Postoperative Junctional Ectopic Tachycardia Research Articles

Epidemiology of Postoperative Junctional Ectopic Tachycardia in Infants Undergoing Cardiac Surgery

BackgroundJunctional ectopic tachycardia (JET) complicates congenital heart surgery in 2% to 8.3% of cases. JET is associated with postoperative morbidity in single-center studies. We used the Pediatric Cardiac Critical Care Consortium data registry to provide a multicenter epidemiologic description of treated JET. MethodsThis is a retrospective study (February 2019-August 2022) of patients with treated JET. Inclusion criteria were (1) <12 months old at the index operation, and (2) treated for JET <72 hours after surgery. Diagnosis was defined by receiving treatment (pacing, cooling, and medications). A multilevel logistic regression analysis with hospital random effect identified JET risk factors. Impact of JET on outcomes was estimated by margins/attributable risk analysis using previous risk-adjustment models. ResultsAmong 24,073 patients from 63 centers, 1436 (6.0%) were treated for JET with significant center variability (0% to 17.9%). Median time to onset was 3.4 hours, with 34% present on admission. Median duration was 2 days (interquartile range, 1-4 days). Tetralogy of Fallot, atrioventricular canal, and ventricular septal defect repair represented >50% of JET. Patient characteristics independently associated with JET included neonatal age, Asian race, cardiopulmonary bypass time, open sternum, and early postoperative inotropic agents. JET was associated with increased risk-adjusted durations of mechanical ventilation (incidence rate ratio, 1.6; 95% CI, 1.5-1.7) and intensive care unit length of stay (incidence rate ratio, 1.3; 95% CI, 1.2-1.3), but not mortality. ConclusionsJET is treated in 6% of patients with substantial center variability. JET contributes to increased use of postoperative resources. High center variability warrants further study to identify potential modifiable factors that could serve as targets for improvement efforts to ameliorate deleterious outcomes.

Clinical risk prediction score for postoperative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease

Accelerated junctional rhythm (AJR) and junctional ectopic tachycardia (JET) are common postoperative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intraoperative treatment may improve outcomes, but patient selection remains a challenge. The purpose of this study was to describe contemporary outcomes of postoperative AJR/JET and develop a risk prediction score to identify patients at highest risk. This was a retrospective cohort study of children aged 0-18 years undergoing cardiac surgery (2011-2018). AJR was defined as usual complex tachycardia with ≥1:1 ventricular-atrial association and junctional rate >25th percentile of sinus rate for age but <170 bpm, whereas JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression. Among 6364 surgeries, AJR occurred in 215 (3.4%) and JET in 59 (0.9%). Age, heterotaxy syndrome, aortic cross-clamp time, ventricular septal defect closure, and atrioventricular canal repair were independent predictors of AJR/JET on multivariate analysis and included in the risk prediction score. The model accurately predicted the risk of AJR/JET with a C-index of 0.72 (95% confidence interval 0.70-0.75). Postoperative AJR and JET were associated with prolonged intensive care unit and hospital length of stay, but not with early mortality. We describe a novel risk prediction score to estimate the risk of postoperative AJR/JET permitting early identification of at-risk patients who may benefit from prophylactic treatment.

Randomized controlled trial to evaluate the effect of prophylactic amiodarone versus dexmedetomidine on reducing the incidence of postoperative junctional ectopic tachycardia after pediatric open heart surgery.

