Rhythm Problems Atrioventricular Septal Defect

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Rhythm ProblemsAtrioventricular Septal Defect

• Alpay Çeliker MD.
• Hacettepe University
• Department of Pediatric Cardiology

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Conduction System in AVSD

• AV Septal Defect
• AV node is located posteriorly

• Normal Heart
• AV node is located in the triangle of Koch

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ECG in AVSD

• Prolonged PR interval
• Left axis deviation and counterclockwise frontal
  plane loop

• Elongation of the anterior division of LBB
• Anomalous development of anterior division of LBB
• 3. Interruption of the anterior division by
  anomalous insertion of chorda tendinea

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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

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Mechanisms of Arrhythmias

• Abnormalities inherent to malformation
• Hemodynamic and hypoxic stress upon heart
• Sequela of reparative surgery
• Residual hemodynamic problems

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Rhythm Problems in AVSD

• Preoperative Rhythm Problems
• Perioperative Rhythm Problems
• Postoperative Rhythm Problems

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Preoperative Arrhythmias

• Acquired atrial tachyarrhythmias
• Late operation
• Atrial fibrillation may be seen 20 and causes
  clinical deterioration
• AV block

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Perioperative Arrhythmias

• Junctional Ectopic Tachycardia
• AV Block

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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
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Junctional Ectopic Tachycardia
? Cardiac Output ? Adrenergic Tone ? Heart Rate

• ? ventricular rate
• Loss of AV synchrony

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JET ECG Diagnosis

• QRS configuration is similar to sinus or atrial
  paced beats
• Rapid ventricular rate gt or to atrial rate
• Dissociated atrial activity or retrograde 11
  conduction or Wenckebach
• Failure to respond adenosine, overdrive pacing or
  cardioversion
• Warm-up phenomenon

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Perioperative JET

• Increased duration of postoperative ventilation
  and CICU stay
• ? incidence with ventricular muscle band
  resection, higher cardiopulmonary bypass
  temperature, transatrial RVOTO relief

RVOT resection More important Than VSD closure
De-Leval group. J Thorac Cardiovasc Surg 2002
123 624-630.
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Treatment in Postop JET

• General Measures
• Optimize sedation/hemodynamics
• Correct fever
• ? Catecholamines
• AV Synchrony
• Class I and II AAD
• Hypothermia Procainamide
• IV Amiodarone

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Treatment Modalities in JET
Walsh ED, et al. J Am Coll Cardiol, 1997 29
1046-1053
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Walsh ED, et al. J Am Coll Cardiol, 1997 29
1046-1053
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Laird et al. Pediatr Cardiol 2003 24 133-137.
SUCCESS 10/11
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Atrial pace slightly faster than JET from
epicardial wires or Esophagus not an isolated
therapy if JET rate gt200 bpm
AMIODARONE PROCAINAMIDE
Core temperature 33-350 C using posterior
cooling blanket under sedation, mechanic
ventilation and paralysis
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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.

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EPS
InfraHisian Block
Permanent Pacemaker
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Cardiac Pacing in AVSD

• SSS Good AV Conduction AAIR
• SSS AV Conduction Disturbance DDD
• AV Block DDD
• Small Child ( lt15 kg) Epicardial implant
• SSS or AV Block with Atrial Tachycardia
  Antitachycardia PM
• Late Recovery of AV Conduction 10

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Perioperative and Longterm Arrhythmias
Arrhythmia Type Perioperative N- Long-term N- Total N-
SVT 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)
Premature SVB VB 2 3 3 (1)
El-Najdawi et al. J Thorac Cardiovasc Surg 2000
19 980-90.
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Atrial Arrhythmias

• Atrial Fibrillation
• Isthmus Dependent Atrial Flutter (IDAF)
• Intraatrial Reentrant Tachycardia (IART)

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Risk of Atrial Reentry Tachycardia

• High Risk (gt 10 )
• Fontan palliation
• Mustard-Senning
• Total correction for Fallot or DORV
• Sinus venosus or late repair of ASD II
• Moderate Risk (1-10 )
• TAPVR
• Ebsteins anomaly
• Complete AVSD
• Mitral valve replacement
• Low Risk (lt1 )
• Early repair ASD II
• VSD repair

IART or IDAF
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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

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Transcatheter Ablation

• Atrial Fibrillation His Ablation
• IDAF and IART Creation of Block Line
• Use of saline irrigated catheters
• Use of 3D Anatomic Mapping

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Efficacy
AAD
Cost
Application Problems
Arrhythmia Surgery
RFA
ATP
Adverse Effects
Treatment Failures
Treatment Methods in Atrial Tachyarrhythmias
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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
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Thank you