Authors: Ahmed Zaghw, MB.BCH - University of California, Davis, CA and Destiny Chau, MD - Arkansas Children’s Hospital /University of Arkansas for Medical Sciences, Little Rock, AR
A 4-month-old male infant undergoes full repair for Tetralogy of Fallot. During the first 24 hours postoperatively, the patient develops a hemodynamically significant arrhythmia requiring aggressive medical intervention. What is the MOST COMMON type of arrhythmia occurring after pediatric cardiac surgery?
Correct!
Wrong!
Question of the Week 400
EXPLANATION
Early postoperative arrhythmias after congenital cardiac surgery occurs with a reported incidence of 7.5% to 48%. Commonly encountered rhythm derangements include junctional ectopic tachycardia (JET), complete heart block, and supraventricular tachycardia. In the postoperative period, arrhythmias are poorly tolerated and may lead to life-threatening hemodynamic instability due to diminished cardiac output. Arrhythmias are commonly associated with surgery in proximity to the sinus node or the AV node. They may also be related to an atriotomy or a ventriculotomy incision. Additional risk factors for early postoperative arrhythmias include electrolyte abnormalities, myocardial ischemia, myocardial inflammation, increased sympathetic tone, prolonged cardiopulmonary bypass and aortic cross-clamp duration, and the use of arrhythmogenic vasoactive medications.
Bradyarrhythmias diminish cardiac output due to a decrease in heart rate. Furthermore, bradyarrhythmia in combination with non-sinus rhythm may impair cardiac filling and decrease resultant stroke volume due to a disruption in atrioventricular (AV) synchrony. Tachyarrhythmias reduce cardiac output by decreasing stroke volume due to a shorter diastolic filling time, and while occurring simultaneously with non-sinus rhythm may similarly compromise cardiac output due to a loss of AV synchrony. When causing a decrease in cardiac output, both bradyarrhythmias and tachyarrhythmias result in decreased myocardial oxygen supply, thus creating an imbalance in myocardial oxygen supply and demand. Tachyarrhythmias may cause additional disparity in myocardial oxygen supply and demand because of increased myocardial oxygen demand secondary to an elevated heart rate.
Overall, JET is the most commonly reported rhythm disturbance after pediatric congenital cardiac surgery. It occurs most frequently after repair of Tetralogy of Fallot, ventricular septal defects, atrioventricular septal defects, Transposition of the Great Arteries, and total anomalous pulmonary venous return. The incidence of JET after Tetralogy of Fallot repair is reported to occur in up to 20% of patients.
Management of JET includes reducing core temperature, atrial pacing, and anti-arrhythmic drugs such as amiodarone. For medically refractory cases, support with extracorporeal membrane oxygenation may be indicated. Cardioversion is generally deemed ineffective for terminating JET.
Susceptibility to a particular rhythm disturbance differs by cardiac lesion and type of cardiac surgery. After orthotopic heart transplantation, atrial fibrillation is the most common arrhythmia in the early postoperative period, occurring in up to 24% of patients. Some reports suggest that the biatrial surgical method is associated with a greater risk of atrial tachyarrhythmias as compared to the bicaval technique. Of note, early cardiac graft rejection may present clinically with atrial tachyarrhythmias.
Complete heart block is the most common postoperative bradyarrhythmia, with a reported incidence of 1.5% to 17.8%. Temporary pacing is an important treatment modality for the postoperative management of bradyarrhythmia with most cases recovering within 1- 2 weeks after surgery.
In conclusion, in the early postoperative period after congenital cardiac surgery, JET is the most common arrhythmia overall. Complete heart block is the most common bradyarrhythmia. The majority of arrhythmias are transient and self-limiting with adequate medical management.
REFERENCES
Delaney JW, Moltedo JM, Dziura JD, et al. Early postoperative arrhythmias after pediatric cardiac surgery. J Thorac Cardiovasc Surg. 2006;131(6):1296-1300.
Talwar S, Patel K, Juneja R, et al. Early postoperative arrhythmias after pediatric cardiac surgery. Asian Cardiovasc Thorac Ann. 2015;23(7):795-801.
Nelson JS, Vanja S, Maul TM, et al. Early arrhythmia burden in pediatric cardiac surgery fast-track candidates: Analysis of incidence and risk factors. Progress in Pediatric Cardiology. 2019;(52): 8-12.
Sahu MK, Das A, Siddharth B, et al. Arrhythmias in children in early postoperative period after cardiac surgery. World J Pediatr Congenit Heart Surg. 2018;9(1):38-46.
Joglar JA, Wan EY, Chung MK, et al. Management of arrhythmias after heart transplant: current state and considerations for future research. Circ Arrhythm Electrophysiol. 2021;14(3):e007954.
Ishaque S, Akhtar S, Ladak AA, et al. Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country. Acute Crit Care. 2022;37(2):217-223.