Junctional ectopic tachycardia (JET) is the most common arrhythmia after pediatric open-heart surgeries (OHS), causing high morbidity and mortality. As diagnosis is often missed in patients with minimal hemodynamic instability, its incidence depends on active surveillance. A prospective randomized trial evaluated the efficacy and safety of prophylactic amiodarone and dexmedetomidine to prevent and control postoperative JET. Consecutive patients aged under 12 years were randomized into amiodarone, dexmedetomidine (initiated during anesthetic induction) and control groups. Outcome measures included incidence of JET, inotropic score, ventilation, and intensive care unit (ICU) duration and hospital stay, as well as adverse drug effects. Two hundred and twenty-five consecutive patients with a median age of 9 months (range 2 days-144 months) and a median weight of 6.3 kg (range 1.8 kg-38 kg) were randomized with 70 patients each to amiodarone and dexmedetomidine groups, and the rest were controls. Ventricular septal defect and Fallot's tetralogy were the common defects. The overall incidence of JET was 16.4%. Syndromic patients, hypokalemia, hypomagnesemia, longer bypass, and cross-clamp duration were the risk factors for JET. Patients with JET had significantly prolonged ventilation (P = 0.043), longer ICU (P = 0.004), and hospital stay (P = 0.034) than those without JET. JET was less frequent in amiodarone (8.5%) and dexmedetomidine (14.2%) groups compared to controls (24.7%) (P = 0.022). Patients receiving amiodarone and dexmedetomidine had significantly lower inotropic requirements, lower ventilation duration (P = 0.008), ICU (P = 0.006), and hospital stay (P = 0.05). Adverse effects such as bradycardia and hypotension after amiodarone and ventricular dysfunction after dexmedetomidine were not significantly different from controls. Prophylactic amiodarone or dexmedetomidine started before OHS is effective and safe for the prevention of postoperative JET.

Hemodynamic profile effects of PM101 amiodarone formulation in patients with post-operative tachyarrhythmias.

Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.

Sotalol versus amiodarone for postoperative junctional tachycardia after congenital heart surgery.

Junctional ectopic tachycardia (JET) is a common arrhythmia after congenital heart disease surgery. There is variability in the choice of antiarrhythmic therapy, with amiodarone used commonly. Intravenous (IV) sotalol is a newly available agent that may be useful for JET. The purpose of this study was to evaluate the safety and efficacy of IV sotalol for postoperative JET and compare outcomes with IV amiodarone. This is a retrospective single-center study of all patients who received IV sotalol or IV amiodarone for postoperative JET at Texas Children's Hospital from December 15, 2015, to December 15, 2020. Data included antiarrhythmic efficacy, hemodynamics, and adverse effects. Successful JET control was defined as a decrease in JET rate to <170 beats/min (or decrease by >20%), or conversion to sinus rhythm, with persistent control over 24 hours without requiring alternative antiarrhythmics or mechanical support. A total of 32 patients (median age 71 days; interquartile range 17-221 days) received IV amiodarone (n = 20 [62%]) or IV sotalol (n = 12 [38%]) for postoperative JET. Amiodarone was successful in treating JET in 75% of cases; sotalol was successful in 83%. The JET rate decreased faster over the first 90 minutes after a sotalol bolus (25 beats/min per hour) than after an amiodarone bolus (8 beats/min per hour) (P < .01); no heart rate difference was seen after 24 hours. Amiodarone infusion was discontinued early because of hypotension/bradycardia in 2 patients; this was not required in any patients receiving sotalol. For children with postoperative JET, both IV sotalol and amiodarone are safe and efficacious. IV sotalol may lead to a faster improvement in heart rate.

β1-receptor polymorphisms and junctional ectopic tachycardia in children after cardiac surgery.

Junctional ectopic tachycardia (JET) is a potentially life‐threatening postoperative arrhythmia in children with specific congenital heart defects and can contribute significantly to postoperative morbidity for at‐risk populations. In adults, β1‐adrenergic receptor (ADRB1) and β2‐adrenergic receptor (ADRB2) genotypes have been associated with increased risk for arrhythmias. However, their association with arrhythmia risk in children is unknown. We aimed to test associations between ADRB1 and ADRB2 genotypes and postoperative JET in patients with congenital heart defects. Children who underwent cardiac surgery were genotyped for the ADRB1 p.Ser49Gly (rs1801252; c.145A>G), p.Arg389Gly (rs1801253; c.1165C>G), ADRB2 p.Arg16Gly (rs1042713; c.46A>G), and p.Glu27Gln (rs1042714; c.79G>C) polymorphisms. The occurrence of postoperative JET was assessed via cardiologist‐interpreted electrocardiograms. Genotype associations with JET were analyzed via logistic regression, adjusted for clinical variables associated with JET, with separate analysis in patients not on a β‐blocker. Of the 343 children included (median age 8 months, 53% boys, 69% European ancestry), 45 (13%) developed JET. The Arg389Arg genotype was not significantly associated with JET in the overall population (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 0.96–4.03, p = 0.064), but was nominally associated in patients not taking a β‐blocker (n = 324, OR = 2.25, 95% CI = 1.05–4.80. p = 0.034). None of the other variants were associated with JET. These data suggest that the ADRB1 Arg389Arg genotype may predict risk for JET following cardiac surgery in pediatric patients in the absence of β‐blockade. Whether treatment with a β‐blocker ameliorates this association requires further research.

