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Supraventricular Tachycardia: from Fetus to Adult

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Supraventricular Tachycardia: from Fetus to Adult Supraventricular Tachycardia: From Fetus to Adult Mohamed Hamdan, MD Learning Objectives Define type of SVT by age Describe clinical approach Describe prenatal and postnatal management of SVT 2 SVT Across the Ages Narrow-complex Wide complex: VT Tachycardia HR >160: fetuses HR >220: infants HR >180: children HR >120: adults Above AV junction Types of SVT Re-entrant Automatic 1. Sudden onset and 1. Warms-up and cools offset down 2. Accessory pathway 2. Sensitive to 3. Terminates with catecholamines adenosine or 3. Does not respond to cardioversion either Most common: AVRT Most common: EAT Mechanism of SVT Re-entrant Automatic 90% <1% 10% AVN dependant AVN independant AVRT Atrial flutter AET AVNRT Atrial fib. CAR PJRT SNRT JET Mahaim Tachycardia IART 5 Re-entrant Automatic Fetal SVT Definition HR > 160 not associated with contraction or periodic decelerations Epidemiology Incidence ~1/1000 of all pregnancies Fetal arrhythmia: 1/3 of referrals to fetal echo lab CHD in 3% Copel et al., Am J Obstet Gynecol 2000 7 Clinical Approach to Fetal SVT 1. Define type SVT vs Flutter vs Fibrillation 2. Define absolute HR 3. Presence of CHD 4. Presence of hydrops 8 1. Type of SVT Best: 16-32 weeks Methods Phonocardiography Fetal echo Magnetocardiography (MCG) Fetal scalp electrode Fetal QRS Maternal QRS 9 Assessment of Rhythm by Fetal Echo Doppler SVC Aorta PAC Normal 10 Assessment of Rhythm by Fetal Echo M-Mode RV RA Atrium Rate~ 500 Ventricle Rate~240 11 2. Determine HR Atrial Rate Variability A:V Ventricular (bpm) Conduction Rate Normal 120-160 >10 bpm 1:1 120-160 Sinus 180-220 5-15 bpm 1:1 180-220 tachycardia SVT >220 No 1:1 >220 Atrial flutter 300-500 No 2-5:1 60-200 Atrial 300-500 Yes, due to 2-5:1 60-200 fibrillation variable AV conduction Bergmans et al., Obstet Gynecol Surv 1985 12 3. Structural Heart Disease Incidence of CHD in fetal SVT: is 0.5-5% Worse outcome Mot common: Ebstein malformation: SVT, flutter Cardiac tumors: Rhabdomyoma AV canal 13 Complete AV Canal Rhabdomyoma LA RA RA LA LV LV RV RV Ebstein RA LA LV RV 14 4. Presence of Hydrops The most important factor in deciding Delivery time Treatment Prognosis Risk factors HR >230 Sustained tachycardia >12 hrs Lower GA 15 Postnatal SVT Epidemiology Incidence: 1/1000 The most common cause in children is Atrio-ventricular Re-entrant Tachycardia (AVRT) AP outside AV node (eg: WPW) In adults: AVNRT (AV Node Re-entrant Tachycardia) AP within the AV node Accessory pathway, either concealed, or manifest (WPW) 25% have associated structural heart disease AVRT vs AVNRT AVRT: Atrio-Ventricular AVNRT: Atrio-Ventricular Re-entrant Tachycardia Nodal Re-entrant Tachycardia Accessory Accessory Pathway Pathway within AVN 18 SVT 19 Sinus Tachycardia vs SVT Sinus Tachycardia SVT Heart Rate <220 infants 230-300 infants <200 children 200-240 children QRS complex Narrow Usually narrow P waves Present, normal axis (0-90) Absent, or after ORS, superior (180-270) Regularity Regular, slows gradually Sudden onset and offset, ‘monotonus’ Etiology Fever, anemia, infection, … Accessory pathway What is Accessory Pathway? Specialized tissue capable of antegrade (down) and/ or retrograde (up) conduction Connect atrium to AVN ventricle, bypassing AV node and AV bundle Fast (non- decrimental) with slow recovery Manifest AP: WPW Concealed AP SVT WPW: Manifest AP SVT No WPW: Concealed AP Wolff-Parkinson-White The most common form of manifest AP Incidence: 0.2 % in general population 0.5 % in patients with CHD 25% of infants with SVT Association Ebstein anomaly of the TV Hypertrophic CMP Mostly sporadic, but can be familial Risk of sudden death Wolff-Parkinson-White 