Neonatal arrhythmias: diagnosis, treatment, and clinical outcome

Ban, Ji-Eun The Korean Pediatric Society 2017 Clinical and Experimental Pediatrics (CEP) Vol.60 No.11

Arrhythmias in the neonatal period are not uncommon, and may occur in neonates with a normal heart or in those with structural heart disease. Neonatal arrhythmias are classified as either benign or nonbenign. Benign arrhythmias include sinus arrhythmia, premature atrial contraction, premature ventricular contraction, and junctional rhythm; these arrhythmias have no clinical significance and do not need therapy. Supraventricular tachycardia, ventricular tachycardia, atrioventricular conduction abnormalities, and genetic arrhythmia such as congenital long-QT syndrome are classified as nonbenign arrhythmias. Although most neonatal arrhythmias are asymptomatic and rarely life-threatening, the prognosis depends on the early recognition and proper management of the condition in some serious cases. Precise diagnosis with risk stratification of patients with nonbenign neonatal arrhythmia is needed to reduce morbidity and mortality. In this article, I review the current understanding of the common clinical presentation, etiology, natural history, and management of neonatal arrhythmias in the absence of an underlying congenital heart disease.

Neonatal arrhythmias: diagnosis, treatment, and clinical outcome

반지은 대한소아청소년과학회 2017 Clinical and Experimental Pediatrics (CEP) Vol.60 No.11

Arrhythmias in the neonatal period are not uncommon, and may occur in neonates with a normal heart or in those with structural heart disease. Neonatal arrhythmias are classified as either benign or nonbenign. Benign arrhythmias include sinus arrhythmia, premature atrial contraction, premature ventricular contraction, and junctional rhythm; these arrhythmias have no clinical significance and do not need therapy. Supraventricular tachycardia, ventricular tachycardia, atrioventricular conduction abnormalities, and genetic arrhythmia such as congenital long-QT syndrome are classified as nonbenign arrhythmias. Although most neonatal arrhythmias are asymptomatic and rarely life-threatening, the prognosis depends on the early recognition and proper management of the condition in some serious cases. Precise diagnosis with risk stratification of patients with nonbenign neonatal arrhythmia is needed to reduce morbidity and mortality. In this article, I review the current understanding of the common clinical presentation, etiology, natural history, and management of neonatal arrhythmias in the absence of an underlying congenital heart disease.

소아 선천성 심장병 개심술 후 발생한 조기 부정맥

최희정,김여향,조준용,현명철,이상범,김규태,Choi, Hee-Joung,Kim, Yeo-Hyang,Cho, Joon-Yong,Hyun, Myung-Chul,Lee, Sang-Bum,Kim, Kyu-Tae 대한소아청소년과학회 2010 Clinical and Experimental Pediatrics (CEP) Vol.53 No.4

