Direct current cardioversion in a case of congenital atrial flutter.

Abstract

The congenital type of atrial flutter has a poor prognosis when unresponsive to digoxin (Moller, Davachi, and Anderson, 1969). Recorded experience with cardioversion is limited but it has been suggested that this type of flutter is refractory to electric countershock (Rodriguez-Coronel, Sueblingvong, and Hastreiter, 1968).We report an infant with congenital heart defects and congenital atrial flutter who appeared resistant to digoxin and ,B-blockade (practolol) but readily reverted to sinus rhythm with direct current (DC) cardioversion.Case Report This was the second pregnancy of a 25-year-old whose health was good until mild hypertension developed at term. Labour was induced at 40 weeks, and the fetal heart was noted to be rapid and irregular. A mature female infant weighing 3 * 8 kg was delivered by emergency caesarean section. No meconium staining was evident, and the Apgar score at one minute was 9. The infant remained active, sucked well, and was pink breathing air.The apex beat was consistently 180-200/minute. No cardiac murmurs were heard at this time and there were no signs of respiratory distress. X-ray showed slight cardiomegaly and clear lung fields. ECG showed atrial flutter with varying AV block and a ventricular rate around 180/minute.An attempt was made to control the ventricular rate using digoxin orally. A total dose of 0 3 mg over the first 24 hours was given, and 0 075 mg daily thereafter. After 3 days there was no change in the underlying arrhytnmia or the ventricular rate (Fig.). At this time a soft systolic murmur became audible at the left sternal edge.At the age of 4 days cardiac catheterization revealed an atrial septal defect with a pulmonary-systemic flow ratio of 2: 1 and a minor degree ofaortic coarctation. During the procedure the atrial flutter reverted to sinus rhythm for two short periods.At 5 days digoxin was stopped. After 24 hours, and with continuous ECG monitoring, practolol was given twice within one hour by slow i.v. injection in a dose of 05 mg diluted in 10 ml saline. No effect was noted on the heart rate or rhythm. Oral practolol 2-2 mg/kg twice daily was given and increased to four times daily without effect on rate or rhythm (Fig.).By 10 days the baby's condition was deteriorating with tachypnoea and feeding difficulty. The liver was palpable two fingers' breadth below the costal margin. X-ray revealed increasing cardiomegaly. DC cardioversion was, therefore, attempted.No anaesthetic was given. Adult electrodes (9 cm diameter) were placed on the right midsternal border and on the apex with about nine-tenths of the surface area of the paddles masked by insulating tape. A shock of 10 watt-seconds was given from a Lown cardiorater.

Congenital paroxysmal atrial tachycardia.

“…In our experience only low energy outputs are necessary. Similar success in infants has been reported by Hassenriick, Chojnacki, and Barber praventricular (1965) and Barclay and Barr (1972 Congenital atrial tachyarrhythmias have been reported in cases of congenital heart disease, the lesions including atrial septal defect, Ebstein's anomaly, transposition of the great vessels, coarctation of the aorta, isolated dextrocardia, and endocardial fibroelastosis (Siderides et al, 1957). Only one of our patients had a congenital cardiac lesion; this was a ventricular septal defect, not previously reported in this condition.…”

Cardiac Arrhythmias Requiring Electric Countershock during the Neonatal Period—A Systematic Review

“…Thirty-four articles (87.2%) [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ] stated the patients’ gestational ages. The described neonates ranged from 25 +2 to 40 +4 weeks of gestation.…”

“…In 6 articles (15.4%) [ 8 , 34 , 35 , 36 , 37 , 38 ] the 62 described neonates (54.9%) were classified into an age group between birth and four weeks post-partum. Eleven articles (28.2%) [ 11 , 12 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ] including twelve neonates (10.6%) reported on the manifestation of arrhythmias between the second and the twenty-fourth day after birth. In two cases arrhythmias were due to surgery [ 41 , 43 ], and in two cases they occurred during the placement of a central venous catheter [ 25 , 40 ].…”

Idiopathic atrial flutter AFL in neonates (Case Report)

“…However, mortality seems to be more often related to the presence of associated medical conditions. 15 Pharmacological or electrical cardioversion to normal sinus rhythm may be effective and, once such reversal is achieved, the patient does not seem to have a risk of recurrence of atrial flutter, except when there is an accessory pathway; in this case, supraventricular tachycardia episodes may occur. In patients without an accessory pathway, it is not usually necessary to maintain the long-term medication.…”

“…In patients without an accessory pathway, it is not usually necessary to maintain the long-term medication. [15][16] Considering the small amount of data available in the national and international literature, mainly from the isolated case reports, there is scarce information about the precise association between neonatal arrhythmias and the umbilical catheterization, including the actual incidence of atrial flutter and the indication of a "universal" therapeutic approach for it. The association between cardiac arrhythmias and maternal diabetes is a research field yet to be developed, which can contribute to the prevention of this disease, supported by a better understanding of the physiopathological mechanisms of these entities.…”