Medtronic Presents: Treating Life-Threatening Heart Rhythms in Y

Last Editorial Review: 10/23/2003

WebMD Live Events Transcript

Event Date: 10/23/2000

Do you know a child or young adult with life-threatening heart rhythms? How are doctors getting the hearts of these children back on pace? Gerald Serwer and Peter Fischbach will answer your questions about treating these special heart patients.

The opinions expressed herein are those of the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live Events. Our guests today are pediatric cardiologists Gerald A. Serwer, MD, and Peter S. Fischbach, MD, of the University of Michigan Congenital Heart Center. We will be discussing how doctors treat children and young adults with abnormal, life-threatening heart rhythms. This event is sponsored by Medtronic. Medtronic has had no influence on the selection of the guest or the content presented in this event. The views expressed by the speaker during this event are those of the speaker and do not necessarily represent the opinions of the sponsor. It is a pleasure having you both here today. Before we begin taking questions, would each of you tell everyone a little bit about your background and area of expertise?

Dr. Gerald Serwer: My area of interest and expertise has been in pediatric pacing and device therapy for abnormal heart rhythms. I have been involved with the evaluation and development of treatments for both abnormally fast and abnormally slow cardiac rhythms. I am also the director of the Midwest Pediatric Pacemaker Registry.

Dr. Peter Fischbach: I'm also interested in treating abnormal heart rhythms in children, and particularly in children with heart disease. I am involved in treating patients with abnormally slow and fast rhythms using pacemakers and defibrillators.

Moderator: We have several questions from members today, so lets begin.

Moderator: MJ_Monell asks: "What is the latest on genetic testing for long Q-T syndrome? My background includes three children: an 11-month-old, a 4-year-old, and 6-year-old. My mother died in 1991 at age 44, and her father died at age 25, both of sudden cardiac death. In 1992, my sister, then age 16, had a cardiac arrest and had her device put in. Also in 1992, I had my device put in at that time, with no episodes. My first shock was in 1994, four days after the birth of my second child."

Dr. Peter Fischbach: Long Q-T syndrome is a genetic disease that's passed on between family members. It's a disease of how the heart generates a heartbeat. It can lead to arrhythmias that are fatal. There has been a huge increase in the knowledge of treating and diagnosing this over the last decade. It becomes much easier when a single member of the family has been diagnosed. Their genetic code can be used to diagnose other family members. Currently, it is a long and difficult process to complete genetic testing and families can expect a two year wait to receive a confirmatory test. About 50% can expect it.

Moderator: Member Mike asks: "Recently, my 8-year-old son has begun to have episodes of SVT (supraventricular tachycardia) at about 200 to 240 bpm (beats per minute). He has had about eight episodes now over three months. He has no other medical history at all, and there is none in the family to speak of. During the attacks, which last about a half-hour, he does not get dizzy, nauseated or lethargic. He seems to be wide awake and doing OK, but he is obviously having tachycardia. A number of these attacks happened while playing sports, but at least one or two of the earliest happened without exertion. He has been seen in the emergency department three times now, and each time he is back to 110 to 120 bpm on arrival. He had a normal echocardiogram about a week ago. He was to see the pediatric cardiologist on Wednesday, but the doctor had a conflict and cancelled. He is rescheduled for this Tuesday. His pediatrician told us not to do anything to try to slow his rate in an unmonitored setting (no coughing, no ice on the face, and no bearing down because he was afraid of cardiac arrest). Can you tell me what to expect next in the normal course of the diagnosis and treatment of this? Are there drugs or other therapies that can be used to try to get a handle on this? Thanks!"

Dr. Peter Fischbach: SVT in children is not uncommon. It usually occurs in children whose hearts are otherwise normal. When you have a small number of episodes and they are not associated with problems, such as this situation where the child feels fine, most people would: 1) make certain of the diagnosis -- that this really is SVT; 2) proceed to treat with certain maneuvers if they work; or 3) drug therapy if those don't work. If the number does not decrease and they are not controlled with drugs, then other forms of therapy might be considered, such as radio frequency ablation techniques. Many times, the episodes will go away without specific therapy; sometimes they do not. Hopefully, they can be easily controlled with nothing more than vagal maneuvers or simple medications. If not, other techniques are available. Based on the age of the onset of your son's SVT, it is approximately 70 to 80% likely that this will be an ongoing problem. There is no definitive indication currently for radio frequency ablation in the pediatric population, but it is becoming first-line treatment in many centers. If your son has a normal EKG (electrocardiogram) at rest, the likelihood of anything bad happening is extremely low, even in the absence of therapy.

Moderator: Kerry asks: "I am a 23-year-old woman with SVT. I take atenolol daily. Are there any alternatives to taking this medication? Do I need to have the new valve obliteration procedure prior to becoming pregnant? Thank you very much!"

