Pediatric Sinus Node Dysfunction Treatment & Management

  • Author: M Silvana Horenstein, MD; Chief Editor: Stuart Berger, MD   more...
 
Updated: Aug 13, 2010
 

Medical Care

No treatment is required for asymptomatic patients, even if they have abnormal SNRTs or SACTs. If the patient is receiving medications that can provoke sinus bradyarrhythmias (eg, beta-blockers, ACE inhibitors), the medications should be stopped if possible.

  • Acute treatment consists of atropine (0.04 mg/kg intravenously [IV] every 2-4 h) and/or isoproterenol (0.05-0.5 mcg/kg/min IV).
  • A transvenous temporary pacemaker sometimes is required despite medical therapy.
  • In patients with bradyarrhythmias-tachyarrhythmias, the tachyarrhythmias may be controlled with digoxin, propranolol, or quinidine. However, these patients should be monitored closely with frequent Holter monitoring to ensure that the bradyarrhythmias are not exacerbated or causing symptoms (eg, dizziness, syncope, CHF); if this is the case, permanent pacemaker therapy is also required.
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Surgical Care

Implantation of a permanent pacemaker is required if bradycardia is severe for the patient's age or if SND is accompanied by dizziness, fatigue, CHF, chest pain and palpitations (in patients with bradyarrhythmias or tachyarrhythmias), and, especially, syncope.

  • Sinus node dsyfunction (SND) is frequently encountered in patients who have undergone Fontan palliation for single ventricle; such patients are often either in junctional rhythm or may have ventricular pacemaker systems for bradycardia. Because ineffective atrial kick with loss of AV synchrony is known to decrease cardiac output in patients with a single ventricle physiology, atrial pacing (if AV node function is adequate) or dual-chamber pacing has been advocated as a better option than ventricular pacing alone.
  • Patients with CHD and postoperative SND who require a more physiologic rhythm can benefit from antitachycardia pacemakers capable of delivering atrial pacing and antitachycardia-pacing therapies.[4] Interestingly, young patients show circadian variability of the atrial threshold, with higher thresholds during night time.[5]
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Diet

Patients with vasovagal syncope may require increased dietary salt intake.

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Activity

Patients may participate in activities as tolerated.

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Contributor Information and Disclosures
Author

M Silvana Horenstein, MD  Assistant Professor, Department of Pediatrics, University of Texas Medical School at Houston; Medical Doctor Consultant, Legacy Department, Best Doctors, Inc

M Silvana Horenstein, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Peter P Karpawich, MD  Professor of Pediatric Medicine, Department of Pediatrics (Cardiology), Wayne State University School of Medicine; Director, Cardiac Electrophysiology and Pacemaker Services, Children's Hospital of Michigan

Peter P Karpawich, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Heart Rhythm Society, Michigan State Medical Society, and Pediatric Electrophysiology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Paul M Seib, MD  Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital

Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

John W Moore, MD, MPH  Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital

John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Gilbert Z Herzberg, MD  Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center

Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD  Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

References

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  2. Fabritz L, Kirchhof P, Fortmuller L, et al. Gene dose-dependent atrial arrhythmias, heart block, and brady-cardiomyopathy in mice overexpressing A(3) adenosine receptors. Cardiovasc Res. Jun 1 2004;62(3):500-8. [Medline].

  3. Pasquali SK, Marino BS, Kaltman JR, et al. Rhythm and conduction disturbances at midterm follow-up after the ross procedure in infants, children, and young adults. Ann Thorac Surg. Jun 2008;85(6):2072-8. [Medline].

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  5. Silvetti MS, De Santis A, Marcora S, De Santo T, Grovale N, Drago F. Circadian pattern of atrial pacing threshold in the young. Europace. Feb 2008;10(2):147-50. [Medline].

  6. Shah MJ, Nehgme R, Carboni M, Murphy JD. Endocardial atrial pacing lead implantation and midterm follow-up in young patients with sinus node dysfunction after the fontan procedure. Pacing Clin Electrophysiol. Jul 2004;27(7):949-54. [Medline].

  7. Ben Ameur Y, Smiri Z, Malek S, et al. Sinus node dysfunction after complete correction of tetralogy of Fallot. Report of a case. Arch Mal Coeur Vaiss. Dec 1998;91(12):1519-23. [Medline].

  8. Brembilla-Perrot B, Beurrier D, Houriez P, et al. Utility of transesophageal atrial pacing in the diagnostic evaluation of patients with unexplained syncope associated or not with palpitations. Int J Cardiol. Sep 2004;96(3):347-53. [Medline].

