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Supraventricular Tachycardia: Diagnosis and Current Acute Management

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Supraventricular Tachycardia: Diagnosis and Current Acute Management Archives ofDisease in Childhood 1991; 66: 647-652 647 PERSONAL PRACTICE Arch Dis Child: first published as 10.1136/adc.66.5.647 on 1 May 1991. Downloaded from Supraventricular tachycardia: diagnosis and current acute management Janice A Till, Elliot A Shinebourne There is a small but potentially avoidable inci- dence of death associated with childhood supra- ventricular tachycardia.1 2 The time of greatest risk is when the child presents for the first time and requires therapeutic intervention. Infants and children tolerate arrhythmias less well than adults as they are more dependent on heart rate for cardiac output and have less reserve.3 4 They are also at risk from drugs given as treatment.5 We discuss our current acute man- agement of supraventricular tachycardia. Diagnosis Between 30 and 40% of children who present with supraventricular tachycardia do so within the first few weeks of life. Their presentation is variable. Supraventricular tachycardia can be the cause of unexplained hydrops of the fetus or Figure I An electrocardiogram recordedfrom a I week old can result in sudden profound cardiovascular neonate with atrioventricular re-entry tachycardia showing collapse in the newborn period.6 More usually the typicalpattern with a P' wave almost midway between neonates and small infants will present with QRS complexes. symptoms of increasing tachypnoea, poor feed- http://adc.bmj.com/ ing, and pallor which have developed over a few days. Occasionally supraventricular tachycardia is intermittent and a strong index of suspicion Classification of supraventricular tachycardia must be maintained if the diagnosis is not to be Junctional tachycardias missed. The older child more usually presents Atrioentricular re-entry tachycardia (AVRT) with a history of palpitations. Orthodromic AVRT: Tachycardia involving a circuit utilising the atrioventricular The most common type of supraventricular node as the antegrade limb and an accessory connection between tachycardia in childhood results from a re-entry ventricle and atrium as the retrograde limb on September 28, 2021 by guest. Protected copyright. Antidromic AVRT: circuit between atria and ventricles involving Tachycardia involvinga circuit utilising an accessory connection the atrioventricular node as the antegrade limb as the antegrade limb and the atrioventricular node as the and an accessory connection between ventricle retrograde limb Atrioventricular nodal re-entry tachycardia (AVNRT) and atrium as the retrograde limb (fig 1). This Tachycardia involving a circuit the two limbs ofwhich are type of tachycardia, atrioventricular re-entry intimately associated with the atrioventricular node. The atria and ventricles are activated as offshoots ofthe circuit. The tachycardia, can be classified as a junctional common type ofAVNRT is typified by slow conduction supraventricular tachycardia (table). An acces- antegradely and fast conduction retrogradely, the uncommon type by fast conduction antegradely and slow conduction sory connection may occur anywhere around retrogradely the atrioventricular ring. If it is capable of sup- LongR-P' tachycardia porting conduction antegradely from atrium to Tachycardia involving a circuit utilising the atrioventricular node as the antegrade limb and a slow conducting pathway as the ventricle, as well as retrogradely, the usual retrogradelimb. Thelattermay be an accessory connection in close situation during supraventricular tachycardia, it association with the atrioventricular node, in the will be manifest on the electrocardiogram dur- posteroseptal position or remote from the atrioventricular node Atrial tachycardias ing sinus rhythm as a short PR interval and Atrial tachycardia delta wave. Such pre-excitation of the ventricle Tachycardia characterised by discrete atrial activity on the surface Department of electrocardiogram with varying ventricular response resulting Paediatrics, together with supraventricular tachycardia is either from a micro re-entry circuit or ectopic focus confined Royal Brompton and the syndrome described by Wolff, Parkinson, within the atria National Heart Hospital and White.7 If conduction is restricted to the Atrialflutter and National Heart Tachycardia characterised by a sawtooth undulation of the and Lung Institute, retrograde direction, atrioventricular re-entry baseline on the surface electrocardiogram probably resulting Fulham Road, tachycardia is possible but there will be no evi- from conduction around a re-entry circuit within the atria London SW3 6HP dence of the connection on the electrocardio- Atrialfibrillation Janice A Till Tachycardia characterised by chaotic low voltage 'fibriliatory' Elliot A