Pediatric Atrial Flutter Treatment & Management
- Author: M Silvana Horenstein, MD; Chief Editor: Steven R Neish, MD, SM more...
In children with atrial flutter, medical care should be broadly directed at the following:
Ensuring hemodynamic stability before, during, and after conversion to sinus rhythm
Minimizing influences favoring initiation or maintenance of atrial arrhythmias (eg, electrolyte disturbances, pericardial effusion, indwelling atrial lines or catheters)
Excluding or managing complications (eg, ventricular dysfunction, thromboembolic phenomena)
Drug therapy may be indicated in some children with atrial flutter. Drug therapy in these cases can be classified under the 3 broad headings of ventricular rate control, acute conversion, and chronic suppression.
Thrombosis and thromboembolic events are recognized complications in patients with atrial flutter, particularly in the setting of repaired congenital heart disease. Patients who have thrombi identified on transesophageal echocardiography or have a history of chronic atrial flutter (>2 wk duration) should be treated with a period of anticoagulation (2-4 wk), if hemodynamically and symptomatically tolerated, before undergoing direct current (DC) cardioversion or other conversion of their rhythm.
According to a legal precedent, patients with Mustard repair of transposition of the great vessels and sick sinus syndrome should not receive quinidine without a previously implanted pacemaker. However, quinidine is now recognized to have a detrimental adverse effect profile in general, and it is essentially no longer used in the treatment of rhythm disorders following congenital heart disease. Disagreement surrounds whether this recommendation should be extrapolated to other antiarrhythmics and other forms of repaired congenital heart disease.
As with most symptomatic arrhythmias, conversion should ideally be achieved before transfer, except in the case of a hemodynamically stable patient referred to an institution with clearly superior expertise and facilities for management of pediatric atrial flutter.
Pace-termination of atrial flutter is best performed with a programmable stimulator that is capable of sensing atrial electrograms and delivering single, double, or multiple extrastimuli at adequate output and individually programmable cycle lengths down to 100 milliseconds.
Short discrete ramps or bursts of atrial stimuli are the most likely to produce a type I conversion of atrial flutter (immediate conversion to sinus rhythm), particularly if they can be delivered in or near the flutter circuit. If such a device is unavailable, a pacemaker capable of burst pacing at a specified rate may be used.
If pacing is performed via an esophageal electrode, the device should be capable of delivering stimuli at pulse widths of 9.9-20 milliseconds and outputs of 10-26 mA.
Patients who are treated with atrial antitachycardia pacing should undergo testing to confirm that their device is effective and not proarrhythmic.
R-wave synchronized cardioversion is the mainstay of therapy in patients who are unstable or if other therapies have failed. In patients who are stable and have chronic atrial flutter, perform cardioversion only after documentation of freedom from intracardiac thrombi or following a 2-week course of anticoagulation.
Cardioversion may be performed at increasing doses of 0.5, 1, 2, and 4 J/kg. Newer biphasic waveform defibrillators may allow for lower energy applications.
Ideally, place defibrillator paddles or pads in an anteroposterior configuration, with the apex paddle located over the mid sternum and the base paddle between the scapulae. An anesthesiologist usually administers a brief general anesthetic, except in truly emergent circumstances that mandate immediate cardioversion.
Hemodynamic instability requires immediate cardioversion as described above. However, patients who are relatively stable may be allowed to remain in flutter while careful consideration of possible interventions is undertaken. The patient should rest in a supine position without undue excitement or agitation. Consider digoxin if not already in use because it frequently increases the conduction ratio and decreases the ventricular rate. However, this effect usually takes many hours.
Medications with the potential to slow the atrial rate without affecting the atrioventricular (AV) node should be used with caution because the conduction ratio often decreases to 1:1 AV association. This may result in a rapid ventricular rate and hemodynamic compromise.
Avoid adrenergic and atropinic agents during sedation or anesthesia for cardioversion. Ketamine is relatively contraindicated. Such agents may result in rapid 1:1 AV conduction, with resultant hemodynamic compromise. On the other hand, insufficient sedation during attempted esophageal overdrive pacing or a failed cardioversion may result in patient distress and 1:1 AV conduction ratio.
Radiofrequency Catheter Ablation
Currently, radiofrequency catheter ablation appears to be somewhat effective in treating postoperative intra-atrial reentrant tachycardia in children.
Because the flutter circuits and critical isthmuses are quite variable in these patients, mapping of flutter circuits may be enhanced by 3-dimensional electroanatomical display systems, identification of split potentials, and demonstration of concealed entrainment during pacing.
Surgical Correction of Atrial Flutter
In patients with atrial flutter, surgical care may include one of the following procedures:
Correction of hemodynamic lesions that could be causing atrial volume loading
Specifically placed atrial incisions or cryoablation prophylactically to prevent atrial flutter
Empiric or map-directed lesions to eliminate documented atrial flutter and its circuits
These surgeries include various modifications and updates to maze procedures and modifications of the Mustard and Fontan procedures. One study reported that a right-sided maze procedure in patients with atrial flutter or fibrillation undergoing congenital heart disease repair significantly reduced arrhythmia recurrence at a mean of 2.7 y after surgery. )
Aggressive strategies to convert atrial flutter and maintain sinus rhythm should be pursued in children. In rare cases of resistant chronic atrial flutter when only rate control can be accomplished, patients should avoid competitive sports. Also restrict the activities of patients likely to develop rapid conduction of intermittent acute episodes of flutter.
