Comparison of Electrophysiologic Profiles in Pediatric Patients with Incidentally Identified Pre-Excitation Compared with Wolff-Parkinson-White Syndrome.

The rising utilization of screening electrocardiograms has resulted in increased incidental identification of ventricular pre-excitation in pediatric patients. We compared accessory pathways of incidentally identified pre-excitation to Wolff-Parkinson-White Syndrome (WPW) with the aim to identify factors important in preprocedural counseling and planning. This single-center, retrospective study of patients ≤18 years without congenital heart disease identified 227 patients diagnosed with pre-excitation and referred for invasive electrophysiology study between 2008 and 2017. WPW Syndrome was diagnosed in 178 patients, while 49 patients had incidental identification of pre-excitation. Anterograde conduction of incidentally identified accessory pathways was not clinically different between the two cohorts at baseline or upon isoproterenol infusion. However, the proportion of accessory pathways meeting high-risk criteria was significantly lower than in patients diagnosed with WPW, 12% versus 28% (p < 0.05). Retrograde conduction at baseline of incidentally diagnosed accessory pathways was slower with a median block cycle length 365 milliseconds (IQR 260 to 450) versus 290 milliseconds (IQR 260 to 330, p < 0.01). In the incidentally identified cohort, right-sided, paraHisian, and fascicular pathways were more common with fewer attempted ablations (71% vs 94%, p < 0.001) and lower success rate (91% vs 97%, p < 0.001). A binomial logistic regression analysis further indicated patients incidentally identified with pre-excitation were associated with having lower rates of inducible supraventricular tachycardia, atrial fibrillation, and ablations performed, in addition, to having right-sided pathways. In conclusion, as patients with incidentally identified pre-excitation present more frequently for consideration of invasive electrophysiology study, these results impact procedural approaches, technical considerations, patient counseling, and outcome expectations.

Verapamil-sensitive idiopathic left ventricular tachycardia in a 6-month-old: unique considerations in diagnosis and management in an infant.

Idiopathic left ventricular tachycardia of the Belhassen type is rare in infants. We present a 6-month-old infant girl with a wide-complex tachycardia with right bundle branch block QRS morphology, a superior axis, and atrioventricular dissociation, consistent with a left anterior fascicular tachycardia. Initial echocardiogram revealed depressed ventricular function. The tachycardia was unresponsive to therapeutic trials of adenosine, esmolol, procainamide, and lidocaine. There was brief conversion of the tachycardia to sinus rhythm with transesophageal atrial overdrive pacing, suggesting a reentrant mechanism of the arrhythmia. Ultimately, the judicious administration of intravenous verapamil resulted in termination of the arrhythmia, which has been sustained on oral therapy.

Multidisciplinary approach to vocal cord dysfunction diagnosis and treatment in one session: a single institutional outcome study.

OBJECTIVE: To determine whether the multidisciplinary approach to the management of vocal cord dysfunction (VCD), which combines patient education and behavioral intervention in the same session that VCD is diagnosed, provides long-term therapeutic benefits. METHODS: Chart review and telephone interviews of patients treated for VCD at The Children's Hospital of Philadelphia were performed in this retrospective nonrandomized study. All forty patients diagnosed with VCD from October 2007 to April 2009 were included. Patients were evaluated with a multidisciplinary team approach, including speech therapy assessment, otolaryngology exam and flexible laryngoscopy. Patients with VCD were educated about their condition and instructed about breathing techniques in the same session. RESULTS: Twenty-two patients were available for a phone interview. Mean age of patients was 13.4 ± 3.0 years. Sixteen patients were female. Mean number of clinic visits was 1.3 ± 0.8. Average time between phone interview and first clinical encounter was 14.0 ± 7.2 months. Compliance rate to demonstrate breathing exercises was 90.9%. Nineteen out of 22 patients (86.4%) reported improvement of their symptoms in frequency and/or severity. Six patients (27.3%) sought additional medical advice related to their respiratory symptoms. Twenty-one patients (95.5%) were able to maintain or increase their level of physical activity following clinic visit. CONCLUSION: Combining the diagnostic encounter with multidisciplinary behavioral intervention in a single visit is an efficacious approach for the long-term management of VCD in the pediatric population.