Recent Developments in Pediatric and Congenital Electrophysiology

Pediatric electrophysiology is a relatively young subspecialty of Pediatric Cardiology, but it has experienced rapid progress in the last 2 decades. The revolutionary therapy of tachyarrhythmias with catheter ablation transformed the field of pediatric electrophysiology in a similar or even more dramatic way to that of adult electrophysiology. Improvements in technology have made catheter ablation safe in children. Exposure to radiation can now be markedly decreased with non-fluoroscopic imaging methods. The use of cryothermal energy has made ablation safer in the vicinity of the AV node or the coronary arteries. Complex postoperative atrial arrhythmias can be managed with advanced electroanatomic mapping technologies. Postoperative ventricular tachycardia can be treated with a combination of pharmacologic therapy, catheter ablation, surgical methods and implantable defibrillator implantation. Genetically determined arrhythmias can be diagnosed and treated more effectively with molecular genetic testing, pharmacologic methods, surgical techniques such as sympathetic denervation and defibrillators. Pediatric electrophysiologists have also adapted techniques of cardiac resynchronization to children and patients with congenital heart disease. Overall, these developments make the present and feature of pediatric electrophysiology very exciting and promising

The Demystification of Non-formal Education: A Critique and Suggestions for a New Research Direction

The purpose of this paper is to initiate an inquiry into a currently fashionable educational phenomenon presently referred to as non-formal education. It is hoped that the paradigm resented will provide yet another interpretive perspective by which we can more fully understand the consequences of this educational phenomenon. It is a major contention of this paper that a more conceptually rigorous approach will enable us to understand better how non-formal education might contribute to or inhibit social change and development in societies undergoing rapid modernization

Radiofrequency catheter ablation of supraventricular tachycardia substrates after mustard and senning operations for d-transposition of the great arteries

OBJECTIVES The purpose of this study was to determine the efficacy and risks of radiofrequency ablation of various forms of supraventricular tachycardia after Mustard and Senning operations for d-transposition of the great arteries. BACKGROUND In this patient group, the reported success rate of catheter ablation of intraatrial reentry tachycardia is about 70% with a negligible complication rate. There are no reports of the use of radiofrequency ablation to treat other types of supraventricular tachycardia. METHODS Standard diagnostic criteria were used to determine supraventricular tachycardia type. Appropriate sites for attempted ablation included 1) intraatrial reentry tachycardia: presence of concealed entrainment with a postpacing interval similar to tachycardia cycle length; 2) focal atrial tachycardia: a P-A interval ≤-20 ms; and 3) typical variety of atrioventricular (AV) node reentry tachycardia: combined electrographic and radiographic features. RESULTS Nine Mustard and two Senning patients underwent 13 studies to successfully ablate all supraventricular tachycardia substrates in eight (73%) patients. Eight of eleven (73%) patients having intraatrial reentry tachycardia, 3/3 having typical AV node reentry tachycardia, and 2/2 having focal atrial reentry tachycardia were successfully ablated. Among five patients having intraatrial reentry tachycardia (IART) and not having ventriculoatrial (V-A) conduction, two suffered high-grade AV block when ablation of the systemic venous portion of the medial tricuspid valve/inferior vena cava isthmus was attempted. CONCLUSIONS Radiofrequency catheter ablation can be effectively and safely performed for certain supraventricular tachycardia types in addition to intraatrial reentry. A novel catheter course is required for slow pathway modification. High-grade AV block is a potential risk of lesions placed in the systemic venous medial isthmus

Radiofrequency Ablation of Life-Threatening Supraventricular Tachycardia Due to a Posteroseptal Accessory Pathway in an Infant

Supraventricular tachycardia (SVT) in infants may be resistant to multiple medications and cause life-threatening symptoms. Despite the known risks, catheter ablation may be necessary in rare cases. We present a 4-month-old 4.5 kg infant who presented with SVT that was resistant to all antiarrhythmic medications, including a combination of propafenone, amiodarone and propranolol at maximal doses. The infant underwent successful radiofrequency ablation of a posteroseptal accessory pathway. Despite later recurrence, medical therapy with propafenone and propranolol at standard doses resulted in complete control of the tachycardia until one year of age, when all medications were stopped without further recurrences

Chest-Compression Alone Cardiopulmonary Resuscitation: Newer Data for a More Practical Approach / Cardio-Cerebral Resuscitation

