1
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Alexander ME, Gongwer R, Trachtenberg FL, Minich LL, Triedman JK, Kaltman JR, Czosek RJ, Tristani-Firouzi M, LaPage MJ, Tsao SS, Radbill AE, DiLorenzo MP, Kovach JR, Stephenson EA, Janson C, Mao C, Salerno JC, Clark BC, Mahgerefteh J, Pilcher T, Johnson TR, Kim JJ, Valdes SO, Cain N, Jackson L, Saarel EV. Limited Relationship Between Echocardiographic Measures and Electrocardiographic Markers of Left Ventricular Size in Healthy Children. Pediatr Cardiol 2024; 45:1055-1063. [PMID: 38520508 DOI: 10.1007/s00246-024-03448-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/07/2024] [Indexed: 03/25/2024]
Abstract
Pediatric ECG standards have been defined without echocardiographic confirmation of normal anatomy. The Pediatric Heart Network Normal Echocardiogram Z-score Project provides a racially diverse group of healthy children with normal echocardiograms. We hypothesized that ECG and echocardiographic measures of left ventricular (LV) dimensions are sufficiently correlated in healthy children to imply a clinically meaningful relationship. This was a secondary analysis of a previously described cohort including 2170 digital ECGs. The relationship between 6 ECG measures associated with LV size were analyzed with LV Mass (LVMass-z) and left ventricular end-diastolic volume (LVEDV-z) along with 11 additional parameters. Pearson or Spearman correlations were calculated for the 78 ECG-echocardiographic pairs with regression analyses assessing the variance in ECG measures explained by variation in LV dimensions and demographic variables. ECG/echocardiographic measurement correlations were significant and concordant in 41/78 (53%), though many were significant and discordant (13/78). Of the 6 ECG parameters, 5 correlated in the clinically predicted direction for LV Mass-z and LVEDV-z. Even when statistically significant, correlations were weak (0.05-0.24). R2 was higher for demographic variables than for echocardiographic measures or body surface area in all pairs, but remained weak (R2 ≤ 0.17). In a large cohort of healthy children, there was a positive association between echocardiographic measures of LV size and ECG measures of LVH. These correlations were weak and dependent on factors other than echocardiographic or patient derived variables. Thus, our data support deemphasizing the use of solitary, traditional measurement-based ECG markers traditionally thought to be characteristic of LVH as standalone indications for further cardiac evaluation of LVH in children and adolescents.
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Affiliation(s)
- Mark E Alexander
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | | | | | | | - John K Triedman
- Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | | | - Richard J Czosek
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Sabrina S Tsao
- Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
- Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | | | | | | | | | | | - Chad Mao
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | | | - Joseph Mahgerefteh
- Children's Hospital at Montefiore, New York, NY, USA
- Mount Sinai Kravis Children's Heart Center, New York, USA
| | | | | | - Jeff J Kim
- Texas Children's Hospital, Houston, TX, USA
| | | | - Nicole Cain
- Medical University of South Carolina, Charleston, SC, USA
| | - Lanier Jackson
- Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth V Saarel
- St. Luke's Health System, Boise, ID, USA
- Cleveland Clinic Lerner College of Medicine at CWRU, Cleveland, OH, USA
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2
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Lamba A, Roston TM, Peltenburg PJ, Kallas D, Franciosi S, Lieve KVV, Kannankeril PJ, Horie M, Ohno S, Brugada R, Aiba T, Fischbach P, Knight L, Till J, Kwok SY, Probst V, Backhoff D, LaPage MJ, Batra AS, Drago F, Haugaa K, Krahn AD, Robyns T, Swan H, Tavacova T, Atallah J, Borggrefe M, Rudic B, Sarquella-Brugada G, Chorin E, Hill A, Kammeraad J, Kamp A, Law I, Perry J, Roberts JD, Tisma-Dupanovic S, Semsarian C, Skinner JR, Tfelt-Hansen J, Denjoy I, Leenhardt A, Schwartz PJ, Ackerman MJ, Wilde AAM, van der Werf C, Sanatani S. An international multicenter cohort study on implantable cardioverter-defibrillators for the treatment of symptomatic children with catecholaminergic polymorphic ventricular tachycardia. Heart Rhythm 2024:S1547-5271(24)02323-3. [PMID: 38588993 DOI: 10.1016/j.hrthm.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Catecholaminergic polymorphic ventricular tachycardia (CPVT) may cause sudden cardiac death (SCD) despite medical therapy. Therefore, implantable cardioverter-defibrillators (ICDs) are commonly advised. However, there are limited data on the outcomes of ICD use in children. OBJECTIVE The purpose of this study was to compare the risk of arrhythmic events in pediatric patients with CPVT with and without ICD. METHODS We compared the risk of SCD in patients with RYR2 (ryanodine receptor 2) variants and phenotype-positive symptomatic patients with CPVT with and without ICD who were younger than 19 years and had no history of sudden cardiac arrest at phenotype diagnosis. The primary outcome was SCD; secondary outcomes were composite end points of SCD, sudden cardiac arrest, or appropriate ICD shocks with or without arrhythmic syncope. RESULTS The study included 235 patients, 73 with ICD (31.1%) and 162 without ICD (68.9%). Over a median follow-up of 8.0 years (interquartile range 4.3-13.4 years), SCD occurred in 7 patients (3.0%), of whom 4 (57.1%) were noncompliant with medications and none had an ICD. Patients with ICD had a higher risk of both secondary composite outcomes (without syncope: hazard ratio 5.85; 95% confidence interval 3.40-10.09; P < .0001; with syncope: hazard ratio 2.55; 95% confidence interval 1.50-4.34; P = .0005). Thirty-one patients with ICD (42.5%) experienced appropriate shocks, 18 (24.7%) inappropriate shocks, and 21 (28.8%) device-related complications. CONCLUSION SCD events occurred only in the no ICD group and in those not on optimal medical therapy. Patients with ICD had a high risk of appropriate and inappropriate shocks, which may be reduced with appropriate device programming. Severe ICD complications were common, and risks vs benefits of ICDs need to be considered.
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Affiliation(s)
- Avani Lamba
- BC Children's Hospital, Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas M Roston
- BC Children's Hospital, Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada; Center for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Puck J Peltenburg
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Dania Kallas
- BC Children's Hospital, Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia Franciosi
- BC Children's Hospital, Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Krystien V V Lieve
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Prince J Kannankeril
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Centre, Nashville, Tennessee
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Seiko Ohno
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan; Department of Bioscience and Genetics, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Ramon Brugada
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain, Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain, Medical Science Department, School of Medicine, University of Girona, Girona, Spain, Cardiology Service, Hospital Josep Trueta, Girona, Spain
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Peter Fischbach
- Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Linda Knight
- Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jan Till
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Sit-Yee Kwok
- Hong Kong Children's Hospital, Hong Kong, SAR, China
| | - Vincent Probst
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | | | | | - Anjan S Batra
- Division of Cardiology, Department of Pediatrics, Irvine and Children's Hospital of Orange County, University of California, Orange, California
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Palidoro-Rome, Italy
| | - Kristina Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway, Department of Cardiology, Karolinska University Hospital, Solna, Sweden, Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Heikki Swan
- Heart and Lung Centre, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Terezia Tavacova
- Department of Pediatric Cardiology, Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague; Motol University Hospital, Prague, Czech Republic
| | - Joseph Atallah
- Cardiology, Faculty of Medicine & Dentistry - Pediatrics Department, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Martin Borggrefe
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany, German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Boris Rudic
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain, Medical Science Department, School of Medicine, Universitat de Girona, Girona, Spain
| | - Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain, Medical Science Department, School of Medicine, Universitat de Girona, Girona, Spain
| | - Ehud Chorin
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Allison Hill
- Children's Hospital Los Angeles, Los Angeles, California
| | - Janneke Kammeraad
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; Department of Pediatric Cardiology, Erasmus MC Sophia, Rotterdam, The Netherlands
| | - Anna Kamp
- Nationwide Children's Hospital, Columbus, Ohio
| | - Ian Law
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - James Perry
- Rady Children's Hospital, San Diego, California
| | - Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada, Population Health Research Institute, Hamilton Health Sciences, and McMaster University, Hamilton, Ontario, Canada
| | | | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group New Zealand, Green Lane Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand, Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark, Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Isabelle Denjoy
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, APHP, Université de Paris Cité, Paris, France
| | - Antoine Leenhardt
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, APHP, Université de Paris Cité, Paris, France
| | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Michael J Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics; Division of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Arthur A M Wilde
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Christian van der Werf
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Shubhayan Sanatani
- BC Children's Hospital, Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada.
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3
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Bergeman AT, Lieve KV, Kallas D, Bos JM, Rosés i Noguer F, Denjoy I, Zorio E, Kammeraad JA, Peltenburg PJ, Tobert K, Aiba T, Atallah J, Drago F, Batra AS, Brugada R, Borggrefe M, Clur SAB, Cox MG, Davis A, Dhillon S, Etheridge SP, Fischbach P, Franciosi S, Haugaa K, Horie M, Johnsrude C, Kane AM, Krause U, Kwok SY, LaPage MJ, Ohno S, Probst V, Roberts JD, Robyns T, Sacher F, Semsarian C, Skinner JR, Swan H, Tavacova T, Tisma-Dupanovic S, Tfelt-Hansen J, Yap SC, Kannankeril PJ, Leenhardt A, Till J, Sanatani S, Tanck MW, Ackerman MJ, Wilde AA, van der Werf C. Flecainide Is Associated With a Lower Incidence of Arrhythmic Events in a Large Cohort of Patients With Catecholaminergic Polymorphic Ventricular Tachycardia. Circulation 2023; 148:2029-2037. [PMID: 37886885 PMCID: PMC10727202 DOI: 10.1161/circulationaha.123.064786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/04/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND In severely affected patients with catecholaminergic polymorphic ventricular tachycardia, beta-blockers are often insufficiently protective. The purpose of this study was to evaluate whether flecainide is associated with a lower incidence of arrhythmic events (AEs) when added to beta-blockers in a large cohort of patients with catecholaminergic polymorphic ventricular tachycardia. METHODS From 2 international registries, this multicenter case cross-over study included patients with a clinical or genetic diagnosis of catecholaminergic polymorphic ventricular tachycardia in whom flecainide was added to beta-blocker therapy. The study period was defined as the period in which background therapy (ie, beta-blocker type [beta1-selective or nonselective]), left cardiac sympathetic denervation, and implantable cardioverter defibrillator treatment status, remained unchanged within individual patients and was divided into pre-flecainide and on-flecainide periods. The primary end point was AEs, defined as sudden cardiac death, sudden cardiac arrest, appropriate implantable cardioverter defibrillator shock, and arrhythmic syncope. The association of flecainide with AE rates was assessed using a generalized linear mixed model assuming negative binomial distribution and random effects for patients. RESULTS A total of 247 patients (123 [50%] females; median age at start of flecainide, 18 years [interquartile range, 14-29]; median flecainide dose, 2.2 mg/kg per day [interquartile range, 1.7-3.1]) were included. At baseline, all patients used a beta-blocker, 70 (28%) had an implantable cardioverter defibrillator, and 21 (9%) had a left cardiac sympathetic denervation. During a median pre-flecainide follow-up of 2.1 years (interquartile range, 0.4-7.2), 41 patients (17%) experienced 58 AEs (annual event rate, 5.6%). During a median on-flecainide follow-up of 2.9 years (interquartile range, 1.0-6.0), 23 patients (9%) experienced 38 AEs (annual event rate, 4.0%). There were significantly fewer AEs after initiation of flecainide (incidence rate ratio, 0.55 [95% CI, 0.38-0.83]; P=0.007). Among patients who were symptomatic before diagnosis or during the pre-flecainide period (n=167), flecainide was associated with significantly fewer AEs (incidence rate ratio, 0.49 [95% CI, 0.31-0.77]; P=0.002). Among patients with ≥1 AE on beta-blocker therapy (n=41), adding flecainide was also associated with significantly fewer AEs (incidence rate ratio, 0.25 [95% CI, 0.14-0.45]; P<0.001). CONCLUSIONS For patients with catecholaminergic polymorphic ventricular tachycardia, adding flecainide to beta-blocker therapy was associated with a lower incidence of AEs in the overall cohort, in symptomatic patients, and particularly in patients with breakthrough AEs while on beta-blocker therapy.
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MESH Headings
- Female
- Humans
- Adolescent
- Male
- Flecainide/adverse effects
- Incidence
- Cross-Over Studies
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/drug therapy
- Tachycardia, Ventricular/epidemiology
- Adrenergic beta-Antagonists/adverse effects
- Defibrillators, Implantable
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
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Affiliation(s)
- Auke T. Bergeman
- Heart Centre, Department of Cardiology (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, The Netherlands (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.)
| | - Krystien V.V. Lieve
- Heart Centre, Department of Cardiology (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, The Netherlands (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.)
| | - Dania Kallas
- Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, Canada (D.K., S.F., S.S.)
| | - J. Martijn Bos
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN (J.M.B., K.T., M.J.A.)
| | - Ferran Rosés i Noguer
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom (F.R.y.N., J.T.)