Ivabradine Versus Amiodarone in the Management of Postoperative Junctional Ectopic Tachycardia: A Randomized, Open-Label, Noninferiority Study.

This study sought to compare the efficacy of ivabradine and amiodarone in the management of postoperative junctional ectopic tachycardia (JET) after cardiac surgery in children. JET is a serious arrhythmia occurring in children after cardiac surgery and requires aggressive management. Amiodarone has been conventionally used in its treatment. Recent studies have reported the utility of ivabradine in this regard. In this open-label randomized controlled trial, 94 children (age≤18 years) who developed postoperative JETwere allocated to receive either amiodarone or ivabradine. The primary endpoint was restoration of normal sinus rhythm. Sinus rhythm was achieved in 43 out of the 46 patients (93.5%) in the amiodarone group and 46 out of the 48 patients (95.8%) in the ivabradine group (mean difference of treatment effect: 2.3%; 95% confidence interval:-6.7% to 11.5%). The median (interquartile range) time taken to achieve sinus rhythm conversion was similar in both the groups: 21.5 (17-30.2) hours versus 22 (13.4-38.5) hours (p=0.36)]. The time taken to rate control of JET was significantly less in the amiodarone group: median 7.0 (5.5-9.5) hours versus 8.0 (5.8-10.8) hours (p=0.02)]. No drug-related adverse events were observed in the ivabradine group. Oral ivabradine is not inferior to intravenous amiodarone in converting postoperative JET to sinus rhythm. There was no difference in time taken to sinus rhythm conversion between the groups, although the rate control was earlier in patients who received amiodarone. Monotherapy with ivabradine may be considered as an alternative toamiodarone in the management of postoperative JET. (Comparison of Two Drugs, Ivabradine and Amiodarone, in theManagement of Junctional Ectopic Tachycardia, an Abnormality in Cardiac Rhythm in Patients Under 18 years Who Undergo Cardiac Surgery: CTRI/2018/08/015182).

Management of post-operative Junctional Ectopic Tachycardia in symptomatic neonates and infants at a tertiary care center in a developing country: Lessons learned!

Purpose: Junctional ectopic tachycardia (JET) is an uncommon form of arrhythmia that occurs after surgical correction of congenital heart defects. Data on neonates and infants are rare. This study highlights the epidemiology, incidence, and management of neonates and infants with JET at a tertiary care center in Lebanon.&#x0D; Methods: We conducted a retrospective chart review between January 1, 2013, and December 31, 2017. All Patients with documented symptomatic junctional ectopic tachycardia on electrocardiogram who required medical treatment post-surgery were included.&#x0D; Results: A total of 9 patients were included. The median age was 18 days, and six were males. Six out of nine (66.67%) were successfully treated with cooling and amiodarone on the initial attempt. The other three cases failed initial treatment with adenosine. However, they were successfully treated with cooling and amiodarone as second-line therapy. All cases of junctional ectopic tachycardia occurred post-surgery at an average of 1.67 ± 1.11 days.&#x0D; Conclusion: Junctional ectopic tachycardia mostly occurs after corrective cardiac surgery and can be successfully treated with cooling and amiodarone. Timely diagnosis significantly affects the outcome.

A Comparative Effectiveness Systematic Review and Meta-analysis of Drugs for the Prophylaxis of Junctional Ectopic Tachycardia.

