therapy. Supraventricular tachycardia, ventricular tachycardia, atrioventricular conduction abnormalities, and genetic arrhythmia such as congenital long-QT syndrome are classified as nonbenign arrhythmias. Although most neonatal arrhythmias are asymptomatic and rarely life-threatening, the prognosis depends on the early recognition and proper management of the condition in some serious cases. Precise diagnosis with risk stratification of patients with nonbenign neonatal arrhythmia is needed to reduce morbidity and mortality. In this article, I review the current understanding of the common clinical presentation, etiology, natural history, and management of neonatal arrhythmias in the absence of an underlying congenital heart disease.
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Affiliation(s)
- Ji-Eun Ban
- Division of Cardiology, Department of Pediatrics, School of Medicine, Ewha Womans University, Seoul, Korea
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Abstract
Ventricular tachycardia is uncommon in children without CHD. We present the case of a 15-year-old boy who presented with severe diabetic ketoacidosis and ventricular tachycardia and was not responsive to traditional anti-arrhythmic therapy. This case highlights the importance of identification of the underlying metabolic derangement causing the arrhythmia to provide appropriate management.
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Rehsia SS, Pepelassis D, Buffo-Sequeira I. Accelerated ventricular rhythm in healthy neonates. Paediatr Child Health 2011; 12:777-9. [PMID: 19030464 DOI: 10.1093/pch/12.9.777] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2007] [Indexed: 11/14/2022] Open
Abstract
Accelerated ventricular rhythm is similar in rate to the original sinus rhythm. Although 19 cases have been reported in healthy neonates without congenital disease, it is seen with some regularity at tertiary care paediatric cardiac centres. Accelerated ventricular rhythm carries good prognosis, but it is frequently misdiagnosed as ventricular tachycardia and is, thus, unnecessarily treated. The present report describes a case of a neonate who was not properly diagnosed after birth and who was inappropriately treated.
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Affiliation(s)
- Sachdeep S Rehsia
- London Health Sciences Centre, Children's Hospital of Western Ontario, Division of Paediatric Cardiology, University of Western Ontario, London, Ontario
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Skinner JR, Sharland G. Detection and management of life threatening arrhythmias in the perinatal period. Early Hum Dev 2008; 84:161-72. [PMID: 18358642 DOI: 10.1016/j.earlhumdev.2008.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/15/2008] [Indexed: 11/20/2022]
Abstract
The management of tachyarrhythmias and bradyarrythmias in the fetus requires a team approach with careful monitoring of fetal well-being as well as care in establishing a precise diagnosis with use of m-mode and Doppler echocardiography to determine the atrial and ventricular rate. A persistent fetal heart rate less than 80 beats per minute (bpm) suggests complete atrioventricular block. A persistent fetal heart rate over 180 bpm suggests pathological tachycardia, most of which are a supraventricular tachycardia mediated via an accessory pathway. However, around 20% are due to atrial flutter, and this review highlights why medical management should be different for these cases, and for those with hydrops or cardiac failure. It also illustrates which fetus or infant may be at particular risk, and illustrates key features in their management before and after birth.
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Affiliation(s)
- Jonathan R Skinner
- Green Lane Paediatric and Congenital Cardiac Services, Starship Hospital, Grafton, Auckland, New Zealand.
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Abstract
The final common pathway to death in all of us is an arrhythmia, yet we still know far too little about the contribution of conduction abnormalities and arrhythmias to the compromised states of the human fetus. At no other time in the human life cycle is the human being at more risk of unexplained and unexpected death than during the prenatal period. The risk of sudden death from 20-40 weeks gestation is 6-12 deaths/1000 fetuses/year. This is equal to, and in some ethnic groups HIGHER than, the risk of death in the adult population with known coronary artery disease over the same time frame (6-12 deaths/1000 patients/year). Because only a small percentage of the United States population is pregnant each year, because fetal demise is not often acknowledged through public displays such as funerals, and finally because fetal death is culturally accepted to a much greater extent than it should be, this critically important area of women's healthcare has not had the technological advances that have been seen in adult cardiac intensive care and other areas of medicine. Fetal cardiac deaths may be preventable and the diseases that lead to these deaths are often treatable, especially if the sophistication of our modern ICU's could somehow be translated to the prenatal monitoring arena. This review article will outline recent advances in evaluating fetal electrophysiology, helping the perinatologist to better understand the nuances of fetal arrhythmias.
