Congenital Cardiac Anesthesia Society
A Section of the the Society for Pediatric Anesthesia

{“questions”:{“kjye7”:{“id”:”kjye7″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Anila B. Elliott, MD, University of Michigan – C.S. Mott Children\u2019s Hospital \r\n\r\nA 3-year-old girl is undergoing surgical repair of an atrial septal defect via median sternotomy. A deep parasternal intercostal plane (DPIP) block is performed at the end of the procedure to facilitate early extubation and post-operative analgesia. Which of the following nerves are the primary targets of this block? \r\n”,”desc”:”EXPLANATION \r\nEffective management of perioperative pain in pediatric cardiac surgery is important, as inadequate pain control has been linked to a range of complications, including extended ICU and hospital stays, respiratory complications, prolonged intubation and hemodynamic instability.^{1<\/sup> Regional anesthesia is increasingly being utilized as a key component of a multimodal approach to improve the perioperative care of this patient population.2<\/sup> Due to the increasing numbers of regional techniques that are being described, there is significant heterogeneity and confusion about nomenclature. El-Boghdadly et al. attempted to standardize the nomenclature to improve communication, education and training.5<\/sup>\r\n\r\n\r\nOne current technique is the deep parasternal intercostal plane block (DPIP) (formerly termed transversus thoracic muscle plane (TTMP) block), which was first described in 2015 by Ueshima and colleagues.3<\/sup> It has been shown to be effective in providing analgesia for surgeries involving a median sternotomy. This muscle plane block involves injecting local anesthetic bilaterally, between the transversus thoracic muscle and the internal intercostal muscles. It targets the anterior cutaneous branches of the intercostal nerves (T2-T6) to provide analgesia to the anterior chest wall.4<\/sup> \r\n\r\n\r\nAlthough many studies of the efficacy of this regional technique have been performed on adult patients, there are a select few that have investigated the impact on pediatric cardiac surgery patients.4<\/sup> The DPIP block offers several advantages, including a reduction in opioid consumption, decreased pain scores, improved hemodynamic stability and enhanced recovery following open-heart surgery.2,4<\/sup> Complications of the block include vascular injury to nearby vasculature, hematoma, infection, and pneumothorax.4<\/sup> \r\n\r\n\r\n\r\nThere are other regional anesthetic techniques for the anterior chest wall that can be performed as part of surgery involving a median sternotomy. The superficial parasternal intercostal plane block (SPIP), formerly termed the pecto-intercostal fascial plane block (PIFB), also blocks the anterior cutaneous branches of the intercostal nerves, and is thought to have a superior safety profile when compared to the deep version of the block, especially in children. Pectoralis blocks (PECS I and PECS II) can also be performed for sternal analgesia.5<\/sup> The PECS I block targets the pectoral nerves, whereas the PECS II block targets the lateral branches of the intercostal nerves (T2-T6).4<\/sup> \r\n\r\n\r\nFigure 1: Summary of innervation of regional blocks for procedures on the anterior chest wall \r\n\r\n\r\n\r\nAdditionally, the erector spinae plane (ESP) block has been shown to be effective in pediatric cardiac surgery. This block targets the dorsal and ventral rami of the thoracic and abdominal spinal nerves, providing reliable coverage of the posterior chest wall.4<\/sup> However, studies have found that its analgesic effect on the anterior chest wall can be inconsistent. \r\n\r\n\r\nAs regional anesthetic techniques continue to evolve, it is important for congenital cardiac anesthesiologists to stay informed about these advancements to optimize patient care and recovery. In this patient, the planned DPIP block would target the anterior cutaneous branches of the intercostal nerves, which is answer B. The lateral cutaneous branches are primarily targeted by posterior chest wall regional techniques, and the pectoral nerves are blocked by the two pectoralis blocks. \r\n\r\n \r\nREFERENCES \r\n1.