- Department of Paediatric Cardiology, Vall d’Hebron University Hospital, Barcelona, Spain (F.R.y.N.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
| | - Isabelle Denjoy
- Service de Cardiologie et CRMR Maladies Cardiaques Héréditaires et Rares, APHP, Hôpital Bichat, Université Paris Cité, France (I.D., A.L.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
| | - Esther Zorio
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain (E.Z.)
- Unidad de Cardiopatías Familiares, Muerte Súbita y Mecanismos de Enfermedad, Instituto de Investigación Sanitaria La Fe, Valencia, Spain (E.Z.)
- Center for Biomedical Network Research on Cardiovascular Diseases, Madrid, Spain (E.Z.)
| | - Janneke A.E. Kammeraad
- Department of Pediatric Cardiology, Erasmus MC–Sophia, Rotterdam, The Netherlands (J.A.E.K.)
| | - Puck J. Peltenburg
- Heart Centre, Department of Cardiology (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, The Netherlands (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.)
| | - Katie Tobert
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN (J.M.B., K.T., M.J.A.)
| | - Takeshi Aiba
- Medical Genome Center, National Cerebral and Cardiovascular Center, Suita, Japan (T.A., S.O.)
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Canada (J.A.)
| | - Fabrizio Drago
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital and Research Institute, Rome, Italy (F.D.)
| | - Anjan S. Batra
- Department of Pediatrics, University of California, Irvine (A.S.B.)
| | - Ramon Brugada
- Cardiovascular Genetics Center, Institut d’Investigació Biomèdica Girona, Hospital Trueta, CIBERCV, University of Girona, Spain (R.B.)
| | - Martin Borggrefe
- Department of Medicine, University Medical Center Mannheim, Germany (M.B.)
| | - Sally-Ann B. Clur
- Department of Pediatric Cardiology, Emma Children’s Hospital (S.-A.B.C.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
| | - Moniek G.P.J. Cox
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, The Netherlands (M.G.P.J.C.)
| | - Andrew Davis
- The Royal Children’s Hospital, Melbourne, Australia (A.D.)
| | - Santokh Dhillon
- IWK Health Center, Dalhousie University, Halifax, Canada (S.D.)
| | - Susan P. Etheridge
- Division of Pediatric Cardiology, University of Utah, Salt Lake City (S.P.E.)
| | - Peter Fischbach
- Sibley Heart Center, Children’s Healthcare of Atlanta, GA (P.F.)
| | - Sonia Franciosi
- Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, Canada (D.K., S.F., S.S.)
| | - Kristina Haugaa
- ProCardio Center for Innovation, Heart, Vessel and Lung Clinic, Oslo University Hospital, Rikshospitalet, Norway (K.H.)
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan (M.H., S.O.)
| | - Christopher Johnsrude
- Division of Pediatric Cardiology, Department of Pediatrics, Norton Children’s Hospital, University of Louisville School of Medicine, KY (C.J.)
| | | | - Ulrich Krause
- Department of Pediatric Cardiology and Intensive Care Medicine, University Medical Center Göttingen, Georg-August-University, Germany (U.K.)
| | - Sit-Yee Kwok
- Department of Paediatrics, Hong Kong Children’s Hospital, China (S.-Y.K.)
| | - Martin J. LaPage
- University of Michigan Congenital Heart Center, Ann Arbor (M.J.L.)
| | - Seiko Ohno
- Medical Genome Center, National Cerebral and Cardiovascular Center, Suita, Japan (T.A., S.O.)
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan (M.H., S.O.)
| | - Vincent Probst
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- Université de Nantes, CHU Nantes, CNRS, INSERM, L’institut du Thorax, France (V.P.)
| | - Jason D. Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Canada (J.D.R.)
| | - Tomas Robyns
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium (T.R.)
| | - Frederic Sacher
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- LIRYC Institute, Bordeaux University Hospital, Bordeaux University, France (F.S.)
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Australia (C.S.)
| | - Jonathan R. Skinner
- Cardiac Inherited Disease Group New Zealand, Green Lane Paediatric and Congenital Cardiac Services, Starship Children’s Hospital, Auckland (J.R.S.)
| | - Heikki Swan
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- Heart and Lung Centre, Helsinki University Hospital and Helsinki University, Finland (H.S.)
| | - Terezia Tavacova
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- Children’s Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic (T.T.)
| | | | - Jacob Tfelt-Hansen
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (J.T.-H.)
- Section of Genetics, Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Denmark (J.T.-H.)
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands (S.-C.Y.)
| | - Prince J. Kannankeril
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University Medical Centre, Nashville, TN (P.J.K.)
| | - Antoine Leenhardt
- Service de Cardiologie et CRMR Maladies Cardiaques Héréditaires et Rares, APHP, Hôpital Bichat, Université Paris Cité, France (I.D., A.L.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
| | - Janice Till
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom (F.R.y.N., J.T.)
| | - Shubhayan Sanatani
- Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, Canada (D.K., S.F., S.S.)
| | - Michael W.T. Tanck
- Epidemiology and Data Science, Amsterdam Public Health, Methodology (M.W.T.T.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
| | - Michael J. Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN (J.M.B., K.T., M.J.A.)
| | - Arthur A.M. Wilde
- Heart Centre, Department of Cardiology (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, The Netherlands (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
| | - Christian van der Werf
- Heart Centre, Department of Cardiology (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.), Amsterdam UMC Location AMC, University of Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, The Netherlands (A.T.B., K.V.V.L., P.J.P., A.A.M.W., C.v.d.W.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart: ERN GUARD-Heart (F.R.y.N., I.D., F.D., S.-A.B.C., V.P., T.R., F.S., H.S., T.T., J.T.-H., A.L., A.A.M.W., C.v.d.W.)
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Dechert BE, LaPage MJ. When Do Smartwatch Heart Rate Concerns in Children Indicate Arrhythmia? J Pediatr 2023; 263:113717. [PMID: 37660972 DOI: 10.1016/j.jpeds.2023.113717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE To determine the incidence and predictors of true arrhythmia in pediatric patients presenting with concerns about smartwatch cardiac data. STUDY DESIGN Single-center, retrospective cohort study of children aged 10-18 years who had presented to a pediatric cardiology clinic between January 2018 and December 2021 with concerns related to smartwatch cardiac data. The primary study outcome was diagnosis of arrhythmia based on clinical evaluation or documentation of arrhythmia by clinical testing. RESULTS There were 126 patients (mean age 15.6 ± 2.4 years) who presented with a smartwatch-based rhythm concern, with tachycardia in 89%. In all, 19 of 126 (15%) patients were diagnosed with true arrhythmia. The odds of a true arrhythmia diagnosis with symptoms vs no symptoms were 3.2 (95% CI 0.7-14.5), and with heart rate (HR) ≥190 beats/min vs HR <190 beats/min, it was 14.3 (95% CI 3.8-52.8). The positive predictive value of HR ≥190 beats/min and symptoms together to predict arrhythmia was only 39% (95% CI 28-52). The negative predictive value for arrhythmia having neither symptoms nor HR >190 was 95% (95% CI 75-99). CONCLUSION The likelihood of a true arrhythmia in pediatric patients presenting with a smartwatch-based HR concern was low. Rarely, smartwatch electrograms or trend data were sufficient for arrhythmia diagnosis.
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Affiliation(s)
- Brynn E Dechert
- Department of Pediatrics, University of Michigan, Ann Arbor, MI.
| | - Martin J LaPage
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
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Pompa AG, LaPage MJ. Outcomes of Infant Supraventricular Tachycardia Management Without Medication. Pediatr Cardiol 2023:10.1007/s00246-023-03263-1. [PMID: 37563317 DOI: 10.1007/s00246-023-03263-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
Most infants presenting with supraventricular tachycardia (SVT) are treated with an antiarrhythmic, primarily to prevent unrecognized future episodes that could lead to tachycardia-induced cardiomyopathy. A common practice at our institution is to not treat after the first presentation of infant SVT and instead educate parents on heart rate monitoring and reasons to present to care. The goal of this study was to evaluate the outcomes of non-pharmacologic treatment of infant SVT at first presentation and compare to outcomes of infants treated with an antiarrhythmic. This was a retrospective single center study of all infants presenting with a first episode of SVT from 2014 to 2021. Excluded were patients with a non-reentry type tachyarrhythmia, atrial flutter, long-RP tachycardia, congenital heart disease, or abnormal ventricular function. Sixty-four infants were included in the study. Thirty-six were managed without an antiarrhythmic. SVT recurred in 28% of the non-treatment group vs 50% in those treated with antiarrhythmics, p = 0.12. Of the patients admitted to the hospital, those in the non-treatment group had a shorter length of stay, 1(IQR 1-1) vs 3(IQR 2-4) days, p < 0.01. Non-treated patients were less likely to present to the emergency department for recurrent SVT, 6% vs 32%, p < 0.01. Neither group had a patient develop tachycardia-induced cardiomyopathy. For infants with structurally and functionally normal hearts, non-treatment combined with parental education after the first episode of SVT does not lead to worse outcomes. This approach avoids the burden of medication administration in an infant and may have the added benefit of empowering parents to feel comfortable managing clinically insignificant tachycardia at home.
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Affiliation(s)
- Anthony G Pompa
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, 1 Children's Pl, 8th Floor NWT, St. Louis, MO, 63108, USA.
| | - Martin J LaPage
- Michigan Medicine Congenital Heart Center, University of Michigan, Ann Arbor, MI, USA
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LaPage MJ. EP News: Pediatric and Congenital Electrophysiology. Heart Rhythm 2023. [DOI: 10.1016/j.hrthm.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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Dechert BE, Kaczor SM, LaPage MJ, Hale BW, Bradley DJ. Nurse Practitioner Delivered Virtual Care in a Pediatric Specialty Clinic. J Pediatr Health Care 2022; 37:287-290. [PMID: 36464520 DOI: 10.1016/j.pedhc.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Virtual care in pediatric specialty practice has become widely used to increase access to care, one in which nurse practitioners (NPs) can play a vital role. We sought to evaluate the outcomes of virtual care provided by pediatric cardiology and electrophysiology (EP) NPs for pediatric and congenital heart disease patients. METHOD Retrospective review of all virtual care visits performed by pediatric EP NPs between October 2019 and October 2021 at a single tertiary care center. RESULTS NPs delivered virtual care for 287 pediatric EP evaluations for 276 patients; 132 (45%) independently, with the remaining 155 collaborating with an electrophysiologist as a shared visit. The mean age was 15.2 ± 8.9 years. DISCUSSION NPs performed a significant subset of these visits independently and were a vital part of all visits in this study. The role of the NP in specialty pediatric virtual care should continue to be supported and advanced.
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Affiliation(s)
- Brynn E Dechert
- Brynn E. Dechert, Pediatric Nurse Practitioner, Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Staci M. Kaczor, Family Nurse Practitioner. Martin J. LaPage, Associate Professor. Benjamin W. Hale, Associate Professor. David J. Bradley, Professor..
| | - Staci M Kaczor
- Brynn E. Dechert, Pediatric Nurse Practitioner, Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Staci M. Kaczor, Family Nurse Practitioner. Martin J. LaPage, Associate Professor. Benjamin W. Hale, Associate Professor. David J. Bradley, Professor
| | - Martin J LaPage
- Brynn E. Dechert, Pediatric Nurse Practitioner, Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Staci M. Kaczor, Family Nurse Practitioner. Martin J. LaPage, Associate Professor. Benjamin W. Hale, Associate Professor. David J. Bradley, Professor
| | - Benjamin W Hale
- Brynn E. Dechert, Pediatric Nurse Practitioner, Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Staci M. Kaczor, Family Nurse Practitioner. Martin J. LaPage, Associate Professor. Benjamin W. Hale, Associate Professor. David J. Bradley, Professor
| | - David J Bradley
- Brynn E. Dechert, Pediatric Nurse Practitioner, Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI. Staci M. Kaczor, Family Nurse Practitioner. Martin J. LaPage, Associate Professor. Benjamin W. Hale, Associate Professor. David J. Bradley, Professor
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LaPage MJ. EP News: Pediatric and Congenital Electrophysiology. Heart Rhythm 2022; 19:1926. [PMID: 37850601 DOI: 10.1016/j.hrthm.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 08/30/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Martin J LaPage
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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LaPage MJ, Bradley DJ, Dechert BE. Successful treatment of acquired heart block with ablation. HeartRhythm Case Rep 2022; 8:745-747. [PMID: 36618595 PMCID: PMC9811012 DOI: 10.1016/j.hrcr.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Martin J. LaPage
- Address reprint requests and correspondence: Dr Martin J. LaPage, 1540 E. Hospital Drive, 11th Floor Pediatric Cardiology, Ann Arbor, MI 48108.
