Episodes Of Supraventricular Tachycardia Research Articles

7238 A rare cause of primary ovarian failure in an adolescent due to a genetic mutation in mitochondrial poly-A-polymerase (mTPAP) mRNA

Abstract Disclosure: J. Epstein: None. S. Veera: None. J. Pappas: None. B.C. Shah: None. Primary ovarian insufficiency (POI) is a dysfunction or loss of ovarian follicles with associated amenorrhea. While most causes are idiopathic, approximately 15% of POI cases are due to single gene or chromosomal abnormalities, such as X chromosome abnormalities. Many of these nuclear genes encode for proteins that function within the mitochondria. Mitochondrial disorders affect tissues with high energy demand, such as the neurological, skeletal, cardiac, and endocrine systems. Furthermore, mature ovaries have a relatively higher concentration of mitochondria, which play a role in cellular respiration along with steroidogenesis. Mutations that disrupt these pathways can therefore lead to ovarian dysfunction. We present a case of a 17-year-old female with concern for primary amenorrhea. She underwent pubarche at age 12 years and thelarche at 14 years, with slowed progression. Height Z score was -1.61 and weight Z score was -0.41. Lab work at presentation was significant for LH 18.6 IU/L (N 2.4-12.6 IU/L), FSH 43.9 IU/L (N 1.1-9.6 IU/L), low estradiol <2.5 pg/mL (N 30-100 pg/mL), low total testosterone 8.3 ng/dL (N 15-31 ng/dL), unremarkable HbA1C, cortisol, thyroid levels, and a 46 XX karyotype. Pelvic ultrasound showed small ovarian volumes with a 1.9 cc right ovary, 1.5 cc left ovary consistent with lack of hormonal stimulation, and uterus length of 4.9 cm (N > 4 cm) consistent with early hormonal stimulation. She was started on transdermal estrogen replacement. Past medical history included stable pericardial effusion, episodes of supraventricular tachycardia, pre-cataracts, speech delays, mild learning disabilities, spastic diplegia, progressive gait abnormalities, ligamentous laxity, and recurrent patellar dislocations requiring multiple orthopedic limb surgeries. Family history was significant for parental consanguinity as first cousins. As the etiology of the POI remained unknown, genetic testing was completed. Whole exome sequencing (WES) revealed a homozygous pathogenic variant in the MTPAP gene: p.(Leu495Arg) (CTG>CGG): c.1484 T>G in exon 9 on chromosome 10p11.23. MTPAP, also known as SPAX4, TENT6, or PAPD1, is a nuclear-encoded polymerase involved in synthesizing the 3’ poly(A) tail of mitochondrial transcripts as well as in mRNA degradation. She was diagnosed with autosomal recessive MTPAP-related neurodevelopmental and movement disorder. Monogenic disorders affecting mitochondrial function are rare causes of POI. A high index of suspicion should be raised when a constellation of neurological, musculoskeletal, and cardiac problems co-exist. WES can be a very useful tool for uncovering rare genetic disorders. Further studies are needed to clarify details of organ specific mitochondrial dysfunction and possible therapeutics in individuals affected with MTPAP-related neurodevelopmental and movement disorders. Presentation: 6/1/2024

Arrhythmia in Adult Congenital Heart Disease

This case report highlights the significance of a multidisciplinary approach in the management of patients with repairedmembranous ventricular septal defect (VSD) who develop postoperative arrhythmias. We present the case of a young femalewho experienced symptomatic episodes of supraventricular tachycardia following VSD repair. Through electrophysiologicalstudy and radiofrequency ablation, multiple tachycardia substrates were identified and successfully ablated. This reportunderscores the importance of combining surgical repair, electrophysiological evaluation and intervention to achieve optimaloutcomes in this specific patient population.

Feasibility and diagnostic yield of a photoplethysmography-based arrhythmia screening and integrated management pathway in a chronic obstructive pulmonary disease outpatient clinic

