Causes of wide QRS complex tachycardia in children
- Susan P Etheridge, MD
Susan P Etheridge, MD
- Professor of Pediatrics
- University of Utah School of Medicine
Tachycardia in children is generally defined as a heart rate exceeding 120 beats per minute in older children and adolescents, and 180 beats per minute in infants and young children. The key to effective management of tachycardia is identifying its site of origin and understanding the underlying mechanism.
Thus, one of the initial steps in the evaluation of a child with tachycardia includes examination of the standard electrocardiogram (ECG), because assessing the width of the QRS complex aids in determining the origin of the arrhythmia and guides management decisions (algorithm 1).
●Narrow QRS complex tachycardia — A narrow QRS complex (QRS duration ≤80 msec) indicates that the origin of the arrhythmia is above or within the atrioventricular (AV) node. The short QRS duration indicates rapid activation of the ventricles through the AV node and the His-Purkinje system, and eliminates ventricular tachycardia (VT) as an etiology of the increased heart rate. Causes of narrow QRS complex tachycardia include sinus tachycardia, atrial fibrillation and flutter, and most cases of supraventricular tachycardia (SVT). These conditions are discussed in detail separately. (See "Sinus tachycardia" and "Epidemiology of and risk factors for atrial fibrillation" and "Supraventricular tachycardia in children: AV reentrant tachycardia (including WPW) and AV nodal reentrant tachycardia" and "Overview of atrial flutter".)
●Wide QRS complex tachycardia — With wide QRS complex (QRS duration >80 msec) tachycardia, VT must be first considered, because VT may rapidly degenerate to ventricular fibrillation and result in cardiac arrest. Wide QRS complex tachycardia may also be seen in patients with supraventricular tachycardia with an aberrant conduction system or antidromic AV reentrant tachycardia. (See 'Supraventricular tachycardia' below and 'Ventricular tachycardia' below.)
Causes of wide QRS complex tachycardia in children will be reviewed here. The evaluation and management of wide QRS complex tachycardia in children are discussed separately. (See "Management and evaluation of wide QRS complex tachycardia in children".)
- Viitasalo MT, Kala R, Eisalo A. Ambulatory electrocardiographic recording in endurance athletes. Br Heart J 1982; 47:213.
- Dickinson DF, Scott O. Ambulatory electrocardiographic monitoring in 100 healthy teenage boys. Br Heart J 1984; 51:179.
- Roggen A, Pavlovic M, Pfammatter JP. Frequency of spontaneous ventricular tachycardia in a pediatric population. Am J Cardiol 2008; 101:852.
- Walsh EP, Cecchin F. Arrhythmias in adult patients with congenital heart disease. Circulation 2007; 115:534.
- Walsh EP, Rockenmacher S, Keane JF, et al. Late results in patients with tetralogy of Fallot repaired during infancy. Circulation 1988; 77:1062.
- Keane JF, Driscoll DJ, Gersony WM, et al. Second natural history study of congenital heart defects. Results of treatment of patients with aortic valvar stenosis. Circulation 1993; 87:I16.
- Houyel L, Vaksmann G, Fournier A, Davignon A. Ventricular arrhythmias after correction of ventricular septal defects: importance of surgical approach. J Am Coll Cardiol 1990; 16:1224.
- Khairy P, Landzberg MJ, Gatzoulis MA, et al. Value of programmed ventricular stimulation after tetralogy of fallot repair: a multicenter study. Circulation 2004; 109:1994.
- Gatzoulis MA, Balaji S, Webber SA, et al. Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicentre study. Lancet 2000; 356:975.
- Deanfield JE, McKenna WJ, Presbitero P, et al. Ventricular arrhythmia in unrepaired and repaired tetralogy of Fallot. Relation to age, timing of repair, and haemodynamic status. Br Heart J 1984; 52:77.
- Bricker JT. Sudden death and tetralogy of Fallot. Risks, markers, and causes. Circulation 1995; 92:158.
- Ghai A, Silversides C, Harris L, et al. Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of Fallot. J Am Coll Cardiol 2002; 40:1675.
- Berul CI, Hill SL, Geggel RL, et al. Electrocardiographic markers of late sudden death risk in postoperative tetralogy of Fallot children. J Cardiovasc Electrophysiol 1997; 8:1349.
- Gatzoulis MA, Till JA, Redington AN. Depolarization-repolarization inhomogeneity after repair of tetralogy of Fallot. The substrate for malignant ventricular tachycardia? Circulation 1997; 95:401.
- Khairy P, Marelli AJ. Clinical use of electrocardiography in adults with congenital heart disease. Circulation 2007; 116:2734.
- Papagiannis J, Kanter RJ, Wharton JM. Radiofrequency catheter ablation of multiple haemodynamically unstable ventricular tachycardias in a patient with surgically repaired tetralogy of Fallot. Cardiol Young 1998; 8:379.
- Stevenson WG, Delacretaz E, Friedman PL, Ellison KE. Identification and ablation of macroreentrant ventricular tachycardia with the CARTO electroanatomical mapping system. Pacing Clin Electrophysiol 1998; 21:1448.