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LaPage MJ. EP News: Pediatric and Congenital Electrophysiology. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Silka MJ, Shah MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN, Berul CI, Cannon B, Cecchin F, Cohen MI, Dalal AS, Dechert BE, Foster A, Gebauer R, Corcia MCG, Kannankeril PJ, Karpawich PP, Kim JJ, Krishna MR, Kubuš P, LaPage MJ, Mah DY, Malloy-Walton L, Miyazaki A, Motonaga KS, Niu MC, Olen M, Paul T, Rosenthal E, Saarel EV, Silvetti MS, Stephenson EA, Tan RB, Triedman J, Bergen NHV, Wackel PL. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary. Ann Pediatr Cardiol 2022; 15:323-346. [PMID: 36589659 PMCID: PMC9802608 DOI: 10.4103/0974-2069.361245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California
| | - Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Monica N Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York University Grossman School of Medicine, New York, New York
| | | | - Aarti S Dalal
- Washington University in St. Louis, St. Louis, Missouri
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter P Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary C Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | | | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Reina B Tan
- New York University Langone Health, New York, New York
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Cain N, Saul JP, Gongwer R, Trachtenberg F, Czosek RJ, Kim JJ, Kaltman JR, LaPage MJ, Janson CM, Singh AK, Hill AC, Landstrom AP, Thacker D, Niu MC, DeWitt ES, Bulic A, Silver ES, Whitehill RD, Decker J, Newburger JW. Relation of Norwood Shunt Type and Frequency of Arrhythmias at 6 Years (from the Single Ventricle Reconstruction Trial). Am J Cardiol 2022; 169:107-112. [PMID: 35101270 DOI: 10.1016/j.amjcard.2021.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 01/21/2023]
Abstract
The Norwood procedure with a right ventricular to pulmonary artery shunt (RVPAS) decreases early mortality, but requires a ventriculotomy, possibly increasing risk of ventricular arrhythmias (VAs) compared with the modified Blalock-Taussig shunt (MBTS). The effect of shunt and Fontan type on arrhythmias by 6 years of age in the SVRII (Single Ventricle Reconstruction Extension Study) was assessed. SVRII data collected on 324 patients pre-/post-Fontan and annually at 2 to 6 years included antiarrhythmic medications, electrocardiography (ECG) at Fontan, and Holter/ECG at 6 years. ECGs and Holters were reviewed for morphology, intervals, atrioventricular conduction, and arrhythmias. Isolated VA were seen on 6-year Holter in >50% of both cohorts (MBTS 54% vs RVPAS 60%), whereas nonsustained ventricular tachycardia was rare and observed in RVPAS only (2.7%). First-degree atrioventricular block was more common in RVPAS than MBTS (21% vs 8%, p = 0.01), whereas right bundle branch block, QRS duration, and QTc were similar. Antiarrhythmic medication usage was common in both groups, but most agents also supported ventricular function (e.g., digoxin, carvedilol). Of the 7 patients with death or transplant between 2 and 6 years, none had documented VAs, but compared with transplant-free survivors, they had somewhat longer QRS (106 vs 93 ms, p = 0.05). Atrial tachyarrhythmias varied little between MBTS and RVPAS but did vary by Fontan type (lateral tunnel 41% vs extracardiac conduit 29%). VAs did not vary by Fontan type. In conclusion, at 6-year follow-up, benign VAs were common in the SVRII population. However, despite the potential for increased VAs and sudden death in the RVPAS cohort, these data do not support significant differences or increased risk at 6 years. The findings highlight the need for ongoing surveillance for arrhythmias in the SVR population.
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Affiliation(s)
- Nicole Cain
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.
| | - J Philip Saul
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
| | | | | | - Richard J Czosek
- The Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey J Kim
- Department of Pediatric, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jonathon R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Martin J LaPage
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Christopher M Janson
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia, Pennsylvania
| | - Anoop K Singh
- Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin
| | - Allison C Hill
- Department of Pediatrics, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andrew P Landstrom
- Department of Pediatrics; Department of Cell Biology, Duke University School of Medicine, Durham, North Carolina
| | - Deepika Thacker
- Department of Pediatrics, Nemours Cardiac Center, Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Mary C Niu
- Department of Pediatrics, Primary Children's Hospital and the University of Utah, Salt Lake City, Utah
| | - Elizabeth S DeWitt
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anica Bulic
- Department of Pediatrics, University of Toronto, SickKids Children's Hospital, Toronto, Ontario, Canada
| | - Eric S Silver
- Department of Pediatrics, Children's Hospital of New York, Columbia University Irving Medical Center, New York, New York
| | - Robert D Whitehill
- Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta Sibley Heart Center, Atlanta, Georgia
| | - Jamie Decker
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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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 Pediatr Congenit Heart Dis 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Peltenburg PJ, Kallas D, Bos JM, Lieve KVV, Franciosi S, Roston TM, Denjoy I, Sorensen KB, Ohno S, Roses-Noguer F, Aiba T, Maltret A, LaPage MJ, Atallah J, Giudicessi JR, Clur SAB, Blom NA, Tanck M, Extramiana F, Kato K, Barc J, Borggrefe M, Behr ER, Sarquella-Brugada G, Tfelt-Hansen J, Zorio E, Swan H, Kammeraad JAE, Krahn AD, Davis A, Sacher F, Schwartz PJ, Roberts JD, Skinner JR, van den Berg MP, Kannankeril PJ, Drago F, Robyns T, Haugaa KH, Tavacova T, Semsarian C, Till J, Probst V, Brugada R, Shimizu W, Horie M, Leenhardt A, Ackerman MJ, Sanatani S, van der Werf C, Wilde AAM. An International Multi-Center Cohort Study on β-blockers for the Treatment of Symptomatic Children with Catecholaminergic Polymorphic Ventricular Tachycardia. Circulation 2021; 145:333-344. [PMID: 34874747 DOI: 10.1161/circulationaha.121.056018] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Symptomatic children with catecholaminergic polymorphic ventricular tachycardia (CPVT) are at risk for recurrent arrhythmic events. Beta-blockers (BBs) decrease this risk, but studies comparing individual BBs in sizeable cohorts are lacking. We aimed to assess the association between risk for arrhythmic events and type of BB in a large cohort of symptomatic children with CPVT. Methods: From two international registries of patients with CPVT, RYR2 variant-carrying symptomatic children (defined as syncope or sudden cardiac arrest prior to BB initiation and age at start of BB therapy <18 years), treated with a BB were included. Cox-regression analyses with time-dependent covariates for BB and potential confounders were used to assess the hazard ratio (HR). The primary outcome was the first occurrence of sudden cardiac death, sudden cardiac arrest, appropriate implantable cardioverter-defibrillator shock, or syncope. The secondary outcome was the first occurrence of any of the primary outcomes except syncope. Results: We included 329 patients (median age at diagnosis 12 [interquartile range, 7-15] years, 35% females). Ninety-nine (30.1%) patients experienced the primary and 74 (22.5%) experienced the secondary outcome during a median follow-up of 6.7 [interquartile range, 2.8-12.5] years. Two-hundred sixteen patients (66.0%) used a non-selective BB (predominantly nadolol [n=140] or propranolol [n=70]) and 111 (33.7%) used a β1-selective BB (predominantly atenolol [n=51], metoprolol [n=33], or bisoprolol [n=19]) as initial BB. Baseline characteristics did not differ. The HR for both the primary and secondary outcomes were higher for β1-selective compared with non-selective BBs (HR, 2.04 95% CI, 1.31-3.17; and HR, 1.99; 95% CI, 1.20-3.30, respectively). When assessed separately, the HR for the primary outcome was higher for atenolol (HR, 2.68; 95% CI, 1.44-4.99), bisoprolol (HR, 3.24; 95% CI, 1.47-7.18), and metoprolol (HR, 2.18; 95% CI, 1.08-4.40) compared with nadolol, but did not differ from propranolol. The HR of the secondary outcome was only higher in atenolol compared with nadolol (HR, 2.68; 95% CI, 1.30-5.55). Conclusions: B1-selective BBs were associated with a significantly higher risk for arrhythmic events in symptomatic children with CPVT compared with non-selective BBs, specifically nadolol. Nadolol, or propranolol if nadolol is unavailable, should be the preferred BB for treating symptomatic children with CPVT.
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Affiliation(s)
- Puck J Peltenburg
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Johan M Bos
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics; Division of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN
| | - Krystien V V Lieve
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Sonia Franciosi
- BC Childrenâs Hospital, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Thomas M Roston
- BC Childrenâs Hospital, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada; Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Isabelle Denjoy
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Université de Paris, Paris, France; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Katrina B Sorensen
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics; Division of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN
| | - Seiko Ohno
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan; Department of Bioscience and Genetics, National Cerebral and Cardiovascular Centre, National Cerebral and Cardiovascular Centre, Suita, Japan
| | | | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan
| | - Alice Maltret
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Université de Paris, Paris, France
| | - Martin J LaPage
- Department of Pediatrics, Division of Cardiology, University of Michigan, Ann Arbor, MI
| | - Joseph Atallah
- Cardiology, Faculty of Medicine and Dentistry - Pediatrics Dept., Stollery Children's Hospital, Edmonton, Canada
| | - John R Giudicessi
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics; Division of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN
| | - Sally-Ann B Clur
- Department of Pediatric Cardiology, Emma Childrenâs Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands;Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Nico A Blom
- Department of Pediatric Cardiology, Emma Childrenâs Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands;Department of Pediatric Cardiology, Willem-Alexander Childrenâs Hospital, Leiden University Medical Centre, Leiden, The Netherlands; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Michael Tanck
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Fabrice Extramiana
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Université de Paris, Paris, France; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Koichi Kato
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Julien Barc
- Université de Nantes, CNRS, INSERM, lâinstitut du thorax, Nantes, France; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Martin Borggrefe
- Department of Medicine, University Medical Center Mannheim, Mannheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group and Cardiology Research Centre, Molecular and Clinical Sciences Research Institute, St. Georgeâs, University of London, London, UK; St. Georgeâs University Hospitals NHS Foundation Trust, Cranmer Terrace, London, UK
| | - Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Spain; Medical Science Department, School of Medicine, Universitat de Girona, Spain; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Rigshospitalet, Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Esther Zorio
- Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Center for Biomedical Network Research on Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Heikki Swan
- Heart and Lung Centre, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Andrew Davis
- The Royal Children's Hospital, Melbourne, Australia; Murdoch Childrenâs Research Institute and Department of Paediatrics, Melbourne University, Melbourne, Australia
| | - Frederic Sacher
- LIRYC Institute, Bordeaux University Hospital, Bordeaux University, Bordeaux, France
| | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences, and McMaster University, Hamilton, Ontario, Canada
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group New Zealand, Green Lane Paediatric and Congenital Cardiac Services, Starship Childrenâs Hospital, Auckland, New Zealand; Department of Paediatrics Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Maarten P van den Berg
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Prince J Kannankeril
- Department of Pediatrics, Monroe Carell Jr Childrenâs Hospital at Vanderbilt, Vanderbilt University Medical Centre, Nashville, TN
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Palidoro-Rome, Italy; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Belgium; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Kristina H Haugaa
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; University of Oslo, Oslo, Norway
| | - Terezia Tavacova
- Department of Pediatric Cardiology, Childrenâs Heart Centre, Second Faculty of Medicine, Charles University in Prague; Motol University Hospital, Prague, Czech Republic
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jan Till
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Vincent Probst
- Université de Nantes, CHU Nantes, CNRS, INSERM, lâinstitut du thorax, Nantes, France; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Ramon Brugada
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain; Cardiology Service, Hospital Josep Trueta, Girona, Spain
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Japan; Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Minoru Horie
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Antoine Leenhardt
- Service de Cardiologie et CNMR Maladies Cardiaques Héréditaires Rares, Hôpital Bichat, Université de Paris, Paris, France; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Michael J Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics; Division of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN
| | - Shubhayan Sanatani
- BC Childrenâs Hospital, Vancouver, Canada; Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Christian van der Werf
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
| | - Arthur A M Wilde
- Amsterdam UMC, University of Amsterdam, Heart Centre; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Member of the European Reference Network for rare, low prevalence and complex diseases of the heart: ERN GUARD-Heart
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15
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Roston TM, Wei J, Guo W, Li Y, Zhong X, Wang R, Estillore JP, Peltenburg PJ, Noguer FRI, Till J, Eckhardt LL, Orland KM, Hamilton R, LaPage MJ, Krahn AD, Tadros R, Vinocur JM, Kallas D, Franciosi S, Roberts JD, Wilde AAM, Jensen HK, Sanatani S, Chen SRW. Clinical and Functional Characterization of Ryanodine Receptor 2 Variants Implicated in Calcium-Release Deficiency Syndrome. JAMA Cardiol 2021; 7:84-92. [PMID: 34730774 DOI: 10.1001/jamacardio.2021.4458] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Calcium-release deficiency syndrome (CRDS), which is caused by loss-of-function variants in cardiac ryanodine receptor 2 (RyR2), is an emerging cause of ventricular fibrillation. However, the lack of complex polymorphic/bidirectional ventricular tachyarrhythmias during exercise stress testing (EST) may distinguish it from catecholaminergic polymorphic ventricular tachycardia (CPVT). Recently, in the first clinical series describing the condition, mouse and human studies showed that the long-burst, long-pause, short-coupled ventricular extra stimulus (LBLPS) electrophysiology protocol reliably induced CRDS ventricular arrhythmias. Data from larger populations with CRDS and its associated spectrum of disease are lacking. Objective To further insight into CRDS through international collaboration. Design, Setting, and Participants In this multicenter observational cohort study, probands with unexplained life-threatening arrhythmic events and an ultrarare RyR2 variant were identified. Variants were expressed in HEK293 cells and subjected to caffeine stimulation to determine their functional impact. Data were collected from September 1, 2012, to March 6, 2021, and analyzed from August 9, 2015, to March 6, 2021. Main Outcomes and Measures The functional association of RyR2 variants found in putative cases of CRDS and the associated clinical phenotype(s). Results Of 10 RyR2 variants found in 10 probands, 6 were loss-of-function, consistent with CRDS (p.E4451del, p.F4499C, p.V4606E, p.R4608Q, p.R4608W, and p.Q2275H) (in 4 [67%] male and 2 [33%] female probands; median age at presentation, 22 [IQR, 8-34] years). In 5 probands with a documented trigger, 3 were catecholamine driven. During EST, 3 probands with CRDS had no arrhythmias, 1 had a monomorphic couplet, and 2 could not undergo EST (deceased). Relatives of the decedents carrying the RyR2 variant did not have EST results consistent with CPVT. After screening 3 families, 13 relatives were diagnosed with CRDS, including 3 with previous arrhythmic events (23%). None had complex ventricular tachyarrhythmias during EST. Among the 19 confirmed cases with CRDS, 10 had at least 1 life-threatening event at presentation and/or during a median follow-up of 7 (IQR, 6-18) years. Two of the 3 device-detected ventricular fibrillation episodes were induced by a spontaneous LBLPS-like sequence. β-Blockers were used in 16 of 17 surviving patients (94%). Three of 16 individuals who were reportedly adherent to β-blocker therapy (19%) had breakthrough events. Conclusions and Relevance The results of this study suggest that calcium-release deficiency syndrome due to RyR2 loss-of-function variants mechanistically and phenotypically differs from CPVT. Ventricular fibrillation may be precipitated by a spontaneous LBLPS-like sequence of ectopy; however, CRDS remains difficult to recognize clinically. These data highlight the need for better diagnostic tools and treatments for this emerging condition.