목 적 : 선천성 심장병의 개심술 직후에 발생하는 부정맥은 술 후 조기 사망의 주된 원인의 하나인데, 이는 심폐 우회술 및 심근보호법의 발달, 술 후 집중치료와 적절한 약물 치료로 감소시킬 수 있다. 이에 이번 연구에서는 선천성 심장병의 개심술 후 조기에 발생한 부정맥의 빈도와 종류, 그 위험 인자들을 조사하여 보았다. 방 법: 2002년 1월부터 2008년 12월까지 선천성 심장병으로 경북대학교병원에서 개심술을 시행받은 561명의 환자를 대상으로 하였다. 이들의 의무기록지를 후향적으로 조사하여 진단명, 수술방법, 수술 후 부정맥이 발생한 시기와 기간, 부정맥의 종류와 치료방법, 부정맥으로 동반된 합병증 및 사망률, 부정맥 발생 당시 혈액 전해질 수치 등을 분석하였다. 결 과 : 소아 개심술 후 조기 부정맥의 빈도는 7.3% (42/578 개심술)로 남아 23명, 여아 18명이었으며, 개심술을 시행 받은 나이는 평균 $8.7{\pm}19.8$개월, 몸무게는 평균 $5.8{\pm}4.0kg$이었다. 발생한 부정맥 종류는 방실 접합부 이소성 빈맥이 17례로 가장 많았고, 다음으로 가속 심실고유 율동이 13례였으며, 또한 대혈관 전위에 대한 동맥 전환술에서 가장 많은 빈도의 부정맥을 보였다(36.4%). 대부분의 부정맥은 치료에 반응이 좋았다. 개심술 후 조기 부정맥의 위험 인자로는 수술 당시 작은 몸무게, 어린 나이, 긴 인공 심폐기 시간과 긴 대동맥 차단 시간이었다($P$<0.05). 부정맥이 발생한 환자에서 그렇지 않은 환자에 비해 인공호흡기 사용시간과 집중치료실 입원기간이 의미있게 길었으나($P$<0.05), 사망률에서는 의미있는 차이가 없었다. 결 론 : 선천성 심장병의 개심술 후 발생하는 조기 부정맥은 주의깊은 감시와 적극적인 치료로 치명적인 결과를 줄일 수 있다. 최근 개심술의 나이가 낮아짐에 따라 술 후 조기 부정맥에 대한 더욱 세심한 관리가 필요할 것으로 생각된다. Purpose : Early postoperative arrhythmias are a major cause of mortality and morbidity after open heart surgery in the pediatric population. We evaluated the incidence and risk factors of early postoperative arrhythmias after surgery of congenital heart disease. Methods : From January 2002 to December 2008, we retrospectively reviewed the medical records of the 561 patients who underwent cardiac surgery in Kyungpook National University Hospital. We analyzed patients' age and weight, occurrence and type of arrhythmia, cardiopulmonary bypass (CPB) time, aortic cross clamp (ACC) time, and postoperative electrolyte levels. Results : Arrhythmias occurred in 42 of 578 (7.3%) cases of the pediatric cardiac surgery. The most common types of arrhythmia were junctional ectopic tachycardia (JET) and accelerated idioventricular rhythm (AIVR), which occurred in 17 and 13 cases, respectively. The arterial switch operation (ASO) of transposition of the great arteries (TGA) had the highest incidence of arrhythmia (36.4%). Most cases of cardiac arrhythmia showed good response to management. Patients with early postoperative arrhythmias had significantly lower body weight, younger age, and prolonged CPB and ACC times ($P$<0.05) than patients without arrhythmia. Although the mean duration of ventilator care and intensive care unit stay were significantly longer ($P$<0.05), the mortality rate was not significantly different among the 2 groups. Conclusion : Early postoperative arrhythmias are a major complication after pediatric cardiac surgery; however, aggressive and immediate management can reduce mortality and morbidity.

Clinical Article : Association between Hypophosphatemia and Cardiac Arrhythmias in the Early Stage of Sepsis: Could Phosphorus Replacement Treatment Reduce the Incidence of Arrhythmias?

( Andrei Schwartz ),( Evgeni Brotfain ),( Leonid Koyfman ),( Ruslan Kutz ),( Shaun E. Gruenbaum ),( Moti Klein ),( Alexander Zlotnik ) 대한전해질학회 2014 Electrolytes & Blood Pressure Vol.12 No.1

It is well known that new-onset arrhythmias are common in septic patients. It is thought that hypophosphatemia in the early stages of sepsis may contribute to the development of new arrhythmias. In this study, we hypothesized that intravenous (IV) phosphorus replacement may reduce the incidence of arrhythmias in critically ill patients. 34 adult septic patients with hypophosphatemia admitted to the general intensive care unit were treated with IV phosphorus replacement per ICU protocol, and the incidence of new arrhythmias were compared with 16 patients from previously published data. IV phosphorus replacement was associated with a significantly reduced incidence of arrhythmias (38% vs. 63%, p=0.04). There were no differences in observed mortality between subgroups, which may be due to the small sample size. This study demonstrated that IV phosphorus replacement might be effective in reducing the incidence of new arrhythmias in septic patients.

Clinically Significant Cardiac Arrhythmia in Patients with Aneurysmal Subarachnoid Hemorrhage

Yeon-Seong Jeong,김형동 대한뇌혈관외과학회 2012 Journal of Cerebrovascular and Endovascular Neuros Vol.14 No.2

Objective:Many previous studies have shown that electrocardiographic (ECG) changes occur patients with subarachnoid hemorrhage (SAH). This study was designed to identify the frequency, influencing factors, and outcome of clinically significant cardiac arrhythmias after SAH. Methods:We retrospectively analyzed clinical data of 122 patients including ECG finding, age, sex, the Hunt-Hess grade, the Fisher‘s grade, the history of hypertension, peak blood pressure and heart rate, location of aneurysm, Glasgow Outcome Scale (GOS) score, the days of admission to the intensive care unit, the presence of symptomatic vasospasm. Results:Of 122 SAH patients, 50% (n=61) had a verified clinically significant arrhythmia. There were no statistically significant independent factors associated with clinically significant arrhythmia in multivariate analysis. Although adjustments for the effects of age, Hunt-Hess grade, and the presence of symptomatic vasospasm on death were made, clinically significant arrhythmias were still independently predictive of death (no arrhythmia versus arrhythmia, 11.5% versus 27.9%, adjusted odds ratio [OR] 3.524, 95% confidence interval [CI] 1.229-10.100, p=0.019) and poor outcome (GOS≦2, 13.1% versus 29.5%, adjusted OR 3.202, 95% CI 1.174-8.732, p=0.023). Conclusion:Clinically significant arrhythmias after SAH are associated with a high mortality rate, and serious cardiac and neurological comorbidity. Patients with an abnormal ECG on admission should undergo close cardiac monitoring, and the presence of rhythm disturbances should prompt aggressive measures to treat myocardial infarction (MI), maintain a normal cardiac rhythm, and minimize the presence of autonomic stress.

