C o n c i Concise Guide to s ConCise Guide to e Pediatric Arrhythmias G Pediatric u i d Christopher Wren, PhD, Consultant Pediatric Cardiologist, Freeman Hospital (NHS), e Newcastle upon Tyne, UK t o Written by one of the foremost pediatric cardiologists in the UK, this essential new P Arrhythmias book is a clear, practical, highly visual guide to the recognition of arrhythmias and e d their management. This innovative new reference: i a • Covers the full range of arrhythmias encountered in pediatric patients t • Presents each arrhythmia – from identification to management options – as well as r i showing how to make a precise non-invasive diagnosis from the ECG c • Makes use of real ECG strips – not perfect redrawn examples – to show what readers A will actually encounter in the clinical setting r r h In addition, the book discusses arrhythmias encountered in various clinical settings – y ChristoPher Wren early and late after operation, and in congenital heart disease or cardiomyopathy – as well t as brief overviews of the use of invasive EP studies, catheter ablation, pacemakers and h m defibrillators. i Whereas other books on this important topic are aimed at and tailored for the needs of a s experts in pediatric cardiology, this book is ideal for pediatricians, pediatric intensivists, trainees in pediatrics, pediatric cardiology and pediatric intensive care, as well as for clinical support staff involved in the cardiac care of children. W R e n Cover design: www.optadesign.co.uk www.wiley.com/go/cardiology 9780470658550.indd 1 11/08/2011 16:10 P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome ii P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome Concise Guide to Pediatric Arrhythmias i P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome ii P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome Concise Guide to Pediatric Arrhythmias Christopher Wren, PhD ConsultantPediatricCardiologist FreemanHospital(NHS) NewcastleuponTyne UK A John Wiley & Sons, Ltd., Publication iii P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome Thiseditionfirstpublished2012©2012byJohnWiley&SonsLtd. 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LibraryofCongressCataloging-in-PublicationData Wren,C.(Christopher) Conciseguidetopediatricarrhythmias/ChristopherWren. p. ; cm. Includesbibliographicalreferencesandindex. ISBN-13:978-0-470-65855-0(pbk. : alk.paper) ISBN-10:0-470-65855-X(pbk. : alk.paper) 1.Arrhythmiainchildren–Handbooks,manuals,etc. I.Title. [DNLM: 1.Arrhythmias,Cardiac–diagnosis–Handbooks. 2.Arrhythmias, Cardiac–therapy–Handbooks. 3.Child. 4.Infant.WS39] RJ426.A7W742012 618.92(cid:2)128–dc23 2011015325 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Thisbookispublishedinthefollowingelectronicformats:ePDF9781119979456;Wiley OnlineLibrary9781119979487;ePub9781119979463;Mobi9781119979470 (cid:3) Setin9/12ptMeridienbyAptaraR Inc.,NewDelhi,India 1 2012 iv P1:OTA/XYZ P2:ABC Color:2C BLBK384-FM BLBK384-Wren-FMBM August12,2011 7:2 Trim:297mmX210mm PrinterName:YettoCome Contents Foreword,vi 21 Idiopathicleftventriculartachycardia,87 Preface,vii 22 Idiopathicrightventriculartachycardia,90 Abbreviations,viii 23 Ventricularprematurebeats,93 1 Anatomy,physiology,andepidemiologyof 24 Ventricularfibrillation,96 arrhythmias,1 25 LongQTsyndrome,99 2 ECGsandotherrecordingdevices,5 26 Catecholaminergicpolymorphicventricular 3 Otherdiagnostictechniques,9 tachycardia,108 4 ThenormalECGandvariants,12 27 Brugadasyndrome,111 5 InterpretationoftheECGintachycardia,16 28 First-andsecond-degreeatrioventricular block,114 6 Adenosineinthediagnosisoftachycardias,26 