Permanent pacemaker implantation with hybrid endocardial perventricular approach in infancy: May be an alternative route in the absence of epicardial lead.

Despite the advancements in technology, establishing the optimal implantation technique for pediatric patients with a pacemaker (PM) indication remains challenging. Although the implantation of an epicardial PM is recommended, especially in children weighing less than 10 kg, transventricular placement of endocardial leads can be performed safely, offering a practical substitute for an epicardial pacing system, particularly in situations where a transvenous approach is unfeasible due to patient size, anatomical constraints or epicardial PM leads were not available as in our case.

Comparison of the effects of conventional method and primary sutureless techniques on early postoperative rhythm problems in patients with total abnormal pulmonary venous return anomaly.

BACKGROUND: Total abnormal pulmonary venous return anomaly is a CHD characterised by abnormal pulmonary venous flow directed to the right atrium. In this study, we aimed to compare the effects of these techniques on early rhythm problems in total abnormal pulmonary venous return anomaly cases operated with conventional or primary sutureless techniques. METHOD: Seventy consecutive cases (median age 1 month, median weight 4 kg) who underwent total abnormal pulmonary venous return anomaly repair with conventional or primary sutureless technique between May 1 2020 and May 1 2022 were evaluated. The rate, diagnosis, and possible risk factors of postoperative arrhythmias were investigated. The results were evaluated statistically. RESULTS: When the total abnormal pulmonary venous return anomaly subgroup of 70 cases was evaluated, 40 cases were supracardiac, 18 cases were infracardiac, 7 cases were cardiac, and 5 cases were mixed type. Twenty-eight (40%) cases had a pulmonary venous obstruction. Primary sutureless technique (57%, supracardiac n = 24, mixed = 3, infracardiac = 13) was used in 40 patients. Median cardiopulmonary bypass time (110 versus 95 minutes) and median aortic clamp time (70 versus 60 minutes), median peak lactate (4.7 versus 4.8 mmol/l) in the first 72 hours, and median peak vasoactive inotropic score in the first 72 hours of the primary sutureless and conventional technique used cases value (8 versus 10) were similar. The total incidence of arrhythmias in the conventional group was significantly higher than in the primary sutureless group (46.7% versus 22.5%, p = 0.04). Supraventricular early beat was observed in 3 (7.5%), sinus tachycardia was seen in 6 (15%), junctional ectopic tachycardia was seen in 1 (2.5%), intra-atrial reentry tachycardia was seen in 1 (2.5%), usual supraventricular tachyarrhythmia was seen in 2 cases (5%) in the primary sutureless group. In the conventional group, supraventricular early beat was observed in six of the cases (20%), sinus tachycardia in five (16.7%), junctional ectopic tachycardia in four (13.3%), intra-atrial reentry tachycardia (10%) in three, and supraventricular tachyarrhythmia in seven cases (23.3%). In the first 30 days, there was a similar mortality rate (10% versus 10%), with four patients in the primary sutureless group and three in the conventional group. The median follow-up period of the cases was 8 months (interquartile range (IQR) 6-10 months). In the follow-up, arrhythmias were detected in two cases (one supraventricular tachyarrhythmia and one intra-atrial reentry tachycardia) in the primary sutureless group and three cases (two supraventricular tachyarrhythmia, one intra-atrial reentry tachycardia) in the conventional technique. All cases were converted to normal sinus rhythm with cardioversion and combined antiarrhythmic therapy. CONCLUSION: Different arrhythmias can be observed in the early period in patients with operated total abnormal pulmonary venous return anomaly. Although a higher rate of rhythm problems was observed in the early period in the conventional method compared to the primary sutureless technique, no significant effect was found on mortality and morbidity between the groups.

The comparison of three different acute kidney injury classification systems after congenital heart surgery.

