Postoperative junctional ectopic tachycardia.
OBJECTIVE
To report the management of junctional ectopic tachycardia after cardiac surgery in an infant. Postoperatively, the patient suffered profound cardiac decompensation secondary to the accelerated rhythm and required extracorporeal membrane oxygenation (ECMO) for haemodynamic support.


METHODS
A 14-day-old, 3.5 kg boy exhibited junctional ectopic tachycardia after cardiopulmonary bypass. Left atrial pressure was 25-28 mmHg. No impact on the tachycardia was seen after rapid overdrive atrial pacing or after 20 micrograms fentanyl i.v., 45 micrograms digitalis, 100 mg magnesium or procainamide (loading dose 15 mg, then 30 mg.kg-1.min-1). Active cooling decreased the nasopharyngeal temperature to 35.2 degrees C, when the heart rate decreased below 180 bpm with a left atrial pressure of 8-10 mmHg. Dopamine (2 micrograms.kg-1.min-1) and dobutamine (5 micrograms.kg-1.min-1) were added to improve the cardiac output. Sodium nitroprusside (0.25 to 1 microgram.kg-1.min) maintained the systolic pressure < 100 mmHg. On arrival in ICU, heart rate increased to 200 bpm. The patient received cardiac massage for severe hypotension 75 min after surgery. Emergency ECMO was instituted for circulatory support. Procainamide, digoxin, dopamine, dobutamine, sodium nitroprusside and hypothermia were continued. Sinus rhythm resumed on the first postoperative day, but procainamide and induced hypothermia at 34 degrees C were maintained for 36 hr after normalization of the rhythm to prevent recurrence of the tachycardia. Total duration of ECMO was three and a half days. Recovery was uneventful.


CONCLUSIONS
The use of ECMO, as a first line of defence, is suitable for the emergency support of patients with JET because of the ease of support of circulation and precise control of hypothermia.
Azzam
F J
FJ
Department of Anesthesiology, Saint Louis University Medical Center, MO 63110, USA.
Fiore
A C
AC
D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D016279:Atrial Function, Left / Q000502:physiology; D001794:Blood Pressure / Q000502:physiology; D002302:Cardiac Output / Q000187:drug effects; D002304:Cardiac Pacing, Artificial; D002315:Cardiopulmonary Bypass; D002316:Cardiotonic Agents / Q000627:therapeutic use; D004071:Digitalis Glycosides / Q000627:therapeutic use; D004280:Dobutamine / Q000627:therapeutic use; D004298:Dopamine / Q000627:therapeutic use; D015199:Extracorporeal Membrane Oxygenation; D005283:Fentanyl / Q000008:administration & dosage; D006336:Heart Massage; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D007022:Hypotension / Q000628:therapy; D007036:Hypothermia, Induced; D007231:Infant, Newborn; D008274:Magnesium / Q000627:therapeutic use; D008297:Male; D009599:Nitroprusside / Q000627:therapeutic use; D011183:Postoperative Complications; D011342:Procainamide / Q000627:therapeutic use; D013613:Tachycardia, Ectopic Junctional / Q000188:drug therapy / Q000209:etiology / Q000628:therapy*; D016896:Treatment Outcome
D018686:Anesthetics, Intravenous; D000889:Anti-Arrhythmia Agents; D000959:Antihypertensive Agents; D002316:Cardiotonic Agents; D004071:Digitalis Glycosides; D009599:Nitroprusside; D004280:Dobutamine; D008274:Magnesium; D011342:Procainamide; D005283:Fentanyl; D004298:Dopamine