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Arrhythmias Post Tetralogy of Fallot Surgical Repair Joseph Atallah, MD CM, SM Division of Pediatric Cardiology Section of Electrophysiology.

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Presentation on theme: "Arrhythmias Post Tetralogy of Fallot Surgical Repair Joseph Atallah, MD CM, SM Division of Pediatric Cardiology Section of Electrophysiology."— Presentation transcript:

1 Arrhythmias Post Tetralogy of Fallot Surgical Repair Joseph Atallah, MD CM, SM Division of Pediatric Cardiology Section of Electrophysiology

2 Outline Why is there a risk of arrhythmias Arrhythmia classification Recognition Treatment Longterm outcomes Summary

3 Arrhythmias … Why?

4 Incidence – Up to 36% of post-op TOF patients will experience some arrhythmic event, mostly insignificant and brief – Majority resolve within 48 hrs post-op Risk factors – Young age at surgery – Longer bypass and aortic cross-clamp time – Complexity of repair

5 Arrhythmia Classification SLOW FAST.

6 Arrhythmia Classification SLOW – Sinus bradycardia – Heart block FAST – Sinus tachycardia – Atrial tachycardia – Supraventricular tachycardia – Junctional tachycardia – Ventricular tachycardia

7 Arrhythmia Classification SLOW – Sinus bradycardia Intrinsic: sinus node dysfunction (rare) Extrinsic: medications (sedation …), increased ICP … – Heart block Results from damage to the AVN, His bundle or bundle branches FAST – Sinus tachycardia Common: medications (inotropes, sedation …), hemodynamic stress … – Atrial tachycardia Rare – Supraventricular tachycardia ORT or AVNRT or atrial flutter – Junctional tachycardia Relatively common: multifactorial – Ventricular tachycardia Rare, more of an issue years post-op

8 Definition and Recognition

9 Heart Block SLOW – Heart block Incidence is 1-3% of all pediatric open heart surgeries Often recognized in the operating room However, may be acute or gradual in onset in first few days post-op Highest risk surgeries – LVOTO surgery – VSD Closure – TOF – ccTGA Definition: more P waves than QRS complexes (more As than Vs)

10 Heart Block SLOW –H–Heart block 2 nd degree (partial) –N–Not every atrial beat is conducted to the ventricle = ventricular rate is slower than the atrial rate (2:1, 3:1 …) 3 rd degree (complete) –N–No (zero) atrial beat is conducted to the ventricle –E–Extreme: HR (VR) = 0 … flat line … bad news … please help! –M–Most common: ventricular escape rhythm at a certain rate »I»Inadequate slow vs. acceptable rate »N»Narrow vs. wide complex QRS

11 P QRS ?T P QRS PP 2 1

12 Heart Block P PP QRS

13 Heart Block Narrow QRS Wide QRS

14 Heart Block

15 Arrhythmia Recognition FAST –S–Supraventricular Tachycardia Usual rate between 180 and 280 bpm Sudden onset and termination Minimal HR variation during SVT –J–Junctional Tachycardia Usual rate between 160 and 230 bpm Gradual onset and termination HR variation during JET

16 Junctional Tachycardia Onset within the first 24 hrs post-op Due to stress injury around the AV node and the His bundle Inappropriate accelerated rhythm with the same QRS morphology as sinus rhythm Often with more Vs then As = VA dissociation Most common after TOF repair

17 Junctional Tachycardia QRS P V A V A V V A

18 Junctional Tachycardia

19 VVVVVAAAA V A

20 Treatment

21 SLOW Weaning sedation Warming up Medications – Atropine – Isoproterenol – Epinephrine Pacing – Atrial, ventricular or both

22 FAST Optimize hemodynamics Correcting electrolyte and acid-base disturbances Weaning certain inotropes (e.g. Epi, Dexmetomedine) Optimizing sedation Cooling Anti-arrhythmic drugs – Procainamide – Amiodarone – Esmolol Overdrive atrial pacing

23 Outcomes

24 Long-term Outcomes Heart Block – At least 60% resolve in the first month post-op ~90% of those will occur in the first 10 days post-op – Remaining require a permanent pacemaker implantation despite the possibility of late recovery of AV conduction Supraventricular tachycardia – May resolve – Medical therapy or ablation Junctional tachycardia – May be very resilient and life threatening – Usually resolves within 2 days but may last 8 days

25 Summary Most common arrhythmias post surgical repair of TOF – Heart block – Junctional tachycardia A simple analytical approach to recognition Multiple treatment options, ultimately: – Pacing for heart block – AAD for junctional tachycardia Long-term outcomes: – Heart block: 30-40% will require pacing – ST and JT usually resolve early on


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