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Affiliation(s)
- Thomas M Roston
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jinhong Wei
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Wenting Guo
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Yanhui Li
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Xiaowei Zhong
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Ruiwu Wang
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - John Paul Estillore
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Puck J Peltenburg
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | | | - Jan Till
- Department of Cardiology, Royal Brompton Hospital, London, United Kingdom
| | - Lee L Eckhardt
- Division of Cardiovascular Medicine, University of Wisconsin, Madison
| | - Kate M Orland
- Division of Cardiovascular Medicine, University of Wisconsin, Madison
| | - Robert Hamilton
- Division of Cardiology, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Martin J LaPage
- Division of Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor
| | - Andrew D Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rafik Tadros
- Division of Cardiology, Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Jeffrey M Vinocur
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.,currently affiliated with Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Dania Kallas
- Children's Heart Centre, Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia Franciosi
- Children's Heart Centre, Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Western University, London, Ontario, Canada.,now affiliated with Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Center, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Member of the European Reference Network ERN GUARD-Heart
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Medicine, Aarhus University, Aarhus, Denmark
| | - Shubhayan Sanatani
- Children's Heart Centre, Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - S R Wayne Chen
- Libin Cardiovascular Institute, Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
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16
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Shah MJ, Silka MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN, Berul CI, Cannon B, Cecchin F, Cohen MI, Dalal AS, Dechert BE, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril PJ, Karpawich PP, Kim JJ, Krishna MR, Kubuš P, LaPage MJ, Mah DY, Malloy-Walton L, Miyazaki A, Motonaga KS, Niu MC, Olen M, Paul T, Rosenthal E, Saarel EV, Silvetti MS, Stephenson EA, Tan RB, Triedman J, Bergen NHV, Wackel PL. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). JACC Clin Electrophysiol 2021; 7:1437-1472. [PMID: 34794667 DOI: 10.1016/j.jacep.2021.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
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Affiliation(s)
- Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California, USA.
| | | | | | | | - Monica N Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York University Grossman School of Medicine, New York, New York, USA
| | | | - Aarti S Dalal
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois, USA
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter P Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan, USA
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary C Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Melissa Olen
- Nicklaus Children's Hospital, Miami, Florida, USA
| | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Reina B Tan
- New York University Langone Health, New York, New York, USA
| | | | - Nicholas H Von Bergen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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17
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Silka MJ, Shah MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN, Berul CI, Cannon B, Cecchin F, Cohen MI, Dalal AS, Dechert BE, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril PJ, Karpawich PP, Kim JJ, Krishna MR, Kubuš P, LaPage MJ, Mah DY, Malloy-Walton L, Miyazaki A, Motonaga KS, Niu MC, Olen M, Paul T, Rosenthal E, Saarel EV, Silvetti MS, Stephenson EA, Tan RB, Triedman J, Von Bergen NH, Wackel PL. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary. Heart Rhythm 2021; 18:1925-1950. [PMID: 34363987 DOI: 10.1016/j.hrthm.2021.07.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California.
| | - Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | | | | | | | - Monica N Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York University Grossman School of Medicine, New York, New York
| | | | - Aarti S Dalal
- Washington University in St. Louis, St. Louis, Missouri
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter P Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary C Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | | | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Reina B Tan
- New York University Langone Health, New York, New York
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Dechert BE, Bradley DJ, Serwer GA, LaPage MJ. The impact of CIEDs with automatic "wireless" remote monitoring on efficiency. Pacing Clin Electrophysiol 2021; 44:1671-1674. [PMID: 34351650 DOI: 10.1111/pace.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/07/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A benefit of automatically transmitting or "wireless" CIEDs (W-CIED) is the prompt detection of device malfunction and arrhythmias. We hypothesized that the use of W-CIEDs would improve the efficiency of remote monitoring by decreasing unnecessary CIED remote transmissions because of the automatic detection of abnormalities. OBJECTIVE To compare the frequency of patient-initiated transmissions in patients with W-CIEDs versus non-wireless CIEDs (NW-CIED) at a single pediatric and congenital heart center. METHODS Retrospective cohort study of patients with W-CIEDs followed over a 2-year period compared to a similar cohort of patients with NW-CIED. All CIED remote transmissions during were reviewed for indication and outcome. RESULTS The W-CIED cohort had 87 patients; mean age 20 ± 13 years; NW-CIED cohort had 220 patients; mean age 22 ± (13) years. The mean number of symptomatic patient-initiated transmissions per patient was 0.93 ± 2.65 in the W-CIED cohort versus 0.39 ± 0.64 in the NW-CIED cohort (p ≤ .001). The mean number of asymptomatic patient-initiated transmission sent per patient in the W-CIED cohort was 1.86 ± 2.59 versus 0.81 ± 1.41 in the NW-CIED cohort (p ≤ .0001). Type of device, age, and presence of congenital heart disease were not significantly associated with the incidence of patient-initiated remote monitoring transmissions. CONCLUSIONS The frequency of patient-initiated transmission was higher in the W-CIED cohort, contradictory to the study hypothesis. This may reflect a lack of patient understanding of the benefit or functionality of W-CIEDs and may be mitigated by education to both providers and patients.
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Affiliation(s)
- Brynn E Dechert
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - David J Bradley
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gerald A Serwer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Martin J LaPage
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
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Baskar S, Spar DS, LaPage MJ, Dechert-Crooks BE, Ochoa LA, Law IH, Karpawich PP, Torpoco-Rivera D, Follansbee CW, Czosek RJ. B-AB20-03 MULTI-CENTER STUDY EVALUATING THE PRACTICE PATTERN AND OUTCOME OF ABLATION WITHIN THE CORONARY SINUS IN PEDIATRIC PATIENTS. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kallas D, Ghadiry-Tavi R, Roston TM, Franciosi S, Fischbach PS, Knight LM, Kannankeril PJ, Krahn AD, Kwok SY, LaPage MJ, Tisma-Dupanovic S, Atallah J, Kean AC, Etheridge SP, Hill AC, Law IH, Balaji S, Johnsrude CL, Backhoff D, Dhillon SS, Perry JC, Kubuš P, Kovach JR, Fournier A, Kamp AN, Kron J, Lau YR, Brugada GS, Hamilton RM, Sanatani S. B-PO05-167 ATRIAL TACHYARRHYTHMIAS IN CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA: A REPORT FROM THE INTERNATIONAL PEDIATRIC CPVT REGISTRY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lamba A, Roston TM, Franciosi S, Kallas D, Fischbach PS, Knight LM, Atallah J, Hill AC, Kannankeril PJ, Kwok SY, Backhoff D, LaPage MJ, Law IH, Balaji S, Dhillon SS, Krahn AD, Tisma-Dupanovic S, Etheridge SP, Johnsrude CL, Kamp AN, Kovach JR, Kubus P, Perry JC, Fournier A, Kean AC, Lau YR, Sanatani S. B-PO03-182 PRIMARY PREVENTION IMPLANTABLE CARDIOVERTER-DEFIBRILLATORS IN CHILDREN WITH CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA: A PROSPECTIVE STUDY OF THE INTERNATIONAL PEDIATRIC CPVT REGISTRY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Peltenburg P, Kallas D, van der Werf C, Lieve KV, Franciosi S, Roston TM, Denjoy I, Martijn Bos J, Sorensen KB, Perez G, Wada Y, Noguer FR, Almaas VM, Yap SC, Khan H, Maltret A, LaPage MJ, Giudicessi JR, Barker Clur SA, Blom NA, Tanck M, Davis AM, Behr E, Rudic B, Brugada GS, Kannankeril PJ, Sacher F, Skinner J, Tfelt-Hansen J, Tavacova T, Baban A, Robyns T, Semsarian C, Schwartz PJ, Van Den Berg MP, Roberts JD, Grima EZ, Swan H, Kammeraad JA, Krahn AD, Haugaa KH, Shimizu W, Till J, Horie M, Probst V, Brugada R, Ackerman MJ, Sanatani S, Leenhardt A, Wilde AA. B-PO04-026 NON-SELECTIVE VERSUS Β1-SELECTIVE BETA-BLOCKERS IN THE TREATMENT OF SYMPTOMATIC CHILDREN WITH CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Anjewierden S, Humpherys J, LaPage MJ, Asaki SY, Aziz PF. Detection of Tachyarrhythmias in a Large Cohort of Infants Using Direct-to-Consumer Heart Rate Monitoring. J Pediatr 2021; 232:147-153.e1. [PMID: 33421423 DOI: 10.1016/j.jpeds.2020.12.080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Current estimates of the incidence of tachyarrhythmias in infants rely on clinical documentation and may not reflect the true rate in the general population. Our aim was to describe the epidemiology of tachyarrhythmia detected in a large cohort of infants using direct-to-consumer heart rate (HR) monitoring. STUDY DESIGN Data were collected from Owlet Smart Sock devices used in infants in the US with birthdates between February 2017 and February 2019. We queried the HR data for episodes of tachyarrhythmia (HR of ≥240 bpm for >60 seconds). RESULTS The study included 100 949 infants (50.8% male) monitored for more than 200 million total hours. We identified 5070 episodes of tachyarrhythmia in 2508 infants. The cumulative incidence of tachyarrhythmia in our cohort was 2.5% over the first year of life. The median age at the time of the first episode of tachyarrhythmia was 36 days (range, 1-358 days). Tachyarrhythmia was more common in infants with congenital heart disease (4.0% vs 2.4%; P = .015) and in females (2.7% vs 2.0%; P < .001). The median length of an episode was 7.3 minutes (range, 60 seconds to 5.4 hours) and the probability of an episode lasting longer than 45 minutes was 16.8% (95% CI, 15.4%-18.3%). CONCLUSIONS We found the cumulative incidence of tachyarrhythmia among infants using direct-to-consumer HR monitors to be higher than previously reported in studies relying on clinical diagnosis. This finding may represent previously undetected subclinical disease in young infants, the significance of which remains uncertain. Clinicians should be prepared to discuss these events with parents.
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Affiliation(s)
- Scott Anjewierden
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH
| | - Jeffrey Humpherys
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Martin J LaPage
- Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, MI
| | - S Yukiko Asaki
- Department of Pediatrics, Pediatric Cardiology, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Peter F Aziz
- Division of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, OH.
