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Junctional Ectopic Tachycardia Clinical Presentation

  • Author: M Silvana Horenstein, MD; Chief Editor: Stuart Berger, MD  more...
 
Updated: Feb 11, 2014
 

History

In general, postoperative junctional ectopic tachycardia (JET) occurs in the hospital with rapid hemodynamic instability, whereas congenital JET may have a more insidious course before producing signs of congestive heart failure.

Postoperative JET usually begins 6-72 hours following cardiopulmonary bypass surgery for repair of congenital heart lesions. It is usually identified during monitoring in the ICU. A fall in blood pressure and cardiac output usually occurs concomitantly.

The onset of congenital JET is often insidious. The clinical presentation of congenital JET may occur from birth to age 4 weeks. However, sporadic cases of intrauterine tachycardia have been reported in infants who presented with JET at birth. Prolonged moderate tachycardia may not be recognized until myocardial dysfunction and signs of congestive heart failure ensue. Heart rate variability is decreased; the heart rate is very regular except for occasional sinus capture beats.

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Physical

Patients with congenital JET present with moderate tachycardia and signs of congestive heart failure. If VA dissociation has occurred, which is usually the case, cannon waves may be present in the jugular venous pulse, and the intensity of the first heart sound varies.

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Causes

The speculative causes of postoperative JET are discussed in Pathophysiology. The one fairly uniform finding is a preceding cardiopulmonary bypass surgery.

The cause of congenital JET is unknown. A family history of JET has been reported in 50-55% patients. It appears that patients with the angiotensin-converting enzyme insertion/deletion (ACE D/D) polymorphism have a greater than 2-fold increase in the incidence of postoperative JET. Therefore, it is hypothesized that the renin-angiotensin-aldosterone system plays an important role in the etiology of JET.[7]

Postoperative JET occurs more often after tetralogy of Fallot repair.[8] It has been associated with resection of muscle bundles, increased traction through the right atrium for relief of right ventricular outflow tract obstruction, and with higher bypass temperatures.

The nonparoxysmal form of junctional tachycardia, which may be a triggered arrhythmia, is observed following digoxin overdose.

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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, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Murray Hamilton, MD, MSc, FRCPC Electrophysiologist, Senior Associate Scientist, Physiology and Experimental Medicine, Labatt Family Heart Centre; Professor, Department of Pediatrics, University of Toronto Faculty of Medicine

Robert Murray Hamilton, MD, MSc, FRCPC is a member of the following medical societies: American Heart Association, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Protective Association, Heart Rhythm Society, Canadian Cardiovascular Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Hugh D Allen, MD Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine

Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, Western Society for Pediatric Research, American College of Cardiology, American Heart Association, American Pediatric Society

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College 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, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, Heart Rhythm Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, American College of Cardiology, American Heart Association, Society for Pediatric Research

Disclosure: Received grant/research funds from Medtronic for consulting.

References
  1. Dodge-Khatami A, Miller OI, Anderson RH, et al. Surgical substrates of postoperative junctional ectopic tachycardia in congenital heart defects. J Thorac Cardiovasc Surg. 2002 Apr. 123(4):624-30. [Medline].

  2. Zampi JD, Hirsch JC, Gurney JG, Donohue JE, Yu S, LaPage MJ, et al. Junctional ectopic tachycardia after infant heart surgery: incidence and outcomes. Pediatr Cardiol. 2012 Dec. 33(8):1362-9. [Medline].

  3. Liu CF, Ip JE, Lin AC, Lerman BB. Mechanistic Heterogeneity of Junctional Ectopic Tachycardia in Adults. Pacing Clin Electrophysiol. 2011 Sep 28. [Medline].

  4. Hoffman TM, Bush DM, Wernovsky G, et al. Postoperative junctional ectopic tachycardia in children: incidence, risk factors, and treatment. Ann Thorac Surg. 2002 Nov. 74(5):1607-11. [Medline].

  5. Andreasen JB, Johnsen SP, Ravn HB. Junctional ectopic tachycardia after surgery for congenital heart disease in children. Intensive Care Med. 2008 May. 34(5):895-902. [Medline].

  6. Zhao H, Cuneo BF, Strasburger JF, Huhta JC, Gotteiner NL, Wakai RT. Electrophysiological characteristics of fetal atrioventricular block. J Am Coll Cardiol. 2008 Jan 1. 51(1):77-84. [Medline].

  7. Borgman KY, Smith AH, Owen JP, Fish FA, Kannankeril PJ. A genetic contribution to risk for postoperative junctional ectopic tachycardia in children undergoing surgery for congenital heart disease. Heart Rhythm. 2011 Dec. 8(12):1900-4. [Medline]. [Full Text].

  8. Imamura M, Dossey AM, Garcia X, Shinkawa T, Jaquiss RD. Prophylactic amiodarone reduces junctional ectopic tachycardia after tetralogy of Fallot repair. J Thorac Cardiovasc Surg. 2011 Oct 27. [Medline].

  9. Saul JP, Scott WA, Brown S, et al. Intravenous amiodarone for incessant tachyarrhythmias in children: a randomized, double-blind, antiarrhythmic drug trial. Circulation. 2005 Nov 29. 112(22):3470-7. [Medline].

  10. Imamura M, Dossey AM, Garcia X, Shinkawa T, Jaquiss RD. Prophylactic amiodarone reduces junctional ectopic tachycardia after tetralogy of Fallot repair. J Thorac Cardiovasc Surg. 2012 Jan. 143(1):152-6. [Medline].

  11. Guccione P, Di Carlo D, Papa M, et al. [Hypothermia treatment of junctional ectopic tachycardia after surgical repair of congenital heart defects]. G Ital Cardiol. 1990 May. 20(5):415-8. [Medline].

  12. Pfammatter JP, Paul T, Ziemer G, Kallfelz HC. Successful management of junctional tachycardia by hypothermia after cardiac operations in infants. Ann Thorac Surg. 1995 Sep. 60(3):556-60. [Medline].

  13. Walsh EP, Saul JP, Sholler GF, et al. Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for congenital heart disease. J Am Coll Cardiol. 1997 Apr. 29(5):1046-53. [Medline].

  14. Wu MH, Lin JL, Chang YC. Catheter ablation of junctional ectopic tachycardia by guarded low dose radiofrequency energy application. Pacing Clin Electrophysiol. 1996 Nov. 19(11 Pt 1):1655-8. [Medline].

  15. Manrique AM, Arroyo M, Lin Y, El Khoudary SR, Colvin E, Lichtenstein S, et al. Magnesium supplementation during cardiopulmonary bypass to prevent junctional ectopic tachycardia after pediatric cardiac surgery: a randomized controlled study. J Thorac Cardiovasc Surg. 2010 Jan. 139(1):162-169.e2. [Medline].

  16. Emmel M, Sreeram N, Brockmeier K. Catheter ablation of junctional ectopic tachycardia in children, with preservation of atrioventricular conduction. Z Kardiol. 2005 Apr. 94(4):280-6. [Medline].

 
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Lead II rhythm strip of a surface ECG from a patient with postoperative JET. Atrial activity (P) is marked with blue lines and ventricular depolarization (QRS) is marked in red. Note the narrow QRS complexes due to their origin at the AV junction. Also note the dissociation between atrial and ventricular depolarizations where some of the QRS complexes seem to "follow" the P waves. However, this is not possible because the PR intervals are exceedingly short to allow conduction. In addition, some of the P waves fall after the QRS.
 
 
 
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