\tAydin, ME., Ahiskalioglu, A., Ates, I., et al. Efficacy of ultrasound-guided transversus thoracic muscle plane block on postoperative opioid consumption after cardiac surgery: a prospective, randomized, double-blind study. JCVA<\/em> 2020; 34(11): 2996-3003 \r\n2.\tCakmak, M., Isik, O. Transversus thoracic muscle plane block for analgesia after pediatric cardiac surgery. JCVA<\/em> 2021; 35(1): 130-136 \r\n3.\tUeshima, H., Kitamura, A. Clinical experiences of ultrasound-guided transversus thoracic muscle plane block: a clinical experience. J Clin Anesth<\/em> 2015; 27: 428-429 \r\n4.\tDost, B., De Cassai, A., Amaral, S., et al. Regional anesthesia for pediatric cardiac surgery: a review. BMC Anesthesiology<\/em> 2025; Retrieved at: https:\/\/bmcanesthesiol.biomedcentral.com\/articles\/10.1186\/s12871-025-02960-z#ref-CR1\r\n5.\tEl-Boghdadly K, Wolmarans M, Stengel AD, et al. Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks. Reg Anesth Pain Med<\/em>. 2021;46(7):571-580. doi:10.1136\/rapm-2020-102451\r\n”,”hint”:””,”answers”:{“kjdni”:{“id”:”kjdni”,”image”:””,”imageId”:””,”title”:”A.\tLateral branches of the intercostal nerves”},”05i0i”:{“id”:”05i0i”,”image”:””,”imageId”:””,”title”:”B.\tAnterior cutaneous branches of the intercostal nerves”,”isCorrect”:”1″},”u1tts”:{“id”:”u1tts”,”image”:””,”imageId”:””,”title”:”C.\tPectoral nerves”}}}}}}

{“questions”:{“0hewp”:{“id”:”0hewp”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Author: Anila B. Elliott, MD, University of Michigan – C.S. Mott Children\u2019s Hospital \r\nA 16-year-old boy with hypoplastic left heart syndrome is undergoing a heart transplant for failing Fontan. He is currently on citalopram for a history of depression. After separating from cardiopulmonary bypass, he remains severely hypotensive despite fluid administration, high dose epinephrine, norepinephrine, vasopressin, milrinone and inhaled nitric oxide. Transthoracic echocardiogram shows hyperdynamic function. Which of the following is the MOST appropriate next step for treatment of his vasoplegia? \r\n”,”desc”:”EXPLANATION \r\nDespite excellent outcomes for Fontan patients in the current era, with 20-year survival of over 85%, many of these patients will require a cardiac transplant.^{1<\/sup> These patients are considered high-risk for vasoplegia following cardiopulmonary bypass (CPB).2<\/sup> Vasoplegic shock is characterized by severe and persistent hypotension (mean arterial pressure < 50mmHg in adolescent and adult patients) with normal or slightly increased cardiac output, low systemic vascular resistance (SVR), lack of fluid responsiveness, and high-dose vasopressor requirement. This can occur in over 30% of patients who undergo heart transplantation.2<\/sup> Patients with Fontan physiology undergoing heart transplantation face additional risks, including long-standing vascular changes that can result in decreased SVR, complex pulmonary artery reconstruction, and prolonged surgical dissection times leading to extended CPB duration. Extensive surgical dissection, chronic liver congestion with decreased production of clotting factors, and aspirin use increase the risk of hemorrhage and need for blood products which can also increase the systemic inflammatory response in a patient population already at risk for vasoplegia due to long-standing vascular changes. Other factors that may contribute include aortopulmonary collaterals (APCs) that can account for 10-50% of total systemic cardiac output, leading to recirculation and increased volume load on the systemic ventricle pre-operatively. Although these are often intervened-upon prior to transplantation, smaller APCs can potentially contribute to volume load on the new graft as well as a high-output state, contributing to vasoplegia. \r\n\r\n\r\nAngiotensin II (Giapreza) was approved by the FDA in 2017 to treat hypotension in adults with distributive shock based on data from the ATHOS-3 trial.3<\/sup> The ATHOS-3 trial (Angiotensin II for the Treatment of High-Output Shock) was a pivotal clinical study to evaluate the efficacy and safety of angiotensin II in patients that remained hypotensive despite high-dose vasoactive medications. This was a double-blinded, randomized, placebo-controlled study, which showed that a significant number of patients had improvement in mean arterial pressure compared to those who received placebo. Angiotensin II acts on angiotensin