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3rd most common SVT in children

In a 4 years old girl with hypo plastic left heart and Fontan surgery you encounter the following ECG tracing on the monitor:


There is sinus rhythm (upright P waves, PR interval 190ms - AVB I°) with frequent premature atrial contractions (PAC; negative P waves, short PR interval).

A few minutes later the ECG changes:

First beat is a PAC, followed by a sinus beat and subsequent run of atrial ectopy (beats 3-5). Further beats in the strip are atrial tachycardia with negative P waves preceding QRS complexes. Cycle lengths is regular (400ms, ie 150 bpm).

Due to associated symptoms of dizziness and impaired consciousness, the caring physician decided to terminate tachycardia by electrical cardioversion.

Synchronized eCV successfully converted tachycardia.

Atrial tachycardia (AT) is the 3rd most common form of supra ventricular tachycardia in children. Patients who had atriotomy or who might have atrial scar regions are at higher risk for AT. PACs are common in these patients. Origins of AT are not restricted to the right atrium as they may frequently originate from the left atrium as well.

Acute therapy includes class I anti-arrhythmic drugs (propafenone, flecainide), class III AADs (sotalol, amiodarone) or eCV.

Adenosine may be of diagnostic value, blocking the AV node and thus revealing continuing P waves at a regular cycle lengths.

Long term therapy may include class I AADs or ivabradine. However, AT usually very well amenable to catheter ablation, which should be considered first choice.

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Martin Manninger-Wünscher
Martin Manninger-Wünscher
26 de mar. de 2023

Great tracing! Which AAD would you give to prevent recurrences? What would be your age and weight cutoff for ablation?

01 de abr. de 2023
Respondendo a

With regard to AADs, I probably would give class I (preferentially flecainide). However, we had some promising results using ivabradine as well. In children with congenital heart disease class III agents should be preferred.

As for the age/weight limit for ablation. That would be heterogeneous, depending on center/EP experience. In children aged 7 and above, or weighting >20kg ablation can be considered safe and first line treatment.

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