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Postoperative arrhythmias:
Treatment options in children
Alpay Celiker M.D.
Professor of Pediatric Cardiology
Acıbadem University, Istanbul, Turkey
Congenital Heart Defects in Newborn
8%
Cardiac Operation
60 %
Possibility to reach adulthood
85%
Major Issues in ACHD
Primary Operation or intervention
 Reoperation or reintervention
 Heart Failure



Sudden Death
Kaemmerer H et al.
Conditions with Specific
Interest
Repaired tetralogy of Fallot
 Atrial switch procedures
 Fontan circulation

Cardiac Surgery&Arrhythmias

Corrected tetralogy of Fallot
– Atrial arrhythmias
– Ventricular arrhythmias

Atrial switch for D-TGA
– Atrial arrhythmias
– Sick sinus syndrome

Fontan circulation
– Atrial arrhythmias
– Sick sinus syndrome
Case 1

11 years old boy suddenly collapsed
with a ventricular tachycardia







DC cardioversion by
paramedics
Restoration of normal
sinus rhythm
History: Total correction
for FT at 1 month old
ECG: RBBB, QRS= 130
msn
ECHO: Mild PR, normal
LV function
MRI: Normal RV EF,
mild PR
Cardiac Cath and
Electrophysiologic Study
Normal hemodynamic findings
 Mild PR
 Normal AV and sinus node function
 No inducible SVT
 Ventricular stimulation:

– VT induction with two PES
• Monomorphic VT with LBBB
• Rate 270 beats/min
Oral amiodarone 10 mg/kg,
propranolol 1 mg/kg started
 EPS after ten days  VT  ICD

How we can know the risk before??
Noninvasive methods
Invasive methods
Total Correction and
Arrhythmias

Ventricular arrhythmias
– Late operation\Long follow-up duration
– Residual VSD
– Severe Pulmonary regurgitation
Atrial arrhythmias
 Sinus node and AV conduction
disorders

MRI
Right ventricle size
 Right ventricle ejection fraction
 Degree of PR
 Late enhancement with Gadolinium

Hacettepe Series: 46 patients
Study Design
Postop FT
History
Resuscitation in one
Syncope in five
Palpitation in 12
significant PR, TR
right ventricular dysfunction
residuel lesions
MRI
Hemodynamic study
Electrophysiological study
Electrophysiological
Findings
Normal
Sustained AF+fibroflutter
Patient Number
%
15
35
8
18,6
Non-sustained AF
3
6,9
SSS and AV conduction
problem
8
18,6
Non-sustained VT
5
11,6
Sustained VT*
4
9,3
43
100
Total
Case 2.
Atrial switch at two years of age
 TV replacement at 10 years of age
 Sinus bradycardia
 Syncope
 Holter; Nonsustained wide QRS
tachycardia
 Electrophysiologic study

Programmed ventricular
stimulation
VF and DC Shock

Atrial flutter
– AA treatment,
catheter ablation,
antitachycardia
pacemaker

Sick sinus
syndrome
– Brady pacing
Mustard
Senning
Procedures
Fontan Circulation
Arrhythmia: 41 % sustained IART
and many of them SSS findings
 Protein Losing Enteropathy (PLE)
 Ventricular Dysfunction
 Thromboembolism
 Conduit obstruction
 Pulmonary artery stenosis
 Pulmonary arterivenous fistulae
 Plastic bronchitis

Fontan & Arrhythmia

SSS or AV Block
– Epicardial pacing
– Pacing from coronary
sinus

IART or atrial
flutter
– DC cardioversion
– AA drug therapy
– Catheter ablation with
3D mapping
– Arrhythmia surgery
Case 3
23 year old male student suddenly
collapsed
 Ventricular fibrillation 
Defibrillated several times
 Brain edema resolved in the
following days
 History:

– Total correction for FT at 3 years old
– Transannular patch, previous shunt
– QRS 180 ms
Cardiac cath &
Electrophysiology
It was performed 5 years ago
 No RVOT gradient, normal PA
pressure
 Aneursymal dilation at RVOT
 Severe PR & moderate TR
 Enlarged RV
 EPS: NS Atrial Flutter, NO NSVT
OR SMVT

Noninvazive and invazive
tests

Noninvazive

Invazive
–
–
–
–
–
QRS duration: > 180 ms
QT dispertion
SAECG: Abnormal
Holter monitorisation: SMVT
Exercise testing
– Cardiac Electrophysiologic study
Indications for Invasive
Evaluation
Syncope of unknown origin
 Resusciated sudden cardiac arrest
 Ventricular tachycardia on Holter ECG
 Exercise induced/aggrevated
ventricular tachycardia/arrhythmia
 During invasive cardiac catheterisation
 Drug-electrophysiologic study

Intervention



Hemodynamic study and
angiocardiography
Diagnostic electrophysiologic study
Interventional treatment (Stents,
PVR’s)

Interventional electrophysiology

Pacemaker-defibrillator implantation
Mapping with Ensite
Velocity
Conclusion
Arrhytmia is a common problem in
patients with operated CHD
 Atrial tachycardia is more frequent
in patients with Senning/Mustard
and Fontan surgery.
 Interventional and surgical approach
are needed in patients with
residual/recurrent lesions.

Conclusion II
Serious arrhythmias may occur in
patients without residual cardiac
lesions.
 Cardiac electrophysiologic study should
be done symptomatic patients.
 3D mapping and new ablation methods
should be used in the treatment of
patients with tachycardia.

Treatment Options
Symptoms
&
frequency
Arrhythmia
Type
Age of patient
AA treatment
results
ABLATION
AAD
DEVICE
INTERVENTION
Complication
Risk
Arrhythmic
sudden
death risk
CHD Type
&
Hemodynamic
Status