  9. Fish FA, Benson W. Disorders of cardiac rhythm and conduction. In: Moss and Adam's Heart Disease in Infants, Children and Adolescents. Vol 1. Philadelphia, PA: Lippincott Williams and Wilkins; 2000:495-6.

  10. Gaynor JW. Management of sinus venosus defects. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006;35-9. [Medline].

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  12. Hu K, Qu Y, Yue Y, Boutjdir M. Functional basis of sinus bradycardia in congenital heart block. Circ Res. Mar 5 2004;94(4):e32-8. [Medline]. [Full Text].

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  16. Morita H, Fukushima-Kusano K, Nagase S, et al. Sinus node function in patients with Brugada-type ECG. Circ J. May 2004;68(5):473-6. [Medline].

  17. Numata T, Abe H, Terao T, Nakashima Y. Possible involvement of hypothyroidism as a cause of lithium-induced sinus node dysfunction. Pacing Clin Electrophysiol. Jun 1999;22(6 Pt 1):954-7. [Medline].

  18. Sanders P, Morton JB, Kistler PM, et al. Electrophysiological and electroanatomic characterization of the atria in sinus node disease: evidence of diffuse atrial remodeling. Circulation. Mar 30 2004;109(12):1514-22. [Medline]. [Full Text].

  19. Smerup M, Hjertholm T, Johnsen SP, et al. Pacemaker implantation after congenital heart surgery: risk and prognosis in a population-based follow-up study. Eur J Cardiothorac Surg. Jul 2005;28(1):61-8. [Medline].

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  21. Takeshita K, Fujimori T, Kurotaki Y, et al. Sinoatrial node dysfunction and early unexpected death of mice with a defect of klotho gene expression. Circulation. Apr 13 2004;109(14):1776-82. [Medline]. [Full Text].

  22. Ueda K, Nakamura K, Hayashi T, et al. Functional characterization of a trafficking-defective HCN4 mutation, D553N, associated with cardiac arrhythmia. J Biol Chem. Jun 25 2004;279(26):27194-8. [Medline]. [Full Text].

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This 12-lead ECG is from an asymptomatic 10 year-old girl, which was brought to our attention because of the irregularity of the P-P intervals. This ECG shows sinus arrhythmia at a rate of 65-75 beats per minute. The P waves all originate from the sinus node because they have a positive axis (upright) in leads I, II, and aVF. The PR interval is 104 milliseconds, and the QRS is narrow at 86 milliseconds, with a normal axis of 64°. The corrected QT (QTc) interval measures 402 milliseconds. Therefore, this is a normal ECG.
Below is an ECG of a 2-year-old girl who was referred to the clinic by the pediatrician for evaluation of a heart murmur. This ECG shows atrial rhythm originating most likely from the lower left atrium (P waves are inverted in lead I and are positive in II and aVF, with a frontal axis of 124°). The PR interval measures 113 milliseconds, and the QRS is narrow at 90 milliseconds. Right ventricular conduction delay is shown, which is best seen in the precordial leads V1 and V2. The QRS frontal axis shows right axis deviation (reference range for a 2-year-old child is 0-110°). The patient does not have right ventricular hypertrophy by voltage criteria. The inverted T waves in V1 are a normal finding at this age. An echocardiogram showed a moderately sized atrial septal defect. Nonsinus atrial rhythm is not a synonym of sinus node dysfunction.
This is a 12-lead ECG from a 12-year-old boy with history of syncope. This patient was healthy until 1 month earlier, when he started to experience episodes of lightheadedness. The ECG shows sinus arrhythmia (bradycardia) at a rate of 50-79 beats per minute with a PR interval of 136 milliseconds. Two junctional escape beats are present after a prolonged pause. The QRS is narrow at 85 milliseconds with a normal frontal axis of 70°. The corrected QT interval (QTc) is 411 milliseconds. A later electrophysiologic (EP) study showed prolonged sinus node recovery time (SNRT) and sinoatrial conduction time (SACT). Because of the patient's symptoms and his sinus node dysfunction, he received an atrial pacemaker. If this 12-lead ECG had been recorded from an asymptomatic patient, the findings would be considered within normal limits and no further workup would be indicated. In this case, the lightheadedness and, ultimately, the syncope define sick sinus syndrome, with the patient requiring pacemaker therapy.
 
 
 
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