Perioperative junctional ectopic tachycardia associated with congenital heart disease: risk factors and appropriate interventions.

The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3 years, range 0.0-53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18-10.07], ACC time exceeding 90 min (OR 1.90; CI 1.27-2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02-5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes.

Timely Use of Venous-Arterial ECMO to Treat Congenital Pediatric Junctional Ectopic Tachycardia: A Case Report.

Supraventricular tachycardia is the most common tachyarrhythmia in pediatrics. Although postoperative junctional ectopic tachycardia (JET) is a known complication of congenital heart surgery that is typically transient, congenital JET is rare and requires aggressive treatment to maintain hemodynamic stability. We describe the case of a 3-month-old, previously healthy female who presented with heart failure and cardiogenic shock secondary to congenital JET for whom extracorporeal membrane oxygenation (ECMO) provided time for selection of effective therapy. Adenosine, cardioversion, and transesophageal pacing were unsuccessful, and her echocardiogram demonstrated bilateral atrial dilation and severe left ventricular systolic dysfunction. Approximately 8 hours after presentation, venous-arterial ECMO was commenced allowing for successful treatment with amiodarone. Her electrocardiogram demonstrated atrioventricular dissociation consistent with JET. She was successfully decannulated from ECMO after 6 days. Her discharge echocardiogram showed normal ventricular function, and she had no significant ECMO sequelae. This case demonstrates the value of early ECMO initiation for cardiovascular support in pediatric patients with a life-threatening arrhythmia and in cardiogenic shock. ECMO support can allow for full diagnostic and therapeutic decisions to effectively reverse the consequences of uncontrolled arrhythmias unrelated to surgical complications.

Management of postoperative junctional ectopic tachycardia in pediatric patients: a survey of 30 centers in Germany, Austria, and Switzerland.

Postoperative junctional ectopic tachycardia (JET) is a frequent complication after pediatric cardiac surgery. Current recommendations on how and when to treat JET are inconsistent. We evaluated the management strategies of postoperative JET in German-speaking countries. We sent an online survey to 30 centers of pediatric cardiology that perform surgery for congenital heart defects in Germany (24), Austria (4), and Switzerland (2). The survey asked 18 questions about how and in what treatment sequence postoperative JET was managed. All 30 centers completed the survey (100% return rate). There was general agreement that the management of JET is based on administration of antiarrhythmic drugs, body surface cooling, and temporary pacing. Many centers presented treatment algorithms based on published literature, all centers named amiodarone as the first drug of choice. Significant disagreement was found concerning the timing and sequential order of additional therapeutic measures and particularly about the dosing of amiodarone and the role of R-wave synchronized atrial pacing. CONCLUSION: This survey reveals that from center to center, the treatment of postoperative JET may vary substantially. Future work should focus on those treatment modalities where a high rate of variation is found. Such studies may be of value to achieve commonly adopted treatment recommendations. What is known: • Treatment of postoperative junctional ectopic tachycardia is predominantly based on administration of antiarrhythmic drugs, therapeutic cooling, and temporary pacing. • Amiodarone is the antiarrhythmic drug of choice in this context. What is new: • Dosing and duration of administration of amiodarone differ relevantly from center to center. • The sequential order of drug administration, therapeutic cooling, and pacing is not consistent.

Junctional ectopic tachycardia in late period after early postoperative complete atrioventricular block: Messenger of return to normal sinus rhythm? : Explanation with four case series.

Junctional ectopic tachycardia(JET) is a rare childhood arrhythmia originating from the area adjacent to the atrioventricular(AV) node. It often occurs after surgical procedures like repair of Tetralogy of Fallot, atrioventricular septal defect and ventricular septal defect, which are all performed in that area. While AV block (AVB) can occur after JET, it is very rare for late JET occurring after early postoperative AVB to be followed by normal sinus rhythm (NSR). There is no information in the literature related to the pathophysiology of this phenomenon. In this text, we present 4 patients who developed complete AV block(CAVB) in the early postoperative period (within the first 24h) after JET in late period (>72h) and returned to NSR with first-degree AV block and then NSR during follow-up. Based on these cases, we hypothesize that there is a link between late JET after early postoperative CAVB and return to NSR.

