Atrial Arrhythmia and Bradycardia as a Presentation of Congenital Long QT Syndrome.

We present a term newborn with atrial arrhythmia on the first day of life (DOL). An echocardiogram showed normal structure and normal function; laboratory testing showed normal electrolytes and thyroid function. After initiation of flecainide, the EKG on DOL 2 showed significant and increasing bradycardia with atrial arrhythmia and extremely prolonged QTc interval. Flecainide was stopped and esmolol started. After 6 h of treatment, atrial tachycardia was suppressed, and the rhythm converted to sinus. Genetic testing found variants of unknown significance in the ALPK3 gene and KCNQ1 gene, which has been associated with long QT syndrome (LQTs). LQTs in infants can present as bradycardia, 2:1 AV block, or torsades de pointes. Our review of the literature found only one other case report of atrial arrhythmia in a newborn with congenital LQTs. Diagnosis of LQTs via EKG alone is difficult in neonates since the ST segment and T wave on the first DOL are usually flattened, making correct measurement of the QTc interval difficult. ß-blockers, the first line of treatment for LQTs, are known to shorten QTc intervals and prevent arrhythmia events. As in our patient, ß-blockers may be helpful for atrial arrhythmia prevention in patients with adrenergically mediated atrial tachycardia. In conclusion, atrial arrhythmia with bradycardia can be a presentation of congenital LQTs and be difficult to recognize. For neonates with this presentation with no evidence of myocarditis, congenital heart disease, or significant respiratory illness, genetic congenital LQTs should be highly suspected, especially when associated with low resting heart rates.

The single-strand DNA/RNA-binding protein, Purbeta, regulates serum response factor (SRF)-mediated cardiac muscle gene expression.

Single-strand DNA-binding proteins, Puralpha and Purbeta, play a role in cell growth and differentiation by modulating both transcriptional and translational controls of gene expression. We have previously characterized binding of Puralpha and Purbeta proteins to a purine-rich negative regulatory (PNR) element of the rat cardiac alpha-myosin heavy chain (MHC) gene that controls cardiac muscle specificity. In this study we investigated the role of upstream sequences of the alpha-MHC promoter in Purbeta-mediated gene repression. In the transient transfection analysis overexpression of Purbeta revealed a negative regulatory effect on serum response factor (SRF)-dependent alpha-MHC and alpha-skeletal actin expression in muscle cell background. Contrary, in nonmuscle cells, Purbeta showed no repressive effect. The results obtained from gel-shift assays demonstrated a sequence specific competitive binding of Purbeta to the minus strand of the SRF-binding, CArG box sequences of different muscle genes, but not to the SRF-binding, SRE sequences of the c-fos gene. These element-specific associations of Purbeta with muscle CArG boxes may, in part, explain why muscle gene expression is downregulated in disease states in which Purbeta levels are elevated. This data also provide a mechanistic distinction between muscle CArG boxes and nonmuscle serum response element (SRE) sequences in terms of their affinity to bind to SRF and their ability to regulate cell-specific gene expression.

Defibrillator for primary prevention in congenital heart disease.

A 21-year-old patient with repaired double-outlet right ventricle and normal ventricular function underwent internal cardioverter defibrillator implantation for primary prevention of sudden death. First occurrence of spontaneous ventricular tachycardia resulted in hemodynamic collapse and syncope but the internal cardioverter defibrillator rescued the patient. ICD implantation for primary prevention may be an appropriate goal in adults with repaired congenital heart disease, even in the setting or normal ventricular function.