Pharmacologic Management of Supraventricular Tachycardias in Children. Part 2: Atrial Flutter,Atrial Fibrillation,and Junctional and Atrial Ectopic Tachycardia
Restricted accessResearch articleFirst published online November, 1997
Pharmacologic Management of Supraventricular Tachycardias in Children. Part 2: Atrial Flutter,Atrial Fibrillation,and Junctional and Atrial Ectopic Tachycardia
To review the literature regarding the use of antiarrhythmic agents in the management of atrial flutter (AF), atrial fibrillation (Afib), junctional ectopic tachycardia (JET), and atrial ectopic tachycardia (AET) in infants and children. To discuss the advantages and disadvantages of specific agents in each type of arrhythmia in an effort to develop treatment guidelines.
DATA SOURCES:
A MEDLINE search encompassing the years 1966-1996 was used to identify pertinent literature for discussion. Additional references were found in the articles, which were retrieved via MEDLINE.
STUDY SELECTION:
Clinical trials that address the use of antiarrhythmic agents for the treatment of supraventricular tachycardia, AF, Afib, JET, and AET in children were selected. Literature pertaining to dosage, pharmacokinetics, efficacy, and toxicity of antiarrhythmic agents in children were considered for possible inclusion in the review; information judged to be pertinent by the authors was included in the discussion.
DATA EXTRACTION:
Although there are numerous reports of antiarrhythmic use in children, there are very few large studies designed that evaluate the use of specific antiarrhythmic agents in the treatment of AF, Afib, JET, or AET. Ideally, controlled clinical trials are used to develop clinical guidelines; however, in this situation, most data and information must be obtained from case series of children treated. Although the results from these types of studies may be useful in developing guidelines for the optimal use of these agents for the treatment of AF, Afib, JET, and AET, controlled trials are required for establishing standard treatment guidelines for all patients.
DATA SYNTHESIS:
Despite limited scientific evaluation of conventional agents in the treatment of AF, Afib, JET, or AET in children, they continue to be the standards of care. Most information regarding the use of conventional agents in children has been extrapolated from the adult literature. Little justification for the use of the agents or dosing in children is available. Controlled trials regarding the use of newer antiarrhythmic agents (propafenone, amiodarone, flecainide) are available; however, the variance in dosing schemes, presence of structural heart disease, and patient age may confound the results.
CONCLUSIONS:
Because of greater clinical experience, conventional antiarrhythmic agents generally remain as first-line therapy in the management of most supraventricular tachycardias in children. Atrial pacing or cardioversion to reestablish sinus rhythm is indicated for initial episodes of AF in infants, followed by chronic prophylactic therapy in those with significant structural heart disease or in infants in whom AF recurs. Attempts to eliminate AF in children outside the neonatal or infancy period should begin with trials of traditional agents such as digoxin or procainamide, and if unsuccessful, subsequent trials of amiodarone. Digoxin and β-blockers remain the mainstay of therapy for children with Afib, followed by procainamide for treatment failures. Intravenous amiodarone, the newest addition to our antiarrhythmic armamentarium, is the most promising agent in the treatment of postoperative JET. This arrhythmia has been traditionally managed with corporal cooling and/or digoxin therapy; however, intravenous amiodarone may now be a valuable option. Although relatively unsuccessful in the management of congenital JET and AET, conventional agents are typically used prior to the initiation of long-term therapy with potentially more toxic agents such as amiodarone or propafenone. Additional well-designed, controlled trials are needed to further evaluate the comparative efficacy of agents such as flecainide, sotalol, moricizine, propafenone, and amiodarone in the management of AF, Afib, JET, and AET in children, as well as to evaluate the dosing and toxicity in various age groups.
MollerJHDavachiFAndersonRC. Atrial flutter in infancy. J Pediatr1969; 75: 643–51.
2.
MendelsohnAMacdonaldDSerwerGA. Natural history of isolated atrial flutter in infancy. J Pediatr1991; 119: 386–91.
