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  • • Treatment of supraventricular tachycardia (SVT).

    • • Life-threatening arrhythmia unresponsive to medications.

      • Younger children with arrhythmia refractory to antiarrhythmic medications.

      • Older children with recurrent SVT.

      • Older children with SVT associated with preexcitation.

    • Treatment of ventricular tachycardia.

    • • Younger children with life-threatening ventricular tachycardia refractory to medications.

      • Older children with recurrent ventricular tachycardia refractory to medications.

      • Older children with recurrent ventricular tachycardia who are unable to tolerate medications due to side effects, or who choose to have procedure.

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Absolute

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  • • Lack of vascular access.

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Relative

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  • • Infants with arrhythmia controlled by medications.

    • Patients with multiorgan system disease.

    • Patients with hemodynamic instability unable to tolerate procedure or anesthesia.

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  • • Cardiac catheterization laboratory.

    • Biplane fluoroscopy.

    • Monitoring for continuous heart rate, blood pressure, oxygen saturation.

    • Respiratory monitoring and support.

    • Vascular access.

    • Anesthesia.

    • Resuscitation equipment, including medications and cardiac defibrillator.

    • Electrode catheters, ablation catheters, energy delivery generator.

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• Risks are higher for small children (< 12–15 kg); lesion growth occurs in the immature heart.
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  • • Hemodynamically unstable arrhythmias.

    • Bleeding.

    • Infection.

    • Vascular injury, including coronary artery damage.

    • Pneumothorax.

    • Cardiac perforation.

    • Thromboembolism.

    • Stroke.

    • Radiation exposure.

    • Cardiac valve injury.

    • Conduction system injury, including complete heart block; may necessitate implantation of permanent pacemaker.

    • Risk of injuring the normal conduction system is highest for right septal ablation sites.

    • Cardiac arrest.

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  • • Not all arrhythmias are amenable to catheter ablation.

    • Highest success rates are for SVT due to accessory connections or for atrioventricular nodal reentry tachycardia.

    • Automatic atrial tachycardias, especially due to a single automatic focus, are amenable to ablation, with slightly lower success rates than above.

    • Ablation of ventricular tachycardias: Lower success rate than SVT.

    • Primary electrical disorders, such as long QT syndrome, are not amenable to catheter ablation.

    • Availability of noncontact mapping systems and “global positioning” systems reduces fluoroscopy time.

    • Neonatal SVT often improves substantially during first 18 months of life and frequently recurs later, such as ages 5–8 and 10–13 years.

    • Delaying intervention until child is older and larger may be indicated.

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  • • Patient should not have any oral intake for at least 4 hours before the study.

    • Antiarrhythmic medications are generally withdrawn for at least 5 half-lives prior to ablation.

    • Sedation is administered; general anesthesia is often preferred for lengthy procedures or for younger patients.

    • Intravenous access is necessary, usually femoral venous, often bilaterally and multiple, in addition to internal jugular or subclavian venous access.

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  • • Supine, with protection of airway.

    • Arms are positioned at sides for long procedures, to avoid potential brachial plexus injury.

    • Adequate padding to avoid pressure injury is needed for extremities and head.

    • Shielding of gonads from radiation is necessary.

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  • Accessory connections...

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