Treatment Challenges of Pediatric Atrial Fibrillation

Pediatric atrial fibrillation (AF) involves several treatment challenges. Because it’s more common in adults, pediatric physicians often lack experience in managing AF in children. In addition, pediatric AF treatment is no longer considered a one-and-done phenomenon as in times past. In fact, recent studies show that the recurrence rate is more than 50 percent within the first year of diagnosis. The low rate of occurrence and the high risk of recurrence impact how physicians diagnose and treat pediatric AF patients.

Here pediatric electrophysiologist, Peter Aziz, MD, of Cleveland Clinic Children’s, discusses barriers to screening pediatric AF, collaborative treatment strategies and future research opportunities.

Q: How common is pediatric AF?

A: Pediatric AF is quite rare. In a study of 7.9 million children, about 1,500 patients (7.5 per 100,000 children) had lone atrial fibrillation.

Q: What causes AF in children?

A: When we see AF in children, it usually occurs with other conditions, such as Wolff-Parkinson-White syndrome, cardiomyopathy, heart valve problems or other heart defects. However, AF can also exist as a stand-alone disease known as lone atrial fibrillation.

Lone AF is more common in males and obese children. It’s also more common with age. Atrial fibrillation is very rare in patients under age 10. [This Q&A focuses on lone atrial fibrillation.]

Q: Are there any challenges involved in screening children for AF?

A: The good news is that most pediatric patients with AF are symptomatic. The only potential barrier to effective screening is that AF isn’t a disease that pediatric doctors are accustomed to identifying and treating. Pediatric practitioners need to consider AF as a potential diagnosis. If a young patient has concerning symptoms, don’t dismiss a serious heart problem or delay the diagnosis because of the patient’s age.

Q: How is AF treated in children?

A: Treatment usually involves at least one of the following:

• Continued observation: patient monitoring and patient education on symptoms, emphasizing the importance of presenting in a timely fashion.
• Medical therapy: prophylactic or abortive medication.
• Catheter ablation: pulmonary vein isolation for patients with AF only (ablation may also be used to address other arrhythmias identified as triggers for AF).

If a patient is considered high risk for thromboembolism, a rare condition in pediatric patients, an anticoagulation medication may be prescribed.

Q: What type of follow-up care do you recommend?

A: Due to the high risk of recurrence, pediatric patients should be followed for an extended period following initial diagnosis and treatment. Additional treatment modalities may be needed as part of follow-up care.

Q: How does Cleveland Clinic use a collaborative approach to treat pediatric AF?

A: When treating pediatric AF, we collaborate with physicians in the Cardiac Electrophysiology and Pacing Section who have more experience treating AF, typically an adult problem, than we do on the pediatric side. When performing a cardiac procedure, we have one of the adult electrophysiologists perform the procedure alongside our pediatric specialist to optimize the efficacy of the therapy. Because we house our pediatric cardiac experts and adult cardiac physicians within the same institution, we foster an environment of interaction and cooperation that benefits our young patients.

Q: Are you aware of any research being conducted in this area of pediatric medicine?

A: We are now participating in an international, multi-institutional study to reinforce data we have gathered at Cleveland Clinic with regard to pediatric AF recurrence, risk, coincidence of arrhythmias and treatment success.

Our current research data involves monitoring patients for about four to five years after the initial diagnosis. Future studies are needed to assess the long-term outcomes following treatment of pediatric AF using current approved modalities. We also hope to explore genetic factors related to pediatric AF.