Valdes SO, Kim JJ, Miller-Hance WC. Arrhythmias: diagnosis and management. In: Andropoulos DB, ed. Anesthesia for Congenital Heart Disease. 3rd ed. Hoboken, NJ; Wiley-Blackwell. 2015: 404-436.
Early postoperative arrhythmias after congenital cardiac surgery occurs with a reported incidence of 7.5% to 48%. Commonly encountered rhythm derangements include junctional ectopic tachycardia (JET), complete heart block, and supraventricular tachycardia. In the postoperative period, arrhythmias are poorly tolerated and may lead to life-threatening hemodynamic instability due to diminished cardiac output. Arrhythmias are commonly associated with surgery in proximity to the sinus node or the AV node. They may also be related to an atriotomy or a ventriculotomy incision. Additional risk factors for early postoperative arrhythmias include electrolyte abnormalities, myocardial ischemia, myocardial inflammation, increased sympathetic tone, prolonged cardiopulmonary bypass and aortic cross-clamp duration, and the use of arrhythmogenic vasoactive medications.
Bradyarrhythmias diminish cardiac output due to a decrease in heart rate. Furthermore, bradyarrhythmia in combination with non-sinus rhythm may impair cardiac filling and decrease resultant stroke volume due to a disruption in atrioventricular (AV) synchrony. Tachyarrhythmias reduce cardiac output by decreasing stroke volume due to a shorter diastolic filling time, and while occurring simultaneously with non-sinus rhythm may similarly compromise cardiac output due to a loss of AV synchrony. When causing a decrease in cardiac output, both bradyarrhythmias and tachyarrhythmias result in decreased myocardial oxygen supply, thus creating an imbalance in myocardial oxygen supply and demand. Tachyarrhythmias may cause additional disparity in myocardial oxygen supply and demand because of increased myocardial oxygen demand secondary to an elevated heart rate.
Overall, JET is the most commonly reported rhythm disturbance after pediatric congenital cardiac surgery. It occurs most frequently after repair of Tetralogy of Fallot, ventricular septal defects, atrioventricular septal defects, Transposition of the Great Arteries, and total anomalous pulmonary venous return. The incidence of JET after Tetralogy of Fallot repair is reported to occur in up to 20% of patients.
Management of JET includes reducing core temperature, atrial pacing, and anti-arrhythmic drugs such as amiodarone. For medically refractory cases, support with extracorporeal membrane oxygenation may be indicated. Cardioversion is generally deemed ineffective for terminating JET.
Susceptibility to a particular rhythm disturbance differs by cardiac lesion and type of cardiac surgery. After orthotopic heart transplantation, atrial fibrillation is the most common arrhythmia in the early postoperative period, occurring in up to 24% of patients. Some reports suggest that the biatrial surgical method is associated with a greater risk of atrial tachyarrhythmias as compared to the bicaval technique. Of note, early cardiac graft rejection may present clinically with atrial tachyarrhythmias.
Complete heart block is the most common postoperative bradyarrhythmia, with a reported incidence of 1.5% to 17.8%. Temporary pacing is an important treatment modality for the postoperative management of bradyarrhythmia with most cases recovering within 1- 2 weeks after surgery.
In conclusion, in the early postoperative period after congenital cardiac surgery, JET is the most common arrhythmia overall. Complete heart block is the most common bradyarrhythmia. The majority of arrhythmias are transient and self-limiting with adequate medical management.
REFERENCES
Delaney JW, Moltedo JM, Dziura JD, et al. Early postoperative arrhythmias after pediatric cardiac surgery. J Thorac Cardiovasc Surg. 2006;131(6):1296-1300.
Talwar S, Patel K, Juneja R, et al. Early postoperative arrhythmias after pediatric cardiac surgery. Asian Cardiovasc Thorac Ann. 2015;23(7):795-801.
Nelson JS, Vanja S, Maul TM, et al. Early arrhythmia burden in pediatric cardiac surgery fast-track candidates: Analysis of incidence and risk factors. Progress in Pediatric Cardiology. 2019;(52): 8-12.
Sahu MK, Das A, Siddharth B, et al. Arrhythmias in children in early postoperative period after cardiac surgery. World J Pediatr Congenit Heart Surg. 2018;9(1):38-46.
Joglar JA, Wan EY, Chung MK, et al. Management of arrhythmias after heart transplant: current state and considerations for future research. Circ Arrhythm Electrophysiol. 2021;14(3):e007954.
Ishaque S, Akhtar S, Ladak AA, et al. Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country. Acute Crit Care. 2022;37(2):217-223.
Valdes SO, Kim JJ, Miller-Hance WC. Arrhythmias: diagnosis and management. In: Andropoulos DB, ed. Anesthesia for Congenital Heart Disease. 3rd ed. Hoboken, NJ; Wiley-Blackwell. 2015: 404-436.