2 1.Delta wave 1 3. Wide QRS 2. Short PR 3 5 4. Left axis deviation 4 5. Absent Q in V6 Clinical Approach to SVT History Sudden onset and offset palpitations Non-specific symptoms Irritability Poor feeding Associated symptoms Pre-syncope, syncope Chest pain Examination Usually normal Work Up Baseline electrolytes EKG At baseline: Wolff or no Wolff? During SVT: Mechanism of SVT During SVT break: Presence of WPW + Mechanism Echo Only at baseline Structural heart disease (25%) LV function Exclude cardiomyopathy Others: Holter, Stress Test, Cardiac Event Monitor Ebstein RA LA LV RV Hypertrophic CMP Dilated CMP RA LA LA RA LV LV RV RV 24-hour ECG (Holter) Look for SVT Look for WPW Look for abnormal P-wave axis & frequent PAC’s Control after medications Cardiac Event Monitor Exercise Stress Test Can induce SVT Essential in WPW Characteristics of accessory pathway Identify risk of sudden death Low vs high risk Depends on refractory period of AP . Cut-off: 250 msec. (240 bpm) Management of SVT Prenatal Management Rate control Maternal Digoxin, Flecainide, Sotalol, Amiodarone Atrium Flec, Sotalol, Amio Accessory AV Node Dig, Sotalol, Amio Pathway Ventricle 37 Effect of Maternal Drugs Lisowski et al., JACC 2000; Krapp et al., Heart 2003; Strasburger et al., Circulation 2004; Oudijk et al., Circulation 2000; Krapp et al., Ultrasound Obstet Gynocol 2002 38 LA LA RA RA LV LV RV RV 39 Postnatal Management Acute Terminate tachycardia X Depends on hemodynamics Adenosine X Cardioversion Amiodarone Chronic To prevent recurrence Treat complications Definitive RFA (Radiofrequency Ablation) Postnatal Management: Acute Treatment Vagal maneuvers Diving reflex Valsalva Gag reflex ‘Standing on the head’ Works better in infants Adenosine Adenosine SVT 42 Post Adenosine Case Report Atrial rate= 500 Ven. Rate= 150-240 43 Adenosine SVT 44 Adenosine: The 3 Commandments Central or upper limb access Run EKG strip Keep defibrillator standby Omar: SVT Omar: SVT Adenosine Post Lidocaine Chronic Treatment Symptomatic or Infants No or little symptoms Baseline EKG No Treatment WPW No WPW 1st line: Dig, ß-blockers, Flec 1st line: Dig, ß-blockers, Flec 2nd line: Sotalol, Amio 2nd line: Sotalol, Amio Re-entrant SVT (AVRT or AVNRT) Atrium Block/Slow AV Node Block Accessory Dig, -Blockers, ß Pathway CCB, Sotalol, Amio AV Node (Vagal, Adenosine, Flec, Sotalol, Amio Cardioversion) Accessory Pathway Ventricle Definitive Treatment Radiofrequency Catheter Ablation In older children & adults Success rate >80% Complication rate <5% SVT 52 Radiofrequency Ablation AP Lateral RA Coronary Sinus LA His Bundle RV SVT 53 Septal pathway Earliest wave SVT 54 Post ablation SVT 55 Prognosis Variable Re-entrant: Good, as most patients have normal hearts Automatic: Guarded, but worse (difficult control) For re-entrant, better prognosis if: Onset in infancy Absence of pre-excitation Absence of structural heart disease Onset of SVT <2 m disappears in > 50% by age 1 yr Onset of SVT > 5 yrs persists in 80% 30% recurrence rate in childhood Take Home Message In fetuses, infants & children: SVT = AVRT (accessory pathway) In adults: more commonly AVNRT (slower) Management depends on whether WPW is present on baseline EKG Adenosine is good therapeutic & diagnostic tool In all arrhythmias, you’re friends are: ß-Blockers Thank You.. Cape of Good Hope Automatic SVT (E.A.T.) Atrium Block/ Slow Ectopic Focus ß-Blockers , Flec, Sotalol, Slow AV Node AV Node Amio Dig, ß-Blockers, CCB, Sotalol, Amio Ventricle Incidence of Fetal Arrhythmia n=1384 Kleinman et al., Ultrasound Obstet Gynecol 1991 60 Wolff-Parkinson-White Risk of sudden death: Symptomatic 0.6% per year Asymptomatic 0.1% per year Risk increases with: Age (adults>adolescents>children) Presence of atrial fibrillation Short refractory period.
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