Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome on HCM!

I am sorry about the difficult conditions that your children and you have passed with his arrhythmia issue.

Regarding your concern, let me explain you as follows:

a- cardiac ablation in small children and infants carries a more specific area of expertise and is less frequently applied compared to all the children and adults.
During cardiac ablation, when applying radio-frequency energy are caused some myocardial lesions at around 5-6 mm diameter.

As you may understand, considering a very small cardiac structure dimensions in infants and small children, and from the other part the ablation lesions (5-6 mm), the probability for leading to complications and serious damages to the heart is higher.

Now returning to your exact question, I would explain that of course cardiac ablation could be performed at this age, but with greater risk of life and other complications.

b-Regarding complications, when a cardiac ablation is performed at this age, I would explain that the risk of death has been reported around 0.12-0.9%.
Because the body size and hence heart dimensions are quite small at this age, also the triangle of Koch (where the radio-frequency energy is applied) is small, the risk of injuring important vital cardiac structures is very high.

Complications like atrio-ventricular block, myocardial and coronary artery injuries, cardiac tamponade, hemothorax, and cardiac death may occur. When indicated, cardiac ablation should be performed at very high expertise centers in cardiology pediatric field.

c- Generally it is recommended that cardiac ablation be performed in children with a body weight greater than 15 Kg to avoid the above mentioned complications. So, the average recommended age is greater that 4-5 years old. At this age the procedure would be performed with greater success and fewer life-threatening complications.

d- Regarding the results, of cardiac ablation in children, I would explain that the success rate would be highly dependent on the level of the operator expertise. In general the success rate is very high (greater than 90-95%), but you should also know that as the child heart is rapidly growing, some tiny accessory pathways (that could be responsible for cardiac arrhythmia) would not be possible to always isolate and burn. So the possibility of relapsing cardiac arrhythmia after the first successful cardiac ablation, remains even years after the procedure, but this is an issue not rarely encountered even in adults.

e- Regarding Inderal daily dosage, I would explain that it is OK, as the daily dose ranges (2-6 mg/kg/day divided every 6-8 hours or three times daily).

It is usually well tolerated but it can also lead to some adverse effects like:

- bradycardia (low heart rate)
- Raynaud phenomena
- high potassium levels
- muscle cramps
- bronchospasms
- etc..

e- Regarding the trip, it is quite safe to travel by plane at this distance.

f- Regarding the sweating when breast feeding, the situation is more complicated. But facing the medical report, I would explain that it is necessary check:

-thyroid and parathyroid hormone levels
- vitamin D levels
- blood electrolytes levels
- arterial blood gas analysis

in order to exclude possible disorders affecting these parameters, which can cause a similar clinical scenario.

g- The normal heart rate of 6 weeks when crying should be between 70-190 bpm.

Hope to have clarified all your uncertainties!

Kind regards,

Dr. Iliri

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Brief Answer:
My opinion as follows:

Detailed Answer:
Hello again, dear XXXX!

Let me explain as follows:

1) In infants the most frequent type of PSVT is atrio-ventricular re-entry tachycardia as a result of the presence of congenital atrio-ventricular bypass tracts.

So, the disorder is of course due to genetic factors leading to over-expression of these atrio-ventricular by-pass tracts.

2) Regarding Inderal and the medical treatment in general, I would say that their efficacy has been beneficial in more than 50% of cases. What your doctor has confirmed to you is true.

Even during medical treatment, episodic PSVT may occur.

At your son’s age not rarely is difficult to promptly notice the appearance of cardiac arrhythmia, but some symptoms may be suggestive: crying, getting a pale skin, drowsiness, profound weakness, or even fainting, etc.

If PSVT occurs at home conditions, it is difficult to apply an emergent treatment, as it is dependent on an exact diagnosis (presence of arrhythmia or no), availability of drugs and a prompt venous access.

And of course of an expert opinion with the right decisions is of crucial importance.

A treatment with minimal side effects would be esmolol (with a short half-life).

Unfortunately, in cases of PSVT recurrences suspicions the best thing to do is to as medical assistance to the nearest pediatric ER service as soon as possible.

