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Fascicular tachycardia in infancy and the use of verapamil: a case series and literature review
  1. Jascha Kehr1,
  2. Alex Binfield2,
  3. Fraser Maxwell3,
  4. Tim Hornung1,
  5. Jonathan R Skinner1,4
  1. 1Green Lane Paediatric and Congenital Cardiac Services, Starship Children’s Hospital, Auckland, New Zealand
  2. 2Department of Paediatrics, Christchurch Hospital, Christchurch, New Zealand
  3. 3Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand
  4. 4Department of Child Health, University of Auckland, Auckland, New Zealand
  1. Correspondence to Dr Jonathan R Skinner, Green Lane Paediatric and Congenital Cardiac Services, Starship Childens Hospital, Auckland 1142, New Zealand; jskinner{at}adhb.govt.nz

Abstract

Objective Guidelines state that verapamil is contraindicated in infants. This is based on reports of cardiovascular collapse and even death after rapid intravenous administration of verapamil in infants with supraventricular tachycardia (SVT). We wish to challenge this contraindication for the specific indication of verapamil sensitive ventricular tachycardia (VSVT) in infants.

Design Retrospective case series and critical literature review.

Setting Hospitals within New Zealand.

Patients We present a series of three infants/young children with VSVT or ‘fascicular VT’.

Results Three children aged between 8 days and 2 years presented with tachycardia 200–220 beats per minute with right bundle brunch block and superior axis. Adenosine failed to cardiovert and specialist review diagnosed VSVT. There were no features of cardiovascular shock. Verapamil was given as a slow infusion over 10–30 min (rather than as a push) and each successfully cardioverted without incident. Critical review of the literature reveals that cardiovascular collapses were associated with a rapid intravenous push in cardiovascularly compromised infants and/or infants given other long-acting antiarrhythmics prior to verapamil.

Conclusions Verapamil is specifically indicated for the treatment of fascicular VT, and for this indication should be used in infancy, as well as in older children, as first-line treatment or after failure of adenosine raises suspicion of the diagnosis. We outline how to distinguish this tachycardia from SVT and propose a strategy for the safe intravenous slow infusion of verapamil in children, noting that extreme caution is necessary with pre-existing ventricular dysfunction.

  • arrhythmia
  • ventricular tachycardia
  • ECG
  • infant
  • calcium channel blocker
  • safety
  • contraindication

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Footnotes

  • Contributors JK and JS conceptualised this article and drafted the initial manuscript. AB, FM and TH identified the cases presented, supplied the relevant clinical information and reviewed the article for accuracy. They also revised it critically for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The Research Governance Committee approval for this report was obtained from Auckland and Waikato District Health Boards.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Next of kin consent obtained.

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