Junctional Ectopic Tachycardia (JET) is an arrhythmia originating from the AV junction, which may occur following congenital heart surgery, especially when the intervention is near the atrioventricular junction. The aim of this systematic review and meta-analysis is to compare the effectiveness of amiodarone, dexmedetomidine, and magnesium in preventing JET following congenital heart surgery. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement, where 11 electronic databases were searched from the date of inception to August 2020. The incidence of JET was calculated with the relative risk of 95% Confidence Interval (CI). Quality assessment of the included studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement. Eleven studies met the predetermined inclusion criteria and were included in this meta-analysis. Amiodarone, dexmedetomidine, and magnesium significantly reduced the incidence of postoperative JET [Amiodarone: risk ratio 0.34; I2= 0%; Z=3.66 (P=0.0002); 95% CI 0.19-0.60. Dexmedetomidine: risk ratio 0.34; I2= 0%; Z=4.77 (P<0.00001); 95% CI 0.21-0.52. Magnesium: risk ratio 0.50; I2= 24%; Z=5.08 (P<0.00001); 95% CI 0.39-0.66]. All three drugs have shown promising results in reducing the incidence of JET. Our systematic review found that dexmedetomidine is better in reducing the length of ICU stays as well as mortality. In addition, dexmedetomidine also has the least pronounced side effects among the three. However, it should be noted that this conclusion was derived from studies with small sample sizes. Therefore, dexmedetomidine may be considered as the drug of choice for preventing JET.

Use of ivabradine in postoperative junctional ectopic tachycardia: A systematic review of case series and case reports

Purpose: When tachyarrhythmias originates from atrioventricular (AV) node, AV junction or bundle of His complex, they are termed “junctional ectopic tachycardia” (JET). Cardiac surgeries especially involving crux of the heart are mainly responsible for JET. Amiodarone and other pharmaco-therapeutic agents are tried as antiarrhythmics for the treatment of postoperative JET. Aim of this review was to discuss about role of ivabradine in the treatment of postoperative JET. Materials and Methods: A search was carried out for this review article on the basis of literature available including scientific databases of PubMed, Embase, Scopus, Google Scholar, using keywords “Ivabradine,” “Postoperative junctional ectopic tachycardia,” “Arrhythmias,” “Funny currents,” from October 2011 to October 2020. Results: After initial screening of 377 articles, 9 studies were included and discussed in detail in the present review article. Conclusion: Treatment of choice of postoperative JET is still not well established. Although there are very few case reports and case series that have been reported on the use of ivabradine in JET, yet it seems to offer a promising use.

Diagnosis and management of junctional ectopic tachycardia in children.

Junctional ectopic tachycardia (JET) is more common in its postoperative form. A thorough understanding of its etiology, pathophysiology, and management strategies is essential. Classically, postoperative JET is considered to arise from surgical trauma. Genetic susceptibility and an intrinsic morphologic/functional defect in the conduction system inherent in congenital heart diseases likely play a significant role. The devastating effects on postoperative hemodynamics warrant prompt attention. A multipronged management approach with general measures, pharmacotherapy, and pacing has decreased morbidity and mortality. Amiodarone and procainamide remain the preferred drugs, while ivabradine appears promising. Carefully planned randomized trials can go a long way in developing a systematic management protocol for postoperative JET.

Junctional ectopic tachycardia in infants and children.

Tachyarrhythmias originating in the atrioventricular (AV) node and AV junction including the bundle of His complex (BH) are called junctional tachycardia (JT) or junctional ectopic tachycardia (JET). Congenital JET (CJET) is a rare arrhythmia that occurs in patients without a preceding cardiac surgery and can be refractory to medical therapy and associated with high morbidity and mortality. CJET has a high rate of morbidity and mortality with death occurring in 35% of cases. JET occurring within 72 hours after cardiac surgery is referred to as postoperative JET (POJET) and caused by direct trauma, ischemic, or stretch injury to the AV conduction tissues during surgical repair of congenital heart defects. Focal junctional tachycardia (FJT) is also known as automatic junctional tachycardia and includes paroxysmal or non‐paroxysmal forms. We discuss a staged approach to therapy with improved pharmacological therapies and the use of catheter‐based therapies.

Ivabradine as an Adjunct for Refractory Junctional Ectopic Tachycardia Following Pediatric Cardiac Surgery: A Preliminary Study.

