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Pediatric Arrhythmia

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What is a heart arrhythmia?

An arrhythmia (also called dysrhythmia) is an abnormal rhythm of the heart. The heart is a pump made of muscle tissue. Its pumping action is regulated by an electrical conduction system that coordinates the contractions of the four chambers of the heart. Problems with this electrical conduction system can cause an arrhythmia.

Arrhythmias can cause the heart to pump less effectively because the coordination of the heart muscle becomes uncoordinated.

Arrhythmias can cause problems with contractions of the heart chambers by:

In an arrhythmia, abnormal conduction through the heart muscle may cause the heart to beat too fast, too slow, or in an irregular manner. In any of these situations, the heart may not be able to pump an adequate amount of blood to the body with each beat. Regardless of why the heart is not pumping well, the effects on the body are often the same, and include poor oxygen and blood delivery to all the tissues of the body.

Prevention & Risk Assessment Diagnosis Children's Team Departments
Prevention & Risk Assessment

Prevention & Risk Assessment

What are the symptoms of arrhythmia?

The following are the most common symptoms of arrhythmias. However, each child may experience symptoms differently. Symptoms may include:

  • Weakness
  • Fatigue
  • Heart palpitations
  • Low blood pressure
  • Dizziness
  • Fainting
  • Difficulty feeding

The symptoms of arrhythmias may resemble other medical conditions or heart problems. Always consult your child's doctor for a diagnosis.

The heart's electrical system

The heart is, in the simplest terms, a pump made up of muscle tissue. The heart's pumping action is regulated by an electrical conduction system that coordinates the contraction of the various chambers of the heart.

How does the heart's electrical system work?

The electrical system in the heart consists of nodes that generate electrical signals that travel down through conduction pathways in the heart muscle similar to the way electricity flows through power lines from the power plant to your house.

  • First, an electrical stimulus is generated in a specialized part of the heart muscle called the sinus node (also called the sinoatrial node, or SA node). This is a small mass of specialized tissue located in the right atrium (right upper chamber of the heart). The sinus node generates a regular electrical stimulus, 60 to190 times per minute, depending on the age of the child and his or her activity level.
  • The electrical impulse travels from the sinus node to the atrioventricular node (also called AV node) located between the atria and the ventricles.
  • In the AV node, the impulses are slowed down for a very short period, allowing the atria to contract a fraction of a second before the ventricles.
  • The blood from the atria empties into the ventricle.
  • The electrical current then continues down the conduction pathway via the bundle of His and into the ventricles.
  • The bundle of His divides into right and left pathways to provide electrical stimulation to the right and left ventricles.
  • The ventricles then contract and pump out blood to the body.

Under some abnormal conditions, certain heart tissue is capable of starting a heartbeat, or becoming the "pacemaker," just like the sinus node. An arrhythmia (abnormal heartbeat) may occur when:

  • The heart's natural pacemaker (the sinus node) develops an abnormal rate or rhythm.
  • The normal conduction pathway is interrupted.
  • Another part of the heart takes over as pacemaker.

What are the different types of arrhythmias?

An atrial arrhythmia is an arrhythmia caused by abnormal function of the sinus node or the atrioventricular node, or by the development of another atrial pacemaker within the atrium that takes over the function of the sinus node.

A ventricular arrhythmia is an arrhythmia caused by an abnormal electrical focus within the ventricles, resulting in abnormal conduction of electrical signals within the ventricles. The sinus node and atrioventricular node may function normally.

Arrhythmias can also be classified as slow (bradyarrhythmia) or fast (tachyarrhythmia). "Brady-" means slow, while "tachy-" means fast.

Listed below are some of the more common arrhythmias:

Atrial Arrhythmias

Ventricular Arrhythmias
Sinus Arrhythmia - a condition in which the heart rate varies with breathing. Sinus arrhythmia is commonly found in children; adults may often have it as well. This is usually a benign condition –and is very normal in children. There are usually no symptoms or problems associated with sinus arrhythmias.
Premature Ventricular Contractions (PVCs) - a condition in which an electrical signal originates in the ventricles and causes the ventricles to contract before receiving the electrical signal from the atria. PVCs are not uncommon and often do not cause symptoms or problems. However, if the frequency of the PVCs increases to several per minute, symptoms such as weakness, fatigue, dizziness, fainting, or palpitations may be experienced.
Sinus Tachycardia - a condition in which the heart rate is faster than normal for the child's age because the sinus node is sending out electrical impulses at a rate faster than usual. Sinus tachycardia is often temporary, occurring when the body is under stress from exercise, strong emotions, fever, or dehydration, to name a few causes. Once the stress is removed, the heart rate will usually return to its usual rate. This condition may cause symptoms such as weakness, fatigue, dizziness, or palpitations if the heart rate becomes too fast to pump an adequate supply of blood to the body. We sometimes see sinus tachycardia in children with Postural Orthostatic Tachycardia syndrome (POTS).
Ventricular Tachycardia (VT) - a condition in which an electrical signal is sent from the ventricles at a very fast rate. If the heart rate is sustained at a high rate, symptoms such as weakness, fatigue, dizziness, fainting, or palpitations may be experienced.

