Abstract
Purpose
To report the management of junctional ectopic tachycardia after cardiac surgery in an infant. Postoperatively, the patient suffered profound cardiac decompensation secondary to the accelerated rhythm and required extracorporeal membrane oxygenation (ECMO) for haemodynamic support.
Clinical features
A 14-day-old, 3.5 kg boy exhibited junctional ectopic tachycardia after cardiopulmonary bypass. Left atrial pressure was 25–28 mmHg. No impact on the tachycardia was seen after rapid overdrive atrial pacing or after 20 μg fentanyliv, 45 μg digitalis, 100 mg magnesium or procainamide (loading dose 15 mg, then 30 mg·kg−1·min−1). Active cooling decreased the nasopharyngeal temperature to 35.2°C, when the heart rate decreased below 180 bpm with a left atrial pressure of 8–10 mmHg. Dopamine (2 μg·kg−1·min−1) and dobutamine (5 μg·kg−1·min−1) were added to improve the cardiac output. Sodium nitroprusside (0.25 to I μg·kg−1·min) maintained the systolic pressure <100 mmHg. On arrival in ICU, heart rate increased to 200 bpm. The patient received cardiac massage for severe hypotension 75 min after surgery. Emergency ECMO was instituted for circulatory support. Procainamide, digoxin, dopamine, dobutamine, sodium nitroprusside and hypothermia were continued. Sinus rhythm resumed on the first postoperative day, but procainamide and induced hypothermia at 34°C were maintained for 36 hr after normalization of the rhythm to prevent recurrence of the tachycardia. Total duration of ECMO was three and a half days. Recovery was uneventful.
Conclusion
The use of ECMO, as a first line of defence, is suitable for the emergency support of patients with JET because of the ease of support of circulation and precise control of hypothermia.
Résumé
Objectif
Décrire le traitement d’une tachycardie ectopique jonctionnelle (TEJ) survenue chez un enfant, après une chirurgie cardiaque, alors qu’il a souffert d’une profonde décompensation cardiaque secondaire au rythme accéléré et a eu besoin d’oxygénation extracorporelle (OEC) pour un soutien hémodynamique.
Aspects cliniques
Un garçon de 14 jours, pesant 3,5 kg, a présenté une tachycardie ectopique jonctionnelle à la suite d’une circulation extracorporelle. La pression auriculaire gauche était de 25–28 mmHg. Il n’y a pas eu d’impact sur la tachycardie à la suite de l’entraînement électrosystolique auriculaire rapide ou l’administration de 20 μg de fentanyl iv, 45 μg de digitale, 100 mg de magnésium ou de procaïnamide (dose d’attaque de 15 mg, suivie de 30 mg·kg−1·min−1). Le refroidissement actif a diminué la température nasopharyngienne à 35,2°C, tandis que la fréquence cardiaque a diminué sous 180 bpm avec une pression auriculaire gauche de 8–10 mmHg. La dopamine (2μg·kg−1·min−1) et la dobutamine (5 μg·kg−1·min−1) ont amélioré le débit cardiaque. Le nitroprussiate de sodium (0,25 à I μg·kg−1·min) a maintenu la pression systolique < 100 mmHg. À l’arrivée à I’USI, la fréquence cardiaque a augmenté à 200 bpm. Le patient a reçu un massage cardiaque pour une hypotension sévère, 75 min après la chirurgie. L’OEC d’urgence a été mise en place pour assurer la circulation. On a poursuivi l’administration de procainamide, de digoxine, de dopamine, de dobutamine, de nitroprussiate de sodium et on a maintenu l’hypothermie. Le rythme sinusal s’est rétabli le jour suivant l’intervention, mais on a maintenu la procaïnamide et l’hypothermie provoquée à 34°C pendant 36 h après le retour du rythme normal afin de prévenir une tachycardie récurrente. La durée totale de l’OEC a été de trois jours et demi. La récupération s’est déroulée sans incident.
Conclusion
Lutilisation de l’OEC, comme défense de première ligne, est appropriée au soutien d’urgence de patients qui présentent une TEJ parce qu’elle entretient aisément la circulation et le contrôle précis de l’hypothermie.
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Azzam, F.J., Fiore, A.C. Postoperative junctional ectopic tachycardia. Can J Anaesth 45, 898–902 (1998). https://doi.org/10.1007/BF03012227
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DOI: https://doi.org/10.1007/BF03012227