Late-Onset Postoperative Junctional Ectopic Tachycardia in Nonsurgical Procedures.

Postoperative junctional ectopic tachycardia (JET) is a narrow complex tachycardia and most frequently occurs during and after surgical repair of certain types of congenital heart defects. Postoperative junctional ectopic tachycardia may produce unfavorable hemodynamics that prolongs stays in the cardiac intensive care unit and hospital, prolongs time on a ventilator, and occasionally requires the use of extracorporeal membrane oxygenation (ECMO) as rescue therapy. The present report describes a rare case of late-onset postoperative junctional ectopic tachycardia, which occurred 13 days after the deployment of a perimembranous ventricular septal defect (PmVSD) occluder in a 17-year-old female teenager. To the best of our knowledge, late-onset postoperative junctional ectopic tachycardia has not previously been reported as a complication in nonsurgical procedures. In this case, the junctional ectopic tachycardia remained resistant to medicines and the haemodynamic imbalance caused a serious life-threatening situation in the patient. The occluder was removed by an emergent thoracotomy; then, the patient was successfully cured by being supported with extracorporeal membrane oxygenation. The findings suggest that during follow-up management, the physician should pay attention postoperatively to junctional ectopic tachycardia even after discharge from the hospital.

Narrow Complex Tachycardia: What is the Mechanism?

This article presents a diagnostic dilemma in which atrioventricular nodal reentrant tachycardia (AVNRT) and junctional tachycardia (JT) were differentiated based on tachycardia initiation with atrial extrastimulus as well as on the response to progressive decremental atrial extrastimuli. The progressive increase in A2H2' and H2H2' in response to atrial extrastimuli favors reentry as the mechanism of the tachycardia. This is a novel mechanistic differentiation of AVNRT from focal JT.

Junctional ectopic tachycardia after congenital heart surgery.

PURPOSE: In this literature review, we try to give anesthesiologists a better understanding about Junctional Ectopic Tachycardia (JET), a narrow complex tachycardia that frequently occurs during and after surgery for congenital heart disease. SOURCE: Information was found in the databases of Pubmed, Science Direct, Medline and the Cochrane Library, by using the mesh terms "Tachycardia, Ectopic Junctional", combined with "Diagnosis", "Etiology", "Physiopathology", "Complications" and "Therapy". The publication date of the articles ranged from 1990 to 2012. PRINCIPAL FINDINGS: Risk factors for the development JET are surgery near the AV node, a duration of cardiopulmonary bypass longer than 90 minutes, young age, the use of inotropic drugs and hypomagnesaemia. The diagnosis of Junctional Ectopic Tachycardia can be made on a 12-lead ECG, demonstrating a narrow-complex tachycardia with inverted P-waves and VA dissociation. Adenosine administration and an atrial electrocardiogram can help to confirm the diagnosis. If JET has a minimal impact on the hemodynamic status of the patient, risk factors should be avoided and the adrenergic tonus should be reduced. Hemodynamic unstable JET can be treated by amiodarone, hypothermia and pacing. Extracorporeal membrane oxygenation (ECMO) and radiofrequency or cryoablation are treatment options for life-threatening and resistant JET. CONCLUSION: JET is the most frequent arrhythmia during and after congenital cardiac surgery. The ECG is the only available method to diagnose JET, demonstrating inverted P-waves and VA-dissociation. Amiodarone seems to be the most effective treatment option, because it can restore sinus rhythm and reduces the JET rate.

Nonpharmacologic control of postoperative supraventricular arrhythmias using AV nodal fat pad stimulation in a young animal open heart surgical model.