29 Completeatrioventricularblock,118 7 Atrialtachycardia,30 30 Sinusnodedysfunctionandsinoatrialdisease,124 8 Multifocalatrialtachycardia,36 31 Earlypostoperativearrhythmias,127 9 Atrialflutter,40 32 Latepostoperativearrhythmias,136 10 Atrialfibrillation,43 33 Arrhythmiasincongenitalheartdefects,147 11 Atrialprematurebeats,46 34 Arrhythmiasincardiomyopathies,151 12 Atrioventricularre-entrytachycardia,49 35 Syncope,155 13 Wolff–Parkinson–Whitesyndrome,55 36 Suddendeath,160 14 Permanentjunctionalreciprocatingtachycardia,61 37 Antiarrhythmicdrugtreatment,163 15 Atriofascicularre-entrytachycardia,64 38 Pacemakersandimplantabledefibrillators,170 16 Atrioventricularnodalre-entrytachycardia,67 39 Catheterablation,177 17 Junctionalectopictachycardia,71 40 Artifacts,180 18 Ventriculartachycardia,74 Appendix,183 19 Neonatalventriculartachycardia,81 Index,185 20 Incessantidiopathicinfantventricular tachycardia,84 v P1:OTA/XYZ P2:ABC Color:2C BLBK384-FMBM BLBK384-Wren-FMBM August18,2011 16:36 Trim:297mmX210mm PrinterName:YettoCome Foreword I was particularly honored when Dr. Wren asked me to message never becomes overwhelming. Complex basic write this brief foreword to his monograph, “A Concise concepts are handled with a light touch, and the reader GuidetoPediatricArrhythmias”.However,whenIreflected isguidedthroughpotentiallycomplicateddiagnosticand on this opportunity, I wondered whether there was a management algorithms with a logical, sequential, and deeper motivation to Dr. Wren’s request. Not noted for thoughtfullyoutlinedrationale.Assuch,itistheperfect my prowess in electrophysiology, I wonder whether he textforthoseintraining,ago-toresourceforthegener- feltitlongoverduethatIbeeducatedinthecauses,iden- alist,orhandyaidememoiretothoseofuswhoaremore tification and treatment of electrical disturbances of the senior. heart! So, whether intended or not, I have indeed been ed- While primarily aimed at the non-specialist, and ucated by reading Dr. Wren’s “Concise Guide to Pediatric trainee, Dr. Wren’s book will provide an important re- Arrhythmias”.Iamcertainthatthoselikewiseexposedto source to anyone caring for children with heart disease. thisbookwillbesimilarlyenlightened.Indeed,Iamsure Anyone that knows Dr. Wren will attest to his simple, itwillrapidlybecomerequiredreadingandastapletext pragmatic,andinsightfulapproachtoproblems,hishuge inourfield. wealthofclinicalexperience,andhisscholarlyandcriti- calapproachtohisownwrittenworks,andthoseofoth- ers. This book is a perfect reflection of those attributes, AndrewRedington providing the reader with a beautifully written, easily HeadofCardiology assimilated, and clinically oriented approach to electro- TheHospitalforSickChildren physiology. While every illustration has an important Toronto,ON message, and every paragraph is rich in content, the Canada vi P1:OTA/XYZ P2:ABC Color:2C BLBK384-FMBM BLBK384-Wren-FMBM August12,2011 7:5 Trim:297mmX210mm PrinterName:YettoCome Preface Mostinfantsandchildrenwitharrhythmiaspresenttoa providevaluableinformation.Ihavechosenthebestex- pediatrician before being referred to a pediatric cardiol- amplesIhaveofallthevariousarrhythmiasbuttheyare ogist for assessment and management. Thus, the pedia- all real ECGs so their quality also varies. They do repre- trician has to be able to recognize the arrhythmia and sentthesituationsthatwearefacedwithinreallifeand in some cases to provide the acute treatment. Other ar- arepreferabletoredrawnidealizedimages. rhythmias arise in children who are already under the Thelayoutofthebookisperhapsalittledifferentfrom care of a