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      Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2 years

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          Abstract

          Background

          Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age.

          Methods

          From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients ( n = 96) had postoperative JET.

          Results

          JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca ( p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn’t affect the duration of mechanical ventilation nor hospital stay ( p = 0.12 and 0.2 respectively) but prolonged the ICU stay ( p = 0.011). JET resolved in 39.5% ( n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% ( n = 30) of patients and its use was associated with longer ICU stay ( p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn’t affect ICU ( p = 0.43) or hospital stay ( p = 0.14) however, long duration of JET increased ICU and hospital stay ( p = 0.02 and 0.009; respectively).

          Conclusion

          JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential.

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          Most cited references26

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          Postoperative junctional ectopic tachycardia in children: incidence, risk factors, and treatment.

          Timothy M. Hoffman, David M. Bush, Gil Wernovsky … (2002)
          Junctional ectopic tachycardia (JET) occurs commonly after pediatric cardiac operation. The cause of JET is thought to be the result of an injury to the conduction system during the procedure and may be perpetuated by hemodynamic disturbances or postoperative electrolyte disturbances, namely hypomagnesemia. The purpose of this study was to determine perioperative risk factors for the development of JET. Telemetry for each patient admitted to the cardiac intensive care unit from December 1997 through November 1998 for postoperative cardiac surgical care was examined daily for postoperative JET. A nested case-cohort analysis of 33 patients who experienced JET from 594 consecutively monitored patients who underwent cardiac operation was performed. Univariate and multivariate analyses were conducted to determine factors associated with the occurrence of JET. The age range of patients with JET was 1 day to 10.5 years (median, 1.8 months). Univariate analysis revealed that dopamine or milrinone use postoperatively, longer cardiopulmonary bypass times, and younger age were associated with JET. Multivariate modeling elicited that dopamine use postoperatively (odds ratio, 6.2; p = 0.01) and age less than 6 months (odds ratio, 4.0; p = 0.02) were associated with JET. Only 13 (39%) of the patients with JET received therapeutic interventions. Junctional ectopic tachycardia occurred in 33 (5.6%) of 594 patients who underwent cardiac operation during the study period. Postoperative dopamine use and younger age were associated with JET. It may be speculated that dopamine should be discontinued in the presence of postoperative JET.
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            Early postoperative arrhythmias after pediatric cardiac surgery.

            James D Dziura, G Kopf, S. Snyder … (2006)
            Early postoperative arrhythmias are a known complication of cardiac surgery; however, little data exists specific to pediatrics. The purpose of this study was to determine the incidence and risk factors associated with the development of arrhythmias immediately after surgery in a pediatric population. Data were collected in a prospective observational format from pediatric patients undergoing cardiac surgery between September 2000 and May 2003. This format included age, anatomy, surgical repair, and serum magnesium and calcium levels, as well as cardiopulmonary bypass and aortic crossclamp times. Patients were continuously monitored, and hemodynamically significant arrhythmias were recorded. Arrhythmias occurred in 28 of the 189 patients enrolled (15%) including 16 with junctional ectopic tachycardia, 7 with complete atrioventricular block, 4 with ventricular tachycardia, and 1 with re-entrant supraventricular tachycardia. Significant differences were found between the arrhythmia and nonarrhythmia groups with regard to age (22 vs 45 months), cardiopulmonary bypass time (189 vs 109 minutes), and aortic crossclamp time (105 vs 44 minutes); P < .05. Magnesium and calcium levels were not significantly different between the groups. Two repairs carried an increased risk: complete atrioventricular septal defect repair, 8 of 11 patients (72%), and the arterial switch 5 of 8 patients (62.5%); P < .05. Atrioventricular septal defects had an even higher incidence when controlled for age, bypass time, and crossclamp time (odds ratio = 7.65). Hemodynamically significant postoperative arrhythmias are a frequent complication of pediatric cardiac surgery. Younger age and longer bypass and crossclamp times are risk factors for arrhythmia. In addition, the repair of atrioventricular septal defects carries an independent risk of arrhythmias.
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              Surgical substrates of postoperative junctional ectopic tachycardia in congenital heart defects.

