arrhythmias

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1. Disorders of cardiacDisorders of cardiac rhythm and conductionrhythm and conduction in childrenin children Ass. Prof.,Ass. Prof., MD,PhDMD,PhD Rakovska L.Rakovska L.…
  • 1. Disorders of cardiacDisorders of cardiac rhythm and conductionrhythm and conduction in childrenin children Ass. Prof.,Ass. Prof., MD,PhDMD,PhD Rakovska L.Rakovska L.
  • 2. Topics for DiscussionTopics for Discussion Definition, classification, etiology, clinical manifestation, diagnostics, treatment and prognosis of following arrhythmias in children: Sinus arrhythmiasSinus arrhythmias Extrasystole (premature beats)Extrasystole (premature beats) TachiarrytmiasTachiarrytmias Heart blockHeart block Sick sinus node syndromSick sinus node syndrom Preexcitation of ventricles syndrome (WPW)Preexcitation of ventricles syndrome (WPW) Syndrome of long QT intervalSyndrome of long QT interval
  • 3. ArrhythmiasArrhythmias ((ссardiac dysrhythmias) orardiac dysrhythmias) or abnormal heart rhythmsabnormal heart rhythms  disorders of frequency, regularity ofdisorders of frequency, regularity of rhythm, source of heart impulsesrhythm, source of heart impulses activation and it also means theactivation and it also means the dysfunction in connection or sequencedysfunction in connection or sequence between atrial and ventricularbetween atrial and ventricular activationactivation..
  • 4.  Less common than in adults.Less common than in adults.  Many pediatric dysrhythmias areMany pediatric dysrhythmias are normal variants that do not requirenormal variants that do not require treatment or even further evaluationtreatment or even further evaluation  Pediatric dysrhythmias can be just asPediatric dysrhythmias can be just as life threatening.life threatening. Pediatric DysrhythmiasPediatric Dysrhythmias
  • 5. Etiological factors of arrhythmiasEtiological factors of arrhythmias in childrenin children  Cardial factorsCardial factors CongenitalCongenital  AcquiredAcquired  Extracardial factorsExtracardial factors
  • 6. Etiological factors of arrhythmiasEtiological factors of arrhythmias in childrenin children Cardial factorsCardial factors Extracardial factorsExtracardial factors Congenital:Congenital: 1.1. CHDCHD (VSD, ASD,(VSD, ASD, Ebstein anomaly, PDA,Ebstein anomaly, PDA, tetralogy Fallow etc.)tetralogy Fallow etc.) 2.2. CarditisCarditis 3.3. CardiomyopathyCardiomyopathy 4.4. Anomalies of heartAnomalies of heart conduction systemconduction system (AV block, WPW syndrome(AV block, WPW syndrome etcetc.).) 5.5. Mitral valve prolapseMitral valve prolapse 1.1. InfectionsInfections 2.2. Psychogenic factorsPsychogenic factors (stress)(stress) 3.3. Diseases and injuries ofDiseases and injuries of nervous systemnervous system 4.4. Electrolyte disturbancesElectrolyte disturbances (↓↑K+, ↓↑Ca2+, ↓Mg2+)(↓↑K+, ↓↑Ca2+, ↓Mg2+) 5.5. IntoxicationsIntoxications ((UremiaUremia)) 6.6. DrugsDrugs (antiarrhythmic agents,(antiarrhythmic agents, digoxin, sympathomimeticdigoxin, sympathomimetic agents)agents)
  • 7. Etiological factors of arrhythmias in childrenEtiological factors of arrhythmias in children Cardial factorsCardial factors Extracardial factorsExtracardial factors Acquired:Acquired: 1.1. Rheumatic feverRheumatic fever 2.2. Nonrheumatic carditisNonrheumatic carditis 3.3. Systemic diseases ofSystemic diseases of connective tissueconnective tissue (SLE,(SLE, systemic sclerosis,systemic sclerosis, dermatomyositis)dermatomyositis) Other:Other: 1.1. Idiopathic cardiomyopathyIdiopathic cardiomyopathy 2.2. AneurysmAneurysm 3.3. Heart tumorsHeart tumors 7.7. DyshormonalDyshormonal conditionsconditions ((ThyrotoxicosisThyrotoxicosis,, ppheochromocytomaheochromocytoma)) 8.8. Traumas of chestTraumas of chest and abdomenand abdomen
  • 8.  Sinus rhythmSinus rhythm originates in the sinus node and hasoriginates in the sinus node and has a normal axis P wave (upright in leads I and AVF)a normal axis P wave (upright in leads I and AVF) preceding each QRS complex.preceding each QRS complex. Sinus (or sinoatrial) node (1) isSinus (or sinoatrial) node (1) is localized on the upper wall of thelocalized on the upper wall of the right atriumright atrium From it Kis-Flack (2) bundle outcomesFrom it Kis-Flack (2) bundle outcomes which connects both atria and thewhich connects both atria and the second node.second node. A-V node (3) or is localized in the lowA-V node (3) or is localized in the low wall of the right atrium, nearwall of the right atrium, near septumseptum From it the His bundle outcomes intoFrom it the His bundle outcomes into ventricular septum (4) and then isventricular septum (4) and then is divided into two partes – right (A)divided into two partes – right (A) and left (and left (ББ).). This bundle connects the bothThis bundle connects the both ventricles.ventricles.
