Pediatric Atrial Ectopic Tachycardia

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Atrial ectopic tachycardia (AET) is a rare arrhythmia; however, it is the most common form of incessant supraventricular tachycardia (SVT) in children. Atrial ectopic tachycardia is believed to be secondary to increased automaticity of a nonsinus atrial focus or foci. This arrhythmia, which is also known as ectopic atrial tachycardia or automatic atrial tachycardia, has a high association with tachycardia-induced cardiomyopathy. Atrial ectopic tachycardia is often refractory to medical therapy and is not usually responsive to direct current (DC) cardioversion.

The diagnosis of atrial ectopic tachycardia is based on the presence of a narrow complex tachycardia (in the absence of aberrancy or preexisting bundle branch block) with visible P waves at an inappropriately rapid rate. The rates range from 120 to 300 beats per minute (bpm) and are typically higher than 200 bpm, although physiologic rates may be observed (see Electrocardiography).

Patients with atrial ectopic tachycardia may present with circulat ory collapse similar to patients with cardiomyopathy. Immediate rate control is desired in these cases. Three options are available for long-term treatment of patients with atrial ectopic tachycardia: medication to suppress the arrhythmia or control the ventricular response, catheter ablation, or, uncommonly, surgery (see Treatment and Management).

Go to Atrial Tachycardia and Multifocal Atrial Tachycardia for information on these topics.

Spontaneous depolarization is a phenomenon of automatic myocardium. The sinus node is usually the pacemaker of the heart, because it has the most rapid spontaneous rate of firing. A small cluster of cells with abnormal automaticity is presumed to be responsible for atrial ectopic tachycardia. The conduction spreads from this cluster to the surrounding atrium and to the ventricles via the atrioventricular (AV) node. A conduction delay from atrium to ventricle often occurs, with most patients demonstrating first-degree AV block and some showing second-degree block.

Because atrial ectopic tachycardia is often incessant, tachycardia-induced cardiomyopathy is commonly observed. Although the exact underlying mechanism of the development of cardiac dysfunction in the setting of chronic arrhythmias is unknown, numerous reports have documented improved cardiac function following ventricular rate control and treatment of the arrhythmia.

Atrial ectopic tachycardia is usually idiopathic. Occasionally, mycoplasmal or viral infections, such as respiratory syncytial virus, may trigger this arrhythmia, although more complex atrial tachycardias, such as chaotic atrial tachycardia, are more frequently found in this scenario. Atrial tumors have been reported to be associated with atrial ectopic tachycardia. Reports of familial cases with an autosomal dominant inheritance are present in the literature. [1] This arrhythmia is also observed in patients who have congenital heart disease and have undergone surgical treatment of this congenital heart disease.

The adult form of atrial ectopic tachycardia may have a different etiology and natural history than the pediatric form.

Although the exact incidence is unknown and few large series have been reported, atrial ectopic tachycardia reportedly comprises 5-10% of pediatric SVTs. Although estimates of the incidence of pediatric SVTs widely vary, atrial ectopic tachycardia likely occurs with an incidence of approximately 1 case per 10,000 children.

Atrial ectopic tachycardia is predominantly observed in infants and children; this accounts for a peak of 11-16% of tachycardias for which a mechanism is determined in young childhood.

Atrial ectopic tachycardia is generally well tolerated. Syncope is unusual, and cardiac arrest is rare, except when encountered as a complication of treatment. Tachycardia-induced cardiomyopathy is the most significant sequela of atrial ectopic tachycardia and may be insidious. The time to development depends on the rate and duration of the tachycardia; however, ventricular dilatation may be present on initial presentation. This can also be reversed with successful treatment of the arrhythmia.

Several reports have documented the spontaneous remission of atrial ectopic tachycardia in the pediatric population and in young adults. [2] This may occur in as many as one third of patients following withdrawal of medication. A review from Texas Children’s Hospital suggests that children younger than 3 years have a better response to medication and a higher rate of spontaneous resolution of the arrhythmia. [3]

For patient education information, see the Heart Health Center, as well as Supraventricular Tachycardia.

Dagres N, Gutersohn A, Wieneke H, Sack S, Erbel R. A new hereditary form of ectopic atrial tachycardia with autosomal dominant inheritance. Int J Cardiol. 2004 Feb. 93(2-3):311-3. [Medline].