Abstract Background Guidelines recommend opportunistic screening for atrial fibrillation (AF) in high-risk populations, including chronic obstructive pulmonary disease (COPD) patients. Purpose We aimed to assess the feasibility and yield of a photoplethysmography (PPG) smartphone app-based pathway for AF detection within a COPD outpatient clinic. Methods Ninety-nine eligible patients from the COPD outpatient clinic at the Maastricht University Medical Center+ underwent a 14-days PPG app-based AF screening. PPG-based AF detection triggered an electrocardiogram (ECG) for AF diagnosis and initiation of a comprehensive AF management. Patients’ adherence and system usability were assessed. Results Patient onboarding was easy, and patients demonstrated good adherence to the protocol (101% [82%-123%]). The usability of the PPG app was satisfactory with a high score in the System Usability Score questionnaire (80.0 [55.0-92.5]). Among 99 patients (mean age 66±9 years; 54% female), 8% had a prior AF diagnosis. Premature beats were common, with 96% of patients showing isolated premature beats (<6 in 960 PPG recordings) and 32% frequent premature beats (≥6 in 210 PPG recordings). The PPG algorithm suspected paroxysmal AF in 6 new cases. AF could be confirmed in 2 patients through resting 12-lead ECG and 1-lead handheld ECG device. One patient who was lost to follow-up. In the remaining 3 patients with suspected AF PPG recordings, analysis of 24-hour, 48-hour and 7-day Holter recordings revealed high burden premature (supra)ventricular beats. Two of these patients manifested self-terminating short episodes of supraventricular tachycardia. Conclusion 14-days opportunistic PPG app-based screening is feasible in COPD outpatient care and results in the detection of new AF cases and premature beats. This novel digital approach offers a practical method to implement recommended AF screening in COPD patients.

Characterising paroxysmal supraventricular tachycardia episodes by patient-perceived episode duration, symptoms, and severity: longitudinal patient-reported outcomes

Abstract Background/Information Paroxysmal supraventricular tachycardia (PSVT) encompasses a range of heart rhythms that are often associated with clinical symptoms. The duration and symptoms a patient experiences during a PSVT episode are variable. The impact of episode duration and symptom type on a patient’s perceived severity of an episode of PSVT has not been well defined. Purpose To characterise the relationship between duration, symptom type, and patient-perceived episode severity in a longitudinal study of patient-reported outcomes in the US and UK. Methods The survey included patients >18 years of age with a self-reported diagnosis of PSVT, without a history of ablation. Surveys included a 30-minute baseline survey (Mar 2019), 5-minute weekly tracking surveys (Mar 2019 to Dec 2019), and a 15-minute closing survey (Dec 2019). Patients were asked during the baseline survey to rate the severity of their PSVT (mild/moderate/severe). Weekly episode surveys assessed patient-reported episode duration, symptoms, severity, and interventions. If multiple episodes occurred, characteristics of the most recent episode were assessed. Results Among 117,252 patients screened, 368 met the inclusion criteria and completed the baseline survey, while 247 patients in the final cohort met the quality control checks. Most patients were White (92%), female (70%), and from the US (80%) and had a mean age of 52 years. At baseline, 47% of patients described their PSVT as moderate severity, while 39% reported mild and 14% reported severe. Overall, 5277 longitudinal weekly surveys were completed, of which 48% captured a PSVT episode (n=2518). Median reported duration of an episode was 15 minutes, with severe episodes having numerically longer duration (71 minutes) than moderate (20 minutes) or mild (6 minutes) episodes. Among severe episodes, 57% lasted 1 hour or longer; only 9% of mild episodes lasted 1 hour or longer (Figure 1). Among all assessed episodes of PSVT, 89% had palpitations, 35% shortness of breath, 26% dizziness, and 17% chest pain; mean number of symptoms per episode was 3.1, while numerically more symptoms were reported with severe episodes (mean 6.0) than with moderate (mean 3.5) or mild (mean 2.1) episodes. Shortness of breath was more frequently reported with severe episodes (81%) than with moderate (43%) or mild (17%) episodes. Similar findings were seen with dizziness and chest pain (Figure 2). Overall, approximately half of the reported episodes during follow-up were classified as moderate severity (47%), followed by mild (44%) and severe (9%). Conclusions Episodes of PSVT of longer duration and/or accompanied by a greater number of symptoms are reported by patients to be more severe. However, heterogeneity of symptoms and episode duration is substantial within a given classification of PSVT severity. Additional studies are needed to better understand how the optimal treatment of patients with PSVT may vary by duration, symptoms, and severity.