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Affiliation(s)
- Janette F Strasburger
- Children's Hospital of Wisconsin - Fox Valley, 200 Theda Clark Medical Plaza, Suite 480, Neenah, WI 54956-2884, USA.
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Vento M, Tudela BF, Escrig R, Sáenz P, Sánchez A, Cano A. Haemolysis alters plasma flecainide levels in newborn infants. Acta Paediatr 2007; 96:466-8. [PMID: 17407483 DOI: 10.1111/j.1651-2227.2007.00132.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Refractory neonatal supra-ventricular tachycardia may require the use of flecainide as anti-arrhythmic. Close control of plasma levels is mandatory due to pro-arrhythmic complications. However, inadvertent hemolysis during blood sampling may cause an increase in measured plasma flecainide concentrations. We conclude, therefore, that dosing of the drug should be always done with caution, and in case of suspected haemolysis plasma levels should be repeated with a new blood sample.
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Affiliation(s)
- M Vento
- Division of Neonatology, Hospital Materno-Infantil La Fe, Valencia, Spain.
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Harris KC, Potts JE, Fournier A, Gross GJ, Kantoch MJ, Cote JM, Sanatani S. Right ventricular outflow tract tachycardia in children. J Pediatr 2006; 149:822-826. [PMID: 17137900 DOI: 10.1016/j.jpeds.2006.08.076] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Revised: 07/05/2006] [Accepted: 08/30/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the clinical spectrum of right ventricular outflow tract tachycardia and its management in children. STUDY DESIGN Five centers identified patients for retrospective review. Patients (age <18 years) demonstrating ventricular tachycardia with an inferior axis and left bundle branch block were included. Patients with structural heart disease, myocarditis, cardiomyopathy, or long QT syndrome were excluded. Demographics, clinical presentation, investigations, and treatment were analyzed. Holter data were used to quantify ectopy. RESULTS Patients (n = 48) were referred for evaluation of incidental findings (39/48), near syncope or syncope (7/48), or other (2/48). Investigations included magnetic resonance imaging (51%), endomyocardial biopsy (25%), and angiography (23%). Medical treatment was initiated in 26 of the 48 patients. The most common indications for treatment were frequent ectopy and symptoms. Medical treatment (P <.007) and observation alone (P <.02) were both associated with a reduction in ectopy. Symptoms persisted in 3 of 13 patients who were treated medically and in all untreated patients. At follow-up, there were no deaths and no difference in ectopy (P <.46) between patients who were treated medically and patients who were observed. Ablation was attempted in 6 of the 48 patients (successful in 4/6). CONCLUSION The clinical spectrum and management of right ventricular outflow tract tachycardia in children are diverse. Both medical therapy and observation alone were associated with a reduction in ectopy.
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Affiliation(s)
- Kevin C Harris
- BC Children's Hospital, Vancouver, British Columbia, Canada
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De Rosa G, Butera G, Chessa M, Pardeo M, Bria S, Buonuomo PS, Zecca E, Romagnoli C. Outcome of newborns with asymptomatic monomorphic ventricular arrhythmia. Arch Dis Child Fetal Neonatal Ed 2006; 91:F419-22. [PMID: 16820390 PMCID: PMC2672755 DOI: 10.1136/adc.2005.092932] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Frequent premature ventricular contractions (PVCs), couplets (CPLTs) and episodes of ventricular tachycardia are extremely rare in the neonatal population. Limited information is available with regard to clinical relevance and outcome. OBJECTIVES To evaluate the clinical characteristics and outcomes of a group of newborns with ventricular arrhythmias without heart disease. PATIENTS AND DESIGN Between January 2000 and January 2003, 16 newborns with ventricular arrhythmias in the absence of heart disease were studied. The newborns were divided into three groups: PVC group (n = 8), CPLT group (n = 4) and ventricular tachycardia group (n = 4). All patients underwent physical examination, electrocardiography, Holter monitoring and echocardiography at diagnosis and at follow-up (1, 3, 6 and 12 months, and yearly thereafter). RESULTS Mean (standard deviation, SD) age of the patients was 3 (1.19) days in the PVC group, 3.25 (0.95) days in the CPLT group and 6.5 (9.1) days in the ventricular tachycardia group. Median follow-up was 36 months (range 24-48 months). PVCs disappeared during follow-up in all the neonates, in the PVC group, at a mean (SD) age of 2.1 (1.24) months; in the CPLT group, couplets disappeared at a mean (SD) age of 6.5 (1) months. All patients with ventricular tachycardia were treated; ventricular tachycardia disappeared at a mean (SD) age of 1.7 (0.9) months. Neither death nor complications occurred. CONCLUSIONS Ventricular arrhythmias in newborns without heart disease have a good long-term prognosis. Frequent PVCs and CPLTs do not require treatment. Sustained ventricular tachycardia or high-rate ventricular tachycardia must be treated, but the prognosis is generally favourable.
