Fascicular tachycardia in infancy and the use of verapamil: a case series and literature review

Abstract

ObjectiveGuidelines state that verapamil is contraindicated in infants. This is based on reports of cardiovascular collapse and even death after rapid intravenous administration of verapamil in infants with supraventricular tachycardia (SVT). We wish to challenge this contraindication for the specific indication of verapamil sensitive ventricular tachycardia (VSVT) in infants.DesignRetrospective case series and critical literature review.SettingHospitals within New Zealand.PatientsWe present a series of three infants/young children with VSVT or ‘fascicular VT’.ResultsThree children aged between 8 days and 2 years presented with tachycardia 200–220 beats per minute with right bundle brunch block and superior axis. Adenosine failed to cardiovert and specialist review diagnosed VSVT. There were no features of cardiovascular shock. Verapamil was given as a slow infusion over 10–30 min (rather than as a push) and each successfully cardioverted without incident. Critical review of the literature reveals that cardiovascular collapses were associated with a rapid intravenous push in cardiovascularly compromised infants and/or infants given other long-acting antiarrhythmics prior to verapamil.ConclusionsVerapamil is specifically indicated for the treatment of fascicular VT, and for this indication should be used in infancy, as well as in older children, as first-line treatment or after failure of adenosine raises suspicion of the diagnosis. We outline how to distinguish this tachycardia from SVT and propose a strategy for the safe intravenous slow infusion of verapamil in children, noting that extreme caution is necessary with pre-existing ventricular dysfunction.

Ventricular Tachycardia in Neonates: A Report of Two Cases and Review of the Literature

“…reports of successful conversion of fascicular VT in young infants with intravenous verapamil [6]. However, intravenous administration of verapamil for the treatment of tachyarrhythmia is contraindicated in infants younger than 1 year of age because of the proven risk of hemodynamic collapse and even death.…”

Case Report: Recurrent Left Posterior Fascicular Ventricular Tachycardia in a Newborn

“…It is often misdiagnosed as SVT with RBBB and left anterior hemiblock aberrancy. In the published literatures, the initial misdiagnosis rate of LPFVT in young infants is as high as 40% ( 2 – 4 , 7 – 11 ). Therefore, we would like to demonstrate the basic principles and caveats in differential diagnosis of LPFVT in the neonatal age group by reviewing the present case.…”

“…AV dissociation, capture beats, and fusion beats were identified during amiodarone infusion. Thirdly, LPFVT does not respond to adenosine ( 2 , 8 , 13 ), while other types of wide QRS tachycardia, which need to be differentiated from VT, including SVT with bundle branch block and SVT with anterograde conduction across an accessory pathway, can usually be terminated by adenosine. Thus, if adenosine injection is not effective in reverting presumed SVT, possibility of LPFVT should be considered.…”

“…Oral amiodarone with propranolol had been given for 9 months to prevent recurrence until LPFVT regressed. Verapamil has recently been used for arrhythmia in infants ( 2 , 16 , 17 ). Slow intravenous infusion at a dose of 0.1 mg/kg over at least 10 min appeared to be safe and efficient in terminating infantile LPFVT, but only one newborn was enrolled ( 2 , 7 , 9 , 11 ).…”

Ventricular Tachycardia in an Infant Without Congenital Anomaly: A Case Report

“…Infants have a better prognosis than older children [10]. Treatment recommendations for pediatrics VT vary from conservative observation to antiarrhythmic drugs, invasive surgical procedures or radiofrequency catheter ablation [12][13][14][15][16][17][18][19][20].…”