Vagal Techniques for Terminating Paroxysmal Tachycardia in Children: Assessment of Clinical Electrophysiological Factors of Valsalva Test Effectiveness

Background: Vagal techniques constitute the first line of medical care for terminating paroxysmal supraventricular tachycardia in children and adults due to ease of application, relative safety and possibility of avoiding injection of antiarrhythmic drugs. Effectiveness of vagal techniques depends on the method of execution, as well as a range of clinical and electrophysiological factors, which require study and specification. Objective: Our aim was to study effectiveness of the modified Valsalva test for terminating paroxysmal tachycardia in children. Methods: Effectiveness of the Valsalva test for terminating paroxysmal tachycardia induced in the course of a transesophageal electrophysiological examination in children aged 7–18 years was studied retrospectively. Results: Data of 306 children (mean age — 13.1 ± 3.2 years) were analyzed; 130 of them (42.5%) suffered from paroxysmal AV nodal reentrant tachycardia (PAVNRT), 176 — from paroxysmal AV reentrant tachycardia involving an additional AV connection (PAVRT). Valsalva test was effective in 88 children (28.8%) — 44 children (33.8%) with PAVNRT and 44 children (25.1%) with PAVRT. In most cases, tachycardia was terminated by means of anterograde block: PAVRT — in 65.5% of the cases, PAVNRT — in 92.7% of the cases. Children with ineffective Valsalva test featured longer duration of the disorder (p = 0.035), higher rate of the initial sinus rhythm before a tachycardic paroxysm (p = 0.043) and higher rhythm rate during tachycardia (p = 0.019), as well as high level of AV node conduction (p = 0.038). Conclusion: Valsalva test terminates paroxysmal tachycardia in not more than 1/3 of children with paroxysmal AV reentrant tachycardia. Test effectiveness depends on duration of the disorder and electrophysiological characteristics of AV node conduction. Valsalva test is especially effective in the onset of tachycardic paroxysm and terminates it by means of anterograde AV node block in most cases. 

1. Белоконь НА, Кубергер МВ. Болезни сердца и сосудов у детей. М.: Медицина. 1987. Т. 2. 448 с.

2. Школьникова МА. Жизнеугрожающие аритмии у детей. М. 1999. 229 с.

3. Чирейкин ЛВ, Шубик ЮВ, Медведев ММ, Татарский БА. Чреспищеводная электрокардиография и электрокардиостимуляция. СПб.: Инкарт. 1999. 150 с.

4. Диагностика и лечение нарушений ритма сердца у детей. Учебное пособие. Под ред. МА Школьниковой, ДФ Егорова. СПб.: Человек. 2012. 432 с.

5. Клинические рекомендации по детской кардиологии и ревматологии. Под. ред. МА Школьниковой, ЕИ Алексеевой. М. 2011. 503 с.

6. Клинические рекомендации по проведению электрофизиологических исследований, катетерной абляции и применению имплантированных антиаритмических устройств. Всероссийское научное общество специалистов по клинической электрофизиологии, аритмологии и кардиостимуляции (ВНОА). 3-е изд., доп. и перераб. М.: МАКС Пресс. 2013. 596 с.

7. Brugada J, Blom N, Sarquella-BrugadaG, BlomstromLundqvist C, Deanfield J, Janousek J, Abrams D, Bauersfeld U, Brugada R, Drago F, de Groot N, Happonen JM, Hebe J, Yen Ho S, Marijon E, Paul T, Pfammatter JP, Rosenthal E. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC Arrhythmia Working group joint consensus statement. Europace. 2013;15:1337–1382.

8. Ludomirsky A, GarsonA. Supraventricular tachycardia. In: Pediatric Arrythmias: Electrophysiology and Pacing. Ed. by PC Gillette, A Garson. Philadelphia: WB Saunders. 1990. P. 380–426.

9. Кручина ТК, Васичкина ЕС, Новик ГА, Егоров ДФ. Синдром Вольфа–Паркинсона–Уайта у детей: клиника, диагностика, лечение. Педиатрическая фармакология. 2011;8 (5):49–53.

10. Кушаковский МС. Аритмии сердца. СПб.: Фолиант. 1999. 640 с.

11. Lim SH, Anantharaman V, Teo WS, Goh PP, Tan AT. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Annals of Emergency Medicine. 1998;31(1):30–35.

12. Smith G. Management of supraventricular tachycardia using the Valsalva manoeuvre: a historical review and summary of published evidence. Eur J Emerg Med. 2012;19(6):346–352.

13. Mehta S. Wafa DE, Ward AJ, Camm AJ. Relative efficacy of various physical maneuvers in the termination of junctional tachycardia. Lancet. 1988;1:1181–1185.

14. Wen ZC, Chen SA, Tai CT, Chiang C, Chiou W, Chang M. Electrophysiological mechanisms and determinants of vagal maneuvers for termination of paroxysmal supraventricular tachycardia. Circulation. 1998;98:2716–2723.

15. Тимербулатов ВМ, Тимербулатов МВ, Какаулина ЛН. О приеме Вальсальвы. Хирургия. Журнал им. НИ Пирогова. 2009;11:58–59.