SVT in pediatrics
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SupraventriculaSupraventricular Tachycardia in r Tachycardia in
PediatricPediatric
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Cardiac arrhythmia
• is a abnormal electrical activity in the heart
• too fast or too slow
• regular or irregular.
DefinationDefination
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OverviewOverview
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Sinus tachycardiaSVTVFVTAtrial fibAtrial flutter
Sinus bradycardiaHeart block
Sinus arrhythmiaPACPVC
Tachycardia Bradycardia
Irregular
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In structurally normal/ abnormal heartCongenital metabolic disorders of mitochondriaSLE
Rheumatic feverMyocarditisToxin (diphtheria)Pro-arrhythmic or anti-arrhythmic drugsSurgical correction of CHD
CongenitalCongenital AcquiredAcquired
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Normal Heart Rate Normal Heart Rate Age Heart RateNewborn 120-160Infant 80- 140Toddler 1-3 yrs 80- 130Pre School 3-5yrs 80- 120School Age 6-12 yrs
70- 110
Adolescent 13+ 60- 100
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Range from Completely asymptomatic Loss of consciousnessSudden cardiac death
In infantsLethargyPoor feedingIrritabilityCardiac failureUnderlying congenital
heart disease
In childrenPalpitationSyncopeDizzinessChronic fatigueShortness of breathChest discomfort
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HistorySymptomsFrequency and length of episodeOnset and triggersAny underlying diseaseMedicationso Triggering factoro Used for underlying cardiac disease
Evaluation Child with Evaluation Child with ArrhythmiaArrhythmia
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DiagnosisDiagnosisAlways do-12 Lead ECG!!!!!-During tachycardia-In sinus rhythm
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Diagnostic methodsDiagnostic methods• Always• Always• Always record a rhythm
strip during any intervention (adenosine, cardioversion, Valsalva, etc.)
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Diagnostic methodsDiagnostic methods• Holter• Event recorder• Exercise ECG• Post-op atrial/ventricular pacing wires• Esophageal pacing leads• Adenosine can be diagnostic• Invasive electrophysiology study
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Sinus RhythmSinus RhythmEvery QRS complex is preceded by a P wave and every P wave must be followed by a QRS The P wave morphology and axis must be normal and PR interval will usually be normal for that age
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Sinus ArrhythmiaSinus Arrhythmia
Most common irregularity of heart rhythm seen in childrenNormal variantHeart rate increases during inspiration and decreases during expiration
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Sinus ArrhythmiaSinus Arrhythmia
Normal phasic variation of heart rate with respiration
Variable P-P intervals
No treatment needed
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TachyarrhythmiaTachyarrhythmia
• Supraventricular Tachycardia• Ventricular Tachycardia
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Basic Mechanism of Basic Mechanism of TachycardiaTachycardia
1.Re- entry – most common2.Automaticity3.Triggered activity - rare
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Re – entry TachycardiaRe – entry Tachycardia
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AutomaticityAutomaticity
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SVTSVTMost common abnormal tachycardia seen in pediatric practiceMost common arrhythmia requiring treatment in pediatric populationMost frequent age presentation: 1st 3 months of life 2nd peaks @ 8-10 and in adolescence
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SVTSVTCommonest mechanism – re-entry- Accessory pathway – 80%-AV nodal re-entry – 20%
-Younger age – accessory pathway-Older age - AVNRT
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SVT - classificationSVT - classificationAV node Dependent Tachycardia
AV Node independent Tachycardia
AVRT - concealed pathway - manifest pathway -WPW syndrome
Sinus node reentrant Tachycardia
AVNRT - Typical ( slow-fast) - Atypical (Fast-slow)
Atrial Tachycardia - Focal atrial tachycardia - Multifocal atrial tachycardia
Juctional Ectopic Tachycardia ( JET)
Atrial Flutter
Permanent Juctional Reciprocating Tachycardia ( PJRT)
Atrial Fibrillation
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P wave in TachycardiaP wave in Tachycardia- Important to identify p wave during the
tachycardia- Helps to guide types of SVT
- No p wave- Short RP tachycardia- Long RP tachycardia
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P wave in TachycardiaP wave in TachycardiaNo visible p Wave, narrow complex- AVNRT
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P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP
- AVRT- Typical AVNRT
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P wave in Tachycardia P wave in Tachycardia – Short RP– Short RP
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P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP
- Atypical AVNRT- PJRT- Atrial tachycardia- Sinus tachycardia- sinus node tachycardia
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P wave in Tachycardia P wave in Tachycardia – Long RP– Long RP
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What's Next?What's Next?LOOK FOR THE R-R interval
- regular- irregular
Gives clues on types of SVT
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ANRT - P wave on ST ANRT - P wave on ST segmentsegment
Regular R-R intervalRegular R-R interval
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AVNRT - p wave absent AVNRT - p wave absent or pseudo r wave on VI or pseudo r wave on VI
Regular R-R intervalRegular R-R interval
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AET - Long RP AET - Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave
morphology morphology Regular R-R intervalRegular R-R interval
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PJRT -Long RP PJRT -Long RP tachycardia with tachycardia with abnormal p wave abnormal p wave
inverted lead II,III,aVF inverted lead II,III,aVF Regular R-R intervalRegular R-R interval
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Atrial flutter – saw tooth Atrial flutter – saw tooth baselinebaseline
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MET – Irregular MET – Irregular TachycardiaTachycardia
Long RPLong RPdifferent p wave different p wave
morphologymorphology
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JET – Irregular R-R JET – Irregular R-R intervalinterval
p wave with VA p wave with VA dissociationdissociation
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ManagementManagementTreatment Option SVT Termination
1.Vagal maneuvers2.Anti arrhythmic drugs ( IV or Oral )3.Electrical Termination
- DC cardioversion- Endocardial pacing- Trans Esophageal pacing
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ManagementManagement
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ManagementManagementVagal Maneuvers
1.Smaller childrens and infants- Ice cold facecloth to the face- Stimulate the vagal response
1.Older childrens- carotid massage- Valsalva technique
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Management - IV Management - IV AdenosineAdenosine
• Diagnostic and therapeutic
• Given via central line better than peripheral
• Short half life
• 100-500mcg/kg given rapid IV push
• ALWAYS!!! Record rhythm strip during adenosine
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Adenosine Response Adenosine Response
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Adenosine responseAdenosine response
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Adenosine ResponseAdenosine Response
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SVT TreatmentSVT Treatment1. IV Verapamil – older childrens 0.1mg/kg
- Contraindicated in < 4 yrs old and in WPW syndrome
2. Digoxin – useful in infants- Contraindicated in WPW
3. IV propranolol 0.1mg/kg4. IV Flecanaide 0.5-2mg/kg5. IV amiodarone 5mg/kg in 30min and
5-15mcg/kg/min6. Cardioversion 0.5-2J/kg
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Management- Management- PreventionPrevention
1.No treatment2.Anti Arrhythmic drug3.Radiofrequency ablation
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Management - Management - PreventionPrevention
No Treatment
-Infrequent eposides-Explain -Educate on valsalva-PRN treatment in ED
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Management - Management - PreventionPrevention
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Management - Management - PreventionPrevention
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Treatment OptionsTreatment Options1. AV node
- Digoxin- Class II – beta blockers- Class III – Amiodarone- Class IV – Verapamil
2. Accessory pathway- Class 1C – Flecanaide- Class III – Amiodarone- WPW- No Verapamil or Digoxin
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Management - Management - PreventionPrevention
Radiofrequency Ablation
– invasive procedure- Curative -Older children's-Incessant SVT- PJRT-Symptomatic SVT-Drug refractory SVT-WPW with symptomatic
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SummarySummary• SVT generally well tolerated, life threatening is
uncommon
• Record 12 lead ECG during arrhythmia
• Record rhythm strip during any intervention
• ECG clue for diagnosis – wide or narrow complex, p wave relationship to QRS and regular or irregular rhythm
• Proper diagnosis can guide appropriate Tx
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THANK YOUTHANK YOU