Junctional Ectopic Tachycardia After Infant Heart ... - David Hanauer

Pediatr Cardiol 

DOI 10.1007/s00246-012-0348-y 

ORIGINAL ARTICLE 

Junctional Ectopic Tachycardia After Infant Heart Surgery: 

Incidence and Outcomes 

Jeffrey D. Zampi • Jennifer C. Hirsch • James G. Gurney • 

Janet E. Donohue • Sunkyung Yu • Martin J. LaPage • 

David A. Hanauer • John R. Charpie 

Received: 24 January 2012 / Accepted: 25 April 2012 

Ó Springer Science+Business Media, LLC 2012 

Abstract Junctional ectopic tachycardia (JET) is an 

arrhythmia observed almost exclusively after open heart 

surgery in children. Current literature on JET has not 

focused on patients at the highest risk of both developing 

and being negatively impacted by JET. The purpose of this 

study was to determine the overall incidence of JET in an 

infant patient cohort undergoing open cardiac surgery, to 

identify patient- and procedure-related factors associated 

with developing JET, and to assess the clinical impact of 

JET on patient outcomes. We performed a nested casecontrol 

study from the complete cohort of patients at our 

institution younger than 1 year of age who underwent open 

heart surgery between 2005 and 2010. JET patients were 

compared with an age matched control group undergoing 

open heart surgery without JET regarding potential risk 

factors and outcomes. The overall incidence of JET in 

J. D. Zampi J. E. Donohue S. Yu M. J. LaPage 

J. R. Charpie 

Division of Pediatric Cardiology, Department of Pediatrics, 

University of Michigan Medical School, Ann Arbor, MI, USA 

J. D. Zampi (&) 

University of Michigan Congenital Heart Center C.S. Mott 

Children’s Hospital, Floor 11, Room 715Z, 

1540 E. Hospital Drive, Ann Arbor, MI 48109-4204, USA 

e-mail: jzampi@med.umich.edu 

J. C. Hirsch 

Division of Pediatric Cardiac Surgery, Department of Surgery, 

University of Michigan Medical School, Ann Arbor, MI, USA 

J. G. Gurney 

St. Jude Children’s Research Hospital, Memphis, TN, USA 

D. A. Hanauer 

Department of Pediatrics, University of Michigan Medical 

School, Ann Arbor, MI, USA 

infants after open cardiac surgery was 14.3 %. From 

multivariate analyses, complete repair of tetralogy of Fallot 

[adjusted odds ratio (AOR) 2.0, 95 % CI 1.12–3.57] and 

longer aortic cross clamp times (AOR 1.02, 95 % CI 

1.01–1.03) increased the risk of developing JET. Patients 

with JET had longer length of intubation, intensive care 

unit stays, and total length of hospitalization, and were 

more likely to require extracorporeal membrane oxygenation 

support (13 vs. 4.3 %). JET is a common postoperative 

arrhythmia in infants after open heart operations. Both 

anatomic substrate and surgical procedure contribute to the 

overall risk of developing JET. Developing JET is associated 

with worse clinical outcomes. 

Keywords Heart defects Congenital Tachycardia 

Ectopic junctional 

Introduction 

Pediatric patients undergoing cardiac surgery to correct 

congenital heart disease (CHD) may have arrhythmias 

during the immediate postoperative period. Junctional 

ectopic tachycardia (JET) is a focal tachycardia originating 

from the atrioventricular (AV) node or proximal His producing 

a normal QRS morphology tachycardia, sometimes 

with ventriculo-atrial dissociation. It is one of the more 

commonly encountered arrhythmias with an overall incidence 

estimated between 3.6 and 10.8 % and even as high 

as 21–27 % in two series [2, 3, 5, 7–9, 11, 12, 14, 15]. JET 

is an arrhythmia that is almost exclusively encountered 

during the immediate postoperative period, with the 

exception of the rare congenital form of JET [6