Junctional ectopic tachycardia (JET) is a relatively common narrow complex rhythm typically characterized by atrioventricular dissociation or retrograde atrial conduction in a 1:1 pattern. Junctional ectopic tachycardia can be a life-threatening disorder, causing severe hemodynamic compromise and increased morbidity and mortality. The treatment of refractory JET can be very difficult, even with multimodal therapeutic interventions. The purpose of this study was to assess the role of ivabradine in cases of JET refractory to amiodarone and esmolol. A total of 480 congenital heart surgeries were carried out at our center in 2017. Twenty (4.16%) patients had postoperative JET. Among these, five infants, aged 7 to 12 months (median: 8 months), had refractory JET. These patients (three tetralogy of Fallot, one ventricular septal defect, one complete atrioventricular septal defect) were treated with oral ivabradine in the dose range of 0.1 to 0.2 mg/kg/12 h as an adjunct to amiodarone. All five patients achieved rate reduction and eventual conversion to sinus rhythm. Mean duration to achieve heart rate of <140 bpm after initiation of ivabradine therapy was 16.8 hours (±7.2 hours), while mean duration to achieve sinus rhythm was 31.6 hours (±13.6 hours). No patient had any recurrence of JET. No patient exhibited any hemodynamic derangement nor side effects attributable to oral ivabradine. Oral ivabradine has the potential to be used as an adjunct to amiodarone in the treatment of JET in infants after surgery for congenital heart disease.

Ivabradine in Post-operative Junctional Ectopic Tachycardia (JET): Breaking New Ground.

Junctional ectopic tachycardia (JET) is the commonest tachyarrhythmia in the early post-operative period in children undergoing open-heart surgery. It frequently leads to hemodynamic instability and needs to be managed aggressively. Amiodarone is the first-line agent along with non-pharmacological interventions. We report our initial experience with the use of Ivabradine in post-operative JET. A retrospective case records review of children with post-operative JET during the period from June 2018 to May 2019 was performed. Eight patients with post-operative JET were treated with Ivabradine during this period. The first patient was initially treated with Amiodarone. All eight patients responded to Ivabradine. The initial response was rate control permitting overdrive pacing. One patient had recurrence of JET 10h after Ivabradine and after return to sinus rhythm. Amiodarone was administered along with the second dose of Ivabradine resulting in remission to sinus rhythm. Ivabradine appears to be an effective alternative to Amiodarone in children with post-operative JET based on our initial clinical experience.

Risk Factors and Outcome of Post Fallot Repair Junctional Ectopic Tachycardia (JET).

Junctional ectopic tachycardia (JET) is a common arrhythmia causing hemodynamic impairment following corrective cardiac surgery such as tetralogy of Fallot (TOF) repair. We report our experience with postoperative JET following surgical repair of TOF. The retrospective study was done from 2003 to 2012 with a total of 105 patients who underwent TOF repair. These patients' clinical and electrocardiographic data (pre-, intra-, and postoperative) were monitored to identify risk factors for the occurrence of JET and to evaluate the outcome of the affected patients. Incidence-Fourteen patients developed JET, with only four patients going directly from sinus rhythm to JET. In all others, either a transient atrioventricular (AV) block or a junctional rhythm preceded JET, mostly intraoperatively, showing a significant relation ( P = .010). Age-Patients with JET were of younger age ( P = .025) and had longer cardiopulmonary bypass ( P = .044) and aortic cross-clamping times ( P = .038). Increased cost and care-The occurrence of JET was associated with a longer stay in the intensive care unit (ICU) and a prolonged need for inotropic support and mechanical ventilation. Time to rate control correlated with length of ICU and hospital stay. All JET patients converted into sinus rhythm, one of them died shortly after cessation of JET and two patients subsequently developed a first-degree AV block. The occurrence of JET remains an important complication during the initial postoperative period by increasing mechanical ventilation time, the need for inotropic support, and prolonging the length of ICU and hospital stay. Risk factors are younger age, longer aortic cross-clamping/bypass times, and intraoperative arrhythmias.

