Junctional Ectopic Tachycardia 

  • Author: M Silvana Horenstein, MD; Chief Editor: Stuart Berger, MD   more...
 
Updated: Nov 28, 2011
 

Background

Junctional ectopic tachycardia (JET) is characterized by rapid heart rate for a person's age that is driven by a focus with abnormal automaticity within or immediately adjacent to the atrioventricular (AV) junction of the cardiac conduction system (ie, AV node–His bundle complex). It does not have the features associated with reentrant tachycardia (eg, AV node reentry) because this form of tachycardia does not respond to a single extrastimulus, does not convert with programmed stimulation or cardioversion, and may or may not have ventriculoatrial (VA) dissociation; also, administration of adenosine results in VA dissociation without termination.

JET primarily occurs in 2 forms: idiopathic chronic junctional ectopic tachycardia, which is observed in the setting of a structurally normal heart, and transient postoperative junctional ectopic tachycardia occurs following repair of congenital heart disease.

In addition, nonparoxysmal junctional tachycardia is a related but rare pattern of arrhythmia that can be observed in the setting of digoxin toxicity.

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Pathophysiology

The pathophysiology of JET is unclear. Postoperative JET is associated with manipulation within the crux of the heart. It is believed to be secondary to trauma, infiltrative hemorrhage, or inflammation of the conduction tissue.[1]

As implied by the synonym junctional automatic tachycardia, the mechanism may be automaticity. Others have suggested that triggered activity is responsible for this disorder.[2]

The location of the responsible tissue is probably truly ectopic to the primary conduction pathway of the AV junction because JET has been successfully treated by the application of radiofrequency catheter lesions without the production of AV block. Intracardiac mapping shows a normal heart volume interval and VA dissociation, or VA association if VA conduction is present.

Junctional acceleration, albeit at a lesser rate than typical JET, is a recognized phenomenon during and following radiofrequency energy delivery for modification of slow pathway conduction in the therapy of AV node reentry.

Histamine, eosinophil cation protein, or other products of mast cell, eosinophil, or basophil degranulation that are liberated in response to cardiopulmonary bypass have been implicated in the genesis of transient postoperative JET. The relative levels of various cytokines may also play a role. Low magnesium levels have been noted in children who develop JET following cardiopulmonary bypass surgery.

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Epidemiology

Frequency

United States

Postoperative JET occurred in 5.6% of 594 patients who underwent cardiac surgery.[3] JET was seen more frequently with postoperative use of dopamine and in younger patients.

International

In one series, postoperative JET was identified in 7.5% of young patients undergoing Fontan procedures. Another recent series described JET in 10.2% of 874 pediatric patients undergoing cardiopulmonary bypass.[4]

Postoperative JET that required intervention was identified in 1.5% of infants undergoing the arterial switch procedure. It was also seen in 21.9% of patients who had undergone cardiac surgery for tetralogy of Fallot.[1]

Mortality/Morbidity

Although not a frequent type of arrhythmia, JET is one of the most serious and difficult-to-treat supraventricular tachycardias. Rare case reports have suggested that JET may be associated with progression to complete AV block. This does not appear to be the case in postoperative JET and has not been the author's experience in the rare cases of idiopathic JET.

  • Postoperative JET is usually transient and begins upon rewarming the patient. Its morbidity and mortality relates to the fact that it occurs at an extremely vulnerable period following cardiac surgery, when nodal inflammation and ischemia may be present and ventricular function is often diminished. The additional insults of poor ventricular filling because of tachycardia and the loss of AV sequential contraction are considered to significantly contribute to morbidity and mortality. However, if the JET rate is not too fast or is somewhat faster than the sinus node rate, it can be well tolerated until JET spontaneously subsides.
  • In a large series of patients with postoperative JET, dopamine use and an age less than 6 months were associated with the development of this tachycardia.[3] However, only 39% of patients required intervention.
  • Congenital JET occurs in neonates and infants as an incessant tachycardia that usually results in tachycardia-induced cardiomyopathy. Mortality in these patients has been reported to be as high as 34% and may occur secondary to congestive heart failure, sudden onset of ventricular fibrillation, and sudden evolution to paroxysmal complete AV block and as result of proarrhythmic effect of drug therapy and medical interventions.
  • In fetuses with JET (as well as those with ventricular tachycardia) third-degree AV block should be ruled out.[5]

Age

  • JET is one of the rarest forms of supraventricular tachycardia in infants. Congenital JET is presumed to be present from birth but may not be identified until months or years later.
  • Postoperative JET most commonly occurs in younger patients (it was found to occur more frequently in patients younger than 6 mo) but is also known to occur in teenagers and adults after cardiopulmonary bypass surgery.
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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)

Robert Murray Hamilton, MD, MSc, FRCPC  Section Head, Electrophysiology, 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 Cardiovascular Society, Canadian Medical Association, Canadian Medical Protective Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Ontario Medical Association, Pediatric Electrophysiology Society, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, Pediatric and Congenital Electrophysiology Society, and Society for Pediatric Research

Disclosure: Johnson & Johnson Consulting fee Consulting

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 College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research

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.

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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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