Deterrence/Prevention of Atrial Flutter
Atrial stretch, surgical scarring, and sinus node dysfunction all appear to play important roles in the development of atrial flutter in patients with congenital heart disease. The development of new surgical techniques to avoid atrial suture lines or dilatation and to prophylactically interrupt potential conduction isthmuses within the atria may reduce the frequency of this disorder in future surgical cohorts of patients with congenital heart disease.
Efforts directed at sparing the sinus node during surgery, coupled with more aggressive pacing strategies in patients with sinus node dysfunction, could also play an important role in prevention of atrial flutter.
Biviano A, Garan H, Hickey K, Whang W, Dizon J, Rosenbaum M. Atrial flutter catheter ablation in adult patients with repaired tetralogy of Fallot: mechanisms and outcomes of percutaneous catheter ablation in a consecutive series. J Interv Card Electrophysiol. 2010 Aug. 28(2):125-35. [Medline].
Boriani G, Gallina M, Merlini L, et al. Clinical relevance of atrial fibrillation/flutter, stroke, pacemaker implant, and heart failure in Emery-Dreifuss muscular dystrophy: a long-term longitudinal study. Stroke. 2003 Apr. 34(4):901-8. [Medline].
Nazarian S, Wagner KR, Caffo BS, Tomaselli GF. Clinical predictors of conduction disease progression in type I myotonic muscular dystrophy. Pacing Clin Electrophysiol. 2011 Feb. 34(2):171-6. [Medline]. [Full Text].
Frost L, Hune LJ, Vestergaard P. Overweight, obesity and risk factors for atrial fibrillation or flutter--secondary publication.The cohort study Diet, Cancer and Health. Ugeskr Laeger. 2005 Sep 12. 167(37):3507-9. [Medline].
Frost L, Vestergaard P. Alcohol consumption and the risk of atrial fibrillation or flutter--secondary publication. A cohort study. Ugeskr Laeger. 2005 Aug 29. 167(35):3308-10. [Medline].
Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and risk of atrial fibrillation or flutter--secondary publication. A population-based study. Ugeskr Laeger. 2005 Aug 29. 167(35):3305-7. [Medline].
Movahed MR, Hashemzadeh M, Jamal MM. Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease. Int J Cardiol. 2005 Dec 7. 105(3):315-8. [Medline].
Earing MG, Cetta F, Driscoll DJ. Long-term results of the Fontan operation for double-inlet left ventricle. Am J Cardiol. 2005 Jul 15. 96(2):291-8. [Medline].
Balaji S, Daga A, Bradley DJ, Etheridge SP, Law IH, Batra AS, et al. An international multicenter study comparing arrhythmia prevalence between the intracardiac lateral tunnel and the extracardiac conduit type of Fontan operations. J Thorac Cardiovasc Surg. 2013 Oct 27. [Medline].
Krapp M, Kohl T, Simpson JM. Review of diagnosis, treatment, and outcome of fetal atrial flutter compared with supraventricular tachycardia. Heart. 2003 Aug. 89(8):913-7. [Medline].
Southall DP, Johnson AM, Shinebourne EA, Johnston PG, Vulliamy DG. Frequency and outcome of disorders of cardiac rhythm and conduction in a population of newborn infants. Pediatrics. 1981 Jul. 68(1):58-66. [Medline].
Silversides CK, Harris L, Haberer K. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol. 2006 Apr 15. 97(8):1206-12. [Medline].
Liberman L, Pass RH, Starc TJ. Optimal surface electrocardiogram lead for identification of the mechanism of supraventricular tachycardia in children. Pediatr Emerg Care. 2008 Jan. 24(1):28-30. [Medline].
Liberman L, Hordof AJ, Altmann K, Pass RH. Low energy biphasic waveform cardioversion of atrial arrhythmias in pediatric patients and young adults. Pacing Clin Electrophysiol. 2006 Dec. 29(12):1383-6. [Medline].
Stulak JM, Dearani JA, Puga FJ. Right-sided Maze procedure for atrial tachyarrhythmias in congenital heart disease. Ann Thorac Surg. 2006 May. 81(5):1780-4; discussion 1784-5. [Medline].
Oudijk MA, Ruskamp JM, Ververs FF, et al. Treatment of fetal tachycardia with sotalol: transplacental pharmacokinetics and pharmacodynamics. J Am Coll Cardiol. 2003 Aug 20. 42(4):765-70. [Medline].
Rebelo M, Macedo AJ, Nogueira G, Trigo C, Kaku S. Sotalol in the treatment of fetal tachyarrhythmia. Rev Port Cardiol. 2006 May. 25(5):477-81. [Medline].