Childrens Health

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Medical Condition

Supraventricular
tachycardia (SVT) in
children
Definition

Abnormally rapid heart rhythm originating above ventricles

HR >220bpm in infants OR >180bpm in children

Types of SVT

Two commonest forms:

1. Atrioventricular re-entrant tachycardia (AVRT)
o includes Wolff-Parkinson-White syndrome
2. Atrioventricular nodal re-entrant tachycardia (AVNRT)

Epidemiology

Commonest sustained arrhythmia in children (estimated between 1 in 250 to

1 in 25 000)
Children with congenital heart disease have increased risk
o HOWEVER majority of children with SVT have no structural cardiac
defect

Pathophysiology (explains ECG finding)

Accessory conduction pathways - i.e. in addition to His-Purkinje pathway

exist in the heart
One of the pathways has unidirectional block such that the accessory
pathway conducts electrical impulses in the opposite direction to the HisPurkinje pathway. Whether His-Purkinje pathway conducts antegrade (i.e. to
ventricles) & accessory pathway then conducts retrograde or vice-versa
determines type of SVT
o Antidromic SVT (<5%): Accessory pathway conducts antegrade first
because it has a shorter refractory period (pre-excitation). This
stimulates ventricular myocardium which then conducts impulse
retrograde through the His-Purkinje pathway
o Orthodromic SVT (most common): Accessory pathway conducts
second because it has a longer refractory period than His-Purkinje
pathway. Consequently His-Purkinje pathway conducts first and

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Medical Condition

antegrade (as normal) but this time electrical impulse travels

retrograde through accessory pathway (?to stimulate SA node more
quickly) resulting in quicker, premature atrial beat
This generates an electrical circuit though which electrical impulses can cycle
repetitively in one direction manifesting in tachycardia

Difference between AVRT & ANVRT

In AVRT, accessory pathway is located anywhere along left/right AV groove

(usually in left lateral/posterioseptal)
In ANVRT, accessory pathway is within AV node i.e. AV node has two
conducting pathways
o Faster pathway (usually more anterior in IV septum) has longer
refractory period and is therefore the one to conduct retrograde.
Slower pathway (usually more posterior in IV septum) has shorter
refractory period and is therefore the one to conduct anterograde.

Clinical features
Presentation

SVT occurs in episodes. Can be persistent in some rare forms.

o Vary wildly in duration: 1 minute to few hours.
o Abrupt onset & termination
Symptoms during episodes tend to be mild as generally they are tolerated
well:
o palpitations
o chest pain
o fatigue
o light-headedness
More severe presentations e.g. syncope <- hypotension are rare
On examination, only abnormality is tachycardia with no decompensation
(Due to symptoms being mild) commonly first presents clinically with heart
failure symptoms/signs e.g. pulmonary congestion ->
o respiratory distress/increased WOB
o tachypnoea
o cyanosis
o pallor
o cough
o irritability
o poor feeding

Natural history
As mentioned above, can lead to myocardial dysfunction -> heart failure

Natural history of AVRT

30-70% of those presenting in infancy stop requiring therapy by 1yo

Others have some recurrence later in childhood

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Medical Condition

Investigations

12-lead ECG to rule out Wolff-Parkinson-White syndrome (wide QRS complex

with delta wave)
Echocardiogram to rule out structural cardiac defects as aetiology

Management
Acute management i.e. termination of
tachycardic episode
If mild/no symptoms (haemodynamically stable), use option 1 and then option 3
if that does not work
If haemodynamically unstable i.e. one of following three:
1. hypotensive
2. signs of shock
3. decreased consciousness
Use option 2

Non-pharmacological measures

Option 1: Valsalva manoeuvre which induces vagal firing from

cardiovascular control centre
o In infants/small children this is done by putting bag of cold ice on their
face for 15-30s to stimulate their diving reflex
o Rectal stimulation using thermometer
o In older children, asking them to bear down
o Usually done by closing one's mouth, pinching one's nose shut while
pressing out as if blowing up a balloon
o Never use carotid massage or orbital pressure in children
Option 2: DC cardioversion: delivery of energy that is synchronized to the
QRS complex
o This depolarises all excitable tissue including those involved in the reentrant circuit
o This then forces a refractory period on these tissues thereby
terminating the re-entrant circuit

Pharmacological measures

Option 3: IV antiarrhythmic adenosine* (terminates >75% of episodes)

o Binds A1 receptors on surface of heart cells to slow sinus rate &
increase AV delay
o Onset of action is so rapid (within 30s of infusion)
o that it needs CONCURRENT 5mL normal saline flush to speed its
delivery to heart before it becomes metabolised
o IV Verapamil is second line but cannot be used in infants/children with
heart failure

Chronic management i.e. outside of episodes

If episodes asymptomatic & infrequent, use expectant treatment:

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Medical Condition

no medical treatment
educate parents to identify episodes and apply Valsalva manoeuvre
when they happen
If episodes symptomatic/frequent, use medications:
o First line: beta blocker* (fewest side effects of all the antiarrhythmics)
propranolol in infants
atenolol in older children
* NOT used in Wolff-Parkinson-White syndrome
o
o