Transcript Rhythm Problems Atrioventricular Septal Defect Alpay Çeliker MD

Rhythm Problems
Atrioventricular Septal Defect
Alpay Çeliker MD.
Hacettepe University
Department of Pediatric Cardiology
Conduction System in AVSD
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Normal Heart
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AV node is located in
the triangle of Koch
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AV Septal Defect
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AV node is located
posteriorly
ECG in AVSD
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1.
Prolonged PR interval
Left axis deviation and counterclockwise
frontal plane loop
Elongation of the
anterior division of LBB
2. Anomalous
development of anterior
division of LBB
3. Interruption of the
anterior division by
anomalous insertion of
chorda tendinea
ECG in AVSD II
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Incomplete RBBB pattern in 84 %
Evidence of atrial enlargement 54 %
Q wave in V6 84 %
Additional factors that influences ECG
 Size of ASD or VSD
 Amount of mitral and tricuspid
regurgitation
 Pulmoner vascular resistance
 Associated defects
Mechanisms of Arrhythmias
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Abnormalities inherent to malformation
Hemodynamic and hypoxic stress upon
heart
Sequela of reparative surgery
Residual hemodynamic problems
Rhythm Problems in AVSD
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Preoperative Rhythm Problems
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Perioperative Rhythm Problems
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Postoperative Rhythm Problems
Preoperative Arrhythmias
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Acquired atrial tachyarrhythmias
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Late operation
Atrial fibrillation may be seen 20 % and
causes clinical deterioration
AV block
Perioperative Arrhythmias
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Junctional Ectopic Tachycardia
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AV Block
AVSD & Perioperative
Arrhythmias
With
arrhythmia
No
arrhythmia
AVSD
Patients
21
24
Mean age
0.9 ± 2.1
1.4 ± 1.9
Incomplete
result
9/11
2/11
Higher ACC, ECC time
and TpI levels
Pfammater et al. J Thorac Cardiovasc
Surg 2002; 123: 258-262
AVSD with Arrhythmia
N=21
AJR
N= 8
SSS
N=7
CAVB
N=1
A Flutter
N=1
JET
N=1
Ectopic Beats
N=1
Junctional Ectopic Tachycardia
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 ventricular rate
Loss of AV synchrony
 Cardiac Output
 Adrenergic Tone
 Heart Rate
JET: ECG Diagnosis
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QRS configuration is similar to sinus or
atrial paced beats
Rapid ventricular rate > or =to atrial rate
Dissociated atrial activity or retrograde
1:1 conduction or Wenckebach
Failure to respond adenosine, overdrive
pacing or cardioversion
Warm-up phenomenon
Perioperative
JET
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Postop JET
N=37/343
10 %
Increased duration of
postoperative
ventilation and CICU
stay
 incidence with
ventricular muscle
band resection, higher
cardiopulmonary
bypass temperature,
transatrial RVOTO
relief
Fallot
N= 25/114
21.9 %
RVOT resection
More important
Than VSD closure
AVSD
N=6/58
10.3%
VSD
N=6/161
3.7 %
De-Leval group. J Thorac Cardiovasc Surg 2002; 123: 624-630.
Treatment in Postop JET
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General Measures
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Optimize sedation/hemodynamics
Correct fever
 Catecholamines
AV Synchrony
Class I and II AAD
Hypothermia + Procainamide
IV Amiodarone
Treatment Modalities in JET
50
Ineffective
40
Poss. Effective
30
Effective
20
10
0
Cat
Fever
Sync
Dig
IB, II,
Proc
Hypo
Comb
IV
Walsh ED, et al. J Am Coll Cardiol, 1997; 29: 1046-1053
Walsh ED, et al. J Am Coll Cardiol, 1997; 29: 1046-1053
Laird et al. Pediatr Cardiol 2003; 24: 133-137.
IV AMIODARONE
N=11
INITIAL THERAPY
N=6
SECONDARY THERAPY
N=5
HYPOTHERMIA
N=3
HYPO&PROC
N=1
CAT REDUCTION
N=1
SUCCESS 10/11
JET
Optimize hemodynamic variables, respiration,
electrolytes, sedation, fever control
Discontinue Catecholamines
Atrial Pacing*
Atrial pace slightly faster
than JET from epicardial
wires or Esophagus
*not an isolated therapy if JET rate
JT rate > 200 bpm or
Persistent rate 170-200 bpm
AAD
Hypothermia
>200 bpm
AMIODARONE
PROCAINAMIDE
Core temperature 33-350 C
using posterior cooling blanket
under sedation, mechanic
ventilation and paralysis
AV Blok
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Postoperative AV block has been
reported to occur in 0-3.5 %.
50 % of postoperative AV block resolves
within the 8 days.
Permanent pacemaker implantation after
15 days is prudent.
Postop CAVB
Temporary Pacing
Monitor 7-10 days
NSR or 1o AVB
Type 1, 2o AVB
EPS
NSR, 1o AVB,
RBBB, LAD
Type II, 2o AVB
InfraHisian
Block
Permanent Pacemaker
30 AVB
Cardiac Pacing in AVSD
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SSS & Good AV Conduction: AAIR
SSS & AV Conduction Disturbance: DDD
AV Block: DDD
Small Child ( <15 kg): Epicardial implant
SSS or AV Block with Atrial
Tachycardia: Antitachycardia PM
Late Recovery of AV Conduction: 10 %
Perioperative and Longterm
Arrhythmias
Arrhythmia
Type
Perioperative
N-%
Long-term
N-%
Total
N-%
18 (5)
12 (4)
24 (7)
At Fibrillation
7 (2)
21 (6)
25 (8)
At Flutter
7 (2)
6 (2)
13 (4)
AV Block
5 (2)
4 (1)
9 (3)
2
3
3 (1)
SVT
Premature SVB
& VB
El-Najdawi et al. J Thorac Cardiovasc Surg 2000; 19: 980-90.
Atrial Arrhythmias
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Atrial Fibrillation
Isthmus Dependent Atrial Flutter (IDAF)
Intraatrial Reentrant Tachycardia (IART)
Risk of Atrial Reentry Tachycardia
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High Risk (> 10 %)
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Fontan palliation
Mustard-Senning
Total correction for Fallot or DORV
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Sinus venosus or late repair of ASD II
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Moderate Risk (1-10 %)
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TAPVR
Ebstein’s anomaly
Complete AVSD
Mitral valve replacement
Low Risk (<1 %)
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Early repair ASD II
VSD repair
IART or IDAF
Therapy Of Atrial Arrhythmias
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DC Cardioversion
AAD: Class Ic, III
AAD & PM
Transcatheter RF Ablation
Arrhythmia Surgery
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Correction of residual defects
Surgical ablation
Maze procedure
Transcatheter Ablation
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Atrial Fibrillation: His
Ablation
IDAF and IART:
Creation of Block Line
Use of saline irrigated
catheters
Use of 3D Anatomic
Mapping
Efficacy
AAD
Cost
RFA
Arrhythmia
Surgery
Adverse Effects
Application
Problems
ATP
Treatment Failures
Treatment Methods in Atrial Tachyarrhythmias
Sudden Death and AVSD
Cardiac Defect
Incidence 1000 pt/year
Aortic Stenosis
5.4
D-TGA
4,9
Fallot Tetralogy
1,5
Aortic Coarctation
1,3
AVSD
0,9