Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2years

Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2years Background: Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age. Methods: From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients (n = 96) had postoperative JET. Results: JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca (p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn’t affect the duration of mechanical ventilation nor hospital stay (p = 0.12 and 0.2 respectively) but prolonged the ICU stay (p = 0.011). JET resolved in 39.5% (n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% (n = 30) of patients and its use was associated with longer ICU stay (p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn’t affect ICU (p = 0.43) or hospital stay (p =0.14) however, long duration of JET increased ICU and hospital stay (p = 0.02 and 0.009; respectively). Conclusion: JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential. Keywords: Congenital heart disease, Arrhythmia, Junctional ectopic tachycardia; tetralogy of Fallot Background characteristics among the published studies. [2] Inci- Postoperative junctional ectopic tachycardia (JET) is a dence of JET is higher when the intervention is close to potential life-threatening arrhythmia occurring after the atrioventricular node and bundle of Hiss as in tetral- congenital cardiac surgery. [1] The incidence of JET ogy of Fallot (TOF) and complete atrioventricular canal following congenital cardiac surgery varies widely in lit- (AVC) repair. [1, 3] Several treatment strategies ranging erature which can be attributed to the different diagnos- from pharmacologic agents to atrial cardiac pacing are tic criteria and the great variability in the patients’ used sequentially to lower the ventricular rate and re-establish atrioventricular synchrony. [4–6] Recently, * Correspondence: A_marouky@hotmail.com; the effect of several pharmacologic agents on reducing Ahmed.elmahrouki1@med.tanta.edu.eg; Ael-Mahrouk@KFSHRC.edu.sa postoperative JET was evaluated. [7–9] Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Generalization of preoperative prophylaxis for arrhythmia Research Center, MBC J-16, P.O Box: 40047, Jeddah 21499, Saudi Arabia Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt in all patients undergoing surgery for congenital heart Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 2 of 7 defects is non-practical and preoperative identification of all patients to identify the preoperative rhythm and PR high risk patients is essential. Although many studies were interval, QRS duration were calculated. Preoperative concerned with postoperative arrhythmia, little have fo- heart rate was reported from the anesthesia records after cused on JET following total TOF repair in infants. [1, 10] sedating the patients. Intraoperative variables include The objectives of this study were to characterize patients cardiopulmonary bypass (CPB) time (minutes), aortic with JET, identify its predictors and subsequent complica- cross clamp time (minutes), temperature of the perfus- tions and the effect of various treatment strategies on the ate, use of transannular patch (TAP) and resection of outcomes in selected TOF patients undergoing total repair right RVOT obstructing muscle bundle and the use of before 2 years of age. right atrial or right ventricular approach. Methods Postoperative data Study population We included all patients who had JET whatever its dur- This is a retrospective cohort study performed at King ation and the onset of JET whether intraoperatively or Faisal Specialized Hospital and Research Centre in postoperatively in the intensive care unit (ICU) was Jeddah, Saudi Arabia. A total of 609 patients underwent determined. The criteria used for JET diagnosis were i) surgical TOF repair between January 2003 and Decem- Heart rate > 175 Bpm ii) Absent P wave from lead II of ber 2017. We excluded patients older than 2 years (n = EKG iii) Narrow QRS complexes iv) Ventricular rate fas- 231) and patients with rhythm disturbances or heart ter than atrial rate with AV dissociation. block preoperative (n = 16). Moreover; patients with Protocol of JET management included discontinuation serious postoperative arrhythmia other than JET (n = 17) of unnecessary inotropes, infusion of IV fluids boluses and patients with missing postoperative JET diagnosis for hypovolemic patients with low central venous pres- criteria from the medical records (n = 23) were excluded. sure, cooling (reducing temperature to 36–36.5 °C), and A total of 322 patients were included in the study. sedation. At the same time postoperative electrolyte im- Approval of the institutional review board was obtained balance was aggressively corrected with K, Ca, and mag- before data collection and the need for patients’ consents nesium. Our Intensive care protocol is to maintain was waived due to the retrospective nature of the study. serum K > 4.1 mmol/L, ionized Ca > 1.1 mmol/L and serum Mg > 1.1 mg/dL. During early study period, di- Operative technique goxin was administered at 5 μcg /kg/dose IV once to Surgical repair was performed by consultant level control the ventricular rate. Amiodarone was adminis- cardiac surgeons through median sternotomy. Bicaval tered as a bolus with 5 mg / kg IV over one hour and if cannulation was performed and cardioplegic arrest was JET persisted, further infusion at 5 μcg /kg/min was done by antegrade cold crystalloid cardioplegia. Median given till sinus rhythm was established or the heart rate temperature of the perfusate was 32 °C. Right atrial inci- slowed to an acceptable rate with stable hemodynamic. sion was performed in 98% of the patients for resection Our policy for possible postoperative pacing is to insert of the RVOT obstructing bundles and closure of the ventricular pacing wire unless the patient showed heart ventricular septal defect and trans-annular patch (TAP) block immediately on recovery from CPB, in this case was used in 64% of the patients. Patients who required we insert both atrial and ventricular pacing wires. TAP were mainly operated upon during the early study Dopamine, dobutamine, milrinone, epinephrine adminis- period and our current strategy is to avoid TAP and tration was reported, and we calculated the inotropic preserve the pulmonary valve when possible. Pulmonary score at the time of onset of arrhythmia using the valvotomy was performed in 71 patients (22.5%) and re- following formula: {(dopamine + dobutamine) × 1} + section of the right ventricular outflow tract (RVOT) (milrinone X 20) + {(epinephrine + norepinephrine) × 100}. obstructing bundles was done in 94.7% (n = 305). Con- comitant tricuspid valve repair was performed in 55 pa- Study endpoints tients (17.4%). Preoperative, operative and postoperative variables were used to predict the occurrence of JET. The impact of JET on dur- Data collection ation of mechanical ventilation (hours), ICU stay (days) and Patients’ medical charts were retrospectively reviewed to total duration of hospital stay (days) were analyzed. collect preoperative variables including patients age at the time of surgery, gender, weight (Kg), body surface Statistical analysis area (BSA) (m2), preoperative B-blockers administration, Data presentation associated cardiac anomalies and previous palliative sur- Continuous variables were presented as mean ± Standard gical procedures as modified Blalock-Tausig Shunt. Pre- deviation and categorical variables as number and operative 12 leads electrocardiogram were reviewed in percent. