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Background: Axillary implant location is an alternative implant location in patients for cardiac implantable electronic devices (CIEDs) for the purposes of improved cosmetic outcome. The impact from the patient's perspective is unknown. The purpose of this study was to compare scar perception scores and quality of life (QOL) in pediatric patients with axillary CIED implant location versus the standard infraclavicular approach., Methods: This is a multicenter prospective study conducted at eight pediatric centers and it includes patients aged from 8 to 18 years with a CIED. Patients with prior sternotomy were excluded. Scar perception and QOL outcomes were compared between the infraclavicular and axillary implant locations., Results: A total of 141 patients (83 implantable cardioverter defibrillator [ICD]/58 pacemakers) were included, 55 with an axillary device and 86 with an infraclavicular device. Patients with an ICD in the axillary position had better perception of scar appearance and consciousness. Patients in the axillary group reported, on average, a total Pediatric QOL Inventory score that was 6 (1, 11) units higher than the infraclavicular group, after adjusting for sex and race (P = 0.02)., Conclusions: QOL is significantly improved in axillary in comparison to the infraclavicular CIED position, regardless of device type. Scar perception is improved in patients with ICD in the axillary position., (© 2018 Wiley Periodicals, Inc.)

Background: Studies in adults suggest that after entrainment from the right ventricle, a post-pacing interval (PPI) minus tachycardia cycle length (TCL), when corrected for atrioventricular node delay (cPPI-TCL), is useful to distinguish atrioventricular nodal reentry tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT), but this has not been evaluated in children., Methods: In 100 children undergoing catheter ablation, entrainment of ORT or AVNRT was performed from the right ventricular apex. The atrial-His (AH) interval was measured on the return cycle (post-AH) and during tachycardia just prior to pacing (pre-AH). The cPPI-TCL was calculated as (PPI-TCL) - (post-AH - pre-AH). In the first 50 children, the best cutoff was identified and then validated in the next 50 children., Results: In the first 50 children, cPPI-TCL was longer in AVNRT compared with ORT (122 +/- 19 ms vs 63 +/- 23 ms, P < 0.001). Furthermore, cPPI-TCL exceeded 95 ms in all AVNRT patients, but was less than < 95 ms in 28 of 29 ORT patients. In the next 50 children, a cPPI-TCL < 95 ms was 100% specific for ORT; a cPPI-TCL > 95 ms was 95% specific for AVNRT. There was even greater separation of cPPI-TCL values comparing AVNRT with ORT utilizing a septal accessory pathway., Conclusions: The cPPI-TCL is a useful technique to distinguish AVNRT from ORT in children. Our data suggest that in children a cPPI-TCL < 95 ms excludes AVNRT, while a value > 95 ms is rarely observed in ORT. This technique is particularly useful to distinguish AVNRT from ORT utilizing a septal accessory pathway. (PACE 2010; 469-474).

Background: Young patients with atrioventricular nodal reentry tachycardia (AVNRT) frequently do not display discrete dual AV node physiology (DAVNP) as classically defined. The purpose of the study was to investigate the prevalence of sustained slow pathway conduction (SSPC; PR > RR during atrial pacing) in young patients with AVNRT and compare it to dual atrioventricular node physiology., Methods: The presence of SSPC and DAVNP was prospectively assessed before and after radiofrequency catheter ablation in 61 young patients (age 4-23 years) with typical AVNRT., Results: Prior to ablation, 32 (52%) displayed DAVNP, while 46 (75%) displayed SSPC; 7 patients (11%) had neither marker. Patients with DAVNP were older than those without (15 +/- 3 vs 13 +/- 4, P = 0.027) and the prevalence increased with age (38% <13 years, 50% 13-15, 70% >15, P = 0.041), while SSPC showed no age predilection. Patients under 13 years displayed SSPC more commonly than DAVNP (81% vs 38%, P = 0.004). DAVNP persisted after ablation in 10/32 (31%) patients, compared to 6/46 (13%) with persistent SSPC after ablation. The ability to use loss of the marker (present before, absent after ablation) as a surrogate for successful ablation was greater for SSPC than for DAVNP (66% vs 36%, P = 0.001)., Conclusion: SSPC is more common than DAVNP in young patients with AVNRT. SSPC is eliminated more frequently than DAVNP after acutely successful ablation, and appears to be a better indicator of the substrate for AVNRT. Elimination of SSPC may serve as a useful surrogate endpoint for slow pathway ablation.

The parasternal location for the insertable loop recorder (ILR) has potential for erosion in small patients, and can be aesthetically unappealing, especially for young women. We assessed the feasibility of the inframammary location in nine patients, utilizing a 2 cm transverse incision at the inferior and medial border of the left or right breast. Signal quality was adequate with clearly discernable atrial and ventricular electrograms. No complications involving the surgical site were observed. Cosmetically, placement of the scar in the natural breast crease has been favorably accepted. Inframammary implantation of the ILR is feasible, and is the preferred method in young women and girls at our center.

Atrioventricular nodal reentry tachycardia (AVNRT) is an uncommon mechanism of supraventricular tachycardia in neonates in whom orthodromic reciprocating tachycardia (ORT) predominates. We report three patients with structurally normal hearts who presented with neonatal ORT, documented by transesophageal electrophysiology studies at 2 to 3 weeks of age. At follow-up study at 8-12 months of age, no infant had inducible ORT, suggesting spontaneous regression of congenital accessory pathways; however, each had inducible tachycardia consistent with the typical form of AVNRT. The clinical significance of this finding is unknown and warrants further study.