type I receptors leading to vasoconstriction and activation of the sympathetic nervous system. The recommended starting dose is 20 nanograms\/kg\/min (0.02mcg\/kg\/min). The dose can be titrated every 5 minutes by 15ng\/kg\/min. Recommended maximum dose is not to exceed 80ng\/kg\/minute within the first 3 hours of treatment according to the manufacturer\u2019s guidelines (https:\/\/www.giapreza.com\/using-giapreza). Maintenance doses typically should not exceed 40ng\/kg\/min. Although the data is limited, there are small single-center trials and case reports of use in pediatric patients. In these publications, Angiotensin II infusion has shown improvement in mean arterial pressure in children with catecholamine-resistant vasodilatory shock.4<\/sup>\r\n\r\n\r\nThe correct answer is B. The patient is hypotensive despite multiple vasopressor infusions.\r\n\r\n\r\nAlthough milrinone discontinuation may result in some increase of mean arterial blood pressure, its long half-life of 2-2.5 hours may limit the effectiveness of this change. A more specific targeted therapy with another potent vasopressor such as angiotensin II is more likely to be effective in severe catecholamine-resistant vasoplegia, as seen in this patient. \r\n\r\n\r\nWhile methylene blue can decrease vasopressor requirements, it may also increase pulmonary vascular resistance. 2<\/sup> In addition, its monoamine oxidase inhibitor effects are contraindicated in patients with a risk of \r\nserotonin syndrome.5<\/sup> Given this patient\u2019s history of depression and selective serotonin reuptake inhibitor use, it is best to avoid methylene blue in this patient.\r\n\r\n\r\n\r\n\r\n \r\nREFERENCES \r\n\r\n1.\tMcCormick, AD., Schumacher, KR. Transplantation of the failing Fontan. Translational Pediatrics 2019; 8(4) \r\n2.\tChan, JL., Kobashigawa, JA., Aintablian, TL., et al. Characterizing predictors and severity of vasoplegia syndrome after heart transplantation. Ann Thorac Surg<\/em>. 2018; 105: 770-777 \r\n3.\tKhanna, A., English, SW., Wang, XS., et al for the ATHOS-3 Investigators. Angiotensin II for the treatment of vasodilatory shock. N Engl J Med<\/em>. 2017; 377:419-430 \r\n4.\tTezel, O., Hutson, TK., Gist, KM., et al. Utilization of synthetic human angiotensin II for catecholamine-resistant vasodilatory shock in critically ill children: a single-center retrospective case series. Crit Care Explor<\/em>. 2023; 5(9):e0978 \r\n5.\tOtero Luna, AV., Johnson, R., Funaro, M., et al. Methylene blue for refractory shock in children: a systematic review and survey practice analysis. Pediatr Crit Care Med<\/em>. 2020; 21(6):e378-e386\r\n”,”hint”:””,”answers”:{“rga9m”:{“id”:”rga9m”,”image”:””,”imageId”:””,”title”:”A.\tDiscontinue milrinone”},”wrrbj”:{“id”:”wrrbj”,”image”:””,”imageId”:””,”title”:”B.\tAngiotensin II (Giapreza) infusion”,”isCorrect”:”1″},”bw37e”:{“id”:”bw37e”,”image”:””,”imageId”:””,”title”:”C.\tAdminister methylene blue”}}}}}}

{“questions”:{“aujh4”:{“id”:”aujh4″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Saneeha Shahid, MD AND Nicholas Houska, DO – University of Colorado, Children\u2019s Hospital of Colorado \r\n\r\nA 31-year-old woman with a history of Tetralogy of Fallot repaired in infancy presents with worsening dyspnea and fatigue. Transthoracic echocardiography and cardiac magnetic resonance imaging demonstrate severe right ventricular dilation due to severe pulmonary insufficiency. A 24-hour Holter monitor demonstrates predominately normal sinus rhythm with 2% premature ventricular contractions and a QRS duration of 200 milliseconds. Which of the following studies is MOST appropriate to obtain before surgical pulmonary valve replacement?”,”desc”:”EXPLANATION \r\nArrhythmias remain a common cause of morbidity and mortality in patients after repair of Tetralogy of Fallot (ToF), with 43% of patients having sustained arrhythmias or needing intervention. As this patient population continues to grow and age, the incidence of both atrial and ventricular arrhythmia continues to increase as well. The mechanism of atrial and ventricular arrhythmias differs, but both can significantly impact long-term outcomes and management. Recent consensus statements discuss the incidence and mechanism of these arrhythmias, and more importantly, recommendations for risk stratification