Research Article|Articles in Press

Clinical risk prediction score for post-operative accelerated junctional rhythm and junctional ectopic tachycardia in children with congenital heart disease



      Accelerated junctional rhythm (AJR) and Junctional ectopic tachycardia (JET) are common post-operative arrhythmias associated with morbidity/mortality. Studies suggest that pre- or intra-operative treatment may improve outcomes, but patient selection remains a challenge.


      Our objective was to describe contemporary outcomes of post-operative AJR/JET and develop a risk-prediction score to identify patients at highest risk.


      Retrospective cohort study of children 0-18 years undergoing cardiac surgery (2011-2018). AJR was defined as usual complex tachycardia with ≥1:1 ventricular-atrial association and junctional rate >25th percentile of sinus rate for age but < 170 bpm while JET was defined as a rate >170 bpm. A risk prediction score was developed using random forest analysis and logistic regression.


      From 6364 surgeries, AJR occurred in 215 (3.4%) and JET in 59 (0.9%). Age, heterotaxy syndrome, aortic cross-clamp time, ventricular septal defect closure and atrio-ventricular canal repair were independent predictors of AJR/JET on multivariate analysis and included in the risk prediction score. The model accurately predicted the risk of AJR/JET with a C-index of 0.72 [95% CI 0.70, 0.75]. Post-operative AJR and JET was associated with prolonged ICU and hospital length of stay, but not with early mortality.


      We describe a novel risk prediction score to estimate the risk of post-operative AJR/JET permitting early identification of at-risk patients who may benefit from prophylactic treatment.



      CHD (Congenital heart disease), AJR (Accelerated junctional rhythm), JET (Junctional ectopic tachycardia), CPB (Cardio-pulmonary bypass), ECMO (Extracorporeal membrane oxygenation), VSD (Ventricular septal defect), AVC (Atrioventricular canal), TOF (Tetralogy of Fallot), CC (Cross-clamp)
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        • Mildh L
        • Hiippala A
        • Rautiainen P
        • Pettilä V
        • Sairanen H
        • Happonen JM
        Junctional ectopic tachycardia after surgery for congenital heart disease: incidence, risk factors and outcome.
        Eur J Cardiothorac Surg. 2011 Jan; 39: 75-80
        • Andreasen JB
        • Johnsen SP
        • Ravn HB
        Junctional ectopic tachycardia after surgery for congenital heart disease in children.
        Intensive Care Med. 2008; 34: 895-902
        • Haas NA
        • Plumpton K
        • Justo R
        • Jalali H
        • Pohlner P
        Postoperative junctional ectopic tachycardia (JET).
        Z Kardiol. 2004; 93: 371-380
      1. Paech C, Da¨hnert I, Kostelka M, Mende M, Gebauer R. Association of temporary complete AV block and junctional ectopic tachycardia after surgery for congenital heart disease. Ann Pediatr Cardiol. 2015;8(1): 14-19

        • Dodge-Khatami A
        • Miller OI
        • Anderson RH
        • et al.
        Surgical substrates of postoperative junctional ectopic tachycardia in congenital heart defects.
        J Thorac Cardiovasc Surg. 2002; 123: 624-630
        • Gillette PC
        Diagnosis and management of postoperative junctional ectopic tachycardia.
        Am J Heart. 1989; 118: 192-194
        • Erickson SJ
        Guidelines for the management of junctional ectopic tachycardia following cardiac surgery in children.
        Current Paediatrics. 2006; 16: 275-278
        • Batra AS
        • Mohari N
        Junctional ectopic tachycardia: current strategies for diagnosis and management.
        Prog Pediatr Cardiol. 2013; 35: 49-54
        • El Amrousy DM
        • Elshmaa NS
        • El-Kashlan M
        • Hassan S
        • Elsanosy M
        • Hablas N
        • et al.
        Efficacy of Prophylactic Dexmedetomidine in Preventing Postoperative Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery.
        J Am Heart Assoc. 2017; 6e004780
        • He D
        • Sznycer-Taub N
        • Cheng Y
        • McCarter R
        • Jonas RA
        • Hanumanthaiah S
        Magnesium Lowers the Incidence of Postoperative Junctional Ectopic Tachycardia in Congenital Heart Surgical Patients: Is There a Relationship to Surgical Procedure Complexity?.
        Pediatr Cardiol. 2015 Aug; 36: 1179-1185
        • El Amrousy D
        • Elshehaby W
        • El Feky W
        • Elshmaa N
        Safety and Efficacy of Prophylactic Amiodarone in Preventing Early Junctional Ectopic Tachycardia (JET) in Children After Cardiac Surgery and Determination of Its Risk Factor.
        Pediatr Cardiol. 2016; 37: 734-739
        • Breiman L.
        Random Forests.
        Machine Learning. 2001; 45: 5-32
      2. Breiman L, Friedman JH, Olshen RA, Stone CJ. Classification and regression trees. Boca Raton, FL: CRC Press; 1984

        • Friedman JH
        Greedy Function Approximation: A Gradient Boosting Machine.
        Ann Stat. 2000; 29: 1189-1232
        • Andreasen JB
        • Johnsen SP
        • Ravn HB
        Junctional ectopic tachycardia after surgery for congenital heart disease in children.
        Intensive Care Med. 2008; 34: 895-902
        • Batra AS
        • Chun DS
        • Johnson TR
        • Maldonado EM
        • Kashyap BA
        • Maiers J
        • et al.
        A prospective analysis of the incidence and risk factors associated with junctional ectopic tachycardia following surgery for congenital heart disease.
        Pediatr Cardiol. 2006; 27: 51-55
        • Yildirim SV
        • Tokel K
        • Saygili B
        • Varan B
        The incidence and risk factors of arrhythmias in the early period after cardiac surgery in pediatric patients.
        Turk J Pediatr. 2008; 50: 549-553
        • Walsh EP
        • Saul JP
        • Sholler GF
        • Triedman JK
        • Jonas RA
        • Wessel DL
        Evaluation of a staged treatment protocol for rapid automatic junctional tachycardia after operation for congenital heart disease.
        J Am Coll Cardiol. 1997 Apr; 29: 1046-1053
        • Entenmann A
        • Michel M
        • Egender F
        • Hessling V
        • Kramer HH
        Impact of Different Diagnostic Criteria on the Reported Prevalence of Junctional Ectopic Tachycardia After Pediatric Cardiac Surgery.
        Pediatr Crit Care Med. 2016 Sep; 17: 845-851
        • Ismail MF
        • Arafat AA
        • Hamouda TE
        • El Tantaway AE
        • Edrees A
        • Bogis A
        • et al.
        Junctional ectopic tachycardia following tetralogy of fallot repair in children under 2 years.
        J Cardiothorac Surg. 2018 Jun; 13: 60
        • Makhoul M
        • Oster M
        • Fischbach P
        • Das S
        • Deshpande S
        Junctional Ectopic Tachycardia After Congenital Heart Surgery in the Current Era.
        Pediatr Cardiol. 2013; 34: 370-374
        • Moak JP
        • Arias P
        • Kaltman JR
        • Cheng Y
        • McCarter R
        • Hanumanthaiah S
        • et al.
        Postoperative junctional ectopic tachycardia: risk factors for occurrence in the modern surgical era.
        Pacing Clin Electrophysiol. 2013 Sep; 36: 1156-1168
        • Arsenault KA
        • Yusuf AM
        • Crystal E
        • Healey JS
        • Morillo CA
        • Nair GM
        • et al.
        Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery.
        Cochrane Database Syst Rev. 2013 Jan; 2013: CD003611