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Ivabradine monotherapy in pediatric patients with focal atrial tachycardia: a single-center study

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Abstract

This study investigated the efficacy of ivabradine monotherapy in pediatric patients with focal atrial tachycardia (FAT). We prospectively enrolled 12 pediatric patients (7.5 ± 4.5 years; six girls) with FAT who were resistant to conventional antiarrhythmics and received ivabradine as monotherapy. Patients were classified as having tachycardia-induced cardiomyopathy (TIC) if they had a left ventricular ejection fraction (LVEF) of < 50% and a left ventricular end-diastolic dimension (LVDD) z-score of > 2 due to tachycardia. Oral ivabradine was initiated at 0.1 mg/kg every 12 h, increased to 0.2 mg/kg every 12 h if no restoration of stable sinus rhythm was observed after two doses, and discontinued after 48 h if neither rhythm nor heart rate control was observed. Of these patients, six (50%) had incessant atrial tachycardia, and 6 had frequent short episodes of FAT. Six patients were diagnosed with TIC, and their mean LVEF and mean LVDD z-score were 36.2 ± 8.7% (range, 27–48%) and 4.2 ± 1.7 (range, 2.2–7.3), respectively. Finally, six patients achieved either rhythm (n = 3) or heart rate control (n = 3) within 48 h of ivabradine monotherapy. One patient achieved rhythm/heart rate control with ivabradine at a dose of 0.1 mg/kg every 12 h, while the others achieved rhythm/heart rate control at a dose of 0.2 mg/kg every 12 h. Five patients received ivabradine monotherapy for chronic therapy, one (20%) of whom had FAT breakthrough 1 month after discharge, and metoprolol was added. Neither FAT recurrence nor adverse effect (with or without beta-blocker) was observed during a median follow-up of 5 months.

Conclusion: Ivabradine is well-tolerated and may provide early heart rate control in pediatric FAT and can be considered early, especially in the presence of left ventricular dysfunction. Further investigations are deserved to confirm the optimal dose and long-term efficacy in this population.

What is Known:

•  Focal atrial tachycardia (FAT) is the most common arrhythmia associated with tachycardia-induced cardiomyopathy (TIC) in children, and the efficacy of conventional antiarrhythmic medications in the treatment of FAT is poor.

•  Ivabradine is currently the only selective hyperpolarization-activated cyclic nucleotide-gated (HCN) inhibitor, which can effectively low HR without negative effect on blood pressure or inotropy.

What is New:

• Ivabradine (0.1–0.2 mg/kg every 12 h) can effectively suppress focal atrial tachycardia in 50% of pediatric patients.

•  Ivabradine provides early control of heart rate and hemodynamic stabilization in children with severe left ventricular dysfunction due to atrial tachycardia within 48 h.

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Data availability

The original data presented in this study are included in the article, further inquiries can be directed to the corresponding author.

Abbreviations

cAMP:

Cyclic adenosine monophosphate

ECG:

Electrocardiograph

ESC:

European Society of Cardiology

EPS:

Electrophysiological study

F:

Female

FAT:

Focal atrial tachycardia

HCN:

Hyperpolarization-activated cyclic nucleotide-gated

HR :

Heart rate

LVDD:

Left ventricular end-diastolic dimension

LVEF:

Left ventricular ejection fraction

M:

Male

TA:

Tricuspid annulus

TIC:

Tachycardia-induced cardiomyopathy

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Acknowledgements

We acknowledge the patients and their parents for participating in this study.

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Author notes

  1. Xinyi Xu and Ying Guo contributed equally.

Authors and Affiliations

  1. Department of Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dong Fang Road, Shanghai, 200127, China

    Xinyi Xu, Ying Guo, Wei Gao, Meirong Huang, Tingliang Liu & Fen Li

Authors
  1. Xinyi Xu
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  2. Ying Guo
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  3. Wei Gao
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  4. Meirong Huang
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  5. Tingliang Liu
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  6. Fen Li
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Contributions

The first two authors made substantial contributions to the patient enrollment and treatment. X.X. and Y.G. should be considered joint first author. T.L. and F.L. contributed to the conception, design, and manuscript revision. M.H. and W.G. collected and analyzed data. X.X. wrote the main manuscript text. All authors approved the final manuscript as submitted. Tingliang Liu provided significant contributions during the manuscript revision phase. He provided new perspectives and study materials and was responsible for most of the revision work. In view of this, we decided to list him as the co-corresponding author with thoughtful deliberation.

Corresponding authors

Correspondence to Tingliang Liu or Fen Li.

Ethics declarations

Ethics approval statement

The study protocol was approved by the Institutional Ethics Committee of Shanghai Children’s Medical Center (SCMCIRB-K2021058-1).

Patient consent statement

Before ivabradine therapy was initiated, the off-label use and potential side effects were explained in detail to the parents, and informed written consent was obtained from the guardians of each patient.

Competing interests

The authors declare that they have no conflicts of interest related.

Additional information

Communicated by Gregorio Milani.

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Xu, X., Guo, Y., Gao, W. et al. Ivabradine monotherapy in pediatric patients with focal atrial tachycardia: a single-center study. Eur J Pediatr 182, 2265–2271 (2023). https://doi.org/10.1007/s00431-023-04891-8

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  • DOI: https://doi.org/10.1007/s00431-023-04891-8

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