Submitting/Presenting Author

Tanner Isaacson

Presenter Status

Resident/Psychology Intern

Abstract Type

Research

Primary Mentor

Dr. Lindsey Malloy-Walton

Start Date

12-5-2021 12:30 PM

End Date

12-5-2021 12:45 PM

Presentation Type

Oral Presentation

Description

Background: Junctional ectopic tachycardia (JET) is one of the most common post-operative arrhythmias encountered following congenital heart surgery. For many, amiodarone is the pharmacologic treatment of choice. While effective, amiodarone has been associated with dose-related adverse effects. Sotalol has been approved for intravenous use in pediatric patients in the United States to treat both supraventricular and ventricular arrhythmias, although pediatric data remains limited. Sotalol has class III antiarrhythmic properties with some mild β-adrenergic blocking effects, similar to amiodarone. Data shows a lower rate of cardiovascular collapse and adverse events with sotalol in patients with congenital heart disease. At present, it is unclear whether IV sotalol is as safe and as effective as amiodarone in the treatment of JET.

Objectives/Goals: The purpose of this pilot study is to evaluate the safety and efficacy of IV sotalol in comparison to IV amiodarone in postoperative patients with confirmed junctional ectopic tachycardia.

Methods: IRB approval was obtained for this pilot randomized prospective study. The most at-risk patients were preoperatively consented and randomized at the onset of JET. Patients were monitored for clinical changes and severe side effects. Efficacy was determined by successful termination of the rhythm, adequate rate control, effective use of AAI/DDD pacing, time to rate control/termination, and recurrence of JET.

Results: Since September 2019, 120 patients were eligible for enrollment and 72 patients consented. During the study period, 8 patients developed postoperative JET, 5 of which consented for the trial. Of these 5 patients (age 6-152 days, average weight 4.23kg), 3 were randomized to sotalol and 2 to amiodarone. Normal cardiac function (EF>55%) by echocardiography was seen prior to drug administration in all patients. All 5 patients in the study achieved adequate rate/rhythm control. Those that received sotalol required ≤ 2 boluses (1mg/kg over an hour) for control. Of the two patients that received amiodarone, the first required 2 boluses (5mg/kg) and nearly 72 hours of an infusion (5-10 mg/kg/day) to maintain control. The second was very difficult to control, receiving 10 boluses (3-5 mg/kg) and an infusion (5-10 mg/kg/day) for 7 days to maintain control. One patient in the sotalol arm had QTc prolongation > 465msec (from 447msec to 496msec) but this did not require early termination of the medication. No significant adverse effects occurred in either group that were attributed to the antiarrhythmic medication.

Conclusions: We have a very low incidence of postoperative JET at our institution. Thus far, both medications have achieved rate/rhythm control with no significant adverse events. Our data shows that the patients who have been randomized to amiodarone have required much longer treatment courses, directly prolonging length of ICU stay, however our study is insufficiently powered to make a definitive conclusion. More data is needed to determine if IV sotalol is as safe and as effective as IV amiodarone in achieving rate and/or rhythm control in patients with postoperative JET.

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May 12th, 12:30 PM May 12th, 12:45 PM

IV amiodarone vs IV sotalol use in postoperative junctional ectopic tachycardia (JET): A randomized study

Background: Junctional ectopic tachycardia (JET) is one of the most common post-operative arrhythmias encountered following congenital heart surgery. For many, amiodarone is the pharmacologic treatment of choice. While effective, amiodarone has been associated with dose-related adverse effects. Sotalol has been approved for intravenous use in pediatric patients in the United States to treat both supraventricular and ventricular arrhythmias, although pediatric data remains limited. Sotalol has class III antiarrhythmic properties with some mild β-adrenergic blocking effects, similar to amiodarone. Data shows a lower rate of cardiovascular collapse and adverse events with sotalol in patients with congenital heart disease. At present, it is unclear whether IV sotalol is as safe and as effective as amiodarone in the treatment of JET.

Objectives/Goals: The purpose of this pilot study is to evaluate the safety and efficacy of IV sotalol in comparison to IV amiodarone in postoperative patients with confirmed junctional ectopic tachycardia.

Methods: IRB approval was obtained for this pilot randomized prospective study. The most at-risk patients were preoperatively consented and randomized at the onset of JET. Patients were monitored for clinical changes and severe side effects. Efficacy was determined by successful termination of the rhythm, adequate rate control, effective use of AAI/DDD pacing, time to rate control/termination, and recurrence of JET.

Results: Since September 2019, 120 patients were eligible for enrollment and 72 patients consented. During the study period, 8 patients developed postoperative JET, 5 of which consented for the trial. Of these 5 patients (age 6-152 days, average weight 4.23kg), 3 were randomized to sotalol and 2 to amiodarone. Normal cardiac function (EF>55%) by echocardiography was seen prior to drug administration in all patients. All 5 patients in the study achieved adequate rate/rhythm control. Those that received sotalol required ≤ 2 boluses (1mg/kg over an hour) for control. Of the two patients that received amiodarone, the first required 2 boluses (5mg/kg) and nearly 72 hours of an infusion (5-10 mg/kg/day) to maintain control. The second was very difficult to control, receiving 10 boluses (3-5 mg/kg) and an infusion (5-10 mg/kg/day) for 7 days to maintain control. One patient in the sotalol arm had QTc prolongation > 465msec (from 447msec to 496msec) but this did not require early termination of the medication. No significant adverse effects occurred in either group that were attributed to the antiarrhythmic medication.

Conclusions: We have a very low incidence of postoperative JET at our institution. Thus far, both medications have achieved rate/rhythm control with no significant adverse events. Our data shows that the patients who have been randomized to amiodarone have required much longer treatment courses, directly prolonging length of ICU stay, however our study is insufficiently powered to make a definitive conclusion. More data is needed to determine if IV sotalol is as safe and as effective as IV amiodarone in achieving rate and/or rhythm control in patients with postoperative JET.