Long-term clinical course of patients with catecholaminergic polymorphic ventricular tachycardia: A more than 10-year follow-up cohort study

ABSTRACT Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited disorder characterized by ventricular arrhythmias induced by physical or emotional stress. Currently, there are limited data available on the long-term prognosis of CPVT. Methods and Results: In this study, which included both retrospective and prospective components, 12 patients with CPVT (7 males and 5 females) under 18 years old were enrolled to gather and evaluate demographic, clinical, and genetic data. The mean age at diagnosis onset was 7.0 ± 3.1 years. All patients experienced syncope. The mean follow-up duration was 20.1 years. During the follow-up period, all patients experienced at least one episode of supraventricular tachycardia (SVT). Despite beta-blocker therapy, nine patients experienced syncope (75%), and four patients were noncompliant with their treatment. An implantable cardiac defibrillator (ICD) implantation was performed in 10 patients (83%), and among those 5 (50%) experienced appropriate shocks. Inappropriate shocks were observed in all patients with an ICD. The left cardiac sympathetic denervation was performed in 6 patients (50%). One patient died during the follow-up period. Genetic testing was performed in eight patients, five of whom had RYR2 mutations, one patient had mutations in CASQ2, one in TECRL, and one was gene-elusive. Conclusions: The prevalence of cardiac events, even after the initiation of beta-blocker therapy, was found to be distressingly high during long-term follow-up. SVT, such as atrial fibrillation, were found to be more common than previously thought. Combination therapy with a beta-blocker and an IC antiarrhythmic drug shows promise. An individualized approach to the selection of treatment strategies is essential.

Rationale and design of the NODE-303 study: evaluating the safety of symptom-prompted, self-administered etripamil for paroxysmal supraventricular tachycardia episodes in real-world settings

Paroxysmal supraventricular tachycardia (PSVT) is a common episodic arrhythmia characterized by unpredictable onset and burdensome symptoms including palpitations, dizziness, chest pain, distress, and shortness of breath. Treatment of acute episodes of PSVT in the clinical setting consists of intravenous adenosine, beta-blockers, and calcium channel blockers (CCBs). Etripamil is an intranasally self-administered L-type CCB in development for acute treatment of AV-nodal dependent PSVT in a non-medical supervised setting. This paper summarizes the rationale and study design of NODE-303 that will assess the efficacy and safety of etripamil. In the randomized, double-blinded, placebo-controlled, Phase 3 RAPID trial, etripamil was superior to placebo in the conversion of single PSVT episodes by 30 minutes post initial dose when administered in the non-healthcare setting; this study required a mandatory and observed test dosing prior to randomization. The primary objective of NODE-303 is to evaluate the safety of symptom-prompted, self-administered etripamil for multiple PSVT episodes in real-world settings, without the need for test dosing prior to first use during PSVT. Secondary endpoints include efficacy and disease burden. Upon perceiving a PSVT episode, the patient applies an electrocardiographic monitor, performs a vagal maneuver, and, if the vagal maneuver is unsuccessful, self-administers etripamil 70 mg, with an optional repeat dose if symptoms do not resolve within 10 minutes after the first dose. A patient may treat up to four PSVT episodes during the study. Adverse events are recorded as treatment-emergent if they occur within 24 hours after the administration of etripamil. Efficacy endpoints include time to conversion to sinus rhythm within 30 and 60 mins after etripamil administration, and the proportion of patients who convert at 3, 5, 10, 20, 30, and 60 min. Patient-reported outcomes are captured by the Brief Illness Perception Questionnaire, the Cardiac Anxiety Questionnaire, the Short Form Health Survey 36, the Treatment Satisfaction Questionnaire for Medication and a PSVT survey. Overall, these data will support the development of a potentially paradigm-changing long-term management strategy for recurrent PSVT.

Abstract 15446: Impact of Patient Demographics on Optimal Beta-Blocker Use After New-Onset Heart Failure: Analysis of the HF-OPT Study (Heart Failure Optimization Study)

Background: While beta-blockers (BB) have helped to improved outcomes in patients with heart failure and a low ejection fraction (HFrEF), the titration to target doses has been suboptimal and it is not clearly understood why. The Heart Failure Optimization Study (HF-OPT) study in newly diagnosed HF patients (pts) collected baseline data, arrhythmias during wearable cardioverter defibrillator (WCD), as well as medications and dosing. Purpose: The objective was to assess which factors were associated with receiving BB at target doses by day 180. Methods: Data from pts with newly diagnosed HFrEF during WCD use was collected from 487 pts (54% from US, 72% male, age 59±13) in the HF-OPT study. Target dose of BB were defined as the lowest maximum dose from either the ESC or ACC/AHA/HFSA guidelines. Supraventricular tachycardia (SVT) was used to label all dysrhythmias originating at or above the atrioventricular node and captured by the WCD. Association between BB and other variables were assessed using logistic regression. Results: 6 months after a new diagnosis of HFrEF, 97% of pts were prescribed BB, but only 25% were on target doses. Univariate analysis showed that only BMI, age, sex, black race, a history of hypertension, and no history of PCI or angina, were associated with receiving target doses of BBs by 180 days. Having episodes of SVT during the first 180 days were also associated with receiving target BB doses (Table). In multivariate analysis, all were significantly associated with target BB dose except BMI, SVT during WCD use and history of PCI. Conclusions: The full beneficial effects of BB may not be achieved in patients with HFrEF if the patients are not recieving target doses. In the HF-OPT study, factors positively associated with reaching target BB doses included younger age, black race, being male, and a history of hypertension. Having a history of angina was associated with not achieving target BB doses. The significance of these differences should be further explored.