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Robinson JA, LaPage MJ, Atallah J, Webster G, Miyake CY, Ratnasamy C, Ollberding NJ, Mohan S, Von Bergen NH, Johnsrude CL, Garnreiter JM, Spar DS, Czosek RJ. Outcomes of Pediatric Patients With Defibrillators Following Initial Presentation With Sudden Cardiac Arrest. Circ Arrhythm Electrophysiol 2021; 14:e008517. [PMID: 33401923 DOI: 10.1161/circep.120.008517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICD) are recommended for secondary prevention after sudden cardiac arrest (SCA). The outcomes of pediatric patients receiving an ICD after SCA remain unclear. The objective of this study is to evaluate outcomes, future risk for appropriate shocks, and identify characteristics associated with appropriate ICD therapy during follow-up. METHODS Multicenter retrospective analysis of patients (age ≤21 years) without prior cardiac disease who received an ICD following SCA. Patient/device characteristics, cardiac function, and underlying diagnoses were collected, along with SCA event characteristics. Patient outcomes including complications and device therapies were analyzed. RESULTS In total, 106 patients were included, median age 14.7 years. Twenty (19%) received appropriate shocks and 16 (15%) received inappropriate shocks (median follow-up 3 years). First-degree relative with SCA was associated with appropriate shocks (P<0.05). In total, 40% patients were considered idiopathic. Channelopathy was the most frequent late diagnosis not made at time of presentation. Neither underlying diagnosis nor idiopathic status was associated with increased incidence of appropriate shock. Monomorphic ventricular tachycardia (hazard ratio, 4.6 [1.2-17.3]) and family history of sudden death (hazard ratio, 6.5 [1.4-29.8]) were associated with freedom from appropriate shock in a multivariable model (area under the receiver operating characteristic curve, 0.8). Time from diagnoses to evaluation demonstrated a nonlinear association with freedom from appropriate shock (P=0.015). In patients >2 years from implantation, younger age (P=0.02) and positive exercise test (P=0.04) were associated with appropriate shock. CONCLUSIONS The risk of future device therapy is high in pediatric patients receiving an ICD after SCA, irrelevant of underlying disease. Lack of a definitive diagnosis after SCA was not associated with lower risk of subsequent events and does not obviate the need for secondary prophylaxis.
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MESH Headings
- Adolescent
- Child
- Child, Preschool
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/instrumentation
- Female
- Humans
- Incidence
- Infant
- Infant, Newborn
- Male
- Primary Prevention/methods
- Retrospective Studies
- Risk Assessment/methods
- Risk Factors
- Secondary Prevention/methods
- Survival Rate/trends
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Treatment Outcome
- United States/epidemiology
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Affiliation(s)
- Jeffrey A Robinson
- The Heart Institute (J.A.R., D.S.S., R.J.C.), Cincinnati Children's Hospital Medical Center, OH
- Dr. C.C. & Mabel L. Criss Heart Center, Children's Hospital & Medical Center, University of Nebraska Medical Center, Omaha (J.A.R.)
| | - Martin J LaPage
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor (M.J.L.)
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, Canada (J.A.)
| | - Gregory Webster
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, IL (G.W.)
| | | | - Christopher Ratnasamy
- Congenital Heart Center, Spectrum Health, Helen DeVos Children's Hospital, Grand Rapids, MI (C.R.)
| | | | - Shaun Mohan
- University of Kentucky HealthCare, Lexington (S.M.)
| | - Nicholas H Von Bergen
- American Family Children's Hospital, University of Wisconsin School of Medicine & Public Health, Madison (N.H.V.B.)
| | | | | | - David S Spar
- The Heart Institute (J.A.R., D.S.S., R.J.C.), Cincinnati Children's Hospital Medical Center, OH
- Division of Biostatistics & Epidemiology (D.S.S., R.J.C.), Cincinnati Children's Hospital Medical Center, OH
| | - Richard J Czosek
- The Heart Institute (J.A.R., D.S.S., R.J.C.), Cincinnati Children's Hospital Medical Center, OH
- Division of Biostatistics & Epidemiology (D.S.S., R.J.C.), Cincinnati Children's Hospital Medical Center, OH
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Abstract
This is the case of a 9-year-old girl who initially presents with episodes of syncope and potentially concerning family history. An extensive evaluation is unrevealing, and she appears to have simple benign autonomic dysfunction. Eventually, a rare and life-threatening disease is uncovered, and she receives appropriate treatment. The case report highlights the persistence and suspicion of the managing providers that ultimately allowed the diagnosis to be revealed as well as some of the key features of the underlying disease.
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Affiliation(s)
- Brynn E Dechert
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan; and
| | - Martin J LaPage
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan; and
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26
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Saul JP, LaPage MJ. "A Song of Ice and Fire"-another verse from the world of ablation. J Cardiovasc Electrophysiol 2019; 30:1135-1137. [PMID: 31111600 DOI: 10.1111/jce.13987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/27/2022]
Abstract
The debate between the use of radiofrequency (RF) or cryoenergy for ablation near the atrioventricular (AV) conducting system or small coronaries has been fueled by the relative efficacies and risks of the two technologies, particularly in smaller hearts. The manuscript by Schneider et al adds another chapter to that ongoing debate.
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Affiliation(s)
- J Philip Saul
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Martin J LaPage
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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27
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Dechert BE, Bradley DJ, Serwer GA, Dick M, LaPage MJ. Frequency of CIED remote monitoring: A quality improvement follow‐up study. Pacing Clin Electrophysiol 2019; 42:959-962. [DOI: 10.1111/pace.13707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Brynn E. Dechert
- Department of PediatricsUniversity of Michigan Ann Arbor Michigan
| | - David J. Bradley
- Department of PediatricsUniversity of Michigan Ann Arbor Michigan
| | - Gerald A. Serwer
- Department of PediatricsUniversity of Michigan Ann Arbor Michigan
| | - Macdonald Dick
- Department of PediatricsUniversity of Michigan Ann Arbor Michigan
| | - Martin J. LaPage
- Department of PediatricsUniversity of Michigan Ann Arbor Michigan
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28
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Moak JP, Law IH, LaPage MJ, Fish F, Shatty I, Dubin AM, Patel A, Fishbach P, Cain N, Johnsrude C, Berul CI, Bangoura A, Hanumanthaiah S, McCarter R. Comparison of the Medtronic SelectSecure and conventional pacing leads: Long-term follow-up in a multicenter pediatric and congenital cohort. Pacing Clin Electrophysiol 2019; 42:356-365. [PMID: 30680764 DOI: 10.1111/pace.13614] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/18/2018] [Accepted: 01/04/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION The Medtronic SelectSecure™ (Minneapolis, MN, USA) pacing lead (SS) has theoretical advantages compared to conventional (C) transvenous pacing leads (PLs). The study purpose was to determine whether differences in electrical function and lead survival exist between these PLs in a large data set of pediatric and congenital patients. METHODS A multicenter historical longitudinal cohort study was performed comparing SS and CPL performance over a 72-month follow-up (FU). Ten centers provided data for both SS and CPL, matched for age, implanted pacing chamber, time period of implantation, and presence of heart disease. RESULTS The cohort consisted of 141 subjects in each group. No statistical differences were observed in age, gender, presence of heart disease, or pacing indication. Atrial and ventricular capture thresholds were stable throughout FU and higher in the SS group (atrial: 0.75 ± 0.02 vs 0.5 ± 0.04 V, ventricular: 1.0 ± 0.04 vs 0.75 ± 0.04 V), P < 0.001. Group PL sensing thresholds did not differ. The SS group required greater energy to pace (atrial: 0.57 ± 0.05 vs 0.32 ± 0.02 mJ, ventricular: 0.83 ± 0.05 vs 0.56 ± 0.06 mJ), P = 0.001. Early lead dislodgement and phrenic nerve stimulation were greater in the SS group (P = 0.03). Long-term lead survival was high and similar between the two groups, P = 0.35. CONCLUSIONS Long-term survival of both PL was high with a low fracture rate. The SS had excellent electrical function but did show higher capture thresholds and increased energy to pace; these differences are offset by other advantages of the SS PL.
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Affiliation(s)
- Jeffrey P Moak
- Division of Cardiology, Children's National Health System, Washington, DC
| | - Ian H Law
- Division of Pediatric Cardiology, University of Iowa, Stead Family Children's Hospital, Iowa City, Iowa
| | - Martin J LaPage
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Frank Fish
- Division of Cardiology, Vanderbilt University, Nashville, Tennessee
| | - Ira Shatty
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Anne M Dubin
- Division of Pediatric Cardiology, Stanford University, Palo Alto, California
| | - Akash Patel
- Division of Cardiology, University California, San Francisco, California
| | - Peter Fishbach
- Division of Cardiology, Sibley Heart Center, Atlanta, Georgia
| | - Nicole Cain
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Charles I Berul
- Division of Cardiology, Children's National Health System, Washington, DC
| | - Aminata Bangoura
- Division of Cardiology, Children's National Health System, Washington, DC
| | | | - Robert McCarter
- Division of Biostatistics and Study Methodology, Children's National Health System, Washington, DC
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29
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Escudero CA, Mah DY, Miyake CY, Stephenson EA, LaPage MJ, Kubuš P, Cohen M, Atallah J. Riata lead failure in pediatric and congenital heart disease patients. J Cardiovasc Electrophysiol 2019; 30:320-325. [DOI: 10.1111/jce.13812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Carolina A. Escudero
- Department of Pediatrics, Division of Cardiology, University of Alberta and Stollery Children's HospitalEdmonton Canada
| | - Douglas Y. Mah
- Department of Cardiology, Boston Children's HospitalBoston Massachusetts
| | - Christina Y. Miyake
- Department of Pediatrics and Molecular Physiology & Biophysics, Baylor College of MedicineHouston Texas
| | | | - Martin J. LaPage
- Division of Pediatric Cardiology University of MichiganAnn Arbor Michigan
| | - Peter Kubuš
- Children's Heart Centre, Motol University HospitalPrague Czech Republic
| | - Mitchell Cohen
- Division of Cardiology, Phoenix Children's HospitalPhoenix Arizona
| | - Joseph Atallah
- Department of Pediatrics, Division of Cardiology, University of Alberta and Stollery Children's HospitalEdmonton Canada
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30
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Roston TM, Yuchi Z, Kannankeril PJ, Hathaway J, Vinocur JM, Etheridge SP, Potts JE, Maginot KR, Salerno JC, Cohen MI, Hamilton RM, Pflaumer A, Mohammed S, Kimlicka L, Kanter RJ, LaPage MJ, Collins KK, Gebauer RA, Temple JD, Batra AS, Erickson C, Miszczak-Knecht M, Kubuš P, Bar-Cohen Y, Kantoch M, Thomas VC, Hessling G, Anderson C, Young ML, Choi SHJ, Cabrera Ortega M, Lau YR, Johnsrude CL, Fournier A, Van Petegem F, Sanatani S. The clinical and genetic spectrum of catecholaminergic polymorphic ventricular tachycardia: findings from an international multicentre registry. Europace 2018; 20:541-547. [PMID: 28158428 DOI: 10.1093/europace/euw389] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/03/2016] [Indexed: 11/12/2022] Open
Abstract
Aims Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an ion channelopathy characterized by ventricular arrhythmia during exertion or stress. Mutations in RYR2-coded Ryanodine Receptor-2 (RyR2) and CASQ2-coded Calsequestrin-2 (CASQ2) genes underlie CPVT1 and CPVT2, respectively. However, prognostic markers are scarce. We sought to better characterize the phenotypic and genotypic spectrum of CPVT, and utilize molecular modelling to help account for clinical phenotypes. Methods and results This is a Pediatric and Congenital Electrophysiology Society multicentre, retrospective cohort study of CPVT patients diagnosed at <19 years of age and their first-degree relatives. Genetic testing was undertaken in 194 of 236 subjects (82%) during 3.5 (1.4-5.3) years of follow-up. The majority (60%) had RyR2-associated CPVT1. Variant locations were predicted based on a 3D structural model of RyR2. Specific residues appear to have key structural importance, supported by an association between cardiac arrest and mutations in the intersubunit interface of the N-terminus, and the S4-S5 linker and helices S5 and S6 of the RyR2 C-terminus. In approximately one quarter of symptomatic patients, cardiac events were precipitated by only normal wakeful activities. Conclusion This large, multicentre study identifies contemporary challenges related to the diagnosis and prognostication of CPVT patients. Structural modelling of RyR2 can improve our understanding severe CPVT phenotypes. Wakeful rest, rather than exertion, often precipitated life-threatening cardiac events.
