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Pediatric Heart News - Pediatric Ventricular Arrhythmias

Pediatric Heart News Winter 2015

Pediatric Ventricular Arrhythmias

Date: April 15, 2015

Jane Crosson, first author of the consensus statement on ventricular arrhythmias.
Jane Crosson, first author of the consensus statement on ventricular arrhythmias.

Rare. Usually benign. Likely to resolve without treatment. And potentially the harbinger of a life-threatening condition.

Ventricular tachycardia in children with structurally normal hearts presents a management challenge. Because it’s rare, there’s been little opportunity to develop a standard diagnostic approach, and treatment approaches have tended to be heterogeneous. To help clinicians make informed decisions despite the relatively sparse data on idiopathic VT, the Pediatric and Congenital Electrophysiology Society and the Heart Rhythm Society formed a writing committee of 13 experts who analyzed the literature, assessed diagnostic and treatment options, and recently published a consensus statement.*

Whenever ventricular arrhythmias are detected in children, says Jane Crosson, director of Johns Hopkins’ pediatric electrophysiology service and first author of the consensus statement, the condition requires careful evaluation to determine the underlying cause. It’s especially important, she says, to rule out long QT syndrome, arrhythmogenic right ventricular dysplasia, myocarditis and cardiac tumors.

Finding the Cause of Ventricular Arrhythmia

The evaluation should begin with a detailed family history, a 12-lead ECG, an echocardiogram, a 24-hour Holter monitor and, if indicated by history or basic testing, an MRI or lab exercise testing. Clues from the family history and the evaluation tests determine the next course of action for pediatric cardiologists.

Ventricular arrhythmias may clinically present as conditions such as premature ventricular contractions (PVC). Most PVCs, often recognized in pediatricians’ offices, are monomorphic, not associated with any other cardiac issue and benign. However, if a Holter monitor reveals that more than 10 percent of heartbeats over a 24-hour period are PVCs, then the child should be followed carefully due to the risk of developing ventricular dysfunction. Options then include frequent monitoring, or if treatment is needed due to symptoms or declining function, medication or an electrophysiology study and cardiac ablation to remove tissue where the arrhythmia is originating can be employed.

Ventricular arrhythmia may also present in other ways, says Crosson. In one case, parents brought their child to the emergency department because of dizzy spells. The ECG showed PVCs, but in this child they were polymorphic, showing up in different patterns, which is a big red flag, says Crosson. A follow-up echocardiogram and MRI showed that the child had either myocarditis or cardiomyopathy—a tough differential diagnosis.

In other situations, a child may present with sustained palpitations and be found in ventricular tachycardia. If the evaluation reveals an otherwise normal heart, the patient can usually be treated as if the diagnosis is SVT, with observation, medication or catheter ablation, depending on the symptom burden.

“The important thing to remember about VT in children with structurally normal hearts,” Crosson says, “is that while it is often benign, the underlying cause must be determined to identify those patients at risk for life-threatening arrhythmias and to avoid overtreating those who will have a benign course.”

* PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart. Jane E. Crosson; David J. Callans; David J. Bradley; et al: Heart Rhythm 2014;11(9):e55-e78

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