A case study of an adverse drug reaction caused by long term use of proton pump inhibitors

Proton pump inhibitors (PPI) are the class of drugs used to treat a wide variety of disorders related to the stomach's acid production. Although it is considered safe for short term use, reports revealed that many serious life-threatening adverse reactions occurred from long term use. Here we report a case of hypomagnesemia and hypocalcemia induced by long-term use of PPIs in a patient with crest syndrome. From his past history, it was revealed that he was on pantoprazole 40 mg for more than 3 months. While he was admitted here for other complaints, we were able to discover that he had hypomagnesemia defined by low magnesium level of 1.3 mg/dL. As a consequence, he also showed signs of hypocalcemia with a low calcium level of 7 mg/dL. A peculiar complaint seen in this patient was three episodes of supraventricular tachycardia which is the most common cardiac manifestations of hypomagnesemia. As a conclusion, hypomagnesemia can sometimes be asymptomatic and cause unspecific and serious manifestations such as asthenia, paresthesia’s, seizures, arrhythmias, and cardiac arrest. Hence routine monitoring of serum magnesium and calcium levels should be made mandatory in practice for patients on long term use of PPI. Besides, it should be kept in mind that interchanging PPI class with histamine 2 receptor antagonist or fitful use of PPI may not cause hypomagnesemia.

Outcomes of Infant Supraventricular Tachycardia Management Without Medication.

Most infants presenting with supraventricular tachycardia (SVT) are treated with an antiarrhythmic, primarily to prevent unrecognized future episodes that could lead to tachycardia-induced cardiomyopathy. A common practice at our institution is to not treat after the first presentation of infant SVT and instead educate parents on heart rate monitoring and reasons to present to care. The goal of this study was to evaluate the outcomes of non-pharmacologic treatment of infant SVT at first presentation and compare to outcomes of infants treated with an antiarrhythmic. This was a retrospective single center study of all infants presenting with a first episode of SVT from 2014 to 2021. Excluded were patients with a non-reentry type tachyarrhythmia, atrial flutter, long-RP tachycardia, congenital heart disease, or abnormal ventricular function. Sixty-four infants were included in the study. Thirty-six were managed without an antiarrhythmic. SVT recurred in 28% of the non-treatment group vs 50% in those treated with antiarrhythmics, p = 0.12. Of the patients admitted to the hospital, those in the non-treatment group had a shorter length of stay, 1(IQR 1-1) vs 3(IQR 2-4) days, p < 0.01. Non-treated patients were less likely to present to the emergency department for recurrent SVT, 6% vs 32%, p < 0.01. Neither group had a patient develop tachycardia-induced cardiomyopathy. For infants with structurally and functionally normal hearts, non-treatment combined with parental education after the first episode of SVT does not lead to worse outcomes. This approach avoids the burden of medication administration in an infant and may have the added benefit of empowering parents to feel comfortable managing clinically insignificant tachycardia at home.

Evaluation of the prehospital use of a Valsalva assist device in the emergency treatment of supraventricular tachycardia (EVADE SVT): study protocol for a stepped wedge cluster randomised controlled trial

IntroductionPatients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical...