Sick Sinus Syndrome - a condition in which the sinus node sends out electrical signals either too slowly or too fast. There may be alternation between too-fast and too-slow rates. This condition may cause symptoms if the rate becomes too slow or too fast for the body to tolerate.
Ventricular Fibrillation (VF) - a condition in which an electrical signal is sent from the ventricles at a very fast and erratic rate. As a result, the ventricles are unable to fill with blood and pump it out, thus causing a very low blood pressure and symptoms such as weakness, dizziness, fainting, or loss of consciousness – cardiac arrest.
Premature Supraventricular Contractions or Premature Atrial Contractions (PAC) - a condition in which the sinus node or another pacemaker site above the ventricles sends out an electrical signal early. PAC’s are very common, and usually do not cause symptoms. Some people may feel a skipped beat, or palpitations. If a PAC occurs very early, the ventricles may be unable to respond, or may respond with a beat that is conducted abnormally.

Junctional Rhythm, Junctional Tachycardia - If the sinus node fails to send out an electrical signal, the heart responds with a back-up signal from the Bundle of His, an area just beyond the AV Node in the AV Junction (the junction of the atria and ventricles). This is called a Junctional beat, or if junctional beats occur in a row, Junction Rhythm. If the rate is rapid (over 100) it is called Junctional Tachycardia.
Supraventricular Tachycardia (SVT) - a condition in which the heart rate speeds up due to a series of early beats from the atrium. SVT usually begins and ends rapidly, occurring in repeated periods. This condition can cause symptoms such as weakness, fatigue, dizziness, fainting, or palpitations if the heart rate becomes too fast. The causes of SVT are explained more under ablation.

Wolff-Parkinson-White Syndrome

(WPW) - Wolff Parkinson White Syndrome is the presence of an extra electrical pathway between the atria and ventricles. This accessory pathway may allow a circuit to occur in which impulses travel in a circle from the accessory pathway to the AV node. This is a form of supraventricular tachycardia (SVT) that can be very fast and potentially life threatening.

Atrial Flutter - a condition in which an abnormal rhythm develops in the atrium secondary to the electrical impulse re-entering in the atria in a circular pattern, or circuit. Each time the impulse goes around the circuit, the atria contract. When the signals from the atria are coming at a faster rate than the ventricles can respond to, the ECG pattern develops a signature "sawtooth" pattern, showing two or more P waves between each QRS complex. The number of P waves between each QRS complex is usually a constant number and is expressed as a ratio (i.e., a two-to-one atrial flutter means that two P waves are occurring between each QRS).

Atrial Fibrillation - a condition in which many erratic electrical signals come from the atria at a very fast and erratic rate. The ventricles contract irregularly. The heart may beat at a normal rate, or very fast.

The symptoms of various arrhythmias may resemble other medical conditions or heart problems. Always consult your child's doctor for a diagnosis.

Diagnosis

Diagnosis

How are arrhythmias diagnosed?

In addition to a complete medical history and physical examination of your child, there are several different types of procedures that may be used to diagnose arrhythmias. Some of these procedures include the following:

  • Electrocardiogram (ECG or EKG). An electrocardiogram is a measurement of the electrical activity of the heart. By placing electrodes at specific locations on the body (chest, arms, and legs), a picture, or tracing, of the electrical activity can be obtained as the electrical activity is received and interpreted by an ECG machine. An ECG can indicate the presence of arrhythmias or other types of heart conditions. There are several variations of the ECG test, including the following:
  • Resting ECG. For this procedure, the clothing on the upper body is removed and small, sticky patches called electrodes are attached to the chest, arms, and legs. These electrodes are connected to the ECG machine by wires. The ECG machine is then started and records the heart's electrical activity for a minute or so. The child is lying down during this ECG.
  • Exercise ECG, or stress test. The child is attached to the ECG machine as described above. However, rather than lying down, the child exercises by walking on a treadmill or pedaling a stationary bicycle while the ECG is recorded. This test is done to assess changes in the ECG during stress such as exercise.
  • Holter monitor. An ECG recording done over a period of 24 or more hours. Three electrodes are attached to the child's chest and connected to a small, portable ECG recorder by lead wires. The child goes about his or her usual daily activities (except for activities such as taking a shower, swimming, or any activity causing an excessive amount of sweating which would cause the electrodes to become loose or fall off) during this procedure. There are two types of Holter monitoring, including the following:
    • Continuous recording
    • The ECG is recorded continuously during the entire testing period.
    • Event monitor, or loop recording
    • The ECG is recorded only when the patient starts the recording when symptoms are felt or when an abnormal rhythm is detected.
    • Holter monitoring may be done when an arrhythmia is suspected but not seen on a resting ECG. Arrhythmias may be short-lived in nature and not seen during the shorter recording times of the resting ECG.
    • Electrophysiologic study (EPS). An invasive test in which a small, thin tube (catheter) is inserted in a large blood vessel in the leg or arm and advanced to the heart. This gives the doctor the capability of finding the site of the arrhythmia's origin within the heart tissue, thus determining how to best treat it. Another procedure called an esophageal electrophysiologic study may be ordered where a soft, thin flexible plastic tube is inserted in the nostril and placed in the esophagus (close to the atria) to provide a more precise ECG recording.
    • Tilt table test. A test recommended for children who have frequent fainting (syncope) episodes. The test displays how the heart rate and blood pressure respond to a change in position--lying down to standing up. During this test, medication may be given intravenously to help prevent a fainting episode once the cause has been identified by the doctor.
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