cardiologist – either as part of the natural his- atraditionaltextbookwithagreatemphasisonECGex- tory of their heart problem or as a consequence of its amples.Manyoftheindividualarrhythmiasarediscussed treatment.Thisbookisintendedtobeusefultopediatric inasmallnumberofpagessothatallthekeyfeaturesare traineesandpediatricianswithaninterestincardiologyas availablealmostataglance. well as to trainees in and practitioners of pediatric card- Ihavetriedtolimitthenumberofabbreviationsinthe iology and pediatric intensive care. It aims to provide a text because they may be confusing for readers whose guide to the recognition of arrhythmias and their man- first language is not English. However, some are in- agement.Itisnotwrittenforthespecialistbecausethere evitableandmostwillbefairlyfamiliar,suchasAV,BBB, arealreadyplentyofadvancedworkswrittenbyexperts andWPW.Alistofabbreviationsisprovided. for experts. It contains no invasive electrophysiological The opinions on antiarrhythmic drug treatment dis- imagesbutdoesgiveabriefguidetohowandwhenin- cussed throughout the book are my own and represent vasivestudymightbeindicatedaswellasanintroductory afairlyEurocentricview.Irecognizethatpracticevaries guidetotheuseofcatheterablationandpacemakersand inotherpartsoftheworldandotherapproachestodrug defibrillators. treatment are adopted. It is not possible to present all I am indebted to many colleagues who have referred options for treatment but it is probably true to say that patientsorwhohavehelpedtosourcesomeoftheECG almost all antiarrhythmic drugs have been used for the examples. They include John O’Sullivan, Richard Kirk, treatmentofalmostallarrhythmiasatsomestage. and Milind Chaudhari in Freeman Hospital, Newcastle Over the past few years I have given many lectures, uponTyneandPhilipReesandMartinLoweinGreatOr- talks,seminars,andcoursesonthesubjectsofECGinter- mondStreetHospital, London.I amalso gratefulto An- pretationandcardiacarrhythmiasininfantsandchildren, drewSands,SatishAdwani,KevinWalsh,PaulOslizlok, andinyoungadultswithcongenitalheartdisease.Ihave Desmond Duff, Frank Casey, and Karen McLeod, and I been consistently impressed by the interest and enthu- amsurethereareothers,whohavegivenpermissionto siasm of those whom I have met, many of whom have useimagesfrompatientswhotheyhavereferred. askedforamonographsuchasthis.Ihopethatthiswill The quality of the ECGs that we have available for meettheneed. analysisvariesandissometimeslessthanideal.However, iftheonlytraceswehavearefromaparamedicrecording ChristopherWren orfromaHolterrecordingorarriveviafax,theymay still 2011 vii P1:OTA/XYZ P2:ABC Color:2C BLBK384-FMBM BLBK384-Wren-FMBM August12,2011 7:5 Trim:297mmX210mm PrinterName:YettoCome Abbreviations AAVRT antidromicatrioventricularre-entry FAT focalatrialtachycardia tachycardia HBT Hisbundletachycardia AET atrialectopictachycardia JET junctionalectopictachycardia AF atrialfibrillation LBBB leftbundlebranchblock AFL atrialflutter LQTS longQTsyndrome AFRT atriofascicularre-entrytachycardia MAT multifocalatrialtachycardia AT atrialtachycardia OAVRT orthodromicatrioventricularre-entry AV atrioventricular tachycardia AVB atrioventricularblock PJRT permanentjunctionalreciprocating AVNRT atrioventricularnodalre-entrytachycardia tachycardia AVRT atrioventricularre-entrytachycardia RBBB rightbundlebranchblock BBB bundlebranchblock SR sinusrhythm CAT chaoticatrialtachycardia ST sinustachycardia CAVB completeatrioventricularblock SVT supraventriculartachycardia CPVT catecholaminergicpolymorphicventricular VT ventriculartachycardia tachycardia WPW Wolff–Parkinson–White viii