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Affiliation(s)
- Thomas M Roston
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Zhiguang Yuchi
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Prince J Kannankeril
- Department of Pediatrics and the Vanderbilt Center for Arrhythmia Research and Therapeutics (VanCART) Vanderbilt University Medical Center and the Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 5230, Nashville, TN 37232-9119, USA
| | - Julie Hathaway
- BC Inherited Arrhythmia Program, 211-1033 Davie St, Vancouver, BC V6E 1M7, Canada
| | - Jeffrey M Vinocur
- Department of Pediatrics, University of Rochester, 601 Elmwood Ave, Box 631, Rochester, NY 14642, USA
| | - Susan P Etheridge
- Department of Pediatrics, University of Utah, 81 N Mario Capecchi Drive Salt Lake City, UT 84113, USA
| | - James E Potts
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Kathleen R Maginot
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 1675 Highland Ave, Madison, WI 53792, USA
| | - Jack C Salerno
- Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Mitchell I Cohen
- Division of Cardiology Phoenix Children's Hospital, 1919 E. Thomas Road, 2nd Floor, Heart Center, Phoenix, AZ 85016, USA
| | - Robert M Hamilton
- Department of Pediatrics, University of Toronto, Hospital for Sick Children, 555 University Avenue Toronto, Ontario M5G 1X8, Canada
| | - Andreas Pflaumer
- Royal Children's Hospital MCRI and University of Melbourne, 50 Flemington Road Parkville, Melbourne 3052, Australia
| | - Saira Mohammed
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Lynn Kimlicka
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Ronald J Kanter
- Nicklaus Children's Hospital, 3100 SW 62 Ave, Cardiology ACB - 2nd Floor Miami, FL 33155, USA
| | - Martin J LaPage
- Department of Pediatrics, University of Michigan, 1500 E Medical Center Drive, #6303, Ann Arbor, MI 48109, USA
| | - Kathryn K Collins
- Department of Pediatrics, University of Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA
| | - Roman A Gebauer
- Department of Pediatric Cardiology, Heart Center, University of Leipzig, Strümpellstrasse 39, Leipzig, Germany
| | - Joel D Temple
- Department of Pediatrics, A. I. DuPont Hospital For Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | - Anjan S Batra
- Department of Pediatrics, University of California at Irvine Medical Center, 1140 W. La Veta Ave., Suite 750, Orange, CA 92868, USA
| | - Christopher Erickson
- Division of Cardiology, UNMC/CUMC/Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA
| | - Maria Miszczak-Knecht
- Department of Cardiology, Children's Memorial Health Institute, Dzieci Polskich 20, 04 -730 Warsaw, Poland
| | - Peter Kubuš
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Vúvalu 84, 15006, Prague, Czech Republic
| | - Yaniv Bar-Cohen
- Department of Pediatrics, Children's Hospital Los Angeles, 4650 Sunset Blvd #34, Los Angeles, CA 90027, USA
| | - Michal Kantoch
- Stollery Children's Hospital, University of Alberta, Clinical Sciences Building, 8440 112 St NW, Edmonton, AB T6G 2B7, Canada
| | - Vincent C Thomas
- Division of Cardiology, UNMC/CUMC/Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA
| | - Gabriele Hessling
- Department of Electrophysiology, German Heart Center Munich, Technical University, Lazarettstr. 3680636 Munich, Germany
| | - Chris Anderson
- Providence Sacred Heart Children's Hospital, 101 W. 8th Ave. Suite 4300E, Spokane, WA 99204, USA
| | - Ming-Lon Young
- Department of Pediatrics, Joe DiMaggio Children's Hospital, 1150 North 35th Avenue Suite 575, Hollywood, FL 33021, USA
| | - Sally H J Choi
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, 100 y perla, Boyeros. 10800, Havana, Cuba
| | - Yung R Lau
- Division of Pediatric Cardiology, University of Alabama at Birmingham, 1700 6th Ave S, Birmingham, AL 35233, USA
| | - Christopher L Johnsrude
- Department of Pediatrics, University of Louisville, 601 S Floyd St #602, Louisville, KY 40208, USA
| | - Anne Fournier
- Département de Pédiatrie, CHU Ste Justine, 3175, chemin Côte Sainte-Catherine, Montréal, QC H3T 1C5 Canada
| | - Filip Van Petegem
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
| | - Shubhayan Sanatani
- Departments of Pediatrics/Medicine/Biochemistry & Molecular Biology, University of British Columbia, 4480 Oak Street, Room 1F3, Vancouver, BC, V6H 3V4, Canada
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Roston TM, Haji-Ghassemi O, LaPage MJ, Batra AS, Bar-Cohen Y, Anderson C, Lau YR, Maginot K, Gebauer RA, Etheridge SP, Potts JE, Van Petegem F, Sanatani S. Catecholaminergic polymorphic ventricular tachycardia patients with multiple genetic variants in the PACES CPVT Registry. PLoS One 2018; 13:e0205925. [PMID: 30403697 PMCID: PMC6221297 DOI: 10.1371/journal.pone.0205925] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/03/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Catecholaminergic polymorphic ventricular tachycardia (CPVT) is often a life-threatening arrhythmia disorder with variable penetrance and expressivity. Little is known about the incidence or outcomes of CPVT patients with ≥2 variants. METHODS The phenotypes, genotypes and outcomes of patients in the Pediatric and Congenital Electrophysiology Society CPVT Registry with ≥2 variants in genes linked to CPVT were ascertained. The American College of Medical Genetics & Genomics (ACMG) criteria and structural mapping were used to predict the pathogenicity of variants (3D model of pig RyR2 in open-state). RESULTS Among 237 CPVT subjects, 193 (81%) had genetic testing. Fifteen patients (8%) with a median age of 9 years (IQR 5-12) had ≥2 variants. Sudden cardiac arrest occurred in 11 children (73%), although none died during a median follow-up of 4.3 years (IQR 2.5-6.1). Thirteen patients (80%) had at least two RYR2 variants, while the remaining two patients had RYR2 variants plus variants in other CPVT-linked genes. Among all variants identified, re-classification of the commercial laboratory interpretation using ACMG criteria led to the upgrade from variant of unknown significance (VUS) to pathogenic/likely pathogenic (P/LP) for 5 variants, and downgrade from P/LP to VUS for 6 variants. For RYR2 variants, 3D mapping using the RyR2 model suggested that 2 VUS by ACMG criteria were P/LP, while 2 variants were downgraded to likely benign. CONCLUSIONS This severely affected cohort demonstrates that a minority of CPVT cases are related to ≥2 variants, which may have implications on family-based genetic counselling. While multi-variant CPVT patients were at high-risk for sudden cardiac arrest, there are insufficient data to conclude that this genetic phenomenon has prognostic implications at present. Further research is needed to determine the significance and generalizability of this observation. This study also shows that a rigorous approach to variant re-classification using the ACMG criteria and 3D mapping is important in reaching an accurate diagnosis, especially in the multi-variant population.
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Affiliation(s)
- Thomas M. Roston
- Departments of Medicine, Pediatrics, and Biochemistry & Molecular Biology, University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Omid Haji-Ghassemi
- Departments of Medicine, Pediatrics, and Biochemistry & Molecular Biology, University of British Columbia, Vancouver, BC, Canada
| | - Martin J. LaPage
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States of America
| | - Anjan S. Batra
- Department of Pediatrics, University of California at Irvine Medical Center, Irvine, CA, United States of America
| | - Yaniv Bar-Cohen
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, United States of America
| | - Chris Anderson
- Providence Sacred Heart Children’s Hospital, Spokane, WA, United States of America
| | - Yung R. Lau
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AB, United States of America
| | - Kathleen Maginot
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, WI, United States of America
| | - Roman A. Gebauer
- Department of Pediatric Cardiology, University of Leipzig, Leipzig, Germany
| | - Susan P. Etheridge
- Department of Pediatrics, University of Utah, and Primary Children’s Hospital, Salt Lake City, UT, United States of America
| | - James E. Potts
- Departments of Medicine, Pediatrics, and Biochemistry & Molecular Biology, University of British Columbia, Vancouver, BC, Canada
| | - Filip Van Petegem
- Departments of Medicine, Pediatrics, and Biochemistry & Molecular Biology, University of British Columbia, Vancouver, BC, Canada
| | - Shubhayan Sanatani
- Departments of Medicine, Pediatrics, and Biochemistry & Molecular Biology, University of British Columbia, Vancouver, BC, Canada
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32
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Gist KM, Marino BS, Palmer C, Fish FA, Moore JP, Czosek RJ, Cassedy A, LaPage MJ, Law IH, Garnreiter J, Cannon BC, Collins KK. Cosmetic outcomes and quality of life in children with cardiac implantable electronic devices. Pacing Clin Electrophysiol 2018; 42:46-57. [PMID: 30334588 DOI: 10.1111/pace.13522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 09/05/2018] [Accepted: 09/12/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Axillary implant location is an alternative implant location in patients for cardiac implantable electronic devices (CIEDs) for the purposes of improved cosmetic outcome. The impact from the patient's perspective is unknown. The purpose of this study was to compare scar perception scores and quality of life (QOL) in pediatric patients with axillary CIED implant location versus the standard infraclavicular approach. METHODS This is a multicenter prospective study conducted at eight pediatric centers and it includes patients aged from 8 to 18 years with a CIED. Patients with prior sternotomy were excluded. Scar perception and QOL outcomes were compared between the infraclavicular and axillary implant locations. RESULTS A total of 141 patients (83 implantable cardioverter defibrillator [ICD]/58 pacemakers) were included, 55 with an axillary device and 86 with an infraclavicular device. Patients with an ICD in the axillary position had better perception of scar appearance and consciousness. Patients in the axillary group reported, on average, a total Pediatric QOL Inventory score that was 6 (1, 11) units higher than the infraclavicular group, after adjusting for sex and race (P = 0.02). CONCLUSIONS QOL is significantly improved in axillary in comparison to the infraclavicular CIED position, regardless of device type. Scar perception is improved in patients with ICD in the axillary position.
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Affiliation(s)
- Katja M Gist
- Heart Institute, Children's Hospital Colorado, University of Colorado Denver: Anschutz Medical Campus, Aurora, CO, USA
| | - Bradley S Marino
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Claire Palmer
- Children's Hospital Colorado Child Health Research Biostatistical Core, University of Colorado Denver: Anschutz Medical Campus, Aurora, CO, USA
| | - Frank A Fish
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy P Moore
- UCLA Medical Center, University of California at Los Angeles, Los Angeles, CA, USA
| | - Richard J Czosek
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amy Cassedy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Martin J LaPage
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ian H Law
- University of Iowa Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
| | - Jason Garnreiter
- Cardinal Glennon Children's Hospital, St. Louis University School of Medicine, St. Louis, MO, USA
| | | | - Kathryn K Collins
- Heart Institute, Children's Hospital Colorado, University of Colorado Denver: Anschutz Medical Campus, Aurora, CO, USA
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Saul JP, LaPage MJ. Delirium Cordis: An Arrhythmia at the Intersection of Pediatric and Adult Electrophysiology. JACC Clin Electrophysiol 2018; 4:649-651. [PMID: 29798793 DOI: 10.1016/j.jacep.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 10/16/2022]
Affiliation(s)
- J Philip Saul
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, West Virginia.
| | - Martin J LaPage
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor, Michigan
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Goldstein SA, LaPage MJ, Dechert BE, Serwer GA, Yu S, Lowery RE, Bradley DJ. Decreased inappropriate shocks with new generation ICDs in children and patients with congenital heart disease. CONGENIT HEART DIS 2018; 13:413-418. [PMID: 29372620 DOI: 10.1111/chd.12585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/17/2017] [Accepted: 12/22/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Inappropriate implantable cardioverter defibrillator (ICD) shocks in children and patients with congenital heart disease (CHD) remain a major complication of device therapy, occurring in as many as 50% of children with ICDs. New generation devices include algorithms designed to minimize inappropriate shocks. This study aimed to evaluate the effect of new generation ICDs on the incidence of inappropriate shocks in the pediatric and CHD population. DESIGN Retrospective study of patients with CHD or under age 25 receiving ICDs between 2000 and 2015. New generation ICDs were defined as those with Medtronic "SmartShock" algorithms. RESULTS Two hundred eight devices were implanted in 146 patients. Rates of inappropriate shocks were similar between diagnoses (P = .71). The rate of inappropriate shock was 15% over median 5.8 years follow-up. In the 36 patients (25%) with new generation ICDs, the rate of inappropriate shock was 6.3% over 4 years. Comparing old to new generation ICDs, freedom from first inappropriate shock was 90.6% versus 97.1% at 1 year and 80.4% versus 97.1% at 3 years (P = .01). Lead fracture was associated with having inappropriate shock (hazard ratio 8.5, P < .0001), and there was no significant difference between the device groups when lead fractures were excluded. Clinical actions were taken in 69% of patients after initial inappropriate shock (such as medication or program change, system revision, or explant). When an action was taken, subsequent inappropriate shock was reduced (5.3% vs 49.2% at 1 year; P = .002). CONCLUSIONS Pediatric and CHD patients are experiencing reduced inappropriate shocks with new generation ICD systems, though reduced lead fracture may account for this improvement. Clinical interventions after inappropriate shock favorably impact the subsequent rate of shocks once an inappropriate shock occurs.