Ivabradine—The Final Crusader for Postoperative Junctional Ectopic Tachycardia, a Case Report with Literature Review

Background: Junctional ectopic tachycardia (JET) is one troublesome supraventricular arrhythmia in postoperative pediatric cardiac surgical patients. Unless treated timely and effectively it may lead to morbidity and even mortality. Aim: To understand the role of Ivabradine in the treatment of JET in postoperative pediatric cardiac surgical patients. Case: We present a postoperative case of complete repair of Tetralogy of Fallot who was in normal sinus rhythm in the preoperative period and developed JET 4 hours later in postoperative period which was persistent despite measures to optimize the internal milieu of the body and conventional antiarrhythmics, that was successfully treated with Ivabradine at a dose of 0.05 mg/kg/12 hourly. Conclusion: Ivabradine can be used to successfully treat postoperative JET in cases ofrefractory to other antiarrhythmic drugs like Digoxin and Amiodarone.

Efficacy of dexmedetomidine in prevention of junctional ectopic tachycardia and acute kidney injury after pediatric cardiac surgery: A meta-analysis.

We conducted a meta-analysis to evaluate the effects of prophylactic perioperative dexmedetomidine administration on postoperative junctional ectopic tachycardia (JET) and acute kidney injury (AKI) in pediatric patients having undergone cardiac surgery. This systematic review was registered with PROSPERO (CRD42017083880). Databases including PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched for randomized controlled trials (RCTs) and observational cohort studies from its inception to March 2018. Two reviewers independently screened literature, extracted data, and assessed the quality of included studies using the Jadad scale and Newcastle-Ottawa score. Meta-analysis was then conducted by RevMan 5.3 and Stata 12.0 software. P value < .05 was considered significant. A total of nine eligible studies (5 RCTs and 4 observational studies) comprising 1851 patients were selected for the final analysis. The results of meta-analysis showed that dexmedetomidine significantly reduced the incidence of postoperative JET (OR =0.35, 95% CI: 0.22 to 0.53, P < .00001), but there was no significant difference between groups in AKI (OR =0.44, 95% CI: 0.19 to 1.04, P=.06) and all-cause mortality (OR =0.87, 95% CI: 0.35 to 2.14, P=.77). The administration of perioperative dexmedetomidine effectively prevents JET in pediatric patients undergoing cardiac surgery but has no significant effect on postoperative renal function. However, the quality of evidence for these findings is low; thus, future larger scale randomized studies are needed to verify the real clinical effects of dexmedetomidine prophylaxis in pediatric patients.

Landiolol Hydrochloride Rapidly Controls Junctional Ectopic Tachycardia After Pediatric Heart Surgery.

Junctional ectopic tachycardia is a supraventricular tachyarrhythmia with atrioventricular dissociation that causes life-threatening postsurgical conditions in pediatric heart patients. This study evaluates the efficacy of landiolol hydrochloride for managing junctional ectopic tachycardia. A single-center retrospective study. PICU at the university hospital. Of 561 pediatric patients who underwent open-heart surgery between 2006 and 2017, 10 patients developed sustained junctional ectopic tachycardia and were selected for landiolol treatment. None. Landiolol decreased mean heart rate significantly from 206.1 ± 14.5 to 158.0 ± 8.6 beats/min within 2 hours after administration (p < 0.01). Mean time to achieve 20% heart rate reduction was 2.1 ± 0.5 hours. Systolic blood pressure between pre and post landiolol administration did not change significantly (72.6 ± 5.9 to 79.7 ± 6.2 mm Hg). Once junctional heart rate was sufficiently suppressed, atrioventricular sequential pacing was introduced to stabilize hemodynamics. Nine of 10 cases (90%) had atrioventricular sequential pacing to maintain appropriate heart rate and restore atrioventricular synchronicity under suppressed junctional heart rate. Subsequently, eight of 10 cases (80%) were converted to regular sinus rhythm within 24 hours after starting landiolol administration. The average time to achieve sinus rhythm conversion was 7.9 ± 3.4 hours. Landiolol rapidly suppresses junctional heart rate in junctional ectopic tachycardia after pediatric heart surgery without significant blood pressure compromises. Subsequent atrioventricular sequential pacing was effective at restoring atrioventricular synchronicity and stabilizing hemodynamics. Combining junctional rate control with landiolol and atrioventricular sequential pacing is therefore suggested as a promising option for prompt management of postoperative junctional ectopic tachycardia.