  Background: Sudden cardiac death (SCD) is a leading cause of mortality in the industrialized nations and, accordingly, is a major public health problem. Despite the guidelines and their updates, the survival rate of victims of out of hospital cardiac arrest (OHCA) remains disappointingly low. There are many contributors to poor survival outcome of victims with OHCA. An improper resuscitation algorithm seems to be the major contributor. Chest-compression alone cardio pulmonary resuscitation (CC-CPR), and cardio-cerebral resuscitation (CCR), seems an attractive alternative to conventional CPR. Methods & Results: Reviewing the recent literature, cardiac-only resuscitation emerges as an attractive alternative to conventional CPR, as this simpler technique of CPR, in which continuous chest compressions are provided without rescue breathing avoids the need for mouth-to-mouth ventilation. Under the weight of evidence supported by several recent studies, the AHA issued a science advisory for the public recommending immediate activation of emergency medical services (EMS) after the victim’s collapse and high quality chest compression regarding location and depth with minimum interruptions. Bystanders not trained in CPR are encouraged to initiate immediately hands-only CPR and continue with compressions until an AED is available or EMS arrives at the scene.   Conclusion: CC- CPR and CCR is not inferior to conventional CPR but also promises a survival benefit for victims of OHCA

Atrioventricular Nodal Reentrant Tachycardia in a Patient With Superior-Inferior Ventricles and Dextrocardia Treated With Cryoablation

A 19-year-old female underwent repair of complex congenital heart disease (atrial and ventricular septal defect with a criss-cross atrioventricular relationship) in infancy. Because or recurrent palpitations she underwent an electrophysiology study. Atypical atrioventricular nodal reentrant tachycardia was diagnosed. Catheter ablation was performed successfully using cryothermal energy. The diagnostic and therapeutic approach is discussed

Cardiopulmonary Resuscitation Update

BACKGROUND AND OBJECTIVES: Every 5 years experts, after reviewing literature and scientific evidence, update the guidelines on Cardiopulmonary resuscitation (CPR). The objective of this report is to review the main changes in resuscitation that occurred over the last 5 year period. CONTENTS: High-quality chest compressions with adequate rate and depth allowing full recoil of the chest with minimal interruptions is the mainstay of the recommended changes. The 30:2 compression ventilation ratio is maintained, but the former order is modified chest compressions first, followed by airway and breathing (C-A-B instead of A-B-C). Avoiding of excessive ventilation is also recommended. Chest compressions-only CPR in primary cardiac arrest victims, is an option for rescuers who are unable or unwilling to perform mouth to mouth ventilation. Advanced life support algorithm is simplified (regarding drugs, routes of administration, endotracheal intubation). Acute coronary syndromes (ACS) treatment has also been updated. Better practices for teaching and learning resuscitation skills are addressed. CONCLUSIONS: Updating CPR guidelines is important, and continuous education is recommended. This will improve the quality of resuscitation and survival of patients in cardiac arrest

Transcatheter Closure of Secundum Atrial Septal Defect Using the Amplatzer Device: Single Center Experience in 140 Patients

In this paper we present our experience with the Amplatzer septal occluder device, employed in 140 patients for percutaneous closure of atrial secundum defect (ASD), from October 2002 to February 2006. The age of patients ranged between 5.3 and 70 years, median 21.9 years. Procedure time ranged between 25 and 240 minutes, median 60 minutes; fluoroscopy time ranged between 3.5 and 45 minutes, median 12 minutes. Transoesophageal echocardiography was used to monitor the implantation procedure. The size of the selected device was 1 to 2 mm larger than the stretched diameter of the defect and ranged between 6-40 mm. Two devices have been implanted in two patients. Serious procedure related complications (embolization and perforation of the left atrial wall) occurred in two cases. At follow up (10 days to 3.4 years, median 2.3 years) complete closure was documented in 97% of this patient group. Unrecognized during implantation, but detected after release, small additional defect with trivial residual shunt was documented in 4 patients. A young critically ill patient, cyanotic due to right-to-left shunt, with complex congenital heart disease developed a brain abscess three months after implantation. In conclusion, percutaneous ASD closure with use of the Amplatzer device in this patient cohort was highly successful with a low complication rate

Cor triatriatum presenting as heart failure with reduced ejection fraction: a case report

Cor triatriatum is a rare congenital cardiac malformation and it usually refers to the left atrium. We report an unusual case of cor triatriatum in a 33 - year old woman presented with congestive heart failure caused by left ventricular systolic dysfunction