3.
DunniganABensonDWBendittDG. Atrial flutter in infancy: diagnosis, clinical features, and treatment. Pediatrics1985; 75: 725–9.
4.
MartinTCHernandezA. Atrial flutter in infancy. J Pediatr1982; 100: 239–42.
5.
GarsonABin-BoelkensMHessleinPSHordofAJKeaneJFNechesWH. Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol1985; 6: 871–8.
6.
Rodiguez-CoronelASueblingvongVHastreiterAR. Clinical forms of atrial flutter in infancy. J Pediatr1968; 73: 69–76.
7.
VetterV. Management of arrhythmias in children — unusual features. Cardiovasc Clin1985; 16: 329–58.
8.
CaseyFAMcCrindleBWHamiltonRMGowRM. Neonatal atrial flutter: significant early morbidity and excellent long-term prognosis. Am Heart J1997; 133: 302–6.
9.
RowlandTWMathewRChameidesLKeaneJF. Idiopathic atrial flutter in infancy: a review of eight cases. Pediatrics1978; 61: 52–6.
10.
GuccionePDragoFDi DonatoRMCiciniMPPasquiniLMarinoB. Oral propafenone therapy for children with arrhythmias: efficacy and adverse effects in midterm follow-up. Am Heart J1991; 122: 1022–7.
11.
ReimerAPaulTKallfelzHC. Efficacy and safety of intravenous and oral propafenone in pediatric cardiac dysrhythmias. Am J Cardiol1991; 68: 741–4.
12.
VignatiGMauriLFiginiA. The use of propafenone in the treatment of tachyarrhythmias in children. Eur Heart J1993; 14: 546–50.
13.
HeuschAKramerHHKrogmannONRammosSBourgeoisM. Clinical experience with propafenone for cardiac arrhythmias in the young. Eur Heart J1994; 15: 1050–6.
14.
ZieglerVGillettePCRossBAEwingL. Flecainide for supraventricular and ventricular arrhythmias in children and young adults. Am J Cardiol1988; 62: 818–20.
15.
ZieglerVGillettePCHammillBRossBAEwingL. Flecainide for supraventricular tachycardia in children. Am J Cardiol1988; 62: 41D–3D.
16.
PerryJCMcQuinnRLSmithRTGothingCFredeilPGarsonA. Flecainide acetate for resistant arrhythmias in the young: efficacy and pharmacokinetics. J Am Coll Cardiol1989; 14: 185–91.
17.
PerryJCGarsonA. Encainide and flecainide in children. Separating the wheat from the chaff. J Am Coll Cardiol1991; 18: 366–7.
18.
FishFAGillettePCBensonDW. Proarrhythmia, cardiac arrest and death in young patients receiving encainide and flecainide. J Am Coll Cardiol1991; 18: 356–65.
19.
GarsonAGillettePCMcVeyPHessleinPSPorterCBJAngellLK. Amiodarone treatment of critical arrhythmias in children and young adults. J Am Coll Cardiol1984; 4: 749–55.
20.
GuccionePPaulTGarsonA. Long term follow-up of amiodarone therapy in the young: continued efficacy, unimpaired growth, moderate side effects. J Am Coll Cardiol1990; 15: 1118–24.
21.
GarsonA. Medicolegal problems in the management of cardiac arrhythmias in children. Pediatrics1987; 79: 84–8.
22.
MaragnesPFournierAKratzCHouyelLDavignonA. Efficacy of sotalol in the pediatric population (abstract). Circulation1990; 82: III-224.
23.
HoskingMHamiltonRGowRFreedomR. Efficacy and side effects of oral sotalol in the young (abstract). PACE1990; 13: 541.
24.
MaragnesPTippleMFournierA. Effectiveness of oral sotalol for treatment of pediatric arrhythmias. Am J Cardiol1992; 69: 751–4.
25.
PfammatterJPPaulTLehmannCKallfelzHC. Efficacy and proarrhythmia of oral sotalol in pediatric patients. J Am Coll Cardiol1995; 26: 1002–7.