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 3 of 7 Data analysis Table 1 Comparison of the preoperative and operative data between JET and non-JET patients Mann-Whitney test was used to compare continuous variables and for categorical variables Chi2 was used or Variable JET group (n = 96) Non-JET (n = 226) P Fisher Exact test if the frequency is less than 5. Multiple Male (n) 56 (58.3%) 144 (63.7%) 0.36 imputation was used to handle the missing variables. Age (months) 7.5 ± 3 8.35 ± 2.99 0.01 Multivariable logistic regression models were used to Weight (Kg) 6.95 ± 1.8 7.37 ± 2.1 0.11 identify the predictors of postoperative JET. Three BSA (m2) 0.36 ± 0.07 0.37 ± 0.6 0.42 models were constructed from the preoperative, op- Oxygen saturation (%) 82.4 ± 7.7 82.8 ± 8 0.14 erative and postoperative variables respectively and Cyanotic spells (n) 20 (21.7%) 42 (19%) 0.58 the variables in each model didn’t exceed 9 variables to power the multivariable analysis. Odds ratio, EKG p-value and 95% confidence interval were reported. Heart Rate (b/m) 103.7 ± 13.5 99.97 ± 12.97 0.03 The effect of JET on the postoperative outcomes was P duration 0.06 ± 0.01 0.06 ± 0.01 0.7 assessed using propensity score analysis. The P-R interval 0.13 ± 0.02 0.13 ± 0.03 0.7 probability of having JET was calculated using multi- QRS 0.06 ± 0.02 0.06 ± 0.01 0.5 variable logistic regression model after adjustment of Pulmonary annulus (mm) 6.36 ± 2 6.47 ± 2.1 0.57 the measured preoperative confounders. Propensity scorewasused intheadjustedmodel to predictthe RVOT gradient (mmHg) 70.8 ± 14.6 71.5 ± 15.1 0.61 effect of JET on the postoperative outcomes. To fulfil Cross-Clamp time (min) 74.4 ± 2.6.5 75.3 ± 27.1 0.77 the linearity assumptions of the model, non-normally Cardiopulmonary 102.1 ± 31.1 101.3 ± 32 0.7 distributed continuous variables were rescaled by, bypass (min) inverse squared and inverse transformations. P-value Temperature (Celsius) 32 ± 1.5 31.7 ± 1.5 0.12 lesser than 0.05 was considered significant. All statis- Tricuspid valve repair (n) 13 (13.5%) 42 (19%) 0.24 tical analyses were performed using STATA 14 Pulmonary valvotomy (n) 25 (26.6%) 47 (20.7%) 0.25 software (Statacorp, Texas- USA). RA approach (n) 93 (96.9%) 223 (98.7%) 0.28 Results RVOT resection (n) 91 (94.8%) 214 (94.7%) 0.97 A total of 322 patients had tetralogy of Fallot repair Trans-annular patch (n) 66 (68.75%) 141 (62.39%) 0.27 during the study period and met the inclusion criteria. Continuous variables are presented as mean ± SD and categorical variables as Patients’ age at time of operation ranged from 2 to number (%) RA right atrial, RVOT right ventricular outflow tract 23 months and male to female ratio was 1.6: 1. JET oc- curred in 96 patients (29.9%) and patients were classified into JET and non-JET groups. difference in patients who received dopamine, dobuta- mine, epinephrine and milrinone between JET and Patients’ characteristics non-JET patients. Levels of serum potassium, calcium Patients who had postoperative JET were significantly and magnesium before the onset of JET were compared younger (p = 0.01) and had higher preoperative heart rate and showed significantly lower magnesium level in (p = 0.03). Associated lesions were Atrial Septal Defect (n patients who developed JET (p = 0.001). (Table 2). = 6), complete AVC (n = 3), persistent Left Superior Vena Cava (n = 1), Patent Ductus Arteriosus (n = 7), Multiple Factors associated with JET Aorto- Pulmonary Collateral Arteries (n = 2), peripheral By multivariable analysis of the measured preoperative pulmonaryarterystenosis(n = 3), pulmonary atresia (n = variables, younger age, cyanotic spells, non-use of 5) and 12 patients had prior modified Blalock Taussig B-blockers and higher preoperative heart rate predicted shunt. There was no statistically significant difference in the postoperative JET (p = 0.011, 0.024, 0.001 and 0.018; associated lesion between patients with and without post- respectively). By constructing a separate model for the operative JET (p = 0.8). Fifteen patients in JET group had operative variables, none of the measured operative vari- preoperative B-blockers (19.5%) versus 62 patients (80.5%) ables predicted the postoperative JET. In the postopera- in Non-JET group (p = 0.015). (Table 1). tive variables model; low magnesium and calcium Operative variables are comparable between both independently predicted the occurrence of JET (p = groups with no statistically significant difference in the 0.004 and 0.001; respectively). (Table 3). measured variables. Table 1 shows the comparison of the preoperative and operative variables. Postoperative Effect of JET inotropes administered before the onset of JET were Ventilation time didn’t differ significantly between JET compared between groups and showed no significant patients (23.4 ± 24.7 h) vs non-JET patients (19.5 ± Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 4 of 7 Table 2 Comparison of the inotropes and serum electrolytes in Table 4 Effect of JET on duration of mechanical ventilation, ICU JET and non-JET groups and hospital stay Variable JET group (n = 96) Non-JET (n = 226) P Variable Coefficient P 95% CI Inotropes Ventilation time −1.5 0.123 −0.036–0.004 Dopamine (n) 22 (23.4%) 65 (29.28%) 0.28 ICU stay −0.3 0.011 −0.057–-0.007 Dobutamine (n) 47 (49.5%) 91 (41%) 0.16 Hospital stay − 0.009 0.2 −.025–.007 inverse squared Epinephrine (n) 34 (36.6%) 85 (37.8%) 0.84 inverse Milrinone (n) 47 (50%) 127 (58.3%) 0.18 Inotrope score 12.3 ± 14 9.2 ± 6 0.17 0.17), gender (p = 0.82), body surface area (p = 0.89), Electrolytes preoperative heart rate (p = 0.86), preoperative oxygen PH 7.36 ± 0.066 7.37 ± 0.06 0.16 saturation (p = 0.37), cyanotic spells (p = 0.86), B Potassium (mmol/L) 3.98 ± 0.45 4.07 ± 0.56 0.17 blockers (p = 0.65), CPB time (p = 0.11) and ischemic Magnesium (mEq/L) 1.01 ± 0.39 1.14 ± 0.43 0.001 time (p = 0.24). After adjustment of the preoperative Calcium (mmol/L) 2.32 ± 0.32 2.24 ± 0.35 0.08 variables, no difference was found in duration of JET Continuous variables are presented as mean ± SD and categorical variables as (p = 0.91), ICU stay (p = 0.43), ventilation time (p = 0.52) number (%) and hospital stay (0.14) between both groups. JET resolved in 39.5% (n = 38) of patients responding to conventional measures. At the same time, postopera- 11.6 h, p = 0.11). Patients with JET had longer ICU stay tive electrolyte imbalance was aggressively corrected (6.1 ± 5.8 vs 5 ± 1.9 days, p = 0.01) and longer hospital with K, Ca, and Mg. Fifty-nine patients (61.5%) received stay (15.1 ± 11.2 vs 13.4 ± 6.5 days, p = 0.04). Propensity digoxin and digoxin administration was not significantly score matching was used to estimate the effect of JET on associated with the duration of mechanical ventilation the duration of ventilation, ICU and hospital stay after (p = 0.77), ICU stay (p = 0.43) nor hospital stay (p = adjustment of the measured preoperative variables. JET 0.98) in patients with JET. Amiodarone was used in didn’t affect the duration of mechanical ventilation nor 31.25% (n = 30) of patients and no relation was found hospital stay (p = 0.12 and 0.2 respectively) but signifi- between the use of amiodarone and the duration of cantly prolonged ICU stay (p = 0.011). (Table 4) Hospital mechanical ventilation (p = 0.07) nor hospital stay (p = mortality occurred in 10 patients (3.11%), 4 patients with 0.35). However, amiodarone use was significantly associ- JET (4.1%) versus 6 patients without JET (2.65%) (p = ated with longer ICU stay (p = 0.017). Betablockers were 0.49). (Table 4). used in 58 patients (64.2%) with no significant