초오 중독 환자에서 나타나는 부정맥은 교정 QT 간격 연장과 어떤 관계를 보이는가?

김태권,진상찬,김성진,최우익 대한응급의학회 2013 大韓應急醫學會誌 Vol.24 No.5

Purpose: This study examined the association between the prolongation of heart rate-corrected QT (QTc) and arrhythmia in patients with aconitine intoxication. Methods: A 13-year retrospective study of patients with aconitine poisoning treated at emergency departments between March 2002 and May 2013 was conducted. The EKGs obtained within 4 hours after the ingestion of aconitine were analyzed to measure the QT and QTc intervals. The QT interval was manually measured and QTc was obtained using Bazett's formula. The patients were divided into a normal QTc group and a prolonged QTc group (prolonged QTc interval defined as >450 ms in men and >470ms in women). General characteristics, clinical features,laboratory results, and abnormal EKG findings of the two groups were compared. Results: Forty-one patients were enrolled in this study. The mean QTc intervals of the normal QTc group (n=20) and prolonged QTc group (n=21) were 446.4±18.2 ms and 500.6±18.1 ms, respectively. The prolonged QTc group had a significant presence of arrhythmia compared with the normal QTc group. Arrhythmia occurred in two of the 20normal QTc group patients and 17 of the 21 prolonged QTc group patients (p<0.001). Premature ventricular contractions were observed in one normal QTc patients and in 17prolonged QTcpatients (p<0.001). Ventricular arrhythmias were the most common arrhythmia in both groups. A bundle branch block occurred in 12 patients, all from the prolonged QTc group (p<0.001). Eleven of 12 patients with a bundle branch block had their electrocardiogram return to normal. Conclusion: A prolonged QTc interval within 4 hours after ingestion of aconitine is a significant predictor of arrhythmia. Serial measuring of the QTc interval is recommended to predict arrhythmia.

Postoperative Life-Threatening Recurrent Ventricular Arrhythmia Triggered by the Swan-Ganz Catheter in a Patient Undergoing Off-Pump Coronary Artery Bypass Surgery

민준철,오세진,성용원,문현종,이정상,최재성 대한흉부외과학회 2014 Journal of Chest Surgery (J Chest Surg) Vol.47 No.4

Recurrent ventricular arrhythmia can be fatal and cause serious complications, particularly when it is caused immediately after an operation. Incorrect placement of a Swan-Ganz catheter can trigger life-threatening ventricular arrhythmia, but even intensive care specialists tend to miss this fact. Here, we report a case of recurrent ventricular arrhythmia causing a severe hemodynamic compromise; the arrhythmia was induced by a severely angulated Swan-Ganz catheter. The recurrent ventricular arrhythmia was not controlled by any measures including repositioning of the catheter, until the complete removal of the Swan-Ganz catheter. It is necessary to keep in mind that the position of the pulmonary artery catheter should be promptly checked if there is intractable recurrent ventricular arrhythmia.

Urate-lowering therapy is associated with a reduced risk of arrhythmias: a systematic review and meta-analysis

( Palapun Waitayangkoon ),( Thiratest Leesutipornchai ),( Witina Techasatian ),( Noppawit Aiumtrakul ),( Manasawee Tanariyakul ),( Chinnawat Arayangkool ),( Tatchaya Kanthajan ),( Todd Nagamine ),( Ja 대한류마티스학회 2024 대한류마티스학회지 Vol.31 No.2

Objective: While urate-lowering therapy (ULT) is linked to increased cardioprotective benefits on primary prevention of cardiovascular events such myocardial infarction or heart failure, little is known regarding their effects on arrhythmia risk. The purpose of this study was to investigate the relationship between incident arrhythmias and ULT. Methods: We searched MEDLINE and Embase from inception to May 2023. Included studies were randomized controlled trials and cohort studies that compared the risk of cardiac arrhythmias among ULT users with non-ULT users. Results: A total of 12,420 patients from five studies were analyzed, comprising 7,359 subjects in the ULT group and 5,061 subjects in the non-ULT group. Our results showed that ULT users had significant reductions in the risk of arrhythmias (pooled relative risk [RR] 0.82, 95% confidence interval [CI]: 0.74~0.92, p<0.001, I²=0.0%) compared to non-ULT users. Subgroup analysis did not show that ULT users had a significant reduced risk of atrial fibrillation (pooled RR 0.76, 95% CI: 0.54~1.05, p=0.096 with I²=15.4%) compared to non-ULT users. Conclusion: ULT is associated with lower risk of overall arrhythmias. Further studies are warranted to confirm our findings.