26.
CampbellRMDickMDJenkinsJMSpicerRLCrowleyDC. Atrial overdrive pacing for conversion of atrial flutter in children. Pediatrics1985; 75: 730–6.
27.
ButoFDunniganAOverholtEBendittDBBensonDW. Transesophageal study of recurrent atrial tachycardia after atrial baffle procedure for complete transposition of the great arteries. Am J Cardiol1986; 57: 1356–62.
28.
RhodesLAWalshEPSaulJP. Conversion of atrial flutter in pediatric patients by transesophageal atrial pacing: a safe, effective, minimally invasive procedure. Am Heart J1995; 130: 323–7.
29.
RadfordDJIzukawaT. Atrial fibrillation in children. Pediatrics1977; 59: 250–6.
30.
ZalidivarNGelbandHTamerDGarciaO. Atrial fibrillation in infancy. J Pediatr1973; 85: 821–2.
GarsonAGillettePC. Junctional ectopic tachycardia in children: electrocardiography, electrophysiology and pharmacologic response. Am J Cardiol1979; 44: 298–302.
33.
GrantJWSerwerGAArmstrongBEOldhamHNAndersonPAW. Junctional tachycardia in infants and children after open heart surgery for congenital heart disease. Am J Cardiol1987; 59: 1216–8.
34.
CaseCLGillettePC. Automatic atrial and junctional tachycardias in the pediatric patient: strategies for diagnosis and management. PACE1993; 16: 1323–35.
35.
VillainEVetterVLGarciaJMHerreJCifarelliAGarsonA. Evolving concepts in the management of congenital junctional ectopic tachycardia: a multicenter study. Circulation1990; 81: 1544–9.
GillettePC. Evolving concepts in the management of congenital junctional ectopic tachycardia: editorial comment. Circulation1990; 81: 1713–4.
38.
GillettePC. Diagnosis and management of postoperative junctional ectopic tachycardia. Am Heart J1989; 118: 192–4.
39.
PfammatterJPPaulTZiemerGKallfelzHC. Successful management of junctional tachycardia by hypothermia after cardiac operations in infants. Ann Thorac Surg1995; 60: 556–60.
40.
BashSEShahJJAlberWHGeissDM. Hypothermia for the treatment of postsurgical greatly accelerated junctional ectopic tachycardia. J Am Coll Cardiol1987; 10: 1095–9.
41.
BalajiSSullivanIDeanfieldJJamesI. Moderate hypothermia in the management of resistant automatic tachycardias in children. Br Heart J1991; 66: 221–4.
42.
TillJARowlandE. Atrial pacing as an adjunct to the management of post-surgical His bundle tachycardia. Br Heart J1991; 66: 225–9.
43.
SapireDWMongkolsmaiCO'RiordanAC. Control of chronic ectopic supraventricular tachycardia with verapamil. J Pediatr1979; 94: 312–4.
44.
GarsonAMoakJPSmithRTMcVeyPNortonJB. Control of postoperative junctional ectopic tachycardia with propafenone (abstract). J Am Coll Cardiol1985; 5: 428.
45.
ParetGGowRMofadaSABohnDBarkerG. Intravenous propafenone in refractory life threatening arrhythmias (abstract). Pediatr Res1990; 27: 33A.
46.
ParetGTaylorRHamiltonREdmondsJBarkerG. Management of junctional ectopic tachycardia in infants and children following cardiac surgery (abstract). Pediatr Res1990; 27: 23A.
47.
MoakJPSmithRTGarsonA. Newer antiarrhythmic drugs in children. Am Heart J1987; 113: 179–85.
48.
RajaPHawkerREChaikitpinyoACooperSGLauKCNunnGR. Amiodarone management of junctional ectopic tachycardia after cardiac surgery in children. Br Heart J1994; 72: 261–5.
49.
PerryJCFenrichALHulseJETriedmanJKFriedmanRALambertiJJ. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol1996; 27: 1246–50.