PO-05-146 AN UNUSUAL ATRIOVENTRICULAR REENTRY TACHYCARDIA: SUCCESSFUL ABLATION OF NOVEL SLOW PATHWAY AT SUPERIOR SEPTAL PERIMITRAL LEFT ATRIUM

Atrioventricular nodal reentrant tachycardia (AVNRT) is a common supraventricular tachycardia (SVT), treated with catheter ablation of slow pathway. The right and left inferior slow pathway (SP) extensions of the AV node are widely recognized, but other SPs are very rare. We present a case of atypical AVNRT that was successfully ablated at the superior septal perimitral left atrium. N/A A 75-year-old man with history of coronary artery disease status post coronary artery bypass grafting and recurrent episodes of symptomatic SVT despite diltiazem and metoprolol presented for catheter ablation. Mid RP SVT (cycle length, CL 350 ms) with concentric atrial activation was inducible with atrial and ventricular extrastimulation. Synchronized premature ventricular complexes and ventricular entrainment excluded AV reentry. Very late coupled premature atrial complex from coronary sinus (CS) delivered synchronous to septal A activation delayed next A and reset SVT indicating AVNRT and excluding ectopic junctional (JT) or atrial tachycardia (AT). Further, AH interval during SVT was much longer than AH with atrial pacing at same CL excluding AT. We concluded mechanism to be atypical AVNRT. On activation mapping of right atrium, earliest A was recorded in the fast pathway region, earlier than locations of right and left slow pathways in the triangle of Koch and CS respectively. Radiofrequency ablation lesions anatomically targeting both slow pathways were delivered at base of triangle of Koch and inside CS without affecting SVT. High density activation maps of both right and left atria were created during SVT using Orion basket catheter and Rhythmia (Boston Scientific) mapping system. Earliest A was recorded in the superior septal perimitral left atrium, superior to the location of His bundle electrogram, and anatomically adjacent to aortic sinuses of Valsalva (not mapped). We concluded this to be an unusual left superior extension of the AV node. Radiofrequency ablation lesion using IntellaNav MiFi catheter at this site promptly terminated SVT. Consolidation lesions were delivered and anchored to the mitral annulus. The tachycardia was no longer inducible on programmed electrical stimulation despite isoproterenol. The patient has remained symptom free for 6 months since ablation. With activation mapping we identified the retrograde slow pathway participating in an unusual atypical AVNRT at superior septal perimitral left atrium.

Prognostic value of cardiac troponin in elderly patients with paroxysmal supraventricular tachycardia: A multicenter study

BackgroundAn elevated level of cardiac troponin I (cTnI) frequently accompanies an episode of supraventricular tachycardia (SVT). However, the predictive value of cTnI in elderly SVT patients has not been examined. MethodsWe collected the electronic medical records of elderly SVT patients (over 65 years old) who visited four Taiwanese emergency departments over a 2-year period. The patients who underwent cTnI testing were included in the cohort and further categorized based on their cTnI results (positive or negative). The study's primary outcomes were the 5-year risks of major adverse cardiovascular events (MACE) and SVT recurrence. ResultsOne hundred and twenty-four patients met the inclusion criteria. Of these patients, 39 (31.5%) had a positive cTnI result, and 85 (68.5%) had a negative cTnI result. Patients with a positive cTnI result were older (p = 0.029) and had a longer hospital stay (p = 0.023) than those with a negative cTnI result. Multivariate analysis showed that age > 75 years (OR = 2.41; 95% CI 1.07–5.45; p = 0.034) was an independent predictor for cTnI elevation. In the survival analysis, no difference in the incidence of five-year MACE (p = 0.656) was observed between the cTnI-positive and cTnI-negative groups. Multivariate analysis revealed that a history of coronary artery disease was the only significant independent risk factor for MACE (HR = 4.30; 95% 95% CI 1.41–13.05; p = 0.010). For SVT recurrence, the multivariate analysis revealed that previous SVT (HR = 3.37; 95% CI 1.53–7.39; p = 0.002), smoking history (HR = 2.32; 95% CI 1.03–5.24; p = 0.043), and RFA treatment (HR = 0.20; 95% CI 0.06–0.65; p = 0.008) were significant independent predictors. ConclusionsAn increased cardiac troponin level may not effectively indicate the risk of MACE in elderly SVT patients. Physicians might want to be cautious when interpreting troponin test results for this specific patient group.

Diagnostic yield of ambulatory cardiac monitoring in pediatric patients with palpitations.

