The Frequency of Cardiac Arrhythmias in Children with Congenital Heart Disease during Angiography-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
Background: Although non-invasive
methods in the diagnosis of congenital heart disease have a special and
wide place but as a practical method, angiography used widely for
diagnosis and therapeutic intervention in children. Because importance
of arrhythmias and their risks during angiography, we decided to
determine the prevalence and types of arrhythmias occurred during
cardiac catheterization.
Method:This cross-sectional study
was performed in patients undergoing cardiac catheterization in Isfahan
University of Medical Sciences during one year at pediatric ward of
Chamran research and medical heart center.
Results: From 372 patients (185
males and 187 females) who underwent angiography, 172 patients had
diagnostic and 200had interventional catheterization of the patients,
160 (43%) had transient arrhythmias were less important during
angiography and 15 (4.5%) were experiencing sustain and important
arrhythmias that need drug or electroshock to terminate or lead to
complications and death in patient.
Conclusion: Arrhythmia in age groups
under 15 year, low weight and interventional angiography was more
happened but no significant relationship was found between arrhythmia
and patient sex, type of disease (cyanotic or non-cyanotic), duration of
angiography and history of cardiac surgery.
Introduction
Although new various non-invasive procedures such as
echocardiography and imaging, in congenital heart disease diagnosis have
a special place, but as a practical method at inefficiency of these
modalities, cardiac angiography said to us the hidden aspects of the
cardiac diseases.The field of cardiac catheterization has evolved,
performing more interventional compared with diagnostic cases. In the
meantime, the nature of interventional cardiology has changed, with a
greater percentage of patients undergoing catheter-based intervention
[1].
In recent years trend to perform some interventional
angiography for cardiac lesions, naturally various side effects,
including arrhythmias during the procedure more has happened [2,3]. With
the development using of occlude in ASD and VSD closure and improvement
of procedure techniques, especially the clinical application of
Amplatzer in ASD and VSD occlusion, closure procedures of inter atrial
and ventricular septal defects has been widely applied in clinical
practice, featured with advantages of satisfying efficacy, little
trauma, quick recovery after surgery, as well as few complications.
However, there have been occasional reports of procedure complications
due to inappropriate inclusion of cases, unqualified techniques of
operators or lack of experience [4].
Arrhythmia is one the most common complications after
surgery, which could severely affect the prognosis of children. In
spite of advances in many noninvasive methods for studying cardiac
lesions in children, angiography is still an essential method for the
calculation of cardiovascular hemodynamic status. Accordingly, all
adverse events related to cardiac catheterization are a major concern to
pediatric cardiologists [5,6]. Given the importance of arrhythmias and
dangers that can be happened during angiography, this article studied
the prevalence and detection of arrhythmias type occurred
during angiography while generating greater awareness and
preparation of the medical team, equipment and medications, to
provide timely treatment for patient [7-9].
In this cross-sectional study that was conducted, all patients
between June 2014 and June 2015 in Isfahan Chamran research
and medical heart center that had undergone angiography
by pediatric cardiologists were studied. Inclusion criteria
included patients undergoing angiography by pediatric service
in this hospital. Exclusion criteria included patients undergoing
angiography in this service that their files were incomplete.
The patients were admitted to the hospital at the day before
angiography. ECG of patients was taken during routine study.
Before angiography, echocardiography was performed. All other
documents of patients were assessed. Routine tests include: (CBC,
ESR, CRP, BUN, Cr, Na, K, BS, PT, PTT, INR, U/A) done for patients.
At least six hours before angiography they were fasted. In the
absence of significant infectious problems, high fever and with
normal general conditions angiography were done. If there was
no problem in breathing during angiography, an anesthesiologist
did not intubate the patient, and with midazolam and ketamine,
deep sedation was performed.
Oxygen and Capnography monitors were performed during
the procedure, and cardiac monitoring was done. During
angiography iso-osmolar contrast were used for imaging. After
the angiography and sheet exit, patients were transferred to beds
with cardiac monitoring and unstable patients are transferred
to intensive care unit. The patient’s with unconsciousness does
not eat anything until complete consciousness and then feeding
start. Patients that had simple diagnostic catheterization without
complication and good general condition, discharged the same
day and if the general condition is unfavorable or intervention is
taken, usually discharged the next day.
Data obtained from patient file records by using a selfmade
checklist. Information such as the type of angiography (a
diagnostic or interventional), type and length of arrhythmia, the
need for medication or electroshock to terminate the arrhythmia,
the patient’s age and other demographic information needed
were extracted. Ethical considerations of confidentiality of
information and need to disseminate the results of the study
as a whole and not the individual, was considered. The data of
this study by using descriptive statistics and independent t-test,
chi-square and Fisher exact test were analyzed with statistical
software SPSS18.
Of the 372 patients in the study who had undergone
angiography, 185 were men. 113 children were smaller than one
year, 134 patients between one to six years and 125 above 6 years of age. 28 patients weight were below 5 kg, 124 between 5kg
-10 kg, and 220 above 10 kg. Angiography in 172 cases (46%) of
patients in the study had been done for diagnostic reasons, and
in 200 cases was interventional. In 352 cases (95%) the duration
of angiography was 30 to 60 minutes, in 9 under half an hour and
in 11 took more than one hour. 105 patients (28 percent) had
cyanotic heart disease and 267 patients (72%) had no cyanosis.