  • 9. Working classification of cardiacWorking classification of cardiac rhythm disorders in childrenrhythm disorders in children ((Belocon N.A., Kuberger M.B., 1987Belocon N.A., Kuberger M.B., 1987):):  I. Disorders of impulseI. Disorders of impulse formationformation A. Nomotopic rhythm forming disordersA. Nomotopic rhythm forming disorders B. Heterotopic (ectopic) disorders of rhythmB. Heterotopic (ectopic) disorders of rhythm  II. Disorders of conduction  III. Combined arrhythmia
  • 10. Working classification of cardiac rhythmWorking classification of cardiac rhythm disorders in childrendisorders in children ((Belocon N.A., Kuberger M.B., 1987Belocon N.A., Kuberger M.B., 1987):):  I. Disorders of impulse formationI. Disorders of impulse formation AA.. Nomotopic rhythm forming disorders:Nomotopic rhythm forming disorders: 1) Sinus arrhythmia1) Sinus arrhythmia 2) Sinus bradycardia2) Sinus bradycardia 3) Sinus tachycardia3) Sinus tachycardia 4) Migration of pacemaker.4) Migration of pacemaker.
  • 11. Working classification of cardiac rhythmWorking classification of cardiac rhythm disorders in childrendisorders in children ((Belocon N.A., Kuberger M.B., 1987Belocon N.A., Kuberger M.B., 1987):): B.B. Heterotopic (ectopic) disorders of rhythm:Heterotopic (ectopic) disorders of rhythm: 1. Extrasystole:1. Extrasystole: a) atrium, atrioventricular, ventricular;a) atrium, atrioventricular, ventricular; b) single, group, allorythmic, interpolar, parasystolic;b) single, group, allorythmic, interpolar, parasystolic; c) early and late.c) early and late. 2. Paroxysmal tachycardia: а) supraventricular (atrial, atrioventricular); б) ventricular. 3. Nonparoxysmal tachycardia: а) atrial with atrioventricular block and without it; б) atrioventricular; в) ventricular. 4. Atrial flutter and fibrillation. 5.Ventricular flutterer and fibrillation.
  • 12. II. Disorders of conduction. 1.Sinoauriculal block. 2.Intracardial block. 3. A-V block (I, II, III degree). 4. Intraventricular block: а) onesided, bothsided; б) incomplete, complete; в) permanent, transitory, intermittent. Working classification of cardiac rhythmWorking classification of cardiac rhythm disorders in childrendisorders in children ((Belocon N.A., Kuberger M.B., 1987Belocon N.A., Kuberger M.B., 1987):):
  • 13. Working classification of cardiac rhythmWorking classification of cardiac rhythm disorders in childrendisorders in children ((Belocon N.A., Kuberger M.B., 1987Belocon N.A., Kuberger M.B., 1987):): III. Combined arrhythmia.III. Combined arrhythmia. 1. Sick sinus syndrome1. Sick sinus syndrome 2. Atrioventricular dissociation.2. Atrioventricular dissociation. 3. Premature of ventricle excitement3. Premature of ventricle excitement syndrome (preexitation syndrome).syndrome (preexitation syndrome). 4. Long QT syndrome.4. Long QT syndrome.