Palpitations are a frequent reason for referral to pediatric cardiology providers and diagnostic workup includes ambulatory cardiac monitoring. While common practice, the diagnostic yield is unknown in the pediatric population. The objective is to evaluate the diagnostic yield of 24-h Holter and extended ambulatory cardiac monitoring in pediatric patients with palpitations. All pediatric patients aged 10-18 years who had ambulatory cardiac monitoring (1-30 days) through the Pocket Electrocardiogram (PocketECG™) system (Medi-Lynx) between January 2016 and July 2020 were included. Patients with an International Classification of Diseases-10 diagnosis code of palpitations (R00.2) during enrollment were evaluated separately. Tachyarrhythmia diagnoses included atrial fibrillation (AF), nonsustained supraventricular tachycardia (nSVT), supraventricular tachycardia (SVT), nonsustained ventricular tachycardia (nVT), and ventricular tachycardia (VT). Age, heart rates, arrhythmia type, and symptomatic transmission data were collected and analyzed. A total of 2388 patients (mean age 11.6 years, 58% F) with the R00.2 code had ambulatory cardiac monitoring (28% 24-h Holter, 72% extended) performed during the study period and there were 6287 total patients (mean age 13.9 years, 54% F) that underwent ambulatory cardiac monitoring (42% 24-h Holter, 58% extended) during that time. Of 2388 patients, 321 (13%) were diagnosed with tachyarrhythmia: AF (9), nSVT (192), SVT (59), and nVT (61). In the overall cohort, 764 (12%) patients were diagnosed with tachyarrhythmia: AF (22), nSVT (478), SVT (85), nVT (177), and VT (2). Symptomatic transmissions with normal cardiac rhythm were common in the R00.2 (n = 1697, 71%) and overall (n = 3848, 61%) groups. No episodes of nSVT, SVT, nVT, or VT were associated with symptomatic transmissions. Ambulatory cardiac monitors are an integral part of the diagnostic workup for pediatric palpitations patients and have demonstrated a high yield of combined positive arrhythmia diagnoses and symptomatic normal transmissions. Further prospective study of this population with the integration of clinical information is warranted.

Anaesthetic Management of Intracranial Abscess in a Patient with Surgically Uncorrected Double Outlet Right Ventricle with Transposition of Great Arteries

Double Outlet Right Ventricle (DORV) with Transposition of Great Arteries (TGA) is a rare variant. The ventriculoarterial discordance due to this anatomical defect leads to parallel circulation. The postnatal survival depends on mixing of oxygenated and deoxygenated blood at various levels by defects like Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), Patent Ductus Arteriosus (PDA). Anaesthetising children with cyanotic Congenital Heart Disease (cCHD) and brain abscess necessitates use of anaesthesia protocol appropriate to both cCHD and intracranial surgery. Anaesthetic considerations related are maintenance of intravascular volume and preload, avoidance of precursors to acidosis such as hypothermia, hypercarbia, and hypotension and challenge for anaesthesiologist is to maintain Pulmonary Vascular Resistance (PVR) and Systemic Vascular Resistance (SVR) by pharmacological and ventilatory means. This report is about a seven-year-old child who was posted for emergency craniotomy and abscess drainage, after routine preanaesthetic check-up. Induced with fentanyl, ketamine and atracurium, anaesthesia was maintained on oxygen, air and sevoflurane. Intraoperatively, normothermia was maintained, and blood pressure was maintained by noradrenaline infusion, metabolic acidosis was corrected with soda-bicarbonate. In between the procedure, the patient had an episode of Supraventricular Tachycardia (SVT), which was managed with lidocaine, metoprolal and adenosine. In such cases, it is vital to pay attention to any potential anaesthetic interactions.

The Effectiveness of Physical Maneuvers in the Conversion of Supra-Ventricular Tachycardia on the Example of the Valsalva’s Maneuver

The Valsalva maneuver (VM) is one of the physical maneuvers used by medical personnel. In emergency medicine, it is known primarily for its use as a non-pharmacological method of restoring sinus rhythm possible to perform in almost every patient, and side effects are noticed incidentally. A distinction is made between the classic and the modified Valsalva tests. Multiple studies confirm its use and effectiveness in cases of supraventricular tachycardia episodes in hemodynamically stable patients. The VM allows to determine heart failure by showing abnormal rise of blood pressure as a response to the Valsalva test and thus suggests impaired ventricular function. This maneuver lowers the preload and thus the enddiastolic volume, thereby enhancing some murmurs and weakening others. As a result of phase IV of VM, clinically significant bradycardia occurs, which is used for, at least temporary, termination of supraventricular tachycardia. Based on the available literature, the effectiveness of the modified Valsalva sample was almost twice as high as that of the classical method. However, both methods are effective in the conversion of supra-ventricular tachycardia. Its implementation is relatively simple and possible to perform for almost any patient, provided that he cooperates. As majority of patients using the services of sanatoriums are people burdened with numerous diseases, including cardiovascular diseases, some of them may present with supraventricular tachycardia. Hence, it is important to know simple, safe and non-pharmacological methods of stopping it, the most common of which is the Valsalva maneuver.