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Affiliation(s)
| | - Martin J LaPage
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Brynn E Dechert
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Gerald A Serwer
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Ray E Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - David J Bradley
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
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Abstract
Although catheter ablation is a standard treatment for pediatric arrhythmias, there are no consensus guidelines for follow-up care. This study describes the variation in post-ablation practices identified through a survey of the pediatric and congenital electrophysiology society (PACES). Pediatric and congenital electrophysiology society members were invited to participate in an online survey of post-ablation practices in September 2014. Survey questions targeted routine post-ablation practices for three common arrhythmia substrates: atrioventricular nodal reentry tachycardia, concealed accessory pathways (AP), and manifest APs. Significant practice variation was defined as <90% concordance among respondents. There were 70 respondents from 67 centers, 29 (41%) in practice for <10 years. Uniform practices included aspirin after left side ablation by 65 (93%), immediate post-procedure ECG by 63 (90%), and performance of outpatient follow-up in 69 (99%) including ECG in 97-100% depending on substrate. The majority, 57 (81%), have standardized follow-up independent of substrate. Post-procedural observation is highly variable, with 25 (36%) discharging patients on the day of ablation, 22 (33%) observing patients in hospital overnight, and 21 (30%) basing hospitalization on pre-defined criteria. Immediate post-procedure echo is performed after all ablations in only 16 (23%). Discharge from outpatient care occurs at a median time of 12 months for each arrhythmia substrate. Common post-ablation practices are evident among pediatric electrophysiologists. However, they report significant variation in post-procedure monitoring practices and testing. The rationale for these variances, and their impact on costs and outcomes, should be defined.
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Affiliation(s)
- Brynn E Dechert
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, C.S. Mott Children's Hospital, University of Michigan, 11th Floor Pediatric Cardiology, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA.
| | - Macdonald Dick
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, C.S. Mott Children's Hospital, University of Michigan, 11th Floor Pediatric Cardiology, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - David J Bradley
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, C.S. Mott Children's Hospital, University of Michigan, 11th Floor Pediatric Cardiology, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
| | - Martin J LaPage
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, C.S. Mott Children's Hospital, University of Michigan, 11th Floor Pediatric Cardiology, 1540 E. Hospital Dr, Ann Arbor, MI, 48109, USA
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von Alvensleben JC, LaPage MJ, Caruthers R, Bradley DJ. Nadolol for Treatment of Supraventricular Tachycardia in Infants and Young Children. Pediatr Cardiol 2017; 38:525-530. [PMID: 27995288 DOI: 10.1007/s00246-016-1544-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/01/2016] [Indexed: 10/20/2022]
Abstract
Supraventricular tachycardia (SVT) is a common infant arrhythmia, for which beta-blockers are frequently chosen as therapy. Propranolol is a common choice though it is dosed every 6-8 h. We reviewed the clinical results of treating infant SVT with an extemporaneous preparation of nadolol. Retrospective cohort study of patients under 2 years old receiving nadolol for SVT at a single center. Patients were ascertained by patient and pharmacy databases. Twenty-eight infants received nadolol, of whom 25 had regular narrow complex tachycardia, 2 atrial flutter, and 1 focal atrial tachycardia. Patient age at initiation was a median 54 days (range 10-720). The final dose was 1 mg/kg/day in 22/28 patients (range 0.5-2). Once-daily dosing was used in 20 patients (71.4%); dosing was BID in 7, TID in 1. Among regular narrow complex tachycardia patients, 18/25 received nadolol monotherapy and 7 required additional agents; flecainide in 6, digoxin in 1. The median age of tachyarrhythmia onset was 18 days (range 1-180) with a median age of nadolol initiation of 30 days (range 11-390). Of the 20 regular narrow complex tachycardia patients initiated on nadolol monotherapy, 85% had no recurrences as of 1-year follow-up. Side effects were suspected in 3 of 28 (10.7%), including wheezing (n = 1, 3.5%), irritability and diarrhea (n = 1, 3.5%), and bradycardia (n = 1, 3.5%). Oral nadolol suspension was a successful treatment for SVT in 85% of patients with minimal adverse effects. Single daily dosing was used in the majority of patients.
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Oster ME, Chen S, Dagincourt N, Bar-Cohen Y, Brothers M, Cain N, Colan SD, Czosek RJ, Decker JA, Gamboa DG, Idriss SF, Kirsh JA, LaPage MJ, Ohye RG, Radojewski E, Shah M, Silver ES, Singh AK, Temple JD, Triedman J, Kaltman JR. Development and impact of arrhythmias after the Norwood procedure: A report from the Pediatric Heart Network. J Thorac Cardiovasc Surg 2016; 153:638-645.e2. [PMID: 27939495 DOI: 10.1016/j.jtcvs.2016.10.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The study objective was to determine the predictors of new-onset arrhythmia among infants with single-ventricle anomalies during the post-Norwood hospitalization and the association of those arrhythmias with postoperative outcomes (ventilator time and length of stay) and interstage mortality. METHODS After excluding patients with preoperative arrhythmias, we used data from the Pediatric Heart Network Single Ventricle Reconstruction Trial to identify risk factors for tachyarrhythmias (atrial fibrillation, atrial flutter, supraventricular tachycardia, junctional ectopic tachycardia, and ventricular tachycardia) and atrioventricular block (second or third degree) among 544 eligible patients. We then determined the association of arrhythmia with outcomes during the post-Norwood hospitalization and interstage period, adjusting for identified risk factors and previously published factors. RESULTS Tachyarrhythmias were noted in 20% of subjects, and atrioventricular block was noted in 4% of subjects. Potentially significant risk factors for tachyarrhythmia included the presence of modified Blalock-Taussig shunt (P = .08) and age at Norwood (P = .07, with risk decreasing each day at age 8-20 days); the only significant risk factor for atrioventricular block was undergoing a concomitant procedure at the time of the Norwood (P = .001), with the greatest risk being in those undergoing a tricuspid valve procedure. Both tachyarrhythmias and atrioventricular block were associated with longer ventilation time and length of stay (P < .001 for all analyses). Tachyarrhythmias were not associated with interstage mortality; atrioventricular block was associated with mortality among those without a pacemaker in the unadjusted analysis (hazard ratio, 2.3; P = .02), but not after adding covariates. CONCLUSIONS Tachyarrhythmias are common after the Norwood procedure, but atrioventricular block may portend a greater risk for interstage mortality.
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Affiliation(s)
- Matthew E Oster
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga.
| | - Shan Chen
- New England Research Institutes, Watertown, Mass
| | | | - Yaniv Bar-Cohen
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Matthew Brothers
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Nicole Cain
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Richard J Czosek
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jamie A Decker
- Department of Pediatrics, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - David G Gamboa
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Salim F Idriss
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Joel A Kirsh
- Department of Paediatrics & Labatt Family Heart Centre, Hospital for Sick Children & University of Toronto, Toronto, Ontario
| | - Martin J LaPage
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Mich
| | - Richard G Ohye
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Mich
| | - Elizabeth Radojewski
- Department of Paediatrics & Labatt Family Heart Centre, Hospital for Sick Children & University of Toronto, Toronto, Ontario
| | - Maully Shah
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Eric S Silver
- Division of Pediatrics, Columbia University Medical Center, New York, NY
| | - Anoop K Singh
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Joel D Temple
- Division of Cardiology, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del
| | - John Triedman
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, The National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
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LaPage MJ. Editorial Commentary: The evolution of autonomy in sports. Trends Cardiovasc Med 2016; 26:698-699. [PMID: 27396554 DOI: 10.1016/j.tcm.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 05/15/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Martin J LaPage
- Division of Pediatric Cardiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI.
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LaPage MJ, Dechert BE, Hirsch-Romano JC, Bradley DJ. Abdominal cardiac devices in pediatric and congenital heart disease: a practice model transition. World J Pediatr Congenit Heart Surg 2015; 6:205-8. [PMID: 25870338 DOI: 10.1177/2150135115569741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Abdominal cardiac implantable electronic device maintenance procedures are traditionally performed by cardiac surgeons. The University of Michigan Congenital Heart Center transitioned from this practice model to one in which electrophysiologists perform the majority of these procedures. This study presents the outcomes of these procedures during this transition. METHODS Retrospective cohort study of all patients undergoing abdominal device maintenance procedure, inclusive of generator change, removal, or placement with preexisting leads from January 2005 to July 2013. Procedures involving epicardial lead placement were excluded. The primary outcome was major complications defined as any intraoperative complication, the requirement of an additional operative intervention, or hospitalization for device-related infection. RESULTS There were 113 procedures on 93 patients. Of these, 84 (74%) procedures were on patients with congenital heart disease. Cardiac surgeons performed 54 (48%) procedures and electrophysiologists performed 59 (52%). Mean age was 16 ± 11 years. The groups were similar regarding age and proportion with congenital heart disease (CHD). Major complications occurred in 3 (5.5%) cardiac surgeon procedures and 2 (3.4%) electrophysiologist procedures. There is no difference in the risk of major complications between groups (P = .59). CONCLUSION This 8.5-year period encompassed a practice model transition from cardiac surgeon-performed abdominal device procedures to primarily electrophysiologist-performed abdominal device procedures. There was no difference in the risk of complications between services. This suggests that electrophysiologist-performed abdominal cardiac device maintenance procedures are a viable practice model, provided there is support and collaboration from the cardiac surgery service.
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Affiliation(s)
- Martin J LaPage
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Brynn E Dechert
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer C Hirsch-Romano
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David J Bradley
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
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40
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Roston TM, Vinocur JM, Maginot KR, Mohammed S, Salerno JC, Etheridge SP, Cohen M, Hamilton RM, Pflaumer A, Kanter RJ, Potts JE, LaPage MJ, Collins KK, Gebauer RA, Temple JD, Batra AS, Erickson C, Miszczak-Knecht M, Kubuš P, Bar-Cohen Y, Kantoch M, Thomas VC, Hessling G, Anderson C, Young ML, Ortega MC, Lau YR, Johnsrude CL, Fournier A, Kannankeril PJ, Sanatani S. Catecholaminergic polymorphic ventricular tachycardia in children: analysis of therapeutic strategies and outcomes from an international multicenter registry. Circ Arrhythm Electrophysiol 2015; 8:633-42. [PMID: 25713214 PMCID: PMC4472494 DOI: 10.1161/circep.114.002217] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 02/11/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Catecholaminergic polymorphic ventricular tachycardia is an uncommon, potentially lethal, ion channelopathy. Standard therapies have high failure rates and little is known about treatment in children. Newer options such as flecainide and left cardiac sympathetic denervation are not well validated. We sought to define treatment outcomes in children with catecholaminergic polymorphic ventricular tachycardia. METHODS AND RESULTS This is a Pediatric and Congenital Electrophysiology Society multicenter, retrospective cohort study of catecholaminergic polymorphic ventricular tachycardia patients diagnosed before 19 years of age. The cohort included 226 patients, including 170 probands and 56 relatives. Symptomatic presentation was reported in 176 (78%). Symptom onset occurred at 10.8 (interquartile range, 6.8-13.2) years with a delay to diagnosis of 0.5 (0-2.6) years. Syncope (P<0.001), cardiac arrest (P<0.001), and treatment failure (P=0.008) occurred more often in probands. β-Blockers were prescribed in 205 of 211 patients (97%) on medication, and 25% experienced at least 1 treatment failure event. Implantable cardioverter defibrillators were placed in 121 (54%) and was associated with electrical storm in 22 (18%). Flecainide was used in 24% and left cardiac sympathetic denervation in 8%. Six deaths (3%) occurred during a cumulative follow-up of 788 patient-years. CONCLUSIONS This study demonstrates a malignant phenotype and lengthy delay to diagnosis in catecholaminergic polymorphic ventricular tachycardia. Probands were typically severely affected. β-Blockers were almost universally initiated; however, treatment failure, noncompliance and subtherapeutic dosing were often reported. Implantable cardioverter defibrillators were common despite numerous device-related complications. Treatment failure was rare in the quarter of patients on flecainide. Left cardiac sympathetic denervation was not uncommon although the indication was variable.