and management. \r\n\r\nOf the patients with arrhythmias after ToF repair, 20% were atrial arrhythmias. These patients are at an increased risk of developing reentrant tachycardia, atrial flutter, and atrial fibrillation. Interestingly, as many as 38% of patients develop multiple types of atrial arrhythmias. The mechanism of atrial arrhythmia is most likely related to residual cardiac lesions associated with atrial dilation and\/or tricuspid regurgitation. Common risk factors for the development of atrial fibrillation, including age, reduced ejection fraction, cardiac surgery, and left atrial dilation, are similar in the adult population with repaired ToF. Atrial arrhythmias are associated with worsened cardiovascular outcomes. Recommendations for management are evolving, but evidence supports ablation over medical management, with a focus on rhythm over rate control. Anticoagulation is also part of arrhythmia management per standard guidelines for stroke prevention. Additionally, patients are at risk for developing bradyarrhythmia after ToF repair and should follow standard guidelines for evaluation and management, which may require pacemaker insertion.\r\n\r\nVentricular arrhythmias are also common after ToF repair and are considered the most common cause of sudden cardiac death in this population. Monomorphic ventricular tachycardia is the most common ventricular arrhythmia observed in this patient population. The likely contributing factors include the original congenital cardiac defect and the type of surgical correction. Patch material, fibrosis, and valve annuli create areas of conduction block and substrate for reentrant electrical conduction. Risk factors for ventricular arrhythmias include age, QRS duration and morphology, type of surgical repair, ventricular dysfunction, and right ventricular hypertrophy. Management guidelines continue to evolve but focus on referring patients for an electrophysiology study with ablation and\/or cardiac implantable electronic device insertion as primary or secondary prevention. Special consideration must be given to the patient population undergoing pulmonary valve intervention. Current guidelines support electrophysiology study and\/or ablation before surgical or transcatheter pulmonary valve replacement in patients with the aforementioned risk factors. \r\n\r\nThe correct answer is C. Given the surgical history and Holter monitor results described for the patient in the stem, an electrophysiology study and possible ablation are appropriate before pulmonary valve replacement. Coronary angiography identifies coronary anatomy for surgical or transcatheter valve replacement but is invasive, and this information can often be obtained with computed tomography angiography. Routine pulmonary function testing is not necessary before surgery unless pulmonary disease is suspected to be the cause of this patient\u2019s symptoms. In this case, the symptoms are readily explained by her cardiac history and diagnostic studies. \r\n\r\n\r\n \r\nREFERENCES \r\nKrieger EV, Zeppenfeld K, DeWitt ES, et al. Arrhythmias in repaired Tetralogy of Fallot: a scientific statement from the American Heart Association. Circ Arrhythm Electrophysiol<\/em>. 2022;15(11):e000084.\r\n\r\nWaldmann V, Bessi\u00e8re F, Gardey K et al. Systematic Electrophysiological Study Prior to Pulmonary Valve Replacement in Tetralogy of Fallot: A Prospective Multicenter Study. Circ Arrhythm Electrophysiol<\/em>. 2023 Jun;16(6):e011745. \r\n”,”hint”:””,”answers”:{“ycks6”:{“id”:”ycks6″,”image”:””,”imageId”:””,”title”:”A.\tCoronary angiography”},”enjvs”:{“id”:”enjvs”,”image”:””,”imageId”:””,”title”:”B.\tPulmonary function tests”},”fglpo”:{“id”:”fglpo”,”image”:””,”imageId”:””,”title”:”C.\tElectrophysiology study”,”isCorrect”:”1″}}}}}