BACKGROUND: We aimed to compare the frequency of acute kidney injury (AKI) and its effects on mortality and morbidity with different classification systems in pediatric patients who had surgery under cardiopulmonary bypass for congenital heart disease. METHODS: This study included children younger than 18 years old who were followed up in the pediatric cardiac intensive care unit between September 1 and December 1, 2020, after congenital heart surgery with cardiopulmonary bypass. Each case was categorized postoperatively in terms of AKI using Pediatric-Modified Risk, Injury, Failure, Loss, and End-Stage (pRIFLE), Acute Kidney Injury Network (AKIN), and Kidney Disease: Improving Global Outcomes (KDIGO). Hospital mortality (developed within the first 30 days postoperatively) and morbidity (longer than 7 days intensive care unit stay) were compared by three model classes. Results were evaluated statistically. RESULTS: One hundred patients were included in the study. The median age was 3 months (1 day-180 months). Acute kidney injury was diagnosed in 49% of the cases according to the pRIFLE classification. It was diagnosed in 31% of the patients by AKIN classification. It was diagnosed in 41% of the patients with the KDIGO criteria. Morbidity was observed in 25% (n = 25) of all cases. The morbidity predictor was 0.800 for pRIFLE, 0.747 for AKIN and 0.853 for KDIGO by receiver operating characteristics analysis. All three categories predicted morbidity significantly (P < 0.001). Mortality was 10% (n = 10) for all groups. The mortality predictor was 0.783 for pRIFLE, 0.717 for AKIN and 0.794 for KDIGO by receiver operating characteristics analysis, and all three categories predicted mortality significantly (P < 0.001). CONCLUSIONS: Regardless of the three methods used, AKI was commonly detected in pediatric patients undergoing congenital heart surgery. pRIFLE classification diagnosed more patients with AKI than AKIN and KDIGO. The KDIGO and pRIFLE classifications were better in predicting hospital mortality.

Electrocardiographic and electrophysiological characteristics of fasciculoventricular fibers in children.

OBJECTIVES: Fasciculoventricular fiber (FVF) that does not cause tachyarrhythmia is a rare form of ventricular preexcitation, which is important to distinguish from Kent fibers. Although, adenosine and some electrocardiographic features are important in the differentiation of Wolff Parkinson White (WPW) than FVF, a clear distinction may not always be possible without an electrophysiological study (EPS). In this study, we aimed to present the clinical and electrophysiological features of our pediatric patients with fasciculoventricular fiber. PATIENTS AND METHOD: Between October 2013 and September 2021, 565 patients who underwent electrophysiological studies due to ventricular preexcitation in our clinic were screened in the study, and 27 (4.7%) patients with fasciculoventricular fiber were included. The data of the patients were obtained from the file records using the electronic internet database system Filemaker® . Electrophysiological study age, weight, gender, symptom, and presence of congenital heart disease of the patients were obtained from the file records. Accessory pathway localization was evaluated according to the modified Arruda algorithm in pre-procedural electrocardiography. In addition, delta wave amplitudes were measured in the first 40 ms from the surface ECG. PR interval, QRS interval, and delta wave amplitude were recorded before and after ablation in patients with additional accessory pathways. Post-procedure values were included in the FVF group. RESULTS: The mean age of the patients was 11.47 ± 4.25 years. All 70.4% of the reasons for admission were symptoms such as palpitations and syncope. Two patients had hypertrophic cardiomyopathy and 1 patient had ccTGA. In the electrophysiological study, additional manifest WPW was found in 9 (33%) patients (3 patients with high risk, 6 patients with orthodromic supraventricular tachycardia), focal atrial tachycardia in a patient, and atrioventricular nodal reentry tachycardia in a patient. While the delta wave amplitude was found to be 2.56 ± 1.38(1-5.5) mm in the first 40 ms in surface electrocardiography in 9 patients with additional accessory pathway, it was found to be 1.64 ± 0.67(0.5-3) mm in the FVF group. There was no statistically significant difference between the 2 groups (p = .398). Delta wave amplitude > 3.5 mm was not detected in any patient with isolated FVF. Interestingly, delta wave amplitude was < 3.5 mm in 7 (78%) of 9 patients who were identified and ablated with an additional accessory pathway. Total 19 of the patients (59.3%) were adenosine-responsive (18 isolated FVF, 1 manifest AP+FVF adenosine-responsive. 8 patients with other manifest AP + FVF had no pre-procedural adenosine-asystole response, and all of them QRS were expanded). CONCLUSION: Although, the fasciculoventricular fibers themselves are not the cause of tachyarrhythmia, the accessory pathway and other tachyarrhythmia substrate frequency accompanying these cases are quite high (approximately 40%) in EPS. The delta wave characteristics of ablated patients are very similar to FVF patients. While all patients with isolated FVF were adenosine responsive, most of those with additional manifest WPW were unresponsive. Therefore, performing EPS in patients with suspected FVF based on surface ECG features seems to be important for the detection of additional tachyarrhythmias and risky accessory pathways.