50.
PerryJFenrichAHulseETriedmanJFriedmanR. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol (abstract). PACE1995; 18: 167.
51.
PerryJCKnilansTKMarlowDDenfieldSWGenrichALFriedmanRA. Intravenous amiodarone for life-threatening tachyarrhythmias in children and young adults. J Am Coll Cardiol1993; 22: 95–8.
52.
WrenCCampbellRW. His bundle tachycardia — arrhythmogenic and antiarrhythmic effects of therapy. Eur Heart J1987; 8: 647–50.
53.
LucetVNgocD DoFidelleJSidiDBatisseALothP. Antiarrhythmic effectiveness of propafenone in children: thirty cases. Arch Mal CoeurVaiss1987; 80: 1385–93.
54.
PaulTReimerAJanousekJKallfelzHC. Efficacy and safety of propafenone in congenital junctional ectopic tachycardia. J Am Coll Cardiol1992; 20: 911–4.
55.
WrenCCampbellRWF. The response of paediatric arrhythmias to intravenous and oral flecainide. Br Heart J1987; 57: 171–5.
56.
KantochMJ. Combination of amiodarone and flecainide. Am J Cardiol1995; 75: 862.
57.
FenrichALPerryJCFriedmanRA. Flecainide and amiodarone combined therapy for refractory tachyarrhythmias in infancy. J Am Coll Cardiol1995; 25: 1195–8.
58.
BinderLSBoecheRAtkinsonD. Evaluation and management of supraventricular tachycardia in children. Ann Emerg Med1991; 20: 51–4.
59.
KoikeKHessleinPSFinlayCDWilliamsWGIzukawaTFreedomRM. Atrial automatic tachycardia in children. Am J Cardiol1988; 61: 1127–30.
60.
SaulJPHulseJEPapagiannisJVan PraaghRWalshEP. Late enlargement of radiofrequency lesions in infant lambs: implications for ablation procedures in small children. Circulation1994; 90: 492–9.
61.
GillettePCGarsonA. Electrophysiologic and pharmacologic characteristics of automatic ectopic atrial tachycardia. Circulation1977; 56: 571–5.
62.
NaheedZJStrasburgerJFBensonDWDealBJ. Natural history and management strategies of automatic atrial tachycardia in children. Am J Cardiol1995; 75: 405–7.
63.
BauersfeldUGowRMHamiltonRMIzukawaT. Treatment of atrial ectopic tachycardia in infants 6 months old. Am Heart J1995; 129: 1145–8.
64.
MehtaAVSanchezGRSacksEJCastaADunnJMDonnerRM. Ectopic automatic atrial tachycardia in children: clinical characteristics, management and follow-up. J Am Coll Cardiol1988; 11: 379–85.
65.
DhalaAACaseCLGillettePC. Evolving treatment strategies for managing atrial ectopic tachycardia in children. Am J Cardiol1994; 74: 283–6.
66.
KuglerJDBaischSDCheathamJPLatsonLAPinskyWWNorbergW. Improvement in left ventricular dysfunction after control of persistent tachycardia. J Pediatr1984; 105: 543–8.
67.
OlssonSBBlomstromPSabelKWilliam-OlssonG. Incessant ectopic atrial tachycardia: successful surgical treatment with regression of dilated cardiomyopathy picture. Am J Cardiol1984; 53: 1465–6.
68.
GiorgiLVHartzlerGOHamakerWR. Incessant focal atrial tachycardia: a surgically remediable cause of cardiomyopathy. J Thorac Cardiovasc Surg1984; 87: 466–73.
69.
JosephsonMESpearJFHarkenAHHorowitzLNKoriaRJ. Surgical excision of automatic atrial tachycardia: anatomic and electrophysiologic correlates. Am Heat J1982; 104: 1076–85.
70.
GillettePCWamplerDGGarsonAZinnerAOttDCooleyD. Treatment of atrial automatic tachycardia by ablation procedures. J Am Coll Cardiol1985; 6: 405–9.
