A Case of Neonatal Atrial Flutter
Figure 1: Chest radiography outlining a large cardiac silhouette and pulmonary edema.
Telemetry outlining the atrial flutter
Back in sinus rhythm once paced.
12-lead ECG while in atrial flutter. Saw-tooth appearance may be partially observed, although often revealed when attempting adenosine - not done in this current ECG.
Back in Sinus rhythm (positive P in lead I and aVF). Signs of left atrial enlargement in lead II. Signs of LV hypertrophy.
Parasternal long axis view outlining the significant LV diltation and failure in the context of flutter. The aortic valve is seen open and close (outlining that there is some remaining ejection). The mitral valve opens and close, outlining that there is some filling.
Apical view outlining the significant LV dilation and dysfunction. There is mild to moderate mitral insufficiency by coulor.
The infant was diagnosed with neonatal atrial flutter. After administering sedation with midazolam and ketamine, we successfully restored sinus rhythm using direct current synchronized cardioversion at 0.5j/kg. The infant showed marked improvement with reduced dyspnea, particularly during feeding. However, her cardiac function had yet to fully recover. Consequently, she was treated with digoxin, an ACE inhibitor, and spironolactone to address her cardiac failure induced by prolonged tachycardia. The infant was discharged five days later, following comprehensive education provided to the caregivers about monitoring for rapid heart rates to ensure timely management.
Managing an infant or child presenting with narrow complex tachyarrhythmia is particularly challenging due to the often unidentified mechanism of the tachycardia. Direct current cardioversion stands as the highly recommended primary therapy. Following the resolution of the arrhythmia, patients typically undergo ECG and ambulatory rhythm monitoring for an additional year. Recurrences are infrequent; however, if an event recurs, a thorough evaluation for intrinsic structural, functional, or channelopathy conditions is imperative.
Neonatal atrial flutter, though uncommon, warrants prompt identification and intervention. Timely management can mitigate the risk of heart failure and shorten hospital stay durations. Importantly, parents should be educated on monitoring their infant's heart rate and identifying early symptoms of congestive heart failure.
- UptoDate, "Atrial Tachyarrhythmias in Children: Neonatal Flutter"