- Walsh EP. Arrhythmias in patients with congenital heart disease. Card Electrophysiol Rev 2002; 6:422.
- Morwood JG, Triedman JK, Berul CI, et al. Radiofrequency catheter ablation of ventricular tachycardia in children and young adults with congenital heart disease. Heart Rhythm 2004; 1:301.
- Laohakunakorn P, Paul T, Knick B, et al. Ventricular tachycardia in nonpostoperative pediatric patients: role of radiofrequency catheter ablation. Pediatr Cardiol 2003; 24:154.
- Dubin AM, Janousek J, Rhee E, et al. Resynchronization therapy in pediatric and congenital heart disease patients: an international multicenter study. J Am Coll Cardiol 2005; 46:2277.
- Cecchin F, Frangini PA, Brown DW, et al. Cardiac resynchronization therapy (and multisite pacing) in pediatrics and congenital heart disease: five years experience in a single institution. J Cardiovasc Electrophysiol 2009; 20:58.
- van der Hulst AE, Delgado V, Blom NA, et al. Cardiac resynchronization therapy in paediatric and congenital heart disease patients. Eur Heart J 2011; 32:2236.
- Splawski I, Timothy KW, Sharpe LM, et al. Ca(V)1.2 calcium channel dysfunction causes a multisystem disorder including arrhythmia and autism. Cell 2004; 119:19.
- Plaster NM, Tawil R, Tristani-Firouzi M, et al. Mutations in Kir2.1 cause the developmental and episodic electrical phenotypes of Andersen's syndrome. Cell 2001; 105:511.
- Mitchell JL, Cuneo BF, Etheridge SP, et al. Fetal heart rate predictors of long QT syndrome. Circulation 2012; 126:2688.
- Zipes DP, Ackerman MJ, Estes NA 3rd, et al. Task Force 7: arrhythmias. J Am Coll Cardiol 2005; 45:1354.
- Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992; 20:1391.
- Tester DJ, Dura M, Carturan E, et al. A mechanism for sudden infant death syndrome (SIDS): stress-induced leak via ryanodine receptors. Heart Rhythm 2007; 4:733.
- Nyegaard M, Overgaard MT, Søndergaard MT, et al. Mutations in calmodulin cause ventricular tachycardia and sudden cardiac death. Am J Hum Genet 2012; 91:703.
- Marsman RF, Barc J, Beekman L, et al. A mutation in CALM1 encoding calmodulin in familial idiopathic ventricular fibrillation in childhood and adolescence. J Am Coll Cardiol 2014; 63:259.
- Chenard AA, Becane HM, Tertrain F, et al. Ventricular arrhythmia in Duchenne muscular dystrophy: prevalence, significance and prognosis. Neuromuscul Disord 1993; 3:201.
- Connuck DM, Sleeper LA, Colan SD, et al. Characteristics and outcomes of cardiomyopathy in children with Duchenne or Becker muscular dystrophy: a comparative study from the Pediatric Cardiomyopathy Registry. Am Heart J 2008; 155:998.
- Spencer CT, Byrne BJ, Gewitz MH, et al. Ventricular arrhythmia in the X-linked cardiomyopathy Barth syndrome. Pediatr Cardiol 2005; 26:632.
- Miyake CY, Del Nido PJ, Alexander ME, et al. Cardiac tumors and associated arrhythmias in pediatric patients, with observations on surgical therapy for ventricular tachycardia. J Am Coll Cardiol 2011; 58:1903.
- Harris KC, Potts JE, Fournier A, et al. Right ventricular outflow tract tachycardia in children. J Pediatr 2006; 149:822.
- Davis AM, Gow RM, McCrindle BW, Hamilton RM. Clinical spectrum, therapeutic management, and follow-up of ventricular tachycardia in infants and young children. Am Heart J 1996; 131:186.
- Reynolds JL, Pickoff AS. Accelerated ventricular rhythm in children: a review and report of a case with congenital heart disease. Pediatr Cardiol 2001; 22:23.
- Van Hare GF, Stanger P. Ventricular tachycardia and accelerated ventricular rhythm presenting in the first month of life. Am J Cardiol 1991; 67:42.
- Paul T, Blaufox AT, Saul JP. Non-contact mapping and ablation of tachycardia originating in the right ventricular outflow tract. Cardiol Young 2002; 12:294.
- Ohe T, Aihara N, Kamakura S, et al. Long-term outcome of verapamil-sensitive sustained left ventricular tachycardia in patients without structural heart disease. J Am Coll Cardiol 1995; 25:54.
- Schneider HE, Kriebel T, Jung K, et al. Catheter ablation of idiopathic left and right ventricular tachycardias in the pediatric population using noncontact mapping. Heart Rhythm 2010; 7:731.
- SUPRAVENTRICULAR TACHYCARDIA
- VENTRICULAR TACHYCARDIA
- Congenital heart disease
- - Management
- Genetic disorders
- - Channelopathy
- - Cardiomyopathy
- Acquired heart disease
- Idiopathic causes
- - Accelerated ventricular rhythm
- - Right ventricular outflow tract tachycardia
- - Idiopathic left ventricular tachycardia