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Transcript
Rhythm Problems Atrioventricular Septal Defect Alpay Çeliker MD. Hacettepe University Department of Pediatric Cardiology Conduction System in AVSD Normal Heart AV node is located in the triangle of Koch AV Septal Defect AV node is located posteriorly ECG in AVSD 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 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 Abnormalities inherent to malformation Hemodynamic and hypoxic stress upon heart Sequela of reparative surgery Residual hemodynamic problems Rhythm Problems in AVSD Preoperative Rhythm Problems Perioperative Rhythm Problems Postoperative Rhythm Problems Preoperative Arrhythmias Acquired atrial tachyarrhythmias Late operation Atrial fibrillation may be seen 20 % and causes clinical deterioration AV block Perioperative Arrhythmias Junctional Ectopic Tachycardia 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 ventricular rate Loss of AV synchrony Cardiac Output Adrenergic Tone Heart Rate JET: ECG Diagnosis 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 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 General Measures 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 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 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 Atrial Fibrillation Isthmus Dependent Atrial Flutter (IDAF) Intraatrial Reentrant Tachycardia (IART) Risk of Atrial Reentry Tachycardia High Risk (> 10 %) Fontan palliation Mustard-Senning Total correction for Fallot or DORV Sinus venosus or late repair of ASD II Moderate Risk (1-10 %) TAPVR Ebstein’s anomaly Complete AVSD Mitral valve replacement Low Risk (<1 %) Early repair ASD II VSD repair IART or IDAF Therapy Of Atrial Arrhythmias DC Cardioversion AAD: Class Ic, III AAD & PM Transcatheter RF Ablation Arrhythmia Surgery Correction of residual defects Surgical ablation Maze procedure Transcatheter Ablation 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