71.
Von BernuthGKramerHHSingerHSchneiderPBrodherr-HebereleinSKienastW. Atrial automatic tachycardia in infancy and childhood. Eur Heart J1992; 15: 1410–5.
72.
JanousekJPaulTReimerAKKallfelzHC. Usefulness of propafenone for supraventricular arrhythmias in infants and children. Am J Cardiol1993; 72: 294–300.
73.
JacobsenJRAndersenEDSandoeEVidebaekJWennevoldA. Chronic supraventricular tachycardia in infancy and childhood. Acta Paediatr Scand1975; 64: 597–604.
74.
GarsonA. Dosing newer antiarrhythmic drugs in children: considerations in pediatric pharmacology. Am J Cardiol1986; 57: 1405–7.
75.
KuckKHKunzeKPSchluterMDuckeckW. Encainide versus flecainide for chronic atrial and junctional ectopic tachycardia. Am J Cardiol1988; 62: 37L–44L.
76.
KunzeKPKuckKHSchluterMBleifeldW. Effect of encainide and flecainide on chronic ectopic atrial tachycardia. J Am Coll Cardiol1986; 7: 1121–6.
77.
BragadaPWellensHJJ. Long term follow-up of incessant supraventricular tachycardia treated with oral encainide. Eur Heart J1987; 8: 369–71.
78.
TillJARowlandEShinebourneEAWardDE. Treatment of refractory supraventricular arrhythmias with flecainide acetate. Arch Dis Child1987; 62: 247–52.
79.
TillJAShinebourneEARowlandEWardDEBhamraRJohnstonA. Paediatric use of flecainide in supraventricular tachycardia: clinical efficacy and pharmacokinetics. Br Heart J1989; 62: 133–9.
80.
HaysMDGillettePC. Atrial automatic ectopic tachycardia successfully treated with encainide in a 4-week-old infant after Senning procedure. Am Heart J1989; 117: 489–91.
81.
FigaFHGowRMHamiltonRMFreedomRM. Clinical efficacy and safety of intravenous amiodarone in infants and children. Am J Cardiol1994; 74: 573–7.
82.
PongiglioneGStrasburgerJFDealBJBensonDW. Use of amiodarone for short-term adjuvant therapy in young patients. Am J Cardiol1991; 68: 603–8.
83.
ShulerCCaseCLGillettePC. Efficacy and safety of amiodarone in infants. Am Heart J1993; 125: 1430–2.
84.
ColloridiVPerriCVentrigliaGCritelliG. Oral sotalol in pediatric atrial ectopic tachycardia. Am Heart J1992; 123: 254–6.
85.
TanelREWalshEPLuluJASaulJP. Sotalol for refractory arrhythmias in pediatric and young adult patients: initial efficacy and long-term outcome. Am Heart J1995; 130: 791–7.
86.
AttuelPDo NgocDFriocourtPMugicaAJCoumelP. Sotalol, more than a β-blocker, a clinical reality. Adv Cardiol Sympos1985; 17: 45–65.
87.
BowmanEPaesBAWayRC. Oral sotalol in neonate with supraventricular tachycardia. Acta Pediatr Scand1988; 77: 171.
88.
YabekSMKatoRIkedaNSinghBN. Cellular electrophysiologic responses of isolated neonatal and adult cardiac fibers to d-sotalol. J Am Coll Cardiol1988; 11: 1094–9.
89.
TippleMPattersonMWSandorGGS. Sotalol as an antiarrhythmic for pediatric arrhythmias (abstract). Clin Invest Med1990; 13: C101.
90.
EvansVGarsonASmithRTMoakJPMcVeyPMcNamaraDG. Ethomozine: a promising drug for “automatic” atrial ectopic focus tachycardia (abstract). Circulation1985; 72: 111–173.
91.