Of 372 patients in this study, 175 patients (47%) were
experiencing arrhythmia. 137 cases had transient PVC, 30
cases had transient bradycardia, 6 cases had transient PSVT, 1
case transient PAC, and 1 case cardiac arrest. From total 175
cases of arrhythmia, in 160 cases arrhythmia were cut without
medication, in 14 cases arrhythmia terminate with medication (a
PVC that needs to be injected lidocaine, 12 cases of bradycardia
with atropine returned, and one of PSVT who replied to the
adenosine) and one needed ECT (unfortunately she was a 8
months old that has dilated cardiomyopathy due to ALCAPA, her
LVEF was very low and didn’t response to medication, ECT and
resuscitation).
The incidence of arrhythmia during angiography is most
in age group under 15 years but in group older than 15 years,
greatly reduced (p =0.007). There was a significant relationship
between the weight and the occurrence of arrhythmia and
so in the weight of upper than 10 kg, reduced the incidence
of arrhythmias during angiography (p =0.05). There was
significant relationship between the reason of angiography
(diagnostic, interventional) and arrhythmia so that arrhythmia
in interventional angiography was most viewed (p =0.01).
No significant relationship between sex and cardiac
arrhythmia during angiography was found (p =0.23). Between
cyanotic and non-cyanotic cardiac disease and arrhythmia was
no significant relationship (p =0.31). Between the duration
of angiography and cardiac arrhythmia no relationship
was observed (p =0.19). The incidence of arrhythmias in
children who have had history of cardiac surgery and children
who had no cardiac surgery were no significant difference
seen (p =0.49). No significant relationship between type of
arrhythmia during angiography and sex, weight, age, reason
of angiography(diagnostic, interventional), cyanotic and noncyanotic
cardiac disease, duration of angiography and history of
cardiac surgerywas found (p =0.35).
Mah DY et al. [10,11] in a study of 6183 patients who had
undergone angiography during six years, studied the incidence
of heart block [10,11]. Among these patients, 135 cases had heart
block. The patients’ average weight was 15 kg, 29% of them were
under one year. Among the patients 72% had complex heart
disease. Angiography time of over than two hours was identified
as one of the risk factors for heart block. 97% of these patients
(135 cases that had complete heart block) recovered within aweek, but others require pacemaker for treatment of heart
block. In our study and this article, incidence of arrhythmias that
didn’t required medication for termination are similar together
and the prevalence of serious arrhythmias that requiring
pharmacological or intervention is greater in our study. Because
in our study type of arrhythmias differed and these arrhythmias
required medication, no pacemaker. Greater incidence in the
down age and weight was similar to this study.
Yilmazer MM et al. [12] analyzed 519 catheterization
procedures performed over a period of two years retrospectively
[12]. Several risk factors related to the patient or catheterization
was analyzed. The incidence of complications was 6.2%. The
most common major and minor complications were arterial
thrombosis that required intervention and transient arrhythmias,
respectively. The independent risk of any complication was
greatest up to 1 year of age (p = 0.02). The risks of a major
complication (p = 0.003) and development of arterial thrombosis
(p = 0.02) were significantly greater in patients <1 year of age
by univariate analysis. Younger age, particularly <1 year of age,
is the strongest predictor of development of any complication.
In our study, the prevalence of transient arrhythmias is high
and in this article is similar to our study and was be the second
complication in their patients. Greater incidence in the down age
and weight was similar to our study.
Odegard KC et al. [2] in study of 7289 patients, who
underwent angiography for 5 years between 2004 and 2009,
examined the incidence of cardiac arrest [2]. And their definition
was included cases of cardiac arrest that leads to cardiac massage
to resuscitate the patient. Among these patients 70 cases had
cardiac arrest, of which 69% were successful resuscitation with
massage. And 26% were in need of ECMO machine and 4 patients
were not restored. Sudden cardiac arrhythmia was the causes of
cardiac arrest in 54% of cases. 71% took less than 11 minutes
recovery time [13-17]. The difference between our study and
this article is that incidence of cardiac arrest in our study was
one patient between 372 cases (lower than this article) but
reason of this difference probably is population number in this
article that is greater than our patients.
Overall the difference between our study and previous
studies was that all types of arrhythmias occurred during
angiography, were examined in our study. That because of
arrhythmia compared to previous studies, is seems greater in
incidence [3]. But not transient arrhythmias that were controlled
with medication or lead to complications or dying patients are
approximately in the range of previous studies.
The study population because of the incompleteness of
patient records is lower than other studies and overall the case
population is lower than other centers, so we suggest the wide
study in this topic with wide range of time and population.
Considering the importance and prevalence of arrhythmias
and their variants during angiography and the risks that can
be diagnosed, can say in patients with complex cardiac disease
with low age and weight which the interventional angiography
takes place , medical teams also should be aware of and prepare
the equipment and provide medications, for timely treatment
underlying problem in these patients.
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