associ- ation with the duration of mechanical ventilation (p = Course of JET 0.8), ICU (p = 0.37) or hospital stay (p = 0.07). Ventricu- JET was diagnosed post cardiopulmonary bypass and in- lar pacing was required in 4 patients (4.16%) because of side the operation room in 30 patients (30.25%) and in progression into heart block. Five patients (5.2%) had a the ICU in 66 patients (68.75%). Subgroup analysis was second episode of JET, 3 of them were males. Their me- done to identify the difference between patients who had dian age was 7 months (ranged from 6 to 15 months) JET intraoperatively and those who had JET in the ICU. and median oxygen saturation was 80% (ranged from 79 No difference between both groups as regard age (p = to 85%). None of these patients had preoperative B-blockers, 3 of them had TAP and JET occurred intra- operatively in 3 patients. Full recovery occurred in 4 Table 3 Predictors of postoperative JET patients and 1 patients progressed to complete heart Variable OR P 95% CI block and required permanent pace maker. Pre-operative The median duration of JET was 30.5 h and ranged Age 0.86 0.011 0.76–0.97 from 3 to 96 h. Longer duration of postoperative JET “i.e. above the median value” was significantly associated Cyanotic spells 2.9 0.024 1.15–7.41 with lower preoperative oxygen saturation (p = 0.01). B-blockers 0.2 0.001 0.08–0.51 After adjustment of the pre- JET variables, longer dur- Preoperative HR 1.02 0.018 1.004–1.04 ation of JET was significantly associated with prolonged Post-operative ICU (p = 0.02) and hospital stay (p = 0.009) but had no Mg 0.37 0.004 0.19–0.7 significant association with the duration of mechanical Ca 0.4 0.001 0.23–0.7 ventilation (p = 0.21) compared with patients with short OR odds ratio, CI confidence interval JET duration. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 5 of 7 Discussion through RA. Although RA approach in a study of 343 Prophylaxis of arrhythmia after pediatric cardiac surgery patients independently predicted postoperative JET in became the focus of many trials recently. [7, 8, 11, 12] the total patient series, no correlation was made with Generalization of prophylaxis in all patients undergoing their 114 subsets of TOF patients. [20] Our surgical surgery for congenital heart disease is difficult and may strategies have been shifted from the use of TAP to pres- increase the hazard of surgery. In literature, various ervation of the pulmonary valve if possible as it has a factors were found associated with the genesis of JET proved efficacy in reducing the incidence of postopera- after surgical repair of congenital heart disease. Most of tive pulmonary regurgitation. [21] Nevertheless, TAP these studies [1, 10, 13–15] were performed in a wide was not associated with JET in our series. Some authors variety of congenital heart defects. Including all types of documented a significant association between JET and congenital heart defects in risk models to predict post- prolonged ischemic and cardiopulmonary bypass time operative JET underpowers the results as the incidence and higher bypass temperature [17, 22–24]. In our study, of JET varies widely in different congenital heart diseases none of the operative variables predicted the postopera- and procedures. Based on several reports, JET is com- tive JET. Cardiopulmonary bypass time affected JET in monly associated with TOF [1, 10] therefore we included studies which included all congenital heart disease pa- in our series TOF patients who underwent corrective tients. In those patients, CPB time differed significantly surgery before 2 years of age. In our series the incidence between different lesions due to the different surgical of JET was 29.8% and this high incidence of JET can be procedure specific to each lesion Inotropes didn’t predict explained by our strict selection criteria of those JET in our patients. In contrary to this, dopamine or high-risk patients. The incidence of JET following TOF inotropic score were risk factors for JET in other series. repair varied in the published series and ranged from 4 [14, 17] Revision of electrolyte profiles in the sample just to 37%. [8, 16–18] The great variability in JET incidence prior to JET occurrence proved that JET group had sta- could be attributed to the diagnostic criteria used and tistically significant lower serum magnesium and Cal- the wide variability in patients’ characteristics especially cium. Serum magnesium carries a lot of debate among age. [2] Another explanation for this variability is the authors, some documented its significance as a risk fac- low patients number, it is remarkable that lower inci- tor or as prophylactic therapy for JET, [25–27] others dence of JET post TOF repair was documented with less documented that magnesium and calcium levels were number of TOF patients included in the study. More- not significantly different between the two groups. [22] over, we included all patients who expressed JET Our experience in management of JET is to imply con- whether were hemodynamically stable or not. In our ventional strategies as correction of reduced intravascu- study; younger age was significantly associated with in- lar volume, reduce body temperature, titrate inotropes creased risk of postoperative JET and this finding is con- to off if not affecting hemodynamic status of patients sistent with other studies [14]. Younger patients are and aggressively correct electrolyte imbalance. In the generally sicker and smaller hearts are more prone to early period of our study we used digoxin before the ad- damage by surgical technique and retraction. Increased ministration of amiodarone. Some authors [14] didn’t preoperative heart rate predicted postoperative JET. recommend the use of digoxin in JET because its direct Normal range of heart rate depends on patients’ age and action of increasing excitability of all forms of myocar- the definition of tachycardia is not consistent. In order dium, however, it was used to delay atrioventricular to have a standardized condition for all patients, we re- node bundle conduction maintaining a reasonable ported the operation room heart rate after the patients ventricular rate and to counteract the negative inotropic were properly sedated. This also could explain the insig- effect of Class III antiarrhythmic (sotalol and amioda- nificant findings of the preoperative ECG measurements rone). Recently amiodarone has gained popularity in JET as usually they are not taken under standardized condi- treatment or prophylaxis. [5, 8] Many authors stated that tions and patients conditions during ECG recording sig- class III antiarrhythmic drugs (sotalol and amiodarone) nificantly affected these ECG intervals. when given orally or intravenous, were shown to be al- Preoperative B-blockers were associated with signifi- most devoid of negative inotropic effects [14, 18], how- cant reduction of postoperative JET in our patients ever amiodarone use was associated with prolonged ICU which is consistent with a previous report. [19] Further stay in our JET patients. randomized studies are required to evaluate Bblockers as In our series the median duration of JET was 30.5 h a preoperative prophylaxis against JET in those high-risk and many cases resolved smoothly without any patients. hemodynamic instability with recurrence of a second Trans-atrial approach is our standardized approach for episode of JET in 5.2% of the patients. Complications in closure of ventricular septal defect and relief of RVOT the form of heart block requiring pacemaker insertion obstruction and 98% of our patients were operated was encountered in 4 patients of the JET group. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 6 of 7 Junctional ectopic tachycardia significantly increased patients with preoperative risk factors could benefit from ICU stay but not the duration of the mechanical ventila- preoperative arrhythmia prophylaxis. JET can be pre- tion of hospital stay. This is explained by the benign vented by aggressive management of postoperative course of our JET patients and the additional treat- electrolyte disturbance. The outcome of JET was not ment required lead to increased ICU stay while there affected by time of JET onset however, prolonged was no effect on total hospital stay. No difference in duration of JET had a negative impact of ICU and patients’ characteristics or the outcome of JET in pa- hospital stay. tients who had JET onset intraoperatively versus those Abbreviations who had JET onset in the ICU. This can be explained BSA: Body surface area; CPB: Cardiopulmonary bypass; ICU: Intensive care by the overlap of the time frame between both groups unit; JET: Junctional Ectopic Tachycardia; RVOT: Right ventricular outflow tract; TAP: Trans-annular patch; TOF: Tetralogy of Fallot and it is recommended for future to classify JET into early and late onset based on time of onset rather Funding than the place of onset. Moreover, the duration of This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. JET had an impact on the patients’ outcome since longer JET episodes lead to prolonged ICU and hos- Availability of data and materials pital stay which is expected due to the increase in Data are available on request to the corresponding author. time required for treating those patients compared Authors’ contributions with shorter JET episodes. IM Conducted the literature search analysis and interpretation of data, AA, In summary, JET post tetralogy of Fallot repair can Conducted the statistical analysis and interpretation of data, HT: Conducted the be predicted based on the preoperative variables. Pre- literature search, EAE: Designed the study, IA, Data Collection, BA, Data Collection, NB, conducted the literature search, MAB, Analysis and interpretation of data, EA, operative cyanotic spells were associated with postop- Involved in the study design, and drafted the manuscript “corresponding author”, erative JET and preoperative B-blockers significantly JA, Supervised the study and conducted the review of data. All authors read and reduced postoperative JET. Postoperative electrolytes approved the final manuscript. imbalance played a role in JET pathogenesis. JET had Ethics approval and consent to participate abenigncourseand didn’t increase hospital mortality The study was approved by the Institutional Review Board Committee of but it prolonged ICU stay. The outcome of JET was King Faisal Specialist hospital and research center Jeddah, Saudi Arabia. The affected by the duration of JET episode but not the need for informed consent was waived due to the retrospective nature of the study. time of onset. Competing interests Study strength and limitations The authors declare that they have no competing interests. The major limitation of the study is the retrospective de- sign with its inherited biases. However, this is an accept- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in able design for rare outcomes. Many of the limitations published maps and institutional affiliations. of previously published reports were managed in our study including limiting selection to a specific age and Author details Cardiothoracic Surgery Department, King Faisal Specialist Hospital and pathology in contrast to other studies which included all Research Center, MBC J-16, P.O Box: 40047, Jeddah 21499, Saudi Arabia. types of congenital heart disease and wide range of age. Cardio-thoracic Surgery Department, Mansoura University, Mansoura, Egypt. The relatively large number in our series and the high Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt. 4 5 Cardio-thoracic Surgery Department, Benha University, Benha, Egypt. The incidence of JET in this subset of patients properly Department of Pediatrics, Faculty of Medicine Cairo University, Cairo, Egypt. powered the multivariable analysis. Missing of some variables is another limitation however missing values Received: 16 March 2018 Accepted: 31 May 2018 didn’t exceed 8% (1–7.1%) in the variables used in the analysis and multiple imputation is a suitable method to References handle these missing variables. Recent studies [7, 9] 1. Sahu MK, Das A, Siddharth B, Talwar S, Singh SP, Abraham A, et al. showed that Dexmedetomidine has a role as a prophy- Arrhythmias in children in early postoperative period after cardiac surgery. 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J Thorac Cardiovasc Surg. 2006; 131(6):1296–300. 23. Valsangiacomo E, Schmid ER, Schupbach RW, Schmidlin D, Molinari L, Waldvogel K, et al. Early postoperative arrhythmias after cardiac operation in children. Ann Thorac Surg. 2002;74(3):792–6. 24. Abdelaziz O, Deraz S. Anticipation and management of junctional ectopic tachycardia in postoperative cardiac surgery: single center experience with high incidence. Ann Pediat Cardiol. 2014;7(1):19–24. 25. Dorman BH, Sade RM, Burnette JS, Wiles HB, Pinosky ML, Reeves ST, et al. Magnesium supplementation in the prevention of arrhythmias in pediatric patients undergoing surgery for congenital heart defects. Am Heart J. 2000; 139(3):522–8. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cardiothoracic Surgery Springer Journals

Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2years

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Abstract

Background: Junctional ectopic tachycardia is a serious arrhythmia that frequently occurs after tetralogy of Fallot repair. Arrhythmia prophylaxis is not feasible for all pediatric cardiac surgery patients and identification of high risk patients is required. The objectives of this study were to characterize patients with JET, identify its predictors and subsequent complications and the effect of various treatment strategies on the outcomes in selected TOF patients undergoing total repair before 2 years of age. Methods: From 2003 to 2017, 609 patients had Tetralogy of Fallot repair, 322 were included in our study. We excluded patients above 2 years and patients with preoperative arrhythmia. 29.8% of the patients (n = 96) had postoperative JET. Results: JET patients were younger and had higher preoperative heart rate. Independent predictors of JET were younger age, higher preoperative heart rate, cyanotic spells, non-use of B-blockers and low Mg and Ca (p = 0.011, 0.018, 0.024, 0.001, 0.004 and 0.001; respectively). JET didn’t affect the duration of mechanical ventilation nor hospital stay (p = 0.12 and 0.2 respectively) but prolonged the ICU stay (p = 0.011). JET resolved in 39.5% (n = 38) of patients responding to conventional measures. Amiodarone was used in 31.25% (n = 30) of patients and its use was associated with longer ICU stay (p = 0.017). Ventricular pacing was required in 4 patients (5.2%). Median duration of JET was 30.5 h and 5 patients had recurrent JET episode. Timing of JET onset didn’t affect ICU (p = 0.43) or hospital stay (p =0.14) however, long duration of JET increased ICU and hospital stay (p = 0.02 and 0.009; respectively). Conclusion: JET increases ICU stay after TOF repair. Preoperative B-blockers significantly reduced JET. Patients with preoperative risk factors could benefit from preoperative arrhythmia prophylaxis and aggressive management of postoperative