Dr. Peter Fischbach: There are alternatives. The first is radio frequency ablation, which is a curative procedure, meaning that if the procedure is successful (which it is in the majority of cases) there is no need for further medication. This may be a good idea prior to pregnancy, as the hormonal changes during pregnancy may induce an increased number of tachycardic episodes. Additionally, medications used to treat arrhythmias may have adverse effects during pregnancy.

Moderator: Beckster3 asks:, "My son has arrhythmias and has used propranolol in the past for it. My son also has ADHD (attention-deficit/hyperactivity disorder). He is on Ritalin (methylphenidate) for that. His arrhythmia problems began about the same time as the diagnosis and treatment of his ADHD. Could this be related? We have had numerous echocardiograms, all with normal results. Still, we have an episode about once a year where we are taking him to the emergency room or doctor's office because his attack is so severe he has actually skipped heartbeats. Any suggestions or recommendations for me?"

Dr. Gerald Serwer: Generally there is no connection between ADHD and abnormal heart rhythms. However, in some people, the medication used to treat ADHD can exacerbate abnormal rhythms and so one can see the two problems together. The decision about whether to continue medications for ADHD really depends on how severe the abnormal rhythms are and how much benefit the child is receiving from the ADHD drug. There often is no relationship, but there can be, depending on the individual child.

Moderator: Bogie8 asks: "My daughter had three heart surgeries at age 21 to correct electrical impulse problems for very rapid heartbeat (Wolff-Parkinson-White syndrome, I believe). At age 24, she is still having problems severe enough to keep her home from work. Symptoms include dizziness, seeing spots, nausea, racing-pounding heartbeat and pain on left side. Where does she go from here? Will this cause problems when she wants to have children?"

Dr. Peter Fischbach: Wolff-Parkinson-White syndrome involves an abnormal connection between the top and bottom of the heart that allows a short circuit to arise. Radio frequency ablation is a procedure that tries to interrupt this extra nerve and break the short circuit. There are times when this is unsuccessful. As a rule, the procedure has been found to be about 90% effective. This can be repeated if it is not successful with the first procedure. If your daughter continues to have SVT that is thought to be supported by this extra nerve, she should be amenable to radio frequency ablation, but it sounds as if she has had several attempts. As things have changed over the last several years, the technology has improved. We are much better now than we were in 1997 and our success rates are higher. If your daughter remains symptomatic at this time, I would imagine her symptoms will worsen during pregnancy. Therefore, it may be advisable to try and have this condition corrected prior to becoming pregnant.

Dr. Gerald Serwer: I certainly agree that radio frequency ablation in this situation should be the first line of treatment. If, however, it is unsuccessful, then potentially medication or even in some situations, special pacemakers have been used to treat this. They are not curative, but they may control the situation and stop the rapid heart rate episodes, if for some reason the radio frequency ablation is unsuccessful.

Moderator: Chris asks: "I am 32 and have ARVD (arrhythmogenic right ventricular dysplasia) and gave birth to a healthy girl nine months ago. I also have an ICD (implantable cardioverter defibrillator). When and how should I test my daughter and are there any signs that I should watch for to indicate any heart problems with her?"

Dr. Gerald Serwer: ARVD is a condition where the right ventricle or right pumping chamber of the heart is abnormal and causes very rapid heart rates to occur that can be life-threatening. As the questioner has said, this is often treated with the placement of an implantable cardioverter defibrillator to safeguard the patient. This condition can sometimes be detected with noninvasive testing either with echocardiography or MRI (magnetic resonance imaging). The difficulty is that it may not be apparent for many years and may not necessarily affect every generation. I would recommend that your daughter be evaluated for this condition, but remember that the test may not be conclusive at such a young age.

Dr. Peter Fischbach: The good news is that ARVD rarely affects young children. There is a great deal of active research investigating the mechanisms behind ARVD and the genetic passing of this disease. I am hopeful that by the time your child is 10 years old, we will know much more about the disease and have much better testing to see if they are affected.

Moderator: Member asks: "Does a child or young adult usually receive the same therapy options that are available to an older adult with a similar diagnosis?"

Dr. Gerald Serwer: Children and adults often have similar, yet very different problems. Initially, many problems that affect children are seen in adults, but the causes are different. In addition, the child's lifestyle may be very different, and therefore, therapies for what would appear to be the same problem may be very different. We still use the same pacemakers and defibrillators in children and adults, but the way they are set and even the way they are implanted is very different. The major concern is that children need to be treated appropriately, because they have different disease processes than the adult. Even a child with a pacemaker does not require it to be programmed the way that an adult's would, so the therapy has to be specific for the child and the child's problems, not like the adult.

Moderator: Blue asks: "My teenager was told he had bigeminy during a sports physical. What is bigeminy and should we worry?"