  • 14. Classification of arrhythmias inClassification of arrhythmias in childrenchildren 1. Bradyarrhythmias1. Bradyarrhythmias  Sinus node dysfunctionSinus node dysfunction  Conduction blockConduction block 2. Tachyarrhythmias2. Tachyarrhythmias  Narrow QRSNarrow QRS  Wide QRSWide QRS 3. Premature Beats3. Premature Beats  AtrialAtrial  VentricularVentricular
  • 15. EpidemiologyEpidemiology Among children with arrhythmias, the mostAmong children with arrhythmias, the most common dysrhythmias arecommon dysrhythmias are sinus tachycardia (50%),sinus tachycardia (50%), supraventricular tachycardia (13%),supraventricular tachycardia (13%), bradycardia (6%),bradycardia (6%), atrial fibrillation (4.6%)atrial fibrillation (4.6%)
  • 16. Arrhythmia PresentationArrhythmia Presentation  PalpitationPalpitation  Feeling of intermission in heart work (Feeling of intermission in heart work (“skipped beat”)“skipped beat”)  DizzinessDizziness  Chest PainChest Pain  DyspneaDyspnea  FatigueFatigue  HypotensionHypotension  Nonspecific symptoms (‘‘fussiness’’ or ‘‘difficulty feeding.’’Nonspecific symptoms (‘‘fussiness’’ or ‘‘difficulty feeding.’’  Syncope (Morgagni-Adams-Stokes attack)  Sudden cardiac deathSudden cardiac death
  • 17. Arrhythmia AssessmentArrhythmia Assessment  ECGECG  24h Holter monitor24h Holter monitor  EchocardiogramEchocardiogram  Stress testStress test  Coronary angiographyCoronary angiography  Electrophysiology studyElectrophysiology study
  • 18. ECG INTERPRETATIONECG INTERPRETATION Algorithm for reading ECGsAlgorithm for reading ECGs EvaluateEvaluate  Rhythm :Rhythm : Sinus or Non-sinusSinus or Non-sinus  RateRate  AxisAxis (QRS axis, T axis)(QRS axis, T axis)  Waves:Waves:  P wave (Atrial depolarization)P wave (Atrial depolarization)  QRS complex (Ventricular depolarization)QRS complex (Ventricular depolarization)  T wave (Ventricular repolarization)T wave (Ventricular repolarization)  U wave (Late phase of ventricularU wave (Late phase of ventricular repolarization)repolarization)  Intervals (PR, QT (QT/QTc), QRS)Intervals (PR, QT (QT/QTc), QRS)  ST segmentsST segments
  • 19.  aa -- Paper speed is 25 mm/secPaper speed is 25 mm/sec  1 large square (5 mm) = 0.2 sec, 1 small square (1 mm) = 0.04 sec, Voltage 101 large square (5 mm) = 0.2 sec, 1 small square (1 mm) = 0.04 sec, Voltage 10 mm/mvmm/mv  b - Paper speed is 50 mm/secb - Paper speed is 50 mm/sec  1 large square (5 mm) = 0.1 sec, 1 small square (1 mm) = 0.02 sec, Voltage 101 large square (5 mm) = 0.1 sec, 1 small square (1 mm) = 0.02 sec, Voltage 10 mm/mvmm/mv
  • 20. Normal ECGNormal ECG
  • 21. Pulse rate in children of different agePulse rate in children of different age (per min)(per min) NeonateNeonate 120-140120-140 8 yr8 yr 80-8580-85 6 mo6 mo 130-135130-135 9 yr9 yr 80-8580-85 1 yr1 yr 120-125120-125 10 yr10 yr 78-8578-85 2 yr2 yr 110-115110-115 11 yr11 yr 78-8478-84 3 yr3 yr 105-110105-110 12 yr12 yr 75-8275-82 4 yr4 yr 100-105100-105 13 yr13 yr 72-8072-80 5 yr5 yr 98-10098-100 14 yr14 yr 72-7872-78 6 yr6 yr 90-9590-95 15 yr15 yr 70-7570-75 7 yr7 yr 85-9085-90
  • 22. Normal values of heart rate in childrenNormal values of heart rate in children Age Heart rate. newborn 140 (<110 - >170) 10-30 days of life 140 (<110 - >170) 1-12 month 132 (<102 - >162) 1-2 years 124 (<94 - >154) 2-4 years 115 (<90 - >140) 4-6 years 106 (<86 - >126) 6-8 years 98 (<78 - >118) 8-10 years 88 (<60 - >108) 10 and older 80 (<60 - >100) < - bradycardia, > - tachycardia.