심박수 변이도와 퍼지 신경망을 이용한 부정맥 추출

장형종 ( Hyoung Jong Jang ),임준식 ( Joon Shik Lim ) 한국인터넷정보학회 2009 인터넷정보학회논문지 Vol.10 No.5

본 논문에서는 심전도 신호로부터 부정맥을 진단하는 방법으로 심박수 변이도와 퍼지 신경망을 이용하는 방안을 제시하고 있다. 제안한 부정맥 진단 알고리즘은 32개 RR 간격의 심박수 변이도, 즉 평균 25초 내외의 심박수 변화를 이용하여 부정맥을 진단하는 알고리즘이다. 부정맥 진단 알고리즘은 32개 RR 간격을 이용하여, 통계적 특징 6개를 추출한 후, 가중 퍼지소속함수기반 신경망으로 학습하여 정상 구간과 부정맥 구간을 분류한다. 부정맥 진단 알고리즘은 Tsipouras 논문군(48개 레코드)에서 SE와 SP 각각 80% 이하의 성능을 보이는 기존연구와는 달리, SE는 88.75%, SP는 82.28%, 전체 분류율은 86.31%의 신뢰성 있는 결과를 나타낸다. This paper presents an approach to detect arrhythmia using heart rate variability and a fuzzy neural network. The proposed algorithm diagnoses arrhythmia using 32 RR-intervals that are 25 seconds on average. We extract six statistical values from the 32 RR-intervals, which are used to input data of the fuzzy neural network. This paper uses the neural network with weighted fuzzy membership functions(NEWFM) to diagnose arrhythmia. The NEWFM used in this algorithm classifies normal and arrhythmia. The performances by Tsipouras using the 48 records of the MIT-BIH arrhythmia database was below 80% of SE(sensitivity) and SP(specificity) in both. The detection algorithm of arrhythmia shows 88.75% of SE, 82.28% of SP, and 86.31% of accuracy.

생체내 심근허혈-재관류 모델에서 멜라토닌의 재관류 부정맥에 대한 심근보호작용에 관한 연구

조규종,김원,홍정석,이미우,장성은,오세현,임경수 대한응급의학회 2001 대한응급의학회지 Vol.12 No.4

Background: Recently, a few studies demonstrated that melatonin reduced the severity of myocardial reperfusion injuries, such as reperfusion arrhythmias. However, it is uncertain whether the melatonin reduces reperfusion arrhythmias in thus anesthetized animals because results were obtained using isolated hearts. Thus, to see whether melatonin reduces reperfusion arrhythmias in anesthetized animals, we examined the effect of melatonin on the incidence of reperfusion arrhythmias in an anesthetized-cat model of regional ischemia. Method: Adult mongrel male cats(n=30, 2.9∼4.2 kg) were anesthetized under positive-pressure artificial ventilation with room air. The animals of the control group(n=15) were subjected to 20-minute left anterior descending coronary artery(LAD) occlusion followed by abrupt reperfusion. The animals in experimental group(n=15) were divided into two. Group I(n=6) was pretreated with melatonin, 1 mg/kg, before occluding the LAD. Group II(n=9) was pretreated with melatonin, 10 mg/kg. The animals in experimental group were subjected to ischemia/reperfusion insult following drug treatment: melatonin was applied intra-peritoneally for 3 minutes just before LAD coronary artery ligation. The Fisher's exact test was used to compare the data from different animal groups. p<0.05 was considered significant. Results: The incidence of ventricular fibrillation(VF) during the reperfusion phase in group II(pretreated with melatonin, 10 mg) was significantly smaller than that in the control group(p-value = 0.0029). However, no statistically significant difference of VF incidence was found between group I(pretreated with melatonin, 1 mg) and the control group. Conclusion: Employing an anesthetized-cat model of regional cardiac ischemia, we investigated the dose-dependant effects of melatonin on reperfusion-induced arrhythmia. The cats pretreated with 10 mg/kg of melatonin before ischemia had a significantly reduced incidence of lethal reperfusion-induced arrhythmia, but there was no difference between the cats pretreated with 1 mg/kg of melatonin before ischemia and the control group.