Dr. Peter Fischbach: Bigeminy is an extra ventricular beat following a normal heartbeat in a patterned fashion. This is normally benign. In the absence of any abnormal examination or other findings of heart disease, it's a benign finding, meaning it presents no risk to your teenager and he or she should be able to participate in sports.

Moderator: Sandra asks: "Is there any new research within last three years that leads you to believe a cure is in the near future for people with polymorphic ventricular tachycardia (PVT)?"


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Dr. Gerald Serwer: Polymorphic ventricular tachycardia is truly not a disease itself. It is a symptom. It can be caused by a large number of diseases. Because of this, it's very difficult to know in any one person what caused it. Because of this, it's hard to predict whether there will be cures in the future, but there may. We have come a long way in the last 10 years and we are treating diseases now that we could not 10 years ago. So it really depends on what is causing the PVT as to whether or not there will be a cure.

Moderator: Member asks: "What can a parent do to help a teenager who needs a pacemaker or ICD? There are so many 'lifestyle' issues!"

Dr. Gerald Serwer: There is no question that having a pacemaker or an ICD is going to alter a teenager's lifestyle. The goal would be to limit the changes as much as is possible, to make their lifestyle only as different as is absolutely necessary. In addition, it's often very helpful to have them talk to other teenagers who have similar devices. Oftentimes, your doctor can arrange this. For a parent to say "I know how you feel" is bad, because unless the parent has a device, they don't know. But other teenagers with similar devices do. We sponsor each year a support group meeting for young patients with ICDs to address these issues. Should one ignore the fact there's a pacemaker? No, you can't. But one should attempt to limit the changes in their life as much as possible with their doctor's advice.

Moderator: How does your treatment of children and young adults differ from that of adults?

Dr. Peter Fischbach: When treating children and young adults, many factors have to be weighed into the decision-making process. Lifestyles are very different between a 5-year-old and a 55-year-old, which impacts therapy choices. Additionally, the decision to treat a patient with an implanted device subjects the patient to long-term therapy. This is also very different if your life expectancy is seven years vs. 70 years. Also, the ability to provide devices to smaller patients involves more invasive procedures than in a large patient. We therefore tend, in many cases, to be much more aggressive with medical management prior to invoking ablation therapy in children than we would in an adult.

Moderator: Member asks: "I am 21 years old and experienced syncope at work in July 2000. I have undergone test after test. I had the Holter monitor and had the event monitor for 30 days with about 13 episodes of sudden tachycardia, dizziness, sweating, and chest pains and they say nothing to my doctors. They have diagnosed me with mitral valve prolapse (MVP), but say it has nothing to do with that. I have been going through this since July of 2000. It is currently October 2000. I am worried I am going to experience syncope when there is no help or die at a young age with a heart condition that just needed the right the doctor. Maybe then I could get some help. Please respond. -- Signed, Tachy and Frustrated at 21"

Dr. Peter Fischbach: Syncope is fainting. There are many causes of fainting. Only a few of which are related to your heart. Most people who have syncope events, or fainting, do so for reasons unrelated to the heart and most conditions are not associated with a catastrophic event. It sounds like you have had the appropriate tests done. If all of these tests have been normal, then I would hope that your risk would be low. The most important thing is that you have confidence in the doctors that you have seen and feel comfortable with their explanations.

Moderator: We are almost out of time, Dr. Fischbach. Do you have any final comments for our members today?

Dr. Peter Fischbach: This is a very exciting time in the treatment of young patients with abnormal heart rhythms. The understanding of these arrhythmias and our ability to treat them has expanded at a rapid pace. We are now able to offer therapies, including curative therapies, to patients with abnormally fast and slow heart rhythms. This knowledge base continues to expand at an exponential rate and the prospects for treating inherited diseases is increasing.

Moderator: Dr. Serwer, you get the final word today.

Dr. Gerald Serwer: In the past, it was often frustrating that pacemaker therapy in children was dictated by the needs of the adult population. But, as pointed out by the questioners, children have special needs and requirements. It is encouraging that these needs are being recognized and addressed by the manufacturers and it's been very encouraging to see advancements aimed at children and young adults. I'm encouraged also that the future for children looks quite good and hopefully these advances will allow them to lead normal lives with normal life expectancies.

Moderator: We have so many questions left, but we are out of time. Our thanks to our guests, pediatric cardiologists Gerald A. Serwer, MD, and Peter S. Fischbach, MD, of the University of Michigan Congenital Heart Center.

Dr. Gerald Serwer: Thank you!

Dr. Peter Fischbach: Thank you!

Moderator: For more information, please visit the Medtronic Heart Rhythm Resource Center and the Medtronic Sudden Heart Attack Resource Center, both on . Also, visit the University of Michigan Congenital Heart Center's web site at: Thank you for joining us today. Be well and goodbye.

This event was brought to you by Medtronic.

The opinions expressed herein are those of the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

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