{“questions”:{“ntcoq”:{“id”:”ntcoq”,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Gibbs Yim, MD AND Nicholas Houska, DO – University of Colorado, Children\u2019s Hospital Colorado \r\n\r\nA 5-year-old boy presents with recurrent respiratory infections, chronic cough, and dysphagia. Computed tomography of the lungs confirms a right aortic arch with an aberrant left subclavian artery, consistent with a vascular ring. Which of the following vascular anomalies is MOST likely associated with this lesion? \r\n\r\n\r\n”,”desc”:”EXPLANATION \r\nKommerell\u2019s diverticulum is an aneurysmal dilation at the base of the left subclavian artery (LSA). It is most commonly associated with a right aortic arch and aberrant LSA but may also occur in a double aortic arch. Embryologically, the diverticulum is formed from the distal left fourth aortic arch. The tissue of the diverticulum is abnormally friable. A histopathologic study of resected diverticular tissue demonstrated cystic medial necrosis in more than half of the cases (Luciano et al.).\r\n\r\nA right aortic arch with aberrant LSA and left ligamentum arteriosum creates a vascular ring in which the trachea and esophagus are encircled by the pulmonary trunk and aorta anteriorly, the aortic arch to the right, an aberrant (retroesophageal) LSA posteriorly, and ligamentum arteriosum to the left. Right arch with aberrant LSA can present with symptoms of tracheoesophageal compression. When compared with a double aortic arch, a vascular ring due to a right arch with aberrant LSA generally presents later in childhood with less severe symptoms. In comparison with other right arch variants, it is less commonly associated with other congenital cardiac anomalies. If repair of the vascular ring is performed by simple ligation of the ligamentum without resection of the diverticulum, respiratory or esophageal symptoms may recur, then requiring additional surgical intervention. Additionally, the diverticulum is at risk for aneurysmal enlargement, rupture, and dissection. Therefore, primary resection of the Kommerell’s diverticulum is often recommended at the time of vascular ring repair. More conservative approaches include observation of the diverticulum, vessel plication, or vessel ligation. \r\n\r\nRepair of the vascular ring in a patient with a right aortic arch and aberrant LSA consists of ligation of the ligamentum arteriosum, resection of the Kommerell’s diverticulum, and reimplantation of the LSA onto the left common carotid artery. During diverticulum resection and LSA reimplantation, a portion of the descending aorta and the left common carotid artery may be clamped temporarily, which can impair perfusion to the abdominal organs and cerebral circulation, respectively. Intraoperative monitoring may include invasive or non-invasive blood pressure measurements of the right upper extremity, bilateral cerebral near-infrared spectroscopy, and either pulse oximetry or noninvasive blood pressure measurement of the lower extremities. Postoperative chylothorax is a known complication of vascular ring repair. \r\n\r\nThe correct answer is B. A right aortic arch with aberrant LSA is commonly associated with Kommerell\u2019s diverticulum. While interruption and coarctation of the aorta can be present in patients with a right aortic arch, they are much less common in the absence of a diagnosis of heterotaxy.\r\n\r\n\r\n \r\nREFERENCES \r\nLuciano D, Mitchell J, Fraisse A, Lepidi H, Kreitmann B, Ovaert C. Kommerell diverticulum should be removed in children with vascular ring and aberrant left subclavian artery. Ann Thorac Surg<\/em>. 2015;100(6):2293-2297.\r\n\r\nWorhunsky DJ, Levy BE, Stephens EH, Backer CL. Vascular rings. Semin Pediatr Surg<\/em>. 2021c;30(6):151128. doi: 10.1016\/j.sempedsurg.2021.151128. Epub 2021 Oct 23. PMID: 34930596.\r\n”,”hint”:””,”answers”:{“u95qt”:{“id”:”u95qt”,”image”:””,”imageId”:””,”title”:”A. Coarctation of the aorta”},”78esu”:{“id”:”78esu”,”image”:””,”imageId”:””,”title”:”B. Kommerell\u2019s Diverticulum”,”isCorrect”:”1″},”2hg8h”:{“id”:”2hg8h”,”image”:””,”imageId”:””,”title”:”C. Interrupted aortic arch”}}}}}

{“questions”:{“wy4e3”:{“id”:”wy4e3″,”mediaType”:”image”,”answerType”:”text”,”imageCredit”:””,”image”:””,”imageId”:””,”video”:””,”imagePlaceholder”:””,”imagePlaceholderId”:””,”title”:”Authors: Destiny F. Chau, MD – Arkansas Children\u2019s Hospital\/University of Arkansas for Medical Sciences, Little Rock, AR AND Meera Gangadharan, MBBS, FAAP, FASA Children\u2019s Memorial Hermann Hospital, University of Texas Health Science Center, Houston, TX \r\n\r\nA 14-year-old patient with a history of long QT syndrome, not currently under treatment with medication or device therapy, is undergoing an appendectomy. During anesthesia emergence, sinus tachycardia at 150 bpm with non-sustained runs of Torsades de