3) Triggers for PSVT recurrences may be several factors, like body fever, electrolytes imbalances, hormonal imbalances, some stimulant juices (certain teas, etc), acute inflammation/infection, etc.

4) Regarding the transformation of those abnormall accessory pathways with aging, my answer is YES! Accessory pathway may undergo degenerative processes and lose their pathological properties capable of generating and maintaining arrhythmias.

This is confirmed in many patients suffering from re-entrant arrhythmias, who have been almost free from recurrences when getting older.

5) Regarding the baby sweating a thorough medical investigation should be performed (including full thyroid hormones profile, parathyroid function, circulating catecholamines , Vitamin D level, and repeated blood electrolytes level).

Let me say that sweating during breastfeeding is normal for infants. So, you should follow further investigations only if sweating is exaggerated and constant (even out of breastfeeding).

6) I reviewed your son thyroid test. In fact it is only TSH level and no free T3 and free T4 levels, which could give a more complete information of the thyroid glands function.
Nevertheless, his TSH level is low, suggesting high T3 and T4.

It is true that during the first weeks after birth, increased hormone levels may be a reflection of the mother’s level, but this effects stays for around two week after birth.

After that, if the levels do not change, it is necessary for further clinical and laboratory investigations and a careful review by an expert in the field.

7) Let me explain that cardiac ablation is always preceded by electrophysiological study as a general rule.

The presence of arrhythmia at the moment of the procedure is not a prerequisite to confirm and fully elucidate the anatomy and mechanisms underlying the arrhythmia, because during the electrophysiological study, some provocative tests are utilized to reveal the arrhythmia occurrence even if it is not present.

8) Unfortunately, there are not any superior medical treatment compared to some others as it will depend on the mechanisms of arrhythmia and some specific health conditions (age, co-morbidities, ongoing treatment strategy, etc.).

Inderal seems to be an acceptable option as long as it appears capable of reducing the potential recurrence rate and controlling the heart rhythm. Medical follow up is the most important clue in this regard.

Hope to have been clear when mentioning each of your questions!

You can ask me directly in case of any further uncertainties.

I apologize of the delayed response. It was due to my professional commitments (prolonged hospital engagement).

Best regards,

Dr. Iliri

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Brief Answer:
I would explain:

Detailed Answer:
Hello XXXX!

I am glad you find my answer helpful!

Regarding your last questions, I would explain:

a- When discussing about potential triggering factors of PSVT, tests utilized for checking any health disorders would be as follows:

- complete blood count
- PCR and ESR for inflammation
- blood electrolyte levels
- thyroid hormone levels periodically (yearly during the first 5 years)
- blood glucose.

b- Regarding winter and PSVT, I would explain that low temperatures can stimulate the sympathetic nervous system (as a physiological reaction), thus increasing catecholamines levels (adrenaline and noradrenaline).

This can lead to increased risk of cardiac arrhythmia in susceptible persons. Staying inside the house in a warm place would avoid these possible adverse reactions.

Hope to have clarified all your uncertainties!

Regarding facebook, unfortunately I do not have an account, as my daily engagements leave me almost no space for utilizing such a wonderful social network. There are at least three other persons with the same name/family name in my country but no one of them is a doctor.

I remain at your disposal for any further medical clarifications in the future.

You can as ask me directly at any time.

Best wishes,

Dr. Iliri

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Brief Answer:
My opinion as follows:

Detailed Answer:
Hello again!

Regarding your concern, I would explain that episodic PSVT, WHEN THE EXISTING CARDIAC FUNCTION AND STRUCTURE ARE NORMAL, are well tolerated and usually not life-threatening (if they are promptly treated and interrupted as soon as possible.

Anyway, when prolonged, PSVT can lead to arterial hypotension and dangerous systemic hypoxia.

So, there is no specific period for these complications. But, I would recommend you to bring him to the hospital as soon as you notice these episodes.

I would recommend buying a pediatric pulseoxymeter (you can find it very cheap on the internet) and it can monitor his heart rate and blood oxygenation, in order to be sure that everything is OK.

To have clarified all your uncertainties!

Wishing all the best,

Dr. Iliri

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