Pediatric and Congenital EPClinical risk prediction score for postoperative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease
Introduction
Postoperative junctional rhythm is a common arrhythmia, especially after certain surgeries for congenital heart disease (CHD).1,2 Depending on the ventricular rate, it may be defined as accelerated junctional rhythm (AJR) or junctional ectopic tachycardia (JET), which are narrow QRS tachycardias with ventricular rates 100–170 bpm or >170 bpm, respectively.3 Both typically occur within 72 hours after cardiac surgery, and risk factors have been proposed from small series. AJR/JET most often occurs after procedures involving manipulation near the conduction system (eg, ventricular septal defect [VSD] closure, atrioventricular canal [AVC] repair, tetralogy of Fallot [TOF] repair, truncus arteriosus repair, Rastelli procedure), but also after other surgeries such as arterial switch operation, stage 1 palliation).1,2 Other risk factors include younger age, lower weight, longer cardiopulmonary bypass (CPB) times, aortic cross-clamp times, higher body temperature, postoperative inotrope use, and hypomagnesemia.1,4 The exact etiology is unknown, but it is hypothesized that postoperative AJR/JET results from a direct mechanical trauma or an indirect stretch injury of the conduction system precipitating automaticity of the bundle of His. This hypothesis is supported by the high incidence of transient postoperative heart block in patients with AJR/JET.5
Postoperative JET has been associated with increased morbidity, including longer ventilatory support and intensive care unit (ICU) stay.6 JET can potentially be life-threatening secondary to loss of atrioventricular (AV) synchrony and compromised ventricular filling in a heart with simultaneous depression of myocardial function after surgery.7,8 Studies suggest that perioperative treatment with dexmedetomidine, magnesium, or amiodarone may improve outcomes, but patient selection remains a challenge.9, 10, 11 However, there are no guidelines on which patients should receive prophylactic therapy.
In this study, we aimed to describe the incidence of AJR/JET, along with their impact on outcomes in a large cohort of patients who underwent surgery for CHD. In addition, we aimed to develop a risk prediction score to identify patients at highest risk for postoperative AJR and JET.
Section snippets
Population
This study was approved under exemption from informed consent by the Institutional Review Board at Boston Children’s Hospital and adhered to the Helsinki guidelines. We completed a retrospective cohort study including children aged 0–18 years who underwent cardiac surgery (with or without CPB) at Boston Children’s Hospital between 2011 and 2018. Patients who underwent orthotopic heart transplant, ventricular assist device implantation, primary extracorporeal membrane oxygenation (ECMO) or
Patient characteristics
A total of 6364 surgeries for CHD occurred during the study period in 5122 patients (n = 2826; 55% male). Median age at time of surgery was 0.9 [0.2–4.4] years. Heterotaxy syndrome was present in 295 patients (5%). Surgical repair included VSD closure in 1086 patients (17%), AVC repair in 347 (5%), arterial switch operation in 267 (4%), stage 1 palliation in 209 (3%), TOF repair in 165 (3%), Rastelli procedure in 75 (1%), and truncus arteriosus repair in 30 (0.4%). Among 6364 patients, 2636
Discussion
In this contemporary series, postoperative AJR occurred in 3.4% of surgeries and JET in 0.9% surgeries. AJR and JET were associated with prolonged ICU and hospital length of stays, but not early mortality. Risk factors included age, heterotaxy syndrome, ischemic time, and surgical procedure, which were then included in a risk prediction score. The ability to identify patients at highest risk for postoperative AJR/JET may provide an opportunity for preemptive intervention to decrease its risk
Conclusion
In this contemporary cohort, the risk of postoperative AJR/JET was low but was associated with prolonged ICU and hospital stays. With aggressive management, there was no increase in mortality. AJR/JET was associated with younger age, heterotaxy syndrome, specific surgical procedures (VSD closure, AVC repair), and longer ischemic times. These risk factors were used to create a score to predict the risk of postoperative AJR/JET. This may allow for early identification of at-risk patients and the
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Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures: The authors have no conflicts of interest to disclose.