pointes are observed. Which of the following pharmacologic treatments for the arrhythmia has the HIGHEST risk of causing hemodynamic instability?”,”desc”:”EXPLANATION \r\nCongenital long QT syndrome (LQTS) is characterized by QT_{c<\/sub> prolongation on the electrocardiogram (ECG) and is associated with increased risk of life-threatening cardiac arrhythmias. LQTS results from heterogeneous genetic abnormalities of potassium or sodium ion channels involved in ventricular repolarization. It is the most common inherited arrhythmia syndrome, occurring in 1 out of every 2,500 individuals. It is associated with syncope, polymorphic ventricular tachycardia (Torsades des pointes) and sudden cardiac arrest. The rate of cardiac events is directly proportional to the degree of QTc<\/sub> prolongation. \r\n\r\nThe genetic mutations associated with LQTS are categorized into three subtypes, accounting for 95% of LQTS, and include LQT1, LQT2, and LQT3. LQT1 and LQT2 relate to mutations affecting potassium channels whereas in LQT3, mutations affect sodium channels. Patients with LQT1 are most triggered by sudden increases in sympathetic tone, such as stress or exercise. This is particularly notable with swimming, which has been associated with drowning in seemingly healthy young individuals. Patients with LQT2 are more prone to emotional stress, such as being frightened or startled. Patients with LQT3 are more likely to have events at rest. \r\n\r\nNonselective beta-blockers are first-line therapy, which can significantly decrease symptomatology, especially in those with LQT1 genotype. Cardiac sympathetic denervation can reportedly reduce the frequency of cardiac arrhythmia and is considered for patients who are intolerant of beta blockers or are poor candidates for cardiac implanted electronic devices.\r\n\r\nPerioperative considerations for patients with LQTS include continuing beta blockers, reducing sympathetic stimulation, avoiding QTc<\/sub> prolonging drugs, and ensuring normal electrolytes, especially potassium, calcium, and magnesium. Although many perioperative anesthetic drugs can prolong the QTc<\/sub>, they can be used without untoward effects. The recommendation is to minimize the simultaneous occurrence of arrhythmogenic triggers, such as avoiding the administration of QTc<\/sub> prolonging drugs during periods of catecholamine surges, for example administering ondansetron during anesthesia emergence. For treatment of sinus tachycardia, esmolol is a good choice for rapid rate control. Further, should Torsades des pointes (TdP) occur, magnesium sulfate is the treatment of choice. Lidocaine, a sodium channel blocker, is also safe to use for ventricular arrhythmias associated with LQTS because it does not prolong the QTc<\/sub> interval. Antiarrhythmic class III agents, such as amiodarone and sotalol, should be avoided because they prolong the action potential duration and refractoriness, which may exacerbate this arrhythmia.\r\n\r\nThe correct answer is C. Amiodarone can worsen the TdP, thus it should be avoided. This patient is having sinus tachycardia with non-sustained runs of TdP, therefore esmolol can be used for rate control of the sinus tachycardia, while lidocaine can be used to treat the non-sustained runs of TdP. Ultimately, magnesium is the treatment of choice for TdP. Cardioversion should be used in the setting of hemodynamically unstable arrhythmias.\r\n\r\n \r\nREFERENCES \r\n\r\nKuntz MT, Eagle SS, Dalal A, Samouil MM, Staudt GE, Londergan BP. What an anesthesiologist should know about pediatric arrhythmias. Paediatr Anaesth<\/em>. 2024;34(12):1187-1199. doi:10.1111\/pan.14980\r\n\r\nShah MJ, Silka MJ, Silva JNA,et al. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients. Heart Rhythm<\/em>. 2021;18(11):1888-1924. doi:10.1016\/j.hrthm.2021.07.038\r\n\r\nValdes SO, Kim JJ, Miller-Hance W. Arrhythmias: Diagnosis and Management. In: Andropoulos DB, Mossad EM, Gottlieb EA, ed. Anesthesia for Congenital Heart Disease<\/em>. 4th ed. Hoboken, New Jersey: Wiley-Blackwell; 2023: 674-709\r\n\r\n”,”hint”:””,”answers”:{“l7tcu”:{“id”:”l7tcu”,”image”:””,”imageId”:””,”title”:”A. Esmolol”},”xy3od”:{“id”:”xy3od”,”image”:””,”imageId”:””,”title”:”B. Lidocaine”},”v0j2h”:{“id”:”v0j2h”,”image”:””,”imageId”:””,”title”:”C. Amiodarone”,”isCorrect”:”1″}}}}}}