  • 23. Pediatric ECGPediatric ECG Intrinsic Heart RatesIntrinsic Heart Rates  Newborn to 3 years:Newborn to 3 years: •• SA node 95 – 120SA node 95 – 120 •• AV node (junctional) 45 – 85AV node (junctional) 45 – 85 •• Purkinje (ventricular) 35 – 55Purkinje (ventricular) 35 – 55  3 years to teenager3 years to teenager •• SA node 55 – 120SA node 55 – 120 •• AV node (junctional) 35 – 65AV node (junctional) 35 – 65 •• Purkinje (ventricular) 25 45‐Purkinje (ventricular) 25 45‐  AdultsAdults •• SA node 60 – 100SA node 60 – 100 •• AV node (junctional) 40-60AV node (junctional) 40-60 •• Purkinje (ventricular) 20 40‐Purkinje (ventricular) 20 40‐
  • 24. Pediatric ECG – QRS AxisPediatric ECG – QRS Axis Hexaxial Reference SystemHexaxial Reference System
  • 25. Pediatric ECG – Determining AxisPediatric ECG – Determining Axis Using the Hexaxial Reference SystemUsing the Hexaxial Reference System II aVFaVF
  • 26. ECG criteria ofECG criteria of regular sinus rhythm:regular sinus rhythm:  Rhythms originating in sinus node have a sinus P-Rhythms originating in sinus node have a sinus P- wave morphologywave morphology  1)1) regular sequential series P-P;regular sequential series P-P;  2)2) permanent P-wave morphologypermanent P-wave morphology ––Up in I, II, AVF; down in AVRUp in I, II, AVF; down in AVR  3)3) P-wave precedes every QRS-complex;P-wave precedes every QRS-complex;  4)4) Position of AP in frontal view 0Position of AP in frontal view 000 - + 90- + 900;0;  5)5) Normal QRS-complex.Normal QRS-complex.
  • 27. SINUS RHYTHMSINUS RHYTHM QRS AFTER EVERY P P BEFORE EVERY QRS ALL P WAVES LOOK THE SAME P WAVE UPRIGHT IN LEADS I AND aVF
  • 28. Nomotopic rhythm formingNomotopic rhythm forming disordersdisorders A)A) ECG of healthy childECG of healthy child B)B)Sinus tachycardiaSinus tachycardia C)C)Sinus bradycardiaSinus bradycardia
  • 29. Sinus tachycardiaSinus tachycardia Sinus tachycardiaSinus tachycardia is defined as acceleration of beatis defined as acceleration of beat rate at rest by 20-40 beats per minute with therate at rest by 20-40 beats per minute with the regular rhythm being maintained.regular rhythm being maintained. Causes:Causes: 1.1. PhysiologicalPhysiological  Vegetative dysfunctions (sympathetic nervous systemVegetative dysfunctions (sympathetic nervous system ton increase, vagus nerve ton reduction)ton increase, vagus nerve ton reduction)  Physical activityPhysical activity  Emotional factorsEmotional factors 2.2. Organic heart lesions (Organic heart lesions (myocarditis, congential andmyocarditis, congential and acquired valvular diseases, etc)acquired valvular diseases, etc) 3.3. Adverse factors, directly affecting the sinus nodeAdverse factors, directly affecting the sinus node cellscells (hypoxemia, infections, toxemia, acidosis, fiver, etc.)(hypoxemia, infections, toxemia, acidosis, fiver, etc.)
  • 30. ECG criteria ofECG criteria of Sinus tachycardiaSinus tachycardia 11)) R-R interval is permanent;R-R interval is permanent; 2) QRS-complex rate in children of elder age is more then 90 –2) QRS-complex rate in children of elder age is more then 90 – 100/min, in children of younger age 10 – 15 beats more as compared100/min, in children of younger age 10 – 15 beats more as compared with age norm;with age norm; 3) P-wave precedes every QRS-complex, the positive in I, II standard3) P-wave precedes every QRS-complex, the positive in I, II standard leads, aVL, V3-V6 and the negative one in VR lead;leads, aVL, V3-V6 and the negative one in VR lead; 4) QRS-complex is not changed;4) QRS-complex is not changed; 5) P-R interval is permanent and corresponds to child age5) P-R interval is permanent and corresponds to child age..