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Affiliation(s)
- G De Rosa
- Department of Pediatric Cardiology, Catholic University Medical School, Rome, Italy.
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Abstract
Arrhythmias are potentially life-threatening problems in the fetus and newborn. Appropriate management depends on accurate diagnosis. Atrioventricular re-entry is the most common type of supraventricular tachycardia in both the fetus and newborn. It should be distinguished from other types of tachycardia - such as atrial flutter, atrial ectopic tachycardia, permanent junctional re-entry tachycardia, and ventricular tachycardia. Neonatal and fetal bradycardias are less common clinical problems. Sustained bradycardia is most often caused by complete atrioventricular block. It can be mimicked by the more common but benign occurrence of non-conducted atrial premature beats.
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Affiliation(s)
- Christopher Wren
- Department of Paediatric Cardiology, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK.
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Abstract
This review provides an updated framework for the diagnosis and management of neonatal tachycardias.
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Abstract
A spectrum of distinctive clinical presentations and electrocardiographic patterns have been recognized in neonates with ventricular arrhythmias. These may range from an incidental finding on a routine physical to cardiovascular collapse due to ventricular fibrillation. It has become increasingly important that the clinician considers ventricular tachycardia in the neonate with tachycardia when the QRS normal does not appear normal. In general, isolated premature ventricular depolarizations, couplets and non-sustained ventricular tachycardia in the absence of heart disease are associated with a favorable prognosis. Most of these arrhythmias tend to resolve during the first month of life. Conversely, sustained ventricular arrhythmias associated with ischemia, myocarditis or ventricular tumors are associated with a guarded prognosis. Treatment is based on the definition of associated cardiovascular disease, support of hemodynamic status and the judicious use of antiarrhythmic agents. Finally, there has been an increased recognition of idiopathic forms of ventricular tachycardia in the neonate which are associated with a favorable prognosis and may not require pharmacologic treatment. This review will discuss these arrhythmias in neonates, associated forms of cardiovascular disease, current treatment options and long-term prognosis.
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Sugiyama H, Yanai J, Komai T, Tan T, Komori S, Nakazawa S. Neonatal catecholaminergic ventricular tachycardia--a case report. JAPANESE CIRCULATION JOURNAL 1999; 63:727-8. [PMID: 10496491 DOI: 10.1253/jcj.63.727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A case of neonatal catecholaminergic ventricular tachycardia is reported. Episodes of fetal tachycardia were detected in a female baby and just after birth, sustained monomorphic ventricular tachycardia of complete left bundle branch block pattern and inferior axis were recorded, suggesting a right ventricular outflow origin. Routine examination did not reveal overt heart disease. Ventricular tachycardia was induced by crying or sucking, elicited by isoproterenol infusion, and was suppressed by intravenous injection of ATP or propranolol. The baby's arrhythmia was controlled with oral propranolol. The ventricular tachycardia seemed to be caused by triggered activity.
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Affiliation(s)
- H Sugiyama
- Department of Pediatrics, Yamanashi Medical University, Tamaho, Japan
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