              A Dodge-Khatami, V Tsang, Robert J. Gil … (2002)
              Junctional ectopic tachycardia is a major cause of postoperative morbidity after surgery for congenital cardiac disease. To elucidate the mechanism of junctional ectopic tachycardia, surgical correlations were studied in four types of congenital heart defects involving closure of a ventricular septal defect, relief of right ventricular outflow tract obstruction, or both. Between 1997 and 1999, a total of 343 consecutive patients underwent repair of tetralogy of Fallot (n = 114), common truncus arteriosus (n = 10), ventricular septal defect (n = 161), and atrioventricular septal defect (n = 58). Variables studied included demographic and bypass data, surgical approaches toward ventricular septal defect closure and relief of right ventricular outflow tract obstruction, and resection as opposed to division of muscle bundles. Junctional ectopic tachycardia occurred most frequently after repair of tetralogy of Fallot (n = 25; 21.9%), with no cases occurring after repair of common trunk, 6 occurring after repair of ventricular septal defect (3.7%), and 6 occurring after repair of atrioventricular septal defect (10.3%). Stepwise logistic regression revealed that resection of muscle bundles (P <.0001), higher bypass temperatures (P <.03), and relief of right ventricular outflow tract obstruction through the right atrium (P <.05) significantly and independently predicted postoperative junctional ectopic tachycardia. Relief of right ventricular outflow tract obstruction appears to be more important in the causation of junctional ectopic tachycardia than does ventricular septal defect closure, which may explain the higher incidence of this complication after tetralogy of Fallot repair. Muscular resection seems to be more arrhythmogenic than is simple division. Increased traction through the right atrium for relief of right ventricular outflow tract obstruction would fit the hypothesis that enhanced automaticity of the His bundle, the morphologic substrate for junctional ectopic tachycardia, may result from direct trauma or infiltrative hemorrhage of the conduction system. When feasible, techniques avoiding both extensive muscle resection and excessive traction should be applied during resection of right ventricular outflow tract obstruction.
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                Author and article information

                Contributors
                Mohamed Fouad Ismail: MFIsmail2299@yahoo.com
                Amr A. Arafat: amr.arafat@med.tanta.edu.eg
                Tamer E. Hamouda: Tamerhamoda@yahoo.com
                Amira Esmat El Tantawy: Amiraesmat@yahoo.com
                Azzahra Edrees: edreesaz@gmail.com
                Abdulbadee Bogis: Dr.abdulbadee@gmail.com
                Alaa B. Mahmoud: alaabasiouni@yahoo.com
                Ahmed Farid Elmahrouk:
                ORCID: http://orcid.org/0000-0002-7678-5700
                00966555042073 , A_marouky@hotmail.com , Ahmed.elmahrouki1@med.tanta.edu.eg , Ael-Mahrouk@KFSHRC.edu.sa
                Ahmed A. Jamjoom: Jamjoom_ahmed@hotmail.com
                Journal
                Journal ID (nlm-ta): J Cardiothorac Surg
                Journal ID (iso-abbrev): J Cardiothorac Surg
                Title: Journal of Cardiothoracic Surgery
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1749-8090
                Publication date (Electronic): 5 June 2018
                Publication date PMC-release: 5 June 2018
                Publication date Collection: 2018
                Volume: 13
                Electronic Location Identifier: 60
                Affiliations
                [1 ]ISNI 0000 0001 2191 4301, GRID grid.415310.2, Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Center, ; MBC J-16, P.O Box: 40047, Jeddah, 21499 Saudi Arabia
                [2 ]ISNI 0000000103426662, GRID grid.10251.37, Cardio-thoracic Surgery Department, , Mansoura University, ; Mansoura, Egypt
                [3 ]ISNI 0000 0000 9477 7793, GRID grid.412258.8, Cardiothoracic Surgery Department, , Tanta University, ; Tanta, Egypt
                [4 ]ISNI 0000 0004 0621 2741, GRID grid.411660.4, Cardio-thoracic Surgery Department, , Benha University, ; Benha, Egypt
                [5 ]ISNI 0000 0004 0639 9286, GRID grid.7776.1, The Department of Pediatrics, , Faculty of Medicine Cairo University, ; Cairo, Egypt
                Author information
                http://orcid.org/0000-0002-7678-5700
                Article
                Publisher ID: 749
                DOI: 10.1186/s13019-018-0749-y
                PMC ID: 5989382
                PubMed ID: 29871684
                SO-VID: 67f912ec-930d-4769-9eae-cba248027836
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 16 March 2018
                Date accepted : 31 May 2018
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Surgery
                Keywords: congenital heart disease,arrhythmia,junctional ectopic tachycardia; tetralogy of fallot
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: congenital heart disease, arrhythmia, junctional ectopic tachycardia; tetralogy of fallot

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