Catheter ablation of focal atrial tachycardia in children using three-dimensional electroanatomic mapping system: a 6-year single-centre experience.

OBJECTIVE: This study demonstrates the clinical and electrophysiological details of catheter ablation conducted in children with focal atrial tachycardia using three-dimensional electroanatomic mapping systems. PATIENTS AND METHODS: Electrophysiological procedures were performed using the EnSite™ system. RESULTS: Between 2014 and 2020, 60 children (median age 12.01 years [16 days-18 years]; median weight 41.5 kg [3-98 kg]) with focal atrial tachycardia and treated with catheter ablation were evaluated retrospectively. Tachycardia-induced cardiomyopathy was developed in 15 patients (25%). Most of the focal atrial tachycardia foci were right-sided (75%), and more than one focus was found in four patients. Radiofrequency ablation was performed in 47 patients (irrigated radiofrequency ablation in seven cases), cryoablation in 9, and radiofrequency ablation and cryoablation in the same session in 4 patients. The median procedural time was 163.5 minutes (82-473 minutes). Fluoroscopy was used in 29 of (48.3%) patients (especially for left-side substrate) with a mean time of 8.6 ± 6.2 minutes. The acute success rate was 95%. The procedure failed in three patients, and recurrence was observed in 3.5% of patients (2/57) during a median follow-up of 17 months (2-69 months). The second ablation was performed in four cases, of which three were successful. Overall success rate was 96.6% with no major complications observed, except in one patient with minimal pericardial effusion. CONCLUSION: Catheter ablation seems to be an effective and safe treatment in focal atrial tachycardia. Electroanatomic mapping system can facilitate the ablation procedure and minimise radiation exposure.

Cryoablation with an 8-mm tip catheter for typical AVNRT in children: a single center 5-year experience.

BACKGROUND: In children with typical atrioventricular nodal reentrant tachycardia (tAVNRT), cryoablation is preferred over radiofrequency ablation (RFA) because of its safety profile and acceptable long-term success rates. In this study, we have assessed the utility of 8-mm tip cryocatheters for tAVNRT ablation in our center. METHODS: All pediatric AVNRT patients who underwent cryoablation with an 8-mm tip cryocatheter in our center between 2013 and 2018 were included. EnSite™ (St. Jude Medical Inc., St. Paul, MN, USA) was used in all patients. RESULTS: A total of 120 patients (64 females, 53%) were included in this study, and the mean age was 13.9 years with a standard deviation of 2.5 years. Eleven patients (9.1%) had structural heart disease, and 12 patients (10%) had additional arrhythmia substrate. The mean number of effective cryolesions was 8 with a standard deviation of 2.3. Fluoroscopy was used in three patients (2.5%). There were minor complications in only four patients (3.3%)-transient first-degree atrioventricular block or transient incomplete right bundle branch block. Acute success rate of cryoablation was 108/120 (90%). In twelve patients, cryoablation was suboptimal, or it failed. The procedure was completed successfully with RFA in the same session in ten patients. Overall acute success rate of ablation (Cryo ± RFA) was 98.5%. During a mean follow-up period of 24.6 months with a standard deviation of 11.3 months, three patients had recurrence (2.5%). Time between the beginning of the effective cryolesion and termination of AVNRT was found associated with acute success of cryoablation (p = 0.013). CONCLUSIONS: Cryoablation of AVNRT with an 8-mm tip catheter in children appears to be safe, with an acceptable acute success rate and a low recurrence rate. A faster termination of AVNRT during the cryolesion, slowing down before ending with atrioventricular block, is a good indicator for acute success.