Bauersfeld U, Gow RM, Hamilton RM, Izukawa T. Treatment of atrial ectopic tachycardia in infants Am Heart J</i>. 1995 Jun. 129(6):1145-8. [Medline].

Salerno JC, Kertesz NJ, Friedman RA, Fenrich AL Jr. Clinical course of atrial ectopic tachycardia is age-dependent: results and treatment in children or =3 years of age. J Am Coll Cardiol. 2004 Feb 4. 43(3):438-44. [Medline].

Gelb BD, Garson A Jr. Noninvasive discrimination of right atrial ectopic tachycardia from sinus tachycardia in “dilated cardiomyopathy”. Am Heart J. 1990. 120:886-91. [Medline].

Kistler PM, Roberts-Thomson KC, Haqqani HM, Fynn SP, Singarayar S, Vohra JK. P-wave morphology in focal atrial tachycardia: development of an algorithm to predict the anatomic site of origin. J Am Coll Cardiol. 2006 Sep 5. 48(5):1010-7. [Medline].

Ge HY, Li XM, Tang XJ, Zhang Y, Liu HJ, Li YH. Optimal noninvasive assessment of initial left ventricular dysfunction in children with ectopic atrial tachycardia. Eur J Pediatr. 2015 Aug. 174(8):1015-22. [Medline].

Higa S, Tai CT, Lin YJ, et al. Focal atrial tachycardia: new insight from noncontact mapping and catheter ablation. Circulation. 2004 Jan 6. 109(1):84-91. [Medline]. [Full Text].

Liew R, Catanchin A, Behr ER, Ward D. Use of non-contact mapping in the treatment of right atrial tachycardias in patients with and without congenital heart disease. Europace. 2008 Aug. 10(8):972-81. [Medline].

Cummings RM, Mahle WT, Strieper MJ, Campbell RM, Costello L, Balfour V. Outcomes following electroanatomic mapping and ablation for the treatment of ectopic atrial tachycardia in the pediatric population. Pediatr Cardiol. 2008 Mar. 29(2):393-7. [Medline].

[Guideline] Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016 Apr 5. 133(14):e471-505. [Medline]. [Full Text].

Ge H, Li X, Zhang Y, Liu H, Jiang H. [Clinical course and treatment of ectopic atrial tachycardia in 144 children]. Zhonghua Er Ke Za Zhi. 2015 Mar. 53(3):214-9. [Medline].

Haas NA, Fox S, Skinner JR. Successful use of an intravenous infusion of flecainide and amiodarone for a refractory combination of postoperative junctional and ectopic tachycardias. Cardiol Young. 2005 Aug. 15(4):427-30. [Medline].

Shubhayan Sanatani, MD Head, Division of Cardiology, Professor, Department of Pediatrics, University of British Columbia Faculty of Medicine; Medical Director, Children’s Heart Centre, Section Head, Heart Rhythm Service, British Columbia Children’s Hospital, Canada

Shubhayan Sanatani, MD is a member of the following medical societies: British Columbia Medical Association, Canadian Cardiovascular Society, Canadian Heart Rhythm Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Audentes Therapeutics.

Robert Murray Hamilton, MD, MSc, FRCPC Electrophysiologist, Senior Associate Scientist, Physiology and Experimental Medicine, Labatt Family Heart Centre; Professor, Department of Pediatrics, University of Toronto Faculty of Medicine

Robert Murray Hamilton, MD, MSc, FRCPC is a member of the following medical societies: American Heart Association, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Heart Rhythm Society, Canadian Cardiovascular Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, Western Society for Pediatric Research, American College of Cardiology, American Heart Association, American Pediatric Society

Disclosure: Nothing to disclose.

Stuart Berger, MD Executive Director of The Heart Center, Interim Division Chief of Pediatric Cardiology, Lurie Childrens Hospital; Professor, Department of Pediatrics, Northwestern University, The Feinberg School of Medicine

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children’s National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Pediatric and Congenital Electrophysiology Society, Society for Pediatric Research

Disclosure: Received research grant from: Medtronic.

Pediatric Atrial Ectopic Tachycardia

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