Follow-up of radiofrequency catheter ablation in children: results in 100 consecutive patients.

OBJECTIVES: The purpose of this study was to determine the outcome of a group of closely followed-up pediatric patients who had undergone radiofrequency ablation for cardiac arrhythmias. BACKGROUND: Although radiofrequency ablation in children has been shown to be effective and safe in the short term, results of longer term follow-up of these children must be considered when determining the place of radiofrequency ablation in the management of pediatric arrhythmias. METHODS: One hundred children aged 2 months to 17 years underwent a total of 119 radiofrequency ablation procedures for cure of tachycardia. Follow-up clinical data, electrocardiograms and 24-h Holter monitors were obtained and analyzed. RESULTS: All patients were alive, and none were lost to follow-up after a mean follow-up of 21.5 months (range 6 to 50). Success at last follow-up included accessory pathways in 66 (89%) of 74 patients, atrioventricular (AV) node reentry in 15 (88%) of 17, intraatrial reentry in 2 (67%) of 3, atrial flutter in 3 (100%) of 3, atrial ectopic tachycardia in 2 (67%) of 3, junctional ectopic tachycardia in 1 (100%) of 1 and ventricular tachycardia in 2 (100%) of 2 (overall success, 90 [90%] of 100). All recurrences were observed within 6 months of ablation. Major and minor complications (7%) included chest burn (one patient), foot microembolus (two patients), hematoma without pulse loss (four patients), femoral arteriovenous fistula requiring repair (one patient) and transient Mobitz I AV block (one patient). Immediate success, recurrence and complication rates were similar in the > or = 12-year old versus the < 12-year old group. Echocardiograms, available in 109 (92%) of 119 patients, showed possible procedure-related abnormalities in 2 (mitral regurgitation in 1, tricuspid regurgitation in 1, both mild), with no aortic insufficiency after 30 left-sided ablations performed by the retrograde approach. Follow-up Holter monitors, available in 77 (77%) of 100 patients, showed possible procedure-related abnormalities in 5 (frequent atrial ectopic tachycardia in 2, atrial flutter in 1, accelerated ventricular rhythm in 2). There were no early or late deaths. CONCLUSIONS: In children, the risks of radiofrequency ablation are low at follow-up evaluation. Longer-term follow-up of children undergoing radiofrequency ablation will be necessary to determine whether coronary abnormalities or serious new arrhythmias will develop.

Combined use of beta-adrenergic blocking agents and long-term cardiac pacing for patients with the long QT syndrome.

OBJECTIVE: The objective of this study was to review our current experience using a combination of beta-adrenergic blocking agents and long-term cardiac pacing to treat patients with the idiopathic long QT syndrome. BACKGROUND: Patients with the idiopathic long QT syndrome are at high risk for sudden cardiac death. Before combination therapy, 20 of the 21 study patients experienced either cardiac arrest (n = 8) or syncope (n = 18) and 11 had documented polymorphous ventricular tachycardia. Nine of these patients had not responded to isolated beta-blocker therapy and five had not responded to isolated left cervicothoracic sympathectomy. METHOD: All patients were treated with combined beta-blocker therapy and long-term cardiac pacing at a rate designed to normalize the QT interval. RESULTS: Cardiac pacing at rates of 70 to 125 beats/min resulted in shortening of the QT and corrected QT (QTc) intervals from 517 +/- 78 and 541 +/- 62 ms to 404 +/- 37 and 479 +/- 41 ms, respectively. The mean follow-up interval after institution of pacing was 55 +/- 45 months. The only sudden death occurred in a patient who had discontinued beta-blocker therapy. Syncope occurred in four patients, two of whom had interrupted pacemaker function due to lead fracture. Pacemaker problems, partly attributable to the specific rate required for QT interval shortening and to avoidance of T wave sensing, were relatively common. No patient who continued the combination therapy died, but 10% of these patients had a recurrence of symptoms. CONCLUSIONS: Combination therapy with a beta-blocker and cardiac pacing appears to be a highly effective primary therapy for symptomatic patients with the long QT syndrome and to provide excellent adjunctive therapy for patients who require insertion of an automatic internal defibrillator.

Cardiac rhythm control devices.

More than 110,000 men, women, and children receive permanent implanted pacemakers annually in the United States alone, and thousands more receive implantable cardioverter defibrillators; more still are treated for a brief period with temporary pacing in critical care settings. Because of the prevalence of rhythm disturbances and the growing use of devices as a means of therapy, critical care nurses may reasonably expect to care for patients receiving or already using such equipment. Knowledge of its function is a useful tool at the bedside. This article discusses basic attributes and behaviors of these devices and methods of diagnosing and dealing with the most commonly seen difficulties associated with them.

Migration of an epicardial pacemaker to the pericardial space in an infant.

We report the case of a 4-month-old infant who was implanted with an epicardial ventricular pacing system at 6 days of age for the prolonged QT syndrome, who subsequently developed migration of the pulse generator to the pericardial space. Tracking of the pulse generator through the diaphragm and into the pericardium followed the route of the myocardial lead. The possibility of pulse generator migration, as well as disruption of the diaphragm and pericardium, should be considered by those who care for infants with implanted pacemakers.

Cis-acting elements of the encephalomyocarditis virus internal ribosomal entry site.

Translation initiation of encephalomyocarditis virus (EMCV) mRNA occurs by ribosomal entry into the 5' untranslated region. Internal ribosome binding to EMCV mRNA requires a viral cis-acting element, termed the internal ribosomal entry site (IRES), and cellular trans-acting factors. The polypyrimidine tract binding protein (PTB) has been identified as one such trans-acting factor required for EMCV IRES-dependent translation. Using a dicistronic mRNA and an in vitro translation system, we have identified cis-acting elements of the EMCV IRES required for IRES-dependent translation. The results identify several regions of the IRES that are required for efficient IRES-dependent translation, including the PTB binding site. Other regions of the IRES may act only as spacer sequences, analogous to the spacer sequences found in rhinovirus and enterovirus IRES elements, to link essential regions of the IRES together. The flexibility of one region of the EMCV IRES was demonstrated by an insertion of 125 nucleotides that had little effect on IRES function while the constraint imposed on another region was demonstrated by a 3-nucleotide deletion that nearly abolished IRES-dependent translation.