Development and impact of arrhythmias after the Norwood procedure: A report from the Pediatric Heart Network

Oster, Matthew E.; Chen, Shan; Dagincourt, Nicholas; Bar‐Cohen, Yaniv; Cain, Nicole; Colan, Steven D.; Czosek, Richard J.; Decker, Jamie A.; Gamboa, David; Idriss, Salim F.; Kirsh, Joel A.; LaPage, Martin J.; Radojewski, Elizabeth; Shah, Maully J.; Silver, Eric S.; Singh, Anoop; Temple, Joel; Triedman, John K.; Kaltman, Jonathan R.

doi:10.1016/j.jtcvs.2016.10.078

Cited by 17 publications

(15 citation statements)

References 25 publications

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“…They also found that although all postoperative arrhythmias were associated with prolonged recovery, only atrioventricular block was associated with diminished transplant-free survival. 2 Tachyarrhythmia was not infrequent in this study, and was associated with prolonged recovery, although not with diminished survival. 2 Conclusions from this study, though, are restricted by several limitations.…”

Section: Bahaaldin Alsoufi MDmentioning

confidence: 49%

“…2 Tachyarrhythmia was not infrequent in this study, and was associated with prolonged recovery, although not with diminished survival. 2 Conclusions from this study, though, are restricted by several limitations. The etiology of tachyarrhythmia is unclear and can be multifactorial, related to metabolic, anatomic, surgical, and demographic factors.…”

Section: Bahaaldin Alsoufi MDmentioning

confidence: 49%

“…Therefore, it is not surprising that the placement of a permanent pacemaker did not necessarily improve the outlook of those patients, with only 2 of the 5 patients who received pacemaker successfully proceeding to subsequent palliation stage. 2,7 Moving back to fast and slow thinking, how can we use the current study by Oster and colleagues 2 to generate an educated, evidence-based conclusion that would improve our inpatient and outpatient management? The answer is difficult, as there are many limitations inherent to the heterogeneous nature of this patient population, the diversity in those fast and slow rhythm disturbances, the management variations between institutions, and the lack of pertinent clinical information despite the comprehensive SVR dataset.…”

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

“…Although the current study by Oster and colleagues 2 did not demonstrate an increased risk of interstage mortality in patients who developed tachyarrhythmia following the Norwood procedure, a large number of deaths that occur following discharge are of unknown etiology, presumably arrhythmia-related and therefore a prophylactic use of antiarrhythmic agents to decrease that interstage mortality might be beneficial, 5 although not suggested by Oster and colleagues. 2 A recent review of the data from the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) demonstrated that not being on digoxin at the time of discharge after the Norwood procedure conferred an increase in the absolute risk of interstage mortality of 11% and an adjusted odds ratio for interstage mortality of 2.9, with the assumption that the beneficial mechanism of digoxin is related to both the antiarrhythmic properties and the effects on the neurohormonal axis of heart failure. 6 Again, challenges in substantiating solid evidence to support such a practice, coupled with concerns about drug toxicity, all limited the interest of programs to adopt those modifications in our outpatient management practice.…”

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

“…Postoperative atrioventricular heart block was less frequent in this study, although it was associated with lower transplant-free survival. 2 The etiology of heart block in unclear. One potential cause is surgical trauma to the atrioventricular node during atrial septectomy, concomitant procedures such as atrioventricular valve or pulmonary venous connection repair, or postoperative catheter-based intervention.…”