Multicenter cohort study on duration of antiarrhythmic medication for supraventricular tachycardia in infants

Antiarrhythmic medication (AM) is commonly used to prevent supraventricular tachycardia (SVT) recurrence in infants. Our aim was to determine whether a shorter duration of AM is sufficient to prevent atrioventricular reentrant tachycardia (AVRT) recurrence and evaluate risk factors for recurrence of SVT after discontinued AM.This multicenter cohort study included all infants diagnosed with SVT in the five university hospitals in Finland between 2005 and 2017. Those diagnosed between 2005 and 2012 received AM for 12 months (group 1), and those diagnosed between 2013 and 2017 received AM for 6 months (group 2). A total of 278 infants presented with AVRT (group 1, n = 181; group 2, n = 97), and the median AM duration was 12.0 months (interquartile range [IQR] 11.4–13.4) and 7.0 months (IQR 6.0–10.2), respectively. Propranolol was the most frequently used first-line AM (92% and 95%). Recurrence-free survival rates were over 88% until 12 months after AM prophylaxis in both groups, without any statistically significant difference between them. Independent risk factors for recurrence of SVT after discontinuation of AM were need of combination AM (HR 2.2, 95% CI 1.14–4.20), Wolff-Parkinson-White (WPW) syndrome (HR 2.4, 95% CI 1.25–4.59), and age over 1 month at admission (HR 2.2, 95% CI 1.12–4.48). Conclusion: Shortening AM duration in infants from 12 to 6 months does not seem to lead to more frequent SVT recurrence. The risk factors for recurrence of SVT were WPW syndrome, need of combination AM, and age over 1 month.What is Known:• Despite the evidence of spontaneous resolution of supraventricular tachycardia episodes in infants, the antiarrhythmic medication is often continued for up to twelve months.• The optimal approach for duration of antiarrhythmic medication remains unknown..What is New:• Shortening the duration of antiarrhythmic medication in infants with supraventricular tachycardia does not seem to increase the risk of subsequent recurrence.• Infants whose arrhythmia was successfully controlled with monotherapy were the group least likely to have recurrence after discontinuation of antiarrhythmic medication.

Inferior Tricuspid Annular Atrial Tachycardia

A 60-year-old male with recurrent episodes of supraventricular tachycardia on regular medications had another episode. Was taken up for electrophysiological study and radiofrequency ablation (EPS and RFA) under 3-D electro-anatomical mapping (EAM). The challenges in the case were need for isoprenaline infusion for sustenance of tachycardia and relatively wider area of ablation requirement for success.

Arrhythmias after SARS-CoV-2 Vaccination in Patients with a Cardiac Implantable Electronic Device: A Multicenter Study.

One of the most concerning adverse events related to the SARS-CoV-2 vaccination is arrhythmia. To ascertain the relationship between vaccination and arrhythmic events, we studied the occurrence of arrhythmia in patients with cardiac implantable electronic devices (CIEDs) before and after a SARS-CoV-2 vaccination. Patients with CIEDs aged ≥18 who visited the CIED clinic at King Chulalongkorn Memorial Hospital and Vajira hospital from August 2021 to February 2022 were included. Information about the SARS-CoV-2 vaccination and side effects was obtained. One hundred eighty patients were included in our study, which compared the incidence of arrhythmias in the 14 days post-vaccination to the 14 days before vaccination. The median age was 70 years. The number of patients who received one, two, and three doses of the vaccine was 180, 88, and 4, respectively. ChAdOx1 was the primary vaccine used in our institutes, accounting for 86% of vaccinations. The vaccination was significantly associated with a 73% increase incidence of supraventricular tachycardia (SVT). In an adjusted model, factors associated with the incidence of SVT were the post-vaccination period, female sex, increasing BMI, chronic kidney disease, and a history of atrial fibrillation. Increased ventricular arrhythmia (VA) episodes were also associated with the post-vaccination period, female sex, decreasing BMI, and chronic kidney disease, but to a lesser degree than those with SVT episodes. No life-threatening arrhythmia was noted in this study. In conclusion, the incidence of arrhythmia in patients implanted with CIEDs was significantly increased after the SARS-CoV-2 vaccination.