BACKGROUND: Supraventricular arrhythmias (junctional ectopic tachycardia [JET] and atrial tachyarrhythmias) frequently complicate recovery from open heart surgery in children and can be difficult to manage. Medical treatment of JET can result in significant morbidity. Our goal was to develop a nonpharmacological approach using autonomic stimulation of selective fat pad (FP) regions of the heart in a young canine model of open heart surgery to control 2 common postoperative supraventricular arrhythmias. METHODS AND RESULTS: Eight mongrel dogs, varying in age from 5 to 8 months and weighting 22±4 kg, underwent open heart surgery replicating a nontransannular approach to tetralogy of Fallot repair. Neural stimulation of the right inferior FP was used to control the ventricular response to supraventricular arrhythmias. Right inferior FP stimulation decreased baseline AV nodal conduction without altering sinus cycle length. AV node Wenckebach cycle length prolonged from 270±33 to 352±89 ms, P=0.02. Atrial fibrillation occurred in 7 animals, simulating a rapid atrial tachyarrhythmias. FP stimulation slowed the ventricular response rate from 166±58 to 63±29 beats per minute, P<0.001. Postoperative JET occurred in 7 dogs. FP stimulation slowed the ventricular rate during postoperative JET from 148±31 to 106±32 beats per minute, P<0.001, and restored sinus rhythm in 7/7 dogs. CONCLUSIONS: Right inferior FP stimulation had a selective effect on the AV node, and slowed the ventricular rate during postoperative JET and atrial tachyarrhythmias in our young canine open heart surgery model. FP stimulation may be a useful new technique for managing children with JET and atrial tachyarrhythmias.

R-wave synchronised atrial pacing in post-operative junctional ectopic tachycardia using a transoesophageal pacemaker.

We report the first case of R-wave synchronised atrial pacing using a transoesophageal pacemaker. A 3-month-old baby developed a junctional ectopic tachycardia after surgical closure of a ventricular septal defect. R-wave synchronised atrial pacing with an external pacemaker was not possible owing to dislocation of the atrial epimyocardial pacing wires. Therefore, a temporary oesophageal pacemaker was connected in series to the external pacemaker to allow transoesophageal atrial pacing triggered by the preceding ventricular actions.

Junctional ectopic tachycardia following repair of congenital heart defects-experience in multimodal management from a West African Centre.

BACKGROUND: Postoperative junctional ectopic tachycardia (JET) is a rare and transient phenomenon occurring after repair of congenital heart defects. Report on this arrhythmia in the subregion is rare. We set out to determine the incidence of this arrhythmia and review the treatment and outcomes of treatment in our centre. METHODS: Retrospective search of the records of all patients aged 18 years and below admitted into the intensive care unit (ICU) following repair or palliation of a congenital heart defect over 5 years, from January 1, 2006 to December 31, 2010. A review of clinical notes, operative records, anaesthetic charts, cardiopulmonary bypass (CPB) records, nursing observation charts, electrocardiograms (ECGs) and out-patient follow-up records was undertaken. RESULTS: 510 children under 18 years were enlisted. 7 cases of postoperative JET were recorded, (1.37%). 184 (36.1%) of these were performed under CPB. All JET cases were from cases done under CPB, 3.8%. Median age was 3 years and median weight 11.3 kg. No patient was febrile at diagnosis. 4 patients had amiodarone administration, 5 had magnesium sulphate infusion, 2 patients had direct current shock (DCS) whilst 3 patients had all three therapeutic modalities. All patients had control of the arrhythmia with conversion to sinus rhythm and no recurrence. CONCLUSION: We report a JET incidence of 1.37% among children undergoing CPB for repair of congenital heart defects. We demonstrate the therapeutic effectiveness of amiodarone, magnesium sulphate infusions and DCS alone or in combination in the management of JET on various substrates with good outcome.

Novel use of atrial overdrive pacing to rapidly differentiate junctional tachycardia from atrioventricular nodal reentrant tachycardia.