electrolyte disturbance is essential. Keywords: Congenital heart disease, Arrhythmia, Junctional ectopic tachycardia; tetralogy of Fallot Background characteristics among the published studies. [2] Inci- Postoperative junctional ectopic tachycardia (JET) is a dence of JET is higher when the intervention is close to potential life-threatening arrhythmia occurring after the atrioventricular node and bundle of Hiss as in tetral- congenital cardiac surgery. [1] The incidence of JET ogy of Fallot (TOF) and complete atrioventricular canal following congenital cardiac surgery varies widely in lit- (AVC) repair. [1, 3] Several treatment strategies ranging erature which can be attributed to the different diagnos- from pharmacologic agents to atrial cardiac pacing are tic criteria and the great variability in the patients’ used sequentially to lower the ventricular rate and re-establish atrioventricular synchrony. [4–6] Recently, * Correspondence: A_marouky@hotmail.com; the effect of several pharmacologic agents on reducing Ahmed.elmahrouki1@med.tanta.edu.eg; Ael-Mahrouk@KFSHRC.edu.sa postoperative JET was evaluated. [7–9] Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Generalization of preoperative prophylaxis for arrhythmia Research Center, MBC J-16, P.O Box: 40047, Jeddah 21499, Saudi Arabia Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt in all patients undergoing surgery for congenital heart Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 2 of 7 defects is non-practical and preoperative identification of all patients to identify the preoperative rhythm and PR high risk patients is essential. Although many studies were interval, QRS duration were calculated. Preoperative concerned with postoperative arrhythmia, little have fo- heart rate was reported from the anesthesia records after cused on JET following total TOF repair in infants. [1, 10] sedating the patients. Intraoperative variables include The objectives of this study were to characterize patients cardiopulmonary bypass (CPB) time (minutes), aortic with JET, identify its predictors and subsequent complica- cross clamp time (minutes), temperature of the perfus- tions and the effect of various treatment strategies on the ate, use of transannular patch (TAP) and resection of outcomes in selected TOF patients undergoing total repair right RVOT obstructing muscle bundle and the use of before 2 years of age. right atrial or right ventricular approach. Methods Postoperative data Study population We included all patients who had JET whatever its dur- This is a retrospective cohort study performed at King ation and the onset of JET whether intraoperatively or Faisal Specialized Hospital and Research Centre in postoperatively in the intensive care unit (ICU) was Jeddah, Saudi Arabia. A total of 609 patients underwent determined. The criteria used for JET diagnosis were i) surgical TOF repair between January 2003 and Decem- Heart rate > 175 Bpm ii) Absent P wave from lead II of ber 2017. We excluded patients older than 2 years (n = EKG iii) Narrow QRS complexes iv) Ventricular rate fas- 231) and patients with rhythm disturbances or heart ter than atrial rate with AV dissociation. block preoperative (n = 16). Moreover; patients with Protocol of JET management included discontinuation serious postoperative arrhythmia other than JET (n = 17) of unnecessary inotropes, infusion of IV fluids boluses and patients with missing postoperative JET diagnosis for hypovolemic patients with low central venous pres- criteria from the medical records (n = 23) were excluded. sure, cooling (reducing temperature to 36–36.5 °C), and A total of 322 patients were included in the study. sedation. At the same time postoperative electrolyte im- Approval of the institutional review board was obtained balance was aggressively corrected with K, Ca, and mag- before data collection and the need for patients’ consents nesium. Our Intensive care protocol is to maintain was waived due to the retrospective nature of the study. serum K > 4.1 mmol/L, ionized Ca > 1.1 mmol/L and serum Mg > 1.1 mg/dL. During early study period, di- Operative technique goxin was administered at 5 μcg /kg/dose IV once to Surgical repair was performed by consultant level control the ventricular rate. Amiodarone was adminis- cardiac surgeons through median sternotomy. Bicaval tered as a bolus with 5 mg / kg IV over one hour and if cannulation was performed and cardioplegic arrest was JET persisted, further infusion at 5 μcg /kg/min was done by antegrade cold crystalloid cardioplegia. Median given till sinus rhythm was established or the heart rate temperature of the perfusate was 32 °C. Right atrial inci- slowed to an acceptable rate with stable hemodynamic. sion was performed in 98% of the patients for resection Our policy for possible postoperative pacing is to insert of the RVOT obstructing bundles and closure of the ventricular pacing wire unless the patient showed heart ventricular septal defect and trans-annular patch (TAP) block immediately on recovery from CPB, in this case was used in 64% of the patients. Patients who required we insert both atrial and ventricular pacing wires. TAP were mainly operated upon during the early study Dopamine, dobutamine, milrinone, epinephrine adminis- period and our current strategy is to avoid TAP and tration was reported, and we calculated the inotropic preserve the pulmonary valve when possible. Pulmonary score at the time of onset of arrhythmia using the valvotomy was performed in 71 patients (22.5%) and re- following formula: {(dopamine + dobutamine) × 1} + section of the right ventricular outflow tract (RVOT) (milrinone X 20) + {(epinephrine + norepinephrine) × 100}. obstructing bundles was done in 94.7% (n = 305). Con- comitant tricuspid valve repair was performed in 55 pa- Study endpoints tients (17.4%). Preoperative, operative and postoperative variables were used to predict the occurrence of JET. The impact of JET on dur- Data collection ation of mechanical ventilation (hours), ICU stay (days) and Patients’ medical charts were retrospectively reviewed to total duration of hospital stay (days) were analyzed. collect preoperative variables including patients age at the time of surgery, gender, weight (Kg), body surface Statistical analysis area (BSA) (m2), preoperative B-blockers administration, Data presentation associated cardiac anomalies and previous palliative sur- Continuous variables were presented as mean ± Standard gical procedures as modified Blalock-Tausig Shunt. Pre- deviation and categorical variables as number and operative 12 leads electrocardiogram were reviewed in percent. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 3 of 7 Data analysis Table 1 Comparison of the preoperative and operative data between JET and non-JET patients Mann-Whitney test was used to compare continuous variables and for categorical variables Chi2 was used or Variable JET group (n = 96) Non-JET (n = 226) P Fisher Exact test if the frequency is less than 5. Multiple Male (n) 56 (58.3%) 144 (63.7%) 0.36 imputation was used to handle the missing variables. Age (months) 7.5 ± 3 8.35 ± 2.99 0.01 Multivariable logistic regression models were used to Weight (Kg) 6.95 ± 1.8 7.37 ± 2.1 0.11 identify the predictors of postoperative JET. Three BSA (m2) 0.36 ± 0.07 0.37 ± 0.6 0.42 models were constructed from the preoperative, op- Oxygen saturation (%) 82.4 ± 7.7 82.8 ± 8 0.14 erative and postoperative variables respectively and Cyanotic spells (n) 20 (21.7%) 42 (19%) 0.58 the variables in each model didn’t exceed 9 variables to power the multivariable analysis. Odds ratio, EKG p-value and 95% confidence interval were reported. Heart Rate (b/m) 103.7 ± 13.5 99.97 ± 12.97 0.03 The effect of JET on the postoperative outcomes was P duration 0.06 ± 0.01 0.06 ± 0.01 0.7 assessed using propensity score analysis. The P-R interval 0.13 ± 0.02 0.13 ± 0.03 0.7 probability of having JET was calculated using multi- QRS 0.06 ± 0.02 0.06 ± 0.01 0.5 variable logistic regression model after adjustment of Pulmonary annulus (mm) 6.36 ± 2 6.47 ± 2.1 0.57 the measured preoperative confounders. Propensity scorewasused intheadjustedmodel to predictthe RVOT gradient (mmHg) 70.8 ± 14.6 71.5 ± 15.1 0.61 effect of JET on the postoperative outcomes. To fulfil Cross-Clamp time (min) 74.4 ± 2.6.5 75.3 ± 27.1 0.77 the linearity assumptions of the model, non-normally Cardiopulmonary 102.1 ± 31.1 101.3 ± 32 0.7 distributed continuous variables were rescaled by, bypass (min) inverse squared and inverse transformations. P-value Temperature (Celsius) 32 ± 1.5 31.7 ± 1.5 0.12 lesser than 0.05 was considered significant. All statis- Tricuspid valve repair (n) 13 (13.5%) 42 (19%) 0.24 tical analyses were performed using STATA 14 Pulmonary valvotomy (n) 25 (26.6%) 47 (20.7%) 0.25 software (Statacorp, Texas- USA). RA approach (n) 93 (96.9%) 223 (98.7%) 0.28 Results RVOT resection (n) 91 (94.8%) 214 (94.7%) 0.97 A total of 322 patients had tetralogy of Fallot repair Trans-annular patch (n) 66 (68.75%) 141 (62.39%) 0.27 during the study period and met the inclusion criteria. Continuous variables are presented as mean ± SD and categorical variables as Patients’ age at time of operation ranged from 2 to number (%) RA right atrial, RVOT right ventricular outflow tract 23 months and male to female ratio was 1.6: 1. JET oc- curred in 96 patients (29.9%) and patients were classified into JET and non-JET groups. difference in patients who received dopamine, dobuta- mine, epinephrine and milrinone between JET and Patients’ characteristics non-JET patients. Levels of serum potassium, calcium Patients who had postoperative JET were significantly and magnesium before the onset of JET were compared younger (p = 0.01) and had higher preoperative heart rate and showed significantly lower magnesium level in (p = 0.03). Associated lesions were Atrial Septal Defect (n patients who developed JET (p = 0.001). (Table 2). = 6), complete AVC (n = 3), persistent Left Superior Vena Cava (n = 1), Patent Ductus Arteriosus (n = 7), Multiple Factors associated with JET Aorto- Pulmonary Collateral Arteries (n = 2), peripheral By multivariable analysis of the measured preoperative pulmonaryarterystenosis(n = 3), pulmonary atresia (n = variables, younger age, cyanotic spells, non-use of 5) and 12 patients had prior modified Blalock Taussig B-blockers and higher preoperative heart rate predicted shunt. There was no statistically significant difference in the postoperative JET (p = 0.011, 0.024, 0.001 and 0.018; associated lesion between patients with and without post- respectively). By constructing a separate model for the operative JET (p = 0.8). Fifteen patients in JET group had operative variables, none of the measured operative vari- preoperative B-blockers (19.5%) versus 62 patients (80.5%) ables predicted the postoperative JET. In the postopera- in Non-JET group (p = 0.015). (Table 1). tive variables model; low magnesium and calcium Operative variables are comparable between both independently predicted the occurrence of JET (p = groups with no statistically significant difference in the 0.004 and 0.001; respectively). (Table 3). measured variables. Table 1 shows the comparison of the preoperative and operative variables. Postoperative Effect of JET inotropes administered before the onset of JET were Ventilation time didn’t differ significantly between JET compared between groups and showed no significant patients (23.4 ± 24.7 h) vs non-JET patients (19.5 ± Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 4 of 7 Table 2 Comparison of the inotropes and serum electrolytes in Table 4 Effect of JET on duration of mechanical ventilation, ICU JET and non-JET groups and hospital stay Variable JET group (n = 96) Non-JET (n = 226) P Variable Coefficient P 95% CI Inotropes Ventilation time −1.5 0.123 −0.036–0.004 Dopamine (n) 22 (23.4%) 65 (29.28%) 0.28 ICU stay −0.3 0.011 −0.057–-0.007 Dobutamine (n) 47 (49.5%) 91 (41%) 0.16 Hospital stay − 0.009 0.2 −.025–.007 inverse squared Epinephrine (n) 34 (36.6%) 85 (37.8%) 0.84 inverse Milrinone (n) 47 (50%) 127 (58.3%) 0.18 Inotrope score 12.3 ± 14 9.2 ± 6 0.17 0.17), gender (p = 0.82), body surface area (p = 0.89), Electrolytes preoperative heart rate (p = 0.86), preoperative oxygen PH 7.36 ± 0.066 7.37 ± 0.06 0.16 saturation (p = 0.37), cyanotic spells (p = 0.86), B Potassium (mmol/L) 3.98 ± 0.45 4.07 ± 0.56 0.17 blockers (p = 0.65), CPB time (p = 0.11) and ischemic Magnesium (mEq/L) 1.01 ± 0.39 1.14 ± 0.43 0.001 time (p = 0.24). After adjustment of the preoperative Calcium (mmol/L) 2.32 ± 0.32 2.24 ± 0.35 0.08 variables, no difference was found in duration of JET Continuous variables are presented as mean ± SD and categorical variables as (p = 0.91), ICU stay (p = 0.43), ventilation time (p = 0.52) number (%) and hospital stay (0.14) between both groups. JET resolved in 39.5% (n = 38) of patients responding to conventional measures. At the same time, postopera- 11.6 h, p = 0.11). Patients with JET had longer ICU stay tive electrolyte imbalance was aggressively corrected (6.1 ± 5.8 vs 5 ± 1.9 days, p = 0.01) and longer hospital with K, Ca, and Mg. Fifty-nine patients (61.5%) received stay (15.1 ± 11.2 vs 13.4 ± 6.5 days, p = 0.04). Propensity digoxin and digoxin administration was not significantly score matching was used to estimate the effect of JET on associated with the duration of mechanical ventilation the duration of ventilation, ICU and hospital stay after (p = 0.77), ICU stay (p = 0.43) nor hospital stay (p = adjustment of the measured preoperative variables. JET 0.98) in patients with JET. Amiodarone was used in didn’t affect the duration of mechanical ventilation nor 31.25% (n = 30) of patients and no relation was found hospital stay (p = 0.12 and 0.2 respectively) but signifi- between the use of amiodarone and the duration of cantly prolonged ICU stay (p = 0.011). (Table 4) Hospital mechanical ventilation (p = 0.07) nor hospital stay (p = mortality occurred in 10 patients (3.11%), 4 patients with 0.35). However, amiodarone use was significantly associ- JET (4.1%) versus 6 patients without JET (2.65%) (p = ated with longer ICU stay (p = 0.017). Betablockers were 0.49). (Table 4). used in 58 patients (64.2%) with no significant associ- ation with the duration of mechanical ventilation (p = Course of JET 0.8), ICU (p = 0.37) or hospital stay (p = 0.07). Ventricu- JET was diagnosed post cardiopulmonary bypass and in- lar pacing was required in 4 patients (4.16%) because of side the operation room in 30 patients (30.25%) and in progression into heart block. Five patients (5.2%) had a the ICU in 66 patients (68.75%). Subgroup analysis was second episode of JET, 3 of them were males. Their me- done to identify the difference between patients who had dian age was 7 months (ranged from 6 to 15 months) JET intraoperatively and those who had JET in the ICU. and median oxygen saturation was 80% (ranged from 79 No difference between both groups as regard age (p = to 85%). None of these patients had preoperative B-blockers, 3 of them had TAP and JET occurred intra- operatively in 3 patients. Full recovery occurred in 4 Table 3 Predictors of postoperative JET patients and 1 patients progressed to complete heart Variable OR P 95% CI block and required permanent pace maker. Pre-operative The median duration of JET was 30.5 h and ranged Age 0.86 0.011 0.76–0.97 from 3 to 96 h. Longer duration of postoperative JET “i.e. above the median value” was significantly associated Cyanotic spells 2.9 0.024 1.15–7.41 with lower preoperative oxygen saturation (p = 0.01). B-blockers 0.2 0.001 0.08–0.51 After adjustment of the pre- JET variables, longer dur- Preoperative HR 1.02 0.018 1.004–1.04 ation of JET was significantly associated with prolonged Post-operative ICU (p = 0.02) and hospital stay (p = 0.009) but had no Mg 0.37 0.004 0.19–0.7 significant association with the duration of mechanical Ca 0.4 0.001 0.23–0.7 ventilation (p = 0.21) compared with patients with short OR odds ratio, CI confidence interval JET duration. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 5 of 7 Discussion through RA. Although RA approach in a study of 343 Prophylaxis of arrhythmia after pediatric cardiac surgery patients independently predicted postoperative JET in became the focus of many trials recently. [7, 8, 11, 12] the total patient series, no correlation was made with Generalization of prophylaxis in all patients undergoing their 114 subsets of TOF patients. [20] Our surgical surgery for congenital heart disease is difficult and may strategies have been shifted from the use of TAP to pres- increase the hazard of surgery. In literature, various ervation of the pulmonary valve if possible as it has a factors were found associated with the genesis of JET proved efficacy in reducing the incidence of postopera- after surgical repair of congenital heart disease. Most of tive pulmonary regurgitation. [21] Nevertheless, TAP these studies [1, 10, 13–15] were performed in a wide was not associated with JET in our series. Some authors variety of congenital heart defects. Including all types of documented a significant association between JET and congenital heart defects in risk models to predict post- prolonged ischemic and cardiopulmonary bypass time operative JET underpowers the results as the incidence and higher bypass temperature [17, 22–24]. In our study, of JET varies widely in different congenital heart diseases none of the operative variables predicted the postopera- and procedures. Based on several reports, JET is com- tive JET. Cardiopulmonary bypass time affected JET in monly associated with TOF [1, 10] therefore we included studies which included all congenital heart disease pa- in our series TOF patients who underwent corrective tients. In those patients, CPB time differed significantly surgery before 2 years of age. In our series the incidence between different lesions due to the different surgical of JET was 29.8% and this high incidence of JET can be procedure specific to each lesion Inotropes didn’t predict explained by our strict selection criteria of those JET in our patients. In contrary to this, dopamine or high-risk patients. The incidence of JET following TOF inotropic score were risk factors for JET in other series. repair varied in the published series and ranged from 4 [14, 17] Revision of electrolyte profiles in the sample just to 37%. [8, 16–18] The great variability in JET incidence prior to JET occurrence proved that JET group had sta- could be attributed to the diagnostic criteria used and tistically significant lower serum magnesium and Cal- the wide variability in patients’ characteristics especially cium. Serum magnesium carries a lot of debate among age. [2] Another explanation for this variability is the authors, some documented its significance as a risk fac- low patients number, it is remarkable that lower inci- tor or as prophylactic therapy for JET, [25–27] others dence of JET post TOF repair was documented with less documented that magnesium and calcium levels were number of TOF patients included in the study. More- not significantly different between the two groups. [22] over, we included all patients who expressed JET Our experience in management of JET is to imply con- whether were hemodynamically stable or not. In our ventional strategies as correction of reduced intravascu- study; younger age was significantly associated with in- lar volume, reduce body temperature, titrate inotropes creased risk of postoperative JET and this finding is con- to off if not affecting hemodynamic status of patients sistent with other studies [14]. Younger patients are and aggressively correct electrolyte imbalance. In the generally sicker and smaller hearts are more prone to early period of our study we used digoxin before the ad- damage by surgical technique and retraction. Increased ministration of amiodarone. Some authors [14] didn’t preoperative heart rate predicted postoperative JET. recommend the use of digoxin in JET because its direct Normal range of heart rate depends on patients’ age and action of increasing excitability of all forms of myocar- the definition of tachycardia is not consistent. In order dium, however, it was used to delay atrioventricular to have a standardized condition for all patients, we re- node bundle conduction maintaining a reasonable ported the operation room heart rate after the patients ventricular rate and to counteract the negative inotropic were properly sedated. This also could explain the insig- effect of Class III antiarrhythmic (sotalol and amioda- nificant findings of the preoperative ECG measurements rone). Recently amiodarone has gained popularity in JET as usually they are not taken under standardized condi- treatment or prophylaxis. [5, 8] Many authors stated that tions and patients conditions during ECG recording sig- class III antiarrhythmic drugs (sotalol and amiodarone) nificantly affected these ECG intervals. when given orally or intravenous, were shown to be al- Preoperative B-blockers were associated with signifi- most devoid of negative inotropic effects [14, 18], how- cant reduction of postoperative JET in our patients ever amiodarone use was associated with prolonged ICU which is consistent with a previous report. [19] Further stay in our JET patients. randomized studies are required to evaluate Bblockers as In our series the median duration of JET was 30.5 h a preoperative prophylaxis against JET in those high-risk and many cases resolved smoothly without any patients. hemodynamic instability with recurrence of a second Trans-atrial approach is our standardized approach for episode of JET in 5.2% of the patients. Complications in closure of ventricular septal defect and relief of RVOT the form of heart block requiring pacemaker insertion obstruction and 98% of our patients were operated was encountered in 4 patients of the JET group. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 6 of 7 Junctional ectopic tachycardia significantly increased patients with preoperative risk factors could benefit from ICU stay but not the duration of the mechanical ventila- preoperative arrhythmia prophylaxis. JET can be pre- tion of hospital stay. This is explained by the benign vented by aggressive management of postoperative course of our JET patients and the additional treat- electrolyte disturbance. The outcome of JET was not ment required lead to increased ICU stay while there affected by time of JET onset however, prolonged was no effect on total hospital stay. No difference in duration of JET had a negative impact of ICU and patients’ characteristics or the outcome of JET in pa- hospital stay. tients who had JET onset intraoperatively versus those Abbreviations who had JET onset in the ICU. This can be explained BSA: Body surface area; CPB: Cardiopulmonary bypass; ICU: Intensive care by the overlap of the time frame between both groups unit; JET: Junctional Ectopic Tachycardia; RVOT: Right ventricular outflow tract; TAP: Trans-annular patch; TOF: Tetralogy of Fallot and it is recommended for future to classify JET into early and late onset based on time of onset rather Funding than the place of onset. Moreover, the duration of This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. JET had an impact on the patients’ outcome since longer JET episodes lead to prolonged ICU and hos- Availability of data and materials pital stay which is expected due to the increase in Data are available on request to the corresponding author. time required for treating those patients compared Authors’ contributions with shorter JET episodes. IM Conducted the literature search analysis and interpretation of data, AA, In summary, JET post tetralogy of Fallot repair can Conducted the statistical analysis and interpretation of data, HT: Conducted the be predicted based on the preoperative variables. Pre- literature search, EAE: Designed the study, IA, Data Collection, BA, Data Collection, NB, conducted the literature search, MAB, Analysis and interpretation of data, EA, operative cyanotic spells were associated with postop- Involved in the study design, and drafted the manuscript “corresponding author”, erative JET and preoperative B-blockers significantly JA, Supervised the study and conducted the review of data. All authors read and reduced postoperative JET. Postoperative electrolytes approved the final manuscript. imbalance played a role in JET pathogenesis. JET had Ethics approval and consent to participate abenigncourseand didn’t increase hospital mortality The study was approved by the Institutional Review Board Committee of but it prolonged ICU stay. The outcome of JET was King Faisal Specialist hospital and research center Jeddah, Saudi Arabia. The affected by the duration of JET episode but not the need for informed consent was waived due to the retrospective nature of the study. time of onset. Competing interests Study strength and limitations The authors declare that they have no competing interests. The major limitation of the study is the retrospective de- sign with its inherited biases. However, this is an accept- Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in able design for rare outcomes. Many of the limitations published maps and institutional affiliations. of previously published reports were managed in our study including limiting selection to a specific age and Author details Cardiothoracic Surgery Department, King Faisal Specialist Hospital and pathology in contrast to other studies which included all Research Center, MBC J-16, P.O Box: 40047, Jeddah 21499, Saudi Arabia. types of congenital heart disease and wide range of age. Cardio-thoracic Surgery Department, Mansoura University, Mansoura, Egypt. The relatively large number in our series and the high Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt. 4 5 Cardio-thoracic Surgery Department, Benha University, Benha, Egypt. The incidence of JET in this subset of patients properly Department of Pediatrics, Faculty of Medicine Cairo University, Cairo, Egypt. powered the multivariable analysis. Missing of some variables is another limitation however missing values Received: 16 March 2018 Accepted: 31 May 2018 didn’t exceed 8% (1–7.1%) in the variables used in the analysis and multiple imputation is a suitable method to References handle these missing variables. Recent studies [7, 9] 1. Sahu MK, Das A, Siddharth B, Talwar S, Singh SP, Abraham A, et al. showed that Dexmedetomidine has a role as a prophy- Arrhythmias in children in early postoperative period after cardiac surgery. World J Pediat Congenit Heart Surg. 2018;9(1):38–46. lactic and therapeutic agent for postoperative JET, 2. Entenmann A, Michel M, Egender F, Hessling V, Kramer HH. Impact of however we didn’t use it in our patients which could be different diagnostic criteria on the reported prevalence of junctional ectopic another limitation of the study. tachycardia after pediatric cardiac surgery. Pediatric Crit Care Med. 2016; 17(9):845–51. 3. Ozyilmaz I, Ergul Y, Ozyilmaz S, Guzeltas A. Junctional ectopic tachycardia in Conclusion late period after early postoperative complete atrioventricular block: Junctional ectopic tachycardia is a frequent complication messenger of return to normal sinus rhythm? : Explanation with four case series. J Electrocardiol. 2017;50(3):378–82. after Tetralogy of Fallot repair. It has a benign course; 4. Imamura T, Tanaka Y, Ninomiya Y, Yoshinaga M. Combination of flecainide however, it prolongs ICU stay after TOF repair. and propranolol for congenital junctional ectopic tachycardia. Pediat Int. Preoperative B-blockers reduced postoperative JET and 2015;57(4):716–8. Ismail et al. Journal of Cardiothoracic Surgery (2018) 13:60 Page 7 of 7 5. Kovacikova L, Hakacova N, Dobos D, Skrak P, Zahorec M. Amiodarone as a 26. He D, Sznycer-Taub N, Cheng Y, McCarter R, Jonas RA, Hanumanthaiah S, et first-line therapy for postoperative junctional ectopic tachycardia. Ann al. Magnesium lowers the incidence of postoperative junctional ectopic Thorac Surg. 2009;88(2):616–22. tachycardia in congenital heart surgical patients: is there a relationship to 6. Saiki H, Nakagawa R, Ishido H, Masutani S, Senzaki H. Landiolol surgical procedure complexity? Pediatr Cardiol. 2015;36(6):1179–85. hydrochloride infusion for treatment of junctional ectopic tachycardia in 27. Manrique AM, Arroyo M, Lin Y, El Khoudary SR, Colvin E, Lichtenstein S, et al. post-operative paediatric patients with congenital heart defect. Europace. Magnesium supplementation during cardiopulmonary bypass to prevent 2013;15(9):1298–303. junctional ectopic tachycardia after pediatric cardiac surgery: a randomized controlled study. J Thorac Cardiovasc Surg. 2010;139(1):162–9.e2. 7. El Amrousy DM, Elshmaa NS, El-Kashlan M, Hassan S, Elsanosy M, Hablas N, et al. Efficacy of prophylactic Dexmedetomidine in preventing postoperative junctional ectopic tachycardia after pediatric cardiac surgery. J Am Heart Assoc. 2017;6:e004780. https://doi.org/10.1161/JAHA.116.004780. 8. Imamura M, Dossey AM, Garcia X, Shinkawa T, Jaquiss RD. Prophylactic amiodarone reduces junctional ectopic tachycardia after tetralogy of Fallot repair. J Thorac Cardiovasc Surg. 2012;143(1):152–6. 9. Kadam SV, Tailor KB, Kulkarni S, Mohanty SR, Joshi PV, Rao SG. Effect of dexmeditomidine on postoperative junctional ectopic tachycardia after complete surgical repair of tetralogy of Fallot: a prospective randomized controlled study. Ann Card Anaesth. 2015;18(3):323–8. 10. Cools E, Missant C. Junctional ectopic tachycardia after congenital heart surgery. Acta Anaesthesiol Belg. 2014;65(1):1–8. 11. El-Shmaa NS, El Amrousy D, El Feky W. The efficacy of pre-emptive dexmedetomidine versus amiodarone in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery. Ann Card Anaesth. 2016;19(4):614–20. 12. Rajput RS, Das S, Makhija N, Airan B. Efficacy of dexmedetomidine for the control of junctional ectopic tachycardia after repair of tetralogy of Fallot. Ann Pediat Cardiol. 2014;7(3):167–72. 13. Andreasen JB, Johnsen SP, Ravn HB. Junctional ectopic tachycardia after surgery for congenital heart disease in children. Intensive Care Med. 2008;34(5):895–902. 14. 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Journal

Journal of Cardiothoracic SurgerySpringer Journals

Published: Jun 5, 2018

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