Shinebourne gram during sinus rhythm, a situation termed waves on the surface electrocardiogram with an irregularly irregular ventricular response, resulting from disordered atrial Correspondence to: concealed pre-excitation. actvity Dr Till. The majority of children with an accessory 648 Till, Shinebourne connection do not have structural congenital cles are depolarised almost simultaneously. As a heart disease. When there is a structural ano- result the P' wave is not easily seen, being hid- maly this is most commonly Ebstein's anomaly den from view by the QRS complex. The other Arch Dis Child: first published as 10.1136/adc.66.5.647 on 1 May 1991. Downloaded from of the tricuspid valve or less frequently, cor- less common junctional tachycardia, the long R- rected transposition (discordant atrioventricular P' tachycardia, can often be distinguished by its connection, discordant ventriculoarterial con- 'persistent' nature, stopping and starting during nection). the electrocardiogram recording, and the char- Atrioventricular re-entry tachycardia ac- acteristic superior P' wave axis, seen just before counts for the great majority of supraventri- the QRS complex (fig 2). This electrocardiog- cular tachycardias presenting in the first year of raphic pattern represents a re-entry circuit life. The spectrum of supraventricular tachycar- involving the atrioventricular node antegradely dia in older children is wider and both atrial and and a slow conducting pathway, which may other junctional tachycardias such as atrioven- either be an accessory pathway or part of the tricular nodal re-entry tachycardia or long R-P' atrioventricular node, retrogradely. It is this tachycardia are more frequently seen. They can long interval between the R wave of the QRS usually be distinguished from the surface elec- complex and the P' wave, representing slow trocardiogram. Junctional tachycardias are conduction in the retrograde pathway, that characterised by a narrow regular QRS complex gives the tachycardia its name.8 and a one to one relationship between the P' Atrial arrhythmias, for example, atrial tachy- waves and the QRS complexes during tachycar- cardia, atrial fibrillation, or flutter, are not often dia. In atrioventricular re-entry tachycardia this seen in the first year of life. They are more one to one relationship is a necessity if the common, especially after cardiac surgery, in the tachycardia is to continue, as disruption of the older child with structural heart disease where relationship between atrium and ventricle will the atria are distorted or distended, or in the interrupt the circuit and stop the tachycardia. child with myocarditis. They may occasionally Typically during atrioventricular re-entry be seen in association with an accessory connec- tachycardia there is a P' wave easily seen follow- tion. Unlike the more common junctional ing the QRS complex. This is because the atria tachycardias they can continue in the presence are depolarised only after the electrical impulse of atrioventricular nodal block; a one to one has travelled sequentially through the His- relationship of atrial to ventricular depolarisa- Purkinje system, ventricular muscle, and acces- tion is not required. sory connection. There is therefore a time inter- Before any treatment is administered the val, usually greater than 70 msec, between ven- tachycardia should be documented by recording tricular and atrial depolarisation. In contrast, a 12 lead electrocardiogram and rhythm strip. during atrioventricular nodal re-entry tachycar- This is important as correct diagnosis of the dia the atria and ventricles are both activated as arrhythmia should guide treatment and prevent offshoots of a re-entry circuit involving a fast use of inappropriate or potentially hazardous and slow pathway in close association with the drugs. Ventricular tachycardia should be exclu- http://adc.bmj.com/ atrioventricular node. The retrograde pathway ded. Ventricular arrhythmias are relatively is typically fast and therefore atria and ventri- uncommon in childhood. When they do occur on September 28, 2021 by guest. Protected copyright. 17:42 17:44 Figure 2 A sectionfrom a 24 hour tape recording performed on an infant with a long R-P' tachycardia. The electrocardiogram (top) (25 mmlsec), shows the tachycardia with P' wave (inverted)just before the QRS complex, terminating spontaneously. Therefollowsfour beats ofsinus rhythm before the tachycardia reinitiates. The three minute sequence shown below shows how thts behaviour continues repeatedly. Supraventricular tachycardia: diagnosis and current acute management6 649 ( Arch Dis Child: first published as 10.1136/adc.66.5.647 on 1 May 1991. Downloaded from Figure 3 (A) Leads I, II, and IIIfrom an electrocardiogram recordedfrom a I year old child with ventricular tachycardia. The child had an otherwise structurally normal
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