Electrocardiographic profile of asymptomatic adolescents by the TELE ECG system in Brazil: analysis of 11058 patients

Abstract Introduction The search for markers that can serve as screening methods for young practitioners of physical activity has always raised an intense discussion between pediatricians and cardiologists. Thus, the ideal investigation algorithm should identify patients at high risk also among asymptomatic patients and be of low cost to society. This would only be possible by including a low cost diagnostic method and largely accessible. In this context, telemedicine systems and in particular tele-electrocardiogram (tele-EKG) systems have low cost and agility and can collaborate to solve this problem. Purpose To analyze the electrocardiographic pattern in asymptomatic patients aged between 10 and 20 years old who underwent EKG by the tele-EKG system between 2007 and 2014 Methods All EKG valid results from asymptomatic patients aged between 10 and 20 years old from 2007 and 2014 sent to the tele-EKG system of a large tertiary hospital were analysed aiming to determine the prevalence of abnormal findings. Results Of the 797,115 exams on the analysed period 25,326 were from patients aged between 10 and 20 years old and 11,058 (55% male) of them were asymptomatic. Regarding disorders of rhythm, ventricular arrhythmias were found in 0.54% and atrial premature beats in 0.47% of the exams. There were 5 episodes of supraventricular tachycardia (0.04%) and one episode of atrial fibrillation. Atrioventricular blocks were: first degree (0.71%) and second degree (0.03%). There was 1 case of 2:1 AV Block and 1 case of advanced AV block. Short PR interval was observed in 0.76% of the exams, with 15 of them showing ventricular pre-excitation (0.13%). Regarding morphological changes in EKG pattern, right bundle branch disorders were present in 7.5% of the patients and left bundle branch in 0.04%. Right bundle branch block occurred in 0.63% and left bundle branch block in only 1 case. Repolarization changes occurred in 1.8% of patients. We found left ventricular overload in 0.25% and right ventricular overload in 0.14% of cases. Only 5 patients had typical EKG of septal hypertrophy (0.045%). There were 1751 diagnostics overall, representing 15.8% of the sample. The most prevalent was right bundle branch abnormalities, followed by repolarization abnormalities (graphic below). Conclusion EKG screening in asymptomatic adolescents is a low cost and feasible method to identify individuals with electrical alterations and who require detailed clinical evaluation. This also may contribute to reduce risk of sudden events during sports activities. Funding Acknowledgement Type of funding sources: None.

S2000 Colonoscopy-Induced Transient Mobitz Type 1 Block

Introduction: Propofol is a commonly used anesthetic in endoscopic procedures. It can prolong the atrioventricular (AV) conduction through vagal stimulation leading to AV block. We report a unique case of a previously healthy patient undergoing a routine screening colonoscopy who developed a Mobitz type 1 block during the procedure, in which propofol was the sole agent used for sedation. Case Description/Methods: A 74-year-old female with a medical history of diverticulosis and a family history of colon cancer in her first-degree relative presented for a routine colonoscopy performed under monitored supervised propofol sedation. During the final phase of the colonoscopy which was performed with minimal air insufflation, she was observed to have a transient 2:1 heart block mixed with periods of 3:2 heart block on the monitor. After the procedure was completed, she reported no cardiac or neurological symptoms. Review of an electrocardiogram strip showed lengthening of the PR interval consistent with Wenckebach (Mobitz type 1 block; Figure. This resolved post procedure. All labs were within normal limits. Prior to this procedure, she had no cardiac history nor was she on any medications. She was referred for a formal cardiology evaluation which included a 14-day Holter monitor showing 22 asymptomatic episodes of supraventricular tachycardia with longest being 26. No treatment was initiated. She also underwent an echocardiogram showing an ejection fraction of 75%, with a normal left ventricle. The incident was deemed to be a vagal affect due to the probe being in the colon/rectum and the effects of propofol. She has not had any recurrences of the Wenckebach phenomenon on subsequent electrocardiograms and continues to remain asymptomatic. Discussion: Propofol can prolong the AV conduction system leading to a heart block even in patients without any cardiac history. The suggested mechanism is hypervagal stimulation causing slow sinus rate, prolongation of stimulus to the bundle of His interval, lengthening of the Wenckebach cycle and the effective refractory period. While air distention in the stomach or colon can also result in a vasovagal reaction and bradycardia, cases of nodal block in this situation are extremely rare. This case demonstrates that in addition to expected vasovagal bradycardia, nodal block is a rare possibility and hence the need for close continuous cardiac monitoring during endoscopy.Figure 1.: Lengthening of the PR interval consistent with Wenckebach (Mobitz type 1 block).