BACKGROUND: Distinguishing between junctional tachycardia (JT) and atrioventricular nodal reentrant tachycardia (AVNRT) is essential to minimize unnecessary catheter ablation and the risk of heart block during treatment of AVNRT. OBJECTIVE: The purpose of this study was to investigate whether the tachycardia response to atrial overdrive pacing at a cycle length (CL) slightly shorter than tachycardia CL can differentiate between JT and AVNRT. We hypothesized that atrial overdrive pacing would transiently suppress JT but would entrain AVNRT. METHODS: Twenty-one patients in whom AVNRT was induced and atrial overdrive pacing during either AVNRT or JT was attempted were included in the study. We predicted that, upon cessation of atrial overdrive pacing, an atrial-His-His-atrial (AHHA) response would identify JT and an atrial-His-atrial (AHA) response would identify AVNRT. RESULTS: A total of 8 JT and 21 typical AVNRT were induced. Atrial overdrive pacing was attempted in all cases of JT and in 16 cases of AVNRT. An AHHA response was observed in 100% (8/8) of JT cases. In 2 cases of AVNRT, atrial overdrive pacing repetitively terminated the tachycardia. In the remaining patients with AVNRT, an AHA response was observed in 100% (14/14) of cases. When a response was able to be elicited, atrial overdrive pacing was 100% sensitive and 100% specific for differentiating JT from AVNRT. CONCLUSION: Atrial overdrive pacing during tachycardia can rapidly differentiate JT from AVNRT, which can improve the safety and efficiency of catheter ablation of these arrhythmias.

Intravenous induction of therapeutic hypothermia in the management of junctional ectopic tachycardia: a pilot study.

Therapeutic hypothermia has been used to treat children with postcardiotomy junctional ectopic tachycardia (JET). However, cooling techniques have not been systematically studied. This pilot study investigates the safety and efficacy of intravenous cold saline infusions used to augment surface cooling to achieve a core temperature of 32-34 degrees C for pediatric patients with JET. For this study, 10 patients with JET were cooled using cooling blankets and 4 degrees C normal saline infusions to a target central temperature of 32-34 degrees C. Vital signs and central temperatures were monitored continuously during the cooling period. Comprehensive metabolic panels, complete blood counts, coagulation studies, and cultures were obtained per study protocol. Therapeutic hypothermia was achieved within 65 min (interquartile range [IQR], 45-75 min). The median heart rate decreased from 187 beats per min (bpm) (IQR, 184-190 bpm) to 158 bpm (IQR, 121-162 bpm). For all the patients, atrioventricular synchrony was restored either with conversion to normal sinus rhythm or with successful atrial pacing. No clinically significant electrolyte abnormalities or bleeding events occurred. Two deaths, not directly attributable to the cooling protocol, occurred. Intravenous induction of therapeutic hypothermia can be safely and effectively performed for children with JET. Further studies, powered for clinically relevant outcomes, should evaluate this potentially valuable therapeutic method.

Pediatric nonpost-operative junctional ectopic tachycardia medical management and interventional therapies.

OBJECTIVES: To determine the outcomes of medical management, pacing, and catheter ablation for the treatment of nonpost-operative junctional ectopic tachycardia (JET) in a pediatric population. BACKGROUND: Nonpost-operative JET is a rare tachyarrhythmia that is associated with a high rate of morbidity and mortality. Most reports of clinical outcomes were published before the routine use of amiodarone or ablation therapies. METHODS: This is an international, multicenter retrospective outcome study of pediatric patients treated for nonpost-operative JET. RESULTS: A total of 94 patients with JET and 5 patients with accelerated junctional rhythm (age 0.8 year, range fetus to 16 years) from 22 institutions were identified. JET patients presenting at age < or =6 months were more likely to have incessant JET and to have faster JET rates. Antiarrhythmic medications were utilized in a majority of JET patients (89%), and of those, amiodarone was the most commonly reported effective agent (60%). Radiofrequency ablation was conducted in 17 patients and cryoablation in 27, with comparable success rates (82% radiofrequency vs. 85% cryoablation, p = 1.0). Atrioventricular junction ablation was required in 3% and pacemaker implantation in 14%. There were 4 (4%) deaths, all in patients presenting at age < or =6 months. CONCLUSIONS: Patients with nonpost-operative JET have a wide range of clinical presentations, with younger patients demonstrating higher morbidity and mortality. With current medical, ablative, and device therapies, the majority of patients have a good clinical outcome.