Efficacy of prophylactic dexmedetomidine in preventing postoperative junctional ectopic tachycardia in pediatric cardiac surgery patients: A systematic review and meta-analysis.

Junctional ectopic tachycardia is a serious tachyarrhythmic complication following pediatric cardiac surgery. It is difficult to manage and is associated with significant morbidity and mortality. Conventional nonpharmacological and pharmacological measures have shown limited effects. Dexmedetomidine is an α2 agonist which has recently been shown in multiple studies to be effective. The aim of this systematic review with meta-analysis was to evaluate the efficacy of prophylactic dexmedetomidine administration in the prevention of junctional ectopic tachycardia in pediatric patients following cardiac surgeries. We searched MEDLINE, EMBASE, Cochrane, Web of Science, and relevant references published in English before December 20, 2017 and performed meta-analysis on the selected studies, with one group receiving prophylactic perioperative dexmedetomidine administration and another group receiving placebo. The primary outcome was the incidence of junctional ectopic tachycardia, secondary outcomes included bradycardia, hypotension, intensive care unit stay, total hospital stay, inotropic scores, and total mechanical ventilation time. Odds ratio or mean difference with 95% confidence intervals were calculated using a random effect model. Seven studies (5 prospective randomized studies and 2 retrospective case-controlled studies) with a total of 1616 patients were analyzed. The incidence of junctional ectopic tachycardia in the dexmedetomidine group was significantly reduced compared to placebo. Similarly, intensive care unit stay, inotropic scores, and total mechanical ventilation time were also significantly decreased in the dexmedetomidine group. No significant increases in adverse events were found. Mortality was low in both groups. Prophylactic dexmedetomidine is effective in reducing the incidence of postoperative junctional ectopic tachycardia without significant increases in adverse events in pediatric patients undergoing surgery for congenital heart diseases.

Dexmedetomidine improves the outcomes in paediatric cardiac surgery: a meta-analysis of randomized controlled trials.

Dexmedetomidine has been shown to decrease cardiac complications in adults undergoing cardiac surgery. Results from clinical trials of dexmedetomidine on outcomes following paediatric cardiac surgery are controversial. We searched EMBASE, PubMed and Cochrane CENTRAL databases for randomized controlled trials comparing the effect of dexmedetomidine versus placebo or other anaesthetic drugs in paediatric patients undergoing cardiac surgery. The primary outcome was the duration of mechanical ventilation. The secondary outcomes were intensive care unit stay, hospital length of stay (LOS), incidence of junctional ectopic tachycardia and postoperative deaths. Nine trials with a total of 837 patients were selected. Compared with controls, dexmedetomidine significantly reduced the postoperative duration of mechanical ventilation [in hours; n = 837; weighted mean difference -2.20, 95% confidence interval (CI) -3.51 to -0.90; P = 0.001; I2 = 97%], intensive care unit LOS (in days; n = 737; weighted mean difference -0.47, 95% CI -0.90 to -0.03; P = 0.03; I2 = 97%) and hospital LOS (in days; n = 291; weighted mean difference -1.80, 95% CI -3.36 to -0.25; P = 0.02; I2 = 96%). Dexmedetomidine also significantly reduced the incidence of postoperative junctional ectopic tachycardia (21/292 vs 50/263; risk ratio 0.40, 95% CI 0.25-0.64; P = 0.0001; I2 = 0.0%), but there was no difference between groups in postoperative deaths (4/182 vs 6/153; odds ratio 0.54, 95% CI 0.15-1.93; P = 0.34; I2 = 0.0%). Perioperative administration of dexmedetomidine to paediatric patients undergoing cardiac surgery may shorten the duration of mechanical ventilation, LOS in the intensive care unit and in the hospital and reduce the incidence of junctional ectopic tachycardia. More high-quality randomized controlled trials are encouraged to verify the beneficial effect of dexmedetomidine before its clinical application in paediatric patients undergoing surgery for congenital heart disease.