Differenzialdiagnose häufiger und seltener Herzrhythmusstörungen in der kinderärztlichen Praxis

Zusammenfassung

Unter Herzrhythmusstörungen werden zu schnelle, zu lang-same oder unregelmäßige Herzaktionen zusammengefasst. Die Störungen können prinzipiell überall im komplexen Erregungsbildungs- und Leitungssystem des Herzens auftreten. Bei Kindern entstehen Herzrhythmusstörungen meistens in den Vorhöfen. Tachykarde Rhythmusstörungen bei pädiatrischen Patienten zeigen meistens einen schmalen QRS-Komplex und sind nicht lebensbedrohlich, aber auch Tachykardien mit breitem QRS-Komplex, die maligne sein können, kommen bei Kindern vor. Daher sind die systematische Analyse des Oberflächen-EKGs, insbesondere die Beurteilung der Lage der P-Welle, relativ zum QRSKomplex und die Morphologie der P-Welle für die Differenzialdiagnose von entscheidender Bedeutung. Neben der Standard-(12-Kanal)-EKG-Aufzeichnung hat das LangzeitEKG über 24 Stunden eine zentrale Bedeutung für die Detektion und Beurteilung von Arrhythmien. Häufig finden sich Herzrhythmusstörungen bei ansonsten gesunden Kindern, seltener im Zusammenhang mit einer organischen Herzerkrankung oder nach Herzoperationen. Sie führen jedoch besonders bei Vorliegen einer kardialen Grunderkrankung zu relevanten Beeinträchtigungen des Kreislaufs. In diesem ersten Teil der Arbeit sollen häufige und seltene tachykarde Rhythmusstörungen, die in der kinderärztlichen Praxis vorkommen, systematisch und anhand von Beispielen dargestellt werden.

Summary

Disturbances of cardiac rhythm and conduction can lead to inappropriately fast, slow or irregular heart rates as compared to age-matched healthy children. Many arrhythmias occur in apparently healthy individuals but may also be recognized in association with other forms of heart disease such as myocarditis, cardiomyopathies, congenital heart disease or post cardiac surgery. The underlying sources for arrhythmias can occur anywhere along the conduction system of the heart. Tachyarrhythmias in children mostly have their origin in the atria or depend on accessory atrioventricular pathways resulting in mostly benign narrow QRS complex tachycardias; however, potentially malignant wide QRS complex tachycardias may also occur in pediatric patients. In order to differentiate tachycardias by means of the surface electrocardiogram, p-wave morphology and location in relation to the QRS complex are crucial factors. Analysis of surface 12-lead EKG together with 24-hours holter monitoring allows the correct identification of arrhythmias in almost all cases.

This first part of this systematic overview highlights the various types of common and uncommon tachyarrhythmias on the basis of examples from pediatric practice.