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

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Thinking, fast and slow

Alsoufi

2017

The Journal of Thoracic and Cardiovascular Surgery

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In his best-selling book titled Thinking, Fast and Slow, 1 the Nobel prize laureate Daniel Kahneman explains the 2 systems that drive the way we think and make choices: System One is fast, intuitive, and emotional; System Two is slower, more deliberate, and more logical. Admittedly, there is little in common between the topic of that book and the focus of the current editorial and related original manuscript, which is arrhythmia following the Norwood operation, except for the fact that arrhythmia can be fast and slow. 1 Nonetheless, we as physicians deal with those 2 thinking systems on a daily basis, and although our decisions are largely based on clinical evidence, some are not, and often are triggered by intuition and anecdotal experiences. Those 2 thinking systems come into play again as we evaluate new information offered by a recent study or research and decide whether or not to adapt any changes in our management strategy.In the current issue of the Journal, Oster and colleagues 2 reviewed the data from the Pediatric Heart Network Single Ventricle Reconstruction Trial (SVR Trial) and examined the incidence and risk factors associated with arrhythmias following the Norwood operation and the implication of those postoperative arrhythmias on outcomes. They found that among the 544 patients in their study cohort, 114 (21%) experienced at least 1 episode of postoperative tachyarrhythmia, and 21 (4%) experienced at least 1 episode of postoperative atrioventricular block. They also found that although all postoperative arrhythmias were associated with prolonged recovery, only atrioventricular block was associated with diminished transplant-free survival. 2 Tachyarrhythmia was not infrequent in this study, and was associated with prolonged recovery, although not with diminished survival. 2 Conclusions from this study, though, are restricted by several limitations. The etiology of tachyarrhythmia is unclear and can be multifactorial, related to metabolic, anatomic, surgical, and demographic factors. 3 Additionally, various types of arrhythmias can be difficult to distinguish and are often associated with different provoking factors. Finally, there are great variations in the threshold to treat and the mode of treatment of tachyarrhythmia episodes among institutions and possibly within the same institution. The information provided by the study by Oster and colleagues 2 suggests that a prophylactic medical treatment in the perioperative period that could successfully decrease the incidence of tachyarrhythmia would be beneficial by decreasing mechanical ventilation and intensive care unit times, with potential subsequent reduction of hospital-related complications and morbidity. In the adult population, prophylactic use of antiarrhythmic agents has been well studied and proved to be successful in decreasing morbidity and resource utilization. 4 Prophylactic use of antiarrhythmic agents in the pediatric population has been much less studied, and an evidence of the benefit of such a practice does not exist in the heter...

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Section: Bahaaldin Alsoufi MDmentioning

confidence: 49%

Section: Bahaaldin Alsoufi MDmentioning

confidence: 49%

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

Section: Bahaaldin Alsoufi MDmentioning

confidence: 99%

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Thinking, fast and slow

Alsoufi

2017

The Journal of Thoracic and Cardiovascular Surgery

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Risk Factors for Development of Ectopic Atrial Tachycardia in Post-operative Congenital Heart Disease

et al. 2017

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Ectopic atrial tachycardia (EAT) is common in surgically repaired congenital heart disease (CHD) and carries the potential for significant hemodynamic compromise. Our objective was to determine the incidence, and risk factors of EAT after CHD surgery. Prospective study of patients that underwent surgery for CHD from February to October 2016 was performed. Demographic, perioperative and electrophysiologic data were collected. Sustained EAT (> 30 s) was documented by telemetry or electrocardiogram and confirmed by a pediatric electrophysiologist. All patients were followed through index hospitalization. During the study period, 17/204 (8%) of patients developed EAT with median time-to-event of 14 days. 15/17 (88%) received anti-arrhythmic therapy for sustained EAT. By univariate analysis, younger age (5 vs. 284 days, P < .001), lower weight (3.2 vs. 7.5 kg, P < .001), single ventricle physiology (P = .05), longer cardiopulmonary bypass time (176 vs. 94 min, P < .001), need for delayed sternal closure (P < .001), and higher STAT category (P < .001) were associated with EAT. Incidence among single ventricle patients was 7/44 (16%), and of those 7/13 (54%) were < 30 days of age. Multivariable Cox regression analysis confirmed age at surgery < 30 days (hazard ratio = 11.7, P = .002) and use of milrinone (hazard ratio = 4.4, P = .007) as independent predictors of EAT. Post-operative EAT is frequent following surgery for CHD especially in neonates. Further study is warranted, specifically in the single ventricle population, given the high potential risk for arrhythmia-induced hemodynamic compromise in this vulnerable population.

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