  • 31. Sinus bradycardiaSinus bradycardia is due to slow discharge of impulses from the sinusis due to slow discharge of impulses from the sinus node.node.  A sinus rate <90A sinus rate <90-100-100 beats/min in neonates andbeats/min in neonates and <60<60-80-80 beats/min thereafter is considered to bebeats/min thereafter is considered to be sinus bradycardia.sinus bradycardia.  Sinus bradycardia is common in:Sinus bradycardia is common in: - well-trained athletes;- well-trained athletes; - healthy individuals during sleep,- healthy individuals during sleep, -- vagus nerve tone increasingvagus nerve tone increasing
  • 32. Causes of pathological sinusCauses of pathological sinus bradycardia:bradycardia:  DiseasesDiseases (hypothyroidism, stomach ulcer, hepatitis)(hypothyroidism, stomach ulcer, hepatitis)  Increased intracranial pressureIncreased intracranial pressure ((cerebralcerebral edema, meningitis, cerebal tumors, etcedema, meningitis, cerebal tumors, etc),),  Patophysiological conditionsPatophysiological conditions ((hypothermia,hypothermia, profound hypoxia, hyperkalemia)profound hypoxia, hyperkalemia)  drugsdrugs ((glycosides, b-adrenoreceptor antagonist,glycosides, b-adrenoreceptor antagonist, etcetc))
  • 33. ECG criteria ofECG criteria of Sinus bradycardiaSinus bradycardia 1)1) QRS-complex rate is less then 100/min in the children of first months of life and less than 60/min in the children of more elderly age; 2) R-R interval permanent; 3) P-wave precedes every QRS-complex; 4) P-wave axe is permanent, localized between 00 and 900 (under normal heart position); 5) P-R interval is permanent and corresponds to the child age.
  • 34. Differential diagnosis of sinusDifferential diagnosis of sinus bradycardiabradycardia  Sinoatrial and AV blockSinoatrial and AV block..  Children with sinus bradycardia are able toChildren with sinus bradycardia are able to increase their heart rate with exercise to aincrease their heart rate with exercise to a much higher rate than 100 beats/min,much higher rate than 100 beats/min, whereas patients with AV block are usuallywhereas patients with AV block are usually unable to do so.unable to do so.
  • 35. Sinus arrhythmiaSinus arrhythmia (irregular sinus rhythm)(irregular sinus rhythm)  common finding in healthy children and represents acommon finding in healthy children and represents a normal variation in the HR associated with breathing.normal variation in the HR associated with breathing. The HR slows during expiration and acceleratesThe HR slows during expiration and accelerates during inspiration.during inspiration.  Anxiety, febrile illnesses and by vagus nerveAnxiety, febrile illnesses and by vagus nerve stimulation (drugs, Valsava test); it is usuallystimulation (drugs, Valsava test); it is usually disappears by exercise, breath-holding, functional testdisappears by exercise, breath-holding, functional test with atropine.with atropine.  Thyrotoxicosis, anemia, hypovolemia, shock, hypoxia,Thyrotoxicosis, anemia, hypovolemia, shock, hypoxia, congestive heart failure, myocardial disease,congestive heart failure, myocardial disease, medications (catecholamines), hypocalcemia, andmedications (catecholamines), hypocalcemia, and
  • 36. ECG criteria of sinus arrhythmiaECG criteria of sinus arrhythmia  R-R interval is not permanent;R-R interval is not permanent;  R-R interval changes permanently all the time ofR-R interval changes permanently all the time of breathing (shortens during inspiration);breathing (shortens during inspiration);  P-P interval is not permanent;P-P interval is not permanent;  P-wave precedes every QRS-complex;P-wave precedes every QRS-complex;  P-wave axis is between 0P-wave axis is between 000 and 90and 9000 ;;  PR interval changes less than 0,2 sec.PR interval changes less than 0,2 sec.
  • 37.  Respiratory sinus arrhythmia does notRespiratory sinus arrhythmia does not require further evaluation or treatment.require further evaluation or treatment.  Non-respiratory sinus arrhythmiaNon-respiratory sinus arrhythmia (unrelated with respiration) is concomitant(unrelated with respiration) is concomitant to heart disease, intracranial pressure rise.to heart disease, intracranial pressure rise.  Treat etiology, not the tachycardia!Treat etiology, not the tachycardia!
  • 38. Wandering atrial pacemakerWandering atrial pacemaker  Atrial pacemaker shifts from sinus node toAtrial pacemaker shifts from sinus node to another atrial siteanother atrial site  Normal variant, irregular rhythmNormal variant, irregular rhythm
  • 39. Extrasystole (PrematureExtrasystole (Premature complexes, Escape Beats)complexes, Escape Beats)  denotes premature heart contraction,denotes premature heart contraction, induced by the ectopic impulse.induced by the ectopic impulse.
  • 40. ExtrasystoleExtrasystole According to the ectopic focus localizationAccording to the ectopic focus localizati
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