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MESH Headings
- Adolescent
- Age Factors
- Anti-Arrhythmia Agents/adverse effects
- Anti-Arrhythmia Agents/therapeutic use
- Child
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Electric Countershock/adverse effects
- Electric Countershock/instrumentation
- Electric Countershock/mortality
- Female
- Humans
- Male
- Patient Selection
- Phenotype
- Registries
- Retrospective Studies
- Risk Factors
- Severity of Illness Index
- Sympathectomy/adverse effects
- Sympathectomy/mortality
- Tachycardia, Ventricular/complications
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/mortality
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/therapy
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Thomas M. Roston
- Department of Pediatrics, Divisions of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Saira Mohammed
- Department of Pediatrics, Divisions of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Jack C. Salerno
- Department of Pediatrics, University of Washington, Seattle, WA
| | | | | | | | - Andreas Pflaumer
- Royal Children’s Hospital MCRI & University of Melbourne, Australia
| | | | - James E. Potts
- Department of Pediatrics, Divisions of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Anjan S. Batra
- University of California at Irvine Medical Center, Orange, CA
| | | | | | - Peter Kubuš
- Children’s Heart Center, Prague, Czech Republic
| | | | - Michal Kantoch
- Stollery Children’s Hospital, University of Alberta, Edmonton, AB, Canada
| | | | | | - Chris Anderson
- Providence Sacred Heart Children’s Hospital, Spokane, WA
| | | | | | - Yung R. Lau
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Shubhayan Sanatani
- Department of Pediatrics, Divisions of Cardiology, University of British Columbia, Vancouver, BC, Canada
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41
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von Alvensleben JC, Dick M, Bradley DJ, LaPage MJ. Transseptal access in pediatric and congenital electrophysiology procedures: defining risk. J Interv Card Electrophysiol 2014; 41:273-7. [PMID: 25416565 DOI: 10.1007/s10840-014-9946-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/26/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Transseptal puncture (TSP) is commonly used to access the left heart for catheter ablation procedures. The specific complication risk of this procedure has not been determined. This study assesses the risk of TSP using a single standard technique during electrophysiology study (EPS) in pediatrics and congenital heart disease (CHD). METHODS Retrospective cohort study of patients undergoing TSP during EPS at the University of Michigan Congenital Heart Center between 1999 and 2011. RESULTS There were 373 left heart ablation procedures during the study period. Excluded were six adults without CHD, five procedures using an alternative imaging modality, five procedures using retrograde aortic access, one transhepatic access, and one where TSP was performed during a prior procedure. Included were 321 pediatric (≤18 years old without CHD) TSP procedures (median age 13 years) and 34 TSP procedures in patients with CHD (median age 28 years). There was one complication directly attributable to TSP: needle perforation of the left atrium without development of effusion in the pediatric group. Post-procedure echocardiograms were performed in 351 (99 %) cases, showing only trivial effusions in seven (1.9 %). CONCLUSIONS This single center experience over 12 years shows the risk of TSP in pediatric and CHD patients to be low, with a 0.3 % (95 % confidence interval (CI) 0, 0.9 %) risk for complications directly related to TSP using only single plane fluoroscopy for visualization.
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42
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Affiliation(s)
- Anna N. Kamp
- Cardiology, The Heart Center; Nationwide Children's Hospital, Ohio State University; Columbus Ohio USA
| | - Martin J. LaPage
- Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Gerald A. Serwer
- Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Macdonald Dick
- Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - David J. Bradley
- Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
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43
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Dechert BE, Serwer GA, Bradley DJ, Dick M, LaPage MJ. Cardiac implantable electronic device remote monitoring surveillance in pediatric and congenital heart disease: Utility relative to frequency. Heart Rhythm 2014; 12:117-22. [PMID: 25304681 DOI: 10.1016/j.hrthm.2014.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heart Rhythm Society expert consensus provides recommendations for surveillance monitoring of cardiac implantable electronic devices (CIEDs), but limited data are available for the pediatric and congenital heart disease population. OBJECTIVE The purpose of this study was to determine the rate of actionable events during CIED surveillance in this population, assess the utility of routine CIED remote monitoring, and assess the potential benefit from more frequent monitoring. METHODS This was a retrospective cohort study of all CIED patients followed at a pediatric and congenital heart center and enrolled in the Medtronic Carelink system with either (1) a chronic (implanted for >6 months) CIED followed between July 1, 2010, and July 1, 2012, on a bimonthly schedule; or (2) a new CIED (implanted <6 months) between July 1, 2008, and July 1, 2012, followed on a monthly schedule. RESULTS Aggregate mean age was 20 ± 13.7 years. There were 608 interrogations on newly implanted CIEDs with an actionable event rate of 11 per 100 patient-years. There were 2614 interrogations of chronic CIEDs with an actionable event rate of 22 per 100 patient-years. The odds of an actionable event on an asymptomatic remote monitoring transmission was lower than if symptomatic (odds ratio 0.04, 95% confidence interval 0.03-0.07). Tachyarrhythmia was the most common event. Predictors of actionable events were identified. CONCLUSION In this population of pediatric and congenital heart disease patients, the rate of actionable events was low, especially on asymptomatic interrogations. Most actionable events were due to tachyarrhythmia. A more frequent than every 90-day monitoring schedule does not appear to be of significant benefit.
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MESH Headings
- Adolescent
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Child
- Child, Preschool
- Defibrillators, Implantable
- Female
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/therapy
- Humans
- Male
- Monitoring, Physiologic/instrumentation
- Pacemaker, Artificial
- Remote Sensing Technology
- Retrospective Studies
- Time Factors
- Young Adult
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Affiliation(s)
- Brynn E Dechert
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan.
| | - Gerald A Serwer
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - David J Bradley
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Macdonald Dick
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Martin J LaPage
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan
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Kean AC, LaPage MJ, Yu S, Dick M, Bradley DJ. Patient and Procedural Correlates of Fluoroscopy Use During Catheter Ablation in the Pediatric and Congenital Electrophysiology Lab. CONGENIT HEART DIS 2014; 10:281-7. [DOI: 10.1111/chd.12213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Adam C. Kean
- Pediatrix Cardiology Associates of New Mexico; Albuquerque NM USA
| | - Martin J. LaPage
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Macdonald Dick
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - David J. Bradley
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
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Dechert B, Bradley DJ, Serwer GA, Dick M, LaPage MJ. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR OUTCOMES IN PEDIATRIC AND CONGENITAL HEART DISEASE: IT'S COMPLICATED. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60575-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dechert B, Serwer GA, Bradley DJ, Dick M, LaPage MJ. IMPLANTABLE CARDIOVERTER DEFIBRILLATORS IN PRIMARY ARRHYTHMIA SYNDROMES: OUTCOME RELATIVE TO MEDICATION. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60455-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Atallah J, Erickson CC, Cecchin F, Dubin AM, Law IH, Cohen MI, LaPage MJ, Cannon BC, Chun TU, Freedenberg V, Gierdalski M, Berul CI. Multi-Institutional Study of Implantable Defibrillator Lead Performance in Children and Young Adults. Circulation 2013; 127:2393-402. [DOI: 10.1161/circulationaha.112.001120] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Implantable cardioverter-defibrillator (ICD) therapy in children and congenital heart disease patients is hampered by poor long-term lead survival. Lead extraction is technically difficult and carries substantial morbidity. We sought to determine the outcomes of ICD leads in pediatric and congenital heart disease patients.
Methods and Results—
The Pediatric Lead Extractability and Survival Evaluation (PLEASE) is a 24-center international registry. Pediatric and congenital heart disease patients with ICD lead implantations from 2005 to 2010 were eligible. Study subjects comprised 878 ICD patients (44% congenital heart disease). Mean±SD age at implantation was 18.6±9.8 years. Of the 965 total leads, 54% were thin (≤7F), of which 57% were Fidelis, and 23% were coated with expanded polytetrafluoroethylene. There were 139 ICD lead failures (14%) in 132 patients (15%) at a mean lead age of 2.0±1.4 years, causing shocks in 53 patients (40%). Independent predictors of lead failure included younger implantation age and Fidelis leads. Actuarial analysis showed an incremental risk of lead failure with younger age at implantation: <8 years compared with >18 years (
P
=0.015). The actuarial yearly failure rate was 2.3% for non-Fidelis and 9.1% for Fidelis leads. Extraction was performed on 143 leads (80% thin, 7% expanded polytetrafluoroethylene coated), with lead age as the only independent predictor for advanced extraction techniques. There were 6 major extraction complications (4%) but no procedural mortality.
Conclusions—
This study demonstrates that ICD leads in children and congenital heart disease patients have an age-related suboptimal performance, further compounded by a high failure rate of Fidelis leads. Advanced extraction techniques were common and correlated with older lead age.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00335036.
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Affiliation(s)
- Joseph Atallah
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Christopher C. Erickson
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Frank Cecchin
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Anne M. Dubin
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Ian H. Law
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Mitchell I. Cohen
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Martin J. LaPage
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Bryan C. Cannon
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Terrence U.H. Chun
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Vicki Freedenberg
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Marcin Gierdalski
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
| | - Charles I. Berul
- From the Stollery Children’s Hospital, Edmonton, AB, Canada (J.A.); UNMC/Children’s Hospital and Medical Center, Omaha, NE (C.E.C.); Children’s Hospital Boston, Boston, MA (F.C.); Packard Children’s Hospital at Stanford, Palo Alto, CA (A.M.D.); University of Iowa Children’s Hospital, Iowa City (I.H.L.); Phoenix Children’s Hospital, Phoenix, AZ (M.I.C.); University of Michigan, Ann Arbor (M.J.L.); Mayo Clinic, Rochester, MN (B.C.C.); Seattle Children’s Hospital, Seattle, WA (T.U.H.C.); and Children’s
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Aziz PF, Serwer GA, Bradley DJ, LaPage MJ, Hirsch JC, Bove EL, Ohye RG, Dick M. Pattern of recovery for transient complete heart block after open heart surgery for congenital heart disease: duration alone predicts risk of late complete heart block. Pediatr Cardiol 2013. [PMID: 23179430 DOI: 10.1007/s00246-012-0595-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Transient complete heart block (TCHB) is defined as complete interruption of atrioventricular conduction (AVC) after cardiac surgery followed by return of conduction. This study aimed to assess the risk for the development of late complete heart block (LCHB) after recovery of TCHB and to examine the electrocardiographic and electrophysiologic properties of the AVC system after TCHB. Of the 44 patients in this study who experienced TCHB, 37 recovered completely. Seven patients progressed from TCHB to intermittent CHB or LCHB requiring pacemaker implantation. Preoperative, early postoperative, and late postoperative electrocardiograms as well as postoperative atrial stimulation were obtained. The results showed that the median duration of TCHB was 5 days in the TCHB group compared with 9 days in the LCHB group (p = 0.01). All 37 subjects with TCHB recovered AVC within 12 days, but only two with LCHB did so (p = 0.02). The risk of LCHB for the patients with 7 days of postoperative TCHB or longer was 13 times greater than for the patients with fewer than 7 days of TCHB (p = 0.01). The median late postoperative PR interval was slightly but significantly longer in the LCHB group than in the TCHB group (p = 0.02). In contrast, the electrophysiologic properties between the two groups did not differ significantly. From those findings, we concluded that delayed recovery of AVC after surgical TCHB (≥7 days), but not electrophysiologic properties of recovered AVC assessed early in the postoperative period strongly, predicts risk of LCHB. Follow-up evaluation of AVC is particularly indicated for the delayed recovery group.
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Affiliation(s)
- Peter F Aziz
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-5204, USA
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LaPage MJ, Reed JH, Collins KK, Law IH, Pilcher TA, Tanel RE, Anderson CC, Young ML, Emmel M, Paul T, Blaufox AD, Arora G, Saul JP. Safety and results of cryoablation in patients <5 years old and/or <15 kilograms. Am J Cardiol 2011; 108:565-71. [PMID: 21624545 DOI: 10.1016/j.amjcard.2011.03.089] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/29/2011] [Accepted: 03/29/2011] [Indexed: 11/19/2022]
Abstract
Current recommendations discourage elective radiofrequency ablation in patients <5 years old and/or weighing <15 kg, primarily because of the greater complication rate. To describe the current use, complications, and immediate outcomes of cryoablation in this patient population, a multicenter retrospective review of all patients <5 years old and/or weighing <15 kg who were treated with cryoablation for arrhythmia was performed. Eleven centers contributed data for 68 procedures on 61 patients. Of those, 34% were elective and 24% (n = 16) were both cryoablation and radiofrequency ablation. The median age and weight at ablation was 3.5 years (range 8 days to 9.9 years) and 15.2 kg (range 2.3 to 23), respectively. Congenital heart disease was present in 23% of the patients. The immediate success rate of cryoablation alone was 74%. No major complications occurred with cryoablation only; however, 2 of the 16 patients who underwent cryoablation and radiofrequency ablation had major complications. Of the 50 patients receiving cryoablation, 8 (16%) had variable degrees of transient atrioventricular block. The recurrence rate was 20% after cryoablation and 30% after cryoablation plus radiofrequency ablation. In conclusion, cryoablation appears to have a high safety profile in these patients. Compared to older and larger patients, the efficacy of cryoablation in this small, young population was lower and the recurrence rates were higher. Cryoablation's effect on the coronary arteries has not been fully elucidated and requires additional research.
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Saul JP, LaPage MJ. Is it time to tell the emperor he has no clothes?: Intravenous amiodarone for supraventricular arrhythmias in children. Circ Arrhythm Electrophysiol 2010; 3:115-7. [PMID: 20407103 DOI: 10.1161/circep.110.953356] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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