Schlüsselwörter

Herzrhythmusstörungen - Tachyarrhythmien - Elektrokardiographie

Keywords

Cardiac arrhythmias - tachycardia - electrocardiography

• Literatur

• 1 Beder SD, Gillette PC, Garson A. et al. Symptomatic sick sinus syndrome in children and adolescents as the only manifestation of cardiac abnormality or associated with unoperated congenital heart disease. Am J Cardiol 1983; 51: 1133-1136.
• 2 Brugada J, Brugada P. Further characterization of the syndrome of right bundle branch block, ST segment elevation, and sudden cardiac death. J Cardiovasc Electrophysiol 1997; 8: 325-331.
• 3 Casta A, Wolff GS, Mehta AV. et al. Dual atrioventricular nodal pathways: A benign finding in arrhythmia-free children with heart disease. Am J Cardiol 1980; 46: 1013-1018.
• 4 Chen SA, Chiang CE, Yang CJ. et al. Sustained atrial tachycardia in adult patients. Circulation 1994; 90: 1262-1278.
• 5 Crosson JE, Hesslein PS, Thilenius OG. et al. AV node reentrant tachycardia in infants. Pacing Clin Electrophysiol 1995; 18: 2144-2149.
• 6 Ellison KE, Friedman PL, Ganz LI. et al. Entrainment mapping and radiofrequence catheter ablation of ventricular tachycardia in right ventricular dysplasia. J Am Coll Cardiol 1998; 32: 724-728.
• 7 Fontaine G, Fontaliran F, Hebert JL. et al. Arrhythmogenic right ventricular dysplasia. Ann Rev Med 1999; 50: 17-35.
• 8 Fujiki A, Usui M, Nagasawa H. et al. ST segment elevation in the right precordial leads with class IC antiarrhythmic drugs: insight into the mechanism of Brugada syndrome. J Cardiovasc Electrophysiol 1999; 10: 214-218.
• 9 Garson A, Gillette PC. Junctional ectopia tachycardia in children: electrocardiography, electro-physiology, and pharmacologic response. Am J Cardiol 1979; 44: 298-302.
• 10 Garson A, Smith RT, Moak JP. et al. Atrial automatic tachycardia in children. In: Touboul P, Waldo AL. (eds). Atrial arrhythmias: current concepts and management. St.Louis: Mosby; 1990: 282-287.
• 11 Gewellig M, Wyse RK, de Leval MR. et al. Early and late arrhythmias after the Fontan operation: predisposing factors and clinical consequences. Br Heart J 1992; 67: 72-79.
• 12 Gussak I, Antzelevitch C, Bjerregaard P. et al. The Brugada syndrome: clinical, electrophysiologic and genetic aspects. J Am Coll Cardiol 1999; 33: 5-15.
• 13 Gutheil H. Sinusarrhythmie. In: Gutheil H. (ed). EKG im Kindes- und Jugendalter. Indikationen, Interpretationen, klinische Konsequenzen. Stuttgart: Georg Thieme Verlag; 1998: 198-199.
• 14 Jacquet L, Galal Z, Stein K. et al. Cardiac rhythm disturbances early after orthotopic heart transplantation: prevalence and clinical importance of the observed abnormalities. J Am Coll Cardiol 1990; 16: 832-837.
• 15 Kaplan BM, Langendorf R, Lev M. et al. Tachycardia-bradycardia syndrome (so-called sick sinus syndrome“). Am J Cardiol 1973; 31: 497-508.
• 16 Ko JK, Deal BJ, Strasburger JF. et al. Supraventricular tachycardia mechanisms and their age distribution in pediatric patients. J Am Coll Cardiol 1992; 69: 1028-1032.
• 17 Ouyang F, Cappato R, Ernst S. et al. Electroanatomic substrate of idiopathic left ventricular tachycardia: unidirectional block and macroreentry within the purkinje network. Circulation 2002; 105: 462-469.
• 18 Page PL, Dandan N, Savard P. et al. Regional distribution of atrial electrical changes induced by stimulation of extracardiac and intracardiac neural elements. J Thorac Cardiovasc Surg 1995; 109: 377-388.
• 19 Ruder MA, Davis JC, Eldar M. et al. Clinical and electrophysiologic characterization of automatic junctional tachycardia in adults. Circulation 1986; 73: 930-937.
• 20 Silka MJ, Kron J, Halperin BD. et al. Mechanisms of AV node reentrant tachycardia in young patients with and without dual AV node physiology. Pacing Clin Electrophysiol 1994; 17: 2129-2133.
• 21 Schwartz PJ, Malliani A. Electrical alternation of the T-wave: clinical and experimental evidence of its relationship with the sympathetic nervous system and with the long QT syndrome. Am Heart J 1975; 89: 45-50.
• 22 Schwartz PJ. Idiopathic long QT syndrome. Progress and questions. Am Heart J 1985; 109: 399-411.
• 23 Schwartz PJ, Zaza A, Locati E. et al. Stress and sudden death. The case of the long QT syndrome. Circulation 1991; 83: II71-II80.
• 24 Thapar MK, Gillette PC. Dual atrioventricular nodal pathways: a common electrophysiologic response in children. Circulation 1979; 60: 1369-1374.
• 25 Tracy CM, Swartz JE, Fletcher RD. et al. Radiofrequency catheter ablation of ectopic atrial tachycardia using paced activation sequence mapping. J Am Coll Cardiol 1993; 21: 910-917.
• 26 Walsh EP. Ablation of ectopic atrial tachycardia in children. In: Huang SKS, Wilber DJ. (eds). Radio-frequency catheter ablation of cardiac arrhythmias, 2. ed. Armonk, NY: Futura; 2000: 115-138.
• 27 Yabek SM, Dillon T, Berman W. et al. Symptomatic sinus node dysfunction in children without structural heart disease. Pediatrics 1982; 69: 590-593.