EvansVLGarsonASmithRTMoakJPMcVeyPMcNamaraDG. Ethomozine (moricizine HCl): a promising drug for “automatic” atrial ectopic tachycardia. Am J Cardiol1987; 60: 83F–6F.
92.
GarnerSSWiestDBReynoldsER. Stability of atenolol in an extemporaneously compounded oral liquid. Am J Hosp Pharm1994; 51: 508–11.
DupuisLLJamesFBacolaG. Stability of sotalol hydrochloride oral liquid formulation. Can J Hosp Pharm1988; 41: 121–3.
96.
MehtaAVChidambaramB. Efficacy and safety of intravenous and oral nadolol for supraventricular tachycardia in children. J Am Coll Cardiol1992; 19: 630–5.
97.
TingelstadJBMcCueCMMauckHP. Propranolol in the management of children with paroxysmal supraventricular tachycardia (abstract). Circulation1968; 38 (suppl VI): 194.
98.
GillettePGarsonAEterovicENechesWMullinsCMcNamaraDG. Oral propranolol treatment in infants and children. J Pediatr1978; 92: 141–4.
99.
PickoffASZiesLFerierPLTamerDWolffGGarciaO. High dose propranolol therapy in the management of supraventricular tachycardia. J Pediatr1979; 94: 144–6.
100.
TrippelDLGillettePC. Atenolol in children with supraventricular tachycardia. Am J Cardiol1989; 64: 233–6.
101.
EpsteinMLKielEAVictoriaBE. Cardiac decompensation following verapamil therapy in infants with supraventricular tachycardia. Pediatrics1985; 75: 737–40.
102.
GarlandJSBerensPJLosekJD. An infant fatality following verapamil therapy for supraventricular tachycardia: cardiovascular collapse following iv verapamil. Pediatr Emerg Care1985; 1: 198–200.
103.
KirkCRGibbsJLThomasRRadley-SmithRQureshiSAQureshiSA. Cardiovascular collapse after verapamil in supraventricular tachycardia. Arch Dis Child1987; 62: 1265–82.
104.
GulamhuseinSKoPCarrutnersSGKleinGJ. Acceleration of the ventricular response during atrial fibrillation in the Wolff-Parkinson-White syndrome after verapamil. Circulation1982; 65: 348–54.
105.
GulamhuseinSKoPKleinGJ. Ventricular fibrillation following verapamil in Wolff-Parkinson-White syndrome. Am Heart J1983; 106: 145.
106.
CoumelPFidelleJ. Amiodarone in the treatment of cardiac arrhythmias in children: one hundred thirty-five cases. Am Heart J1980; 11: 1063–9.
107.
TippleMSandorG. Efficacy and safety of oral sotalol in early infancy. PACE1991; 14: 2062–5.
108.
MustoBD'OnofrioACavallaroCMustoA. Electophysiological effects and clinical efficacy of propafenone in children with recurrent paroxysmal supraventricular tachycardia. Circulation1988; 78: 863–9.
109.
GarsonAMoakJPSmithRTNortonJB. Usefulness of intravenous propafenone for control of postoperative junctional ectopic tachycardia. Am J Cardiol1987; 59: 1422–4.
110.
The Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med1989; 321: 406–12.
111.
PriestlyKALadusansEJRosenthalEHoltDWTynanMJJonesODH. Experience with flecainide for the treatment of cardiac arrhythmias in children. Eur Heart J1988; 9: 1284–90.
112.
MustoBD'OnofrioACavallaroCMustoAGrecoK. Electrophysiological effects in children with recurrent paroxysmal supraventricular tachycardia. Am J Cardiol1988; 62: 229–33.
113.
DunniganABendittDGBensonDW. Modes of onset (“initiating events”) for paroxysmal atrial tachycardia in infants and children. Am J Cardiol1986; 57: 1280–7.
114.
WardDEJonesSShinebourneEA. Use of flecainide acetate for refractory junctional tachycardias in children with the Wolff-Parkinson-White syndrome. Am J Cardiol1986; 57: 787–90.
