Guidelines Summary

No specific guidelines have been developed for the management of pediatric atrial flutter. The 2015 American College of Cardiology, American Heart Association, and the Heart Rhythm Society (ACC/AHA/HRS) joint guidelines for the management of supraventricular tachycardia note that although the guidelines are intended for adults (age ≥18 years) and offer no specific recommendations for pediatric patients, in some cases, the data from noninfant pediatric patients was reviewed and helped to apprise the guidelines.^[20]

The guidelines state that pharmacologic therapy for pediatric atrial flutter is largely based on practice patterns owing to the lack of random controlled trials of antiarrhythmic medications in children. Amiodarone, sotalol, propafenone, or flecainide may be used in infants. In older children, beta-blockers are used most often as the initial therapy. Flecainide is not used as a first-line agent in children because of the rare occurrence of adverse events. Catheter ablation may be successfully performed in children of all ages, with success rates comparable to those reported in adults.^[20]

Medication

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Wacker-Gussmann A, Strasburger JF, Srinivasan S, Cuneo BF, Lutter W, Wakai RT. Fetal atrial flutter: electrophysiology and associations with rhythms involving an accessory pathway. J Am Heart Assoc. 2016 Jun 14. 5(6):[QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Balaji S, Daga A, Bradley DJ, 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. 2014 Aug. 148(2):576-81. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Lin JH, Kean AC, Cordes TM. The risk of thromboembolic complications in Fontan patients with atrial flutter/fibrillation treated with electrical cardioversion. Pediatr Cardiol. 2016 Oct. 37(7):1351-60. [QxMD MEDLINE Link].
Vadmann H, Nielsen PB, Hjortshoj SP, et al. Atrial flutter and thromboembolic risk: a systematic review. Heart. 2015 Sep. 101(18):1446-55. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Crochelet AS, Jacquemart C, Massin M. [Repeated electrical cardioversions and amiodarone for recurrent neonatal atrial flutter]. Arch Pediatr. 2015 Oct. 22(10):1032-4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016 Apr 5. 133(14):e471-505. [QxMD MEDLINE Link]. [Full Text].
Naccarelli GV, Wolbrette DL, Levin V, et al. Safety and efficacy of dronedarone in the treatment of atrial fibrillation/flutter. Clin Med Insights Cardiol. 2011. 5:103-19. [QxMD MEDLINE Link]. [Full Text].
Ekiz A, Kaya B, Bornaun H, et al. Flecainide as first-line treatment for fetal supraventricular tachycardia. J Matern Fetal Neonatal Med. 2017 Feb 14. 1-6. [QxMD MEDLINE Link].
Li X, Zhang Y, Liu H, Jiang H, Ge H, Zhang Y. Efficacy of intravenous sotalol for treatment of incessant tachyarrhythmias in children. Am J Cardiol. 2017 Feb 10. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ekiz A, Kaya B, Bornaun H, et al. Flecainide as first-line treatment for fetal supraventricular tachycardia. J Matern Fetal Neonatal Med. 2018 Feb. 31(4):407-12. [QxMD MEDLINE Link].
Sumitomo N, Horigome H, Miura M, et al, for the Heartful Investigators. Study design for control of HEART rate in inFant and child tachyarrhythmia with heart failure Using Landiolol (HEARTFUL): A prospective, multicenter, uncontrolled clinical trial. J Cardiol. 2017 Sep. 70(3):232-7. [QxMD MEDLINE Link].
von Alvensleben JC, LaPage MJ, Caruthers R, Bradley DJ. Nadolol for treatment of supraventricular tachycardia in infants and young children. Pediatr Cardiol. 2017 Mar. 38(3):525-30. [QxMD MEDLINE Link].
Lin JH, Kean AC, Cordes TM. The risk of thromboembolic complications in Fontan patients with atrial flutter/fibrillation treated with electrical cardioversion. Pediatr Cardiol. 2016 Oct. 37(7):1351-60. [QxMD MEDLINE Link].
Yilmaz-Semerci S, Bornaun H, Kurnaz D, et al. Neonatal atrial flutter: Three cases and review of the literature. Turk J Pediatr. 2018. 60(3):306-9. [QxMD MEDLINE Link]. [Full Text].
Low S, Kiper C, Armstrong A, Cua CL. Echocardiographic diagnosis of atrial flutter in a neonate. Echocardiography. 2018 Sep. 35(9):1439-41. [QxMD MEDLINE Link].

Media Gallery

Rhythm strip depicting lead II of a patient with atrial flutter with an atrial rate of 300 beats per minute (bpm). Atrioventricular conduction rate is variable at 2:1 and 3:1. Therefore, the ventricular rate ranges from 100-150 bpm.

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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.

Chief Editor

Syamasundar Rao Patnana, MD Professor of Pediatrics and Medicine, Division of Cardiology, Emeritus Chief of Pediatric Cardiology, University of Texas Medical School at Houston and Children's Memorial Hermann Hospital

Syamasundar Rao Patnana, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Alvin J Chin, MD Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Cardiology Division, Children's Hospital of Philadelphia

Alvin J Chin, MD, is a member of the following medical societies: American Association for the Advancement of Science, American Heart Association, and Society for Developmental Biology

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.

Pediatric Atrial Flutter Guidelines

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