Aortic cusp ablation for premature ventricular contractions and ventricular tachycardia in children: a 5-year single-center experience.

PURPOSE: Aortic cusps might be the source of supraventricular or ventricular arrhythmias. For many years, aortic cusp ablation has been widely used to treat premature ventricular contractions (PVCs) and ventricular tachycardia (VT). However, the data on the outcomes of this procedure in children are limited. The study aimed to convey or describe our own aortic cusp ablation experiences in children and, thus, contribute to the literature. METHODS: The focus was pediatric cases of ventricular arrhythmia in which the origin of the PVCs was ablated above the Valsalva. The sample comprised patients who underwent aortic cusp ablation between 2013 and 2018. The demographic characteristics, noninvasive test results, procedure details, and follow-up results for the patients were noted. RESULTS: The 3D EnSite Precision cardiac mapping system and limited fluoroscopy were used. A total of 26 procedures were performed on 22 patients. The mean age was 14.4 ± 3.0 (9-19) years, and the mean weight was 57.3 ± 17.5 (27-99) kg. The mean follow-up period after the first presentation was 38.6 ± 22.9 (3-72) months. There were significant differences in the values of the transition index, V2S/V3R, IIR/IIIR, aVRS/aVLS ratio, and QRS polarity in I at various locations. The most common ablation site was the left coronary cusp (LCC). Radio frequency (RF) ablation, cryoablation, and irrigated RF ablation were found to be effective energy sources in 15, 4, and 3 patients, respectively. Patients who underwent ablation at the LCC-right coronary cusp (RCC) commissure were more likely to present with only VT and to experience worsening symptoms. Twelve patients had previously undergone ablation of the right ventricular outflow tract (RVOT). Ablation in the RVOT had been previously performed in all the patients who eventually underwent ablation at the RCC and the LCC-RCC commissure. CONCLUSION: Aortic cusp ablation can be safely performed in children. The careful evaluation of previous noninvasive tests provides important data for determining the location. There might be significant differences in the signs and requirements on the basis of the locations during mapping and ablation.

The Transjugular Approach: An Alternative Route to Improve Ablation Success in Right Anteriorly and Anterolaterally-Located Supraventricular Tachycardia Substrates in Children.

Catheter ablation via the femoral vein has been widely used in children. However, in certain conditions, an alternative vascular access is required for a successful ablation. Herein we reported that, accessory pathways (APs) and ectopic foci which reside right anterior and anterolateral to tricuspid valve orifice can be safely and effectively ablated with transjugular venous approach. Eleven procedures performed via the transjugular venous approach were reviewed retrospectively from the 355 electrophysiological procedures performed between March 2016 and November 2017. EnSite 3D electro-anatomic mapping and limited flouroscopy was used in all patients. The mean age of patients was 14.4 ± 2.9 years (12-18) and 6/11 (54.5%) were males. Seven of the patients had previous ablation procedures via the femoral vein approach and due to failure or recurrence the procedures had to be repeated. In these patients mean procedure time shortened from 196 ± 80 (105-280) to 111 ± 13 (96-125) min with the transjugular approach. 10/11 patients had APs, and one patient had focal atrial tachycardia. One of the APs was a Mahaim pathway. Ablation localisations were right anterior and right anterolateral in 8/11 and 3/11 patients respectively. The average fluoroscopy time was 3.38 ± 6.5 (0-15) min. All of the RF ablations via transjugular approach were successful (100%, 11/11). The mean follow-up period was 10.6 ± 1.1 (9-12) months. So far no recurrence has been observed. Right anterior and anterolateral regions are the most challenging areas in terms of catheter stabilization even when long sheaths are used during femoral route ablation. Ablation attempts in these regions have partial success, frequent recurrence, and high complication rates. This study revealed that transjugular approach seems as an effective alternative for those cases where transfemoral approach is unsuccessful for the ablation targets located in the right anterior and antero-lateral regions.