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Absolute or relative bradycardias or tachycardias

Chemical cardioversion in patients not tolerating rate control, or not responding to DC cardioversion. Consider risks/benefits of need for cardioversion. Up to 50-60% will spontaneously revert to sinus rhythm. Drugs to consider for chemical cardioversion are IV procainamide, amiodarone, ibutilide, and sotalol. Increased electrolyte imbalance predisposes to drug-induced proarrhythmias.

Potentially reversible causes for SVT perioperatively

1. Myocardial ischemia

2. Acidosis

3. Hypotension or hemodynamic instability

4. Hypoxia

5. Hypercarbia

6. Electrolyte disturbances (magnesium, potassium, calcium)

7. Anesthetic factors – increased sympathetic stimulation

8. Pharmacologic/ proarrhythmic drugs

Do I need to treat?

Factors to consider:

(i) Hemodynamic stability

(ii) Evidence of myocardial ischemia?

(iii) Evidence of heart failure as a result of the arrhythmia?

(iv) Presence of symptoms

(v) Duration of SVT (>24-48 hours)

Timing

AF often occurs between 2 and 4 days post-op, with a peak incidence at day 2.

Special considerations for patients with orthotopic cardiac transplants

AF and AFlutter are associated with acute graft rejection and transplant vasculopathy, but can also occur in the early (1-6 days) postoperative period. The occurrence of persistent or paroxysmal SVT in patients with cardiac transplants should warrant urgent transplant specialist assessment, specifically evaluating the patient for evidence of acute graft rejection or transplant vasculopathy (echocardiogram, right ventricular endomyocardial biopsy, coronary angiogram).

Special considerations for patients with congenital heart disease

SVT s in this situation are often due to, or associated with, hemodynamic deterioration (shunts, right ventricular dysfunction, valvular dysfunction) and require urgent specialist assessment. The use of antiarrhythmics with less hypotensive side effect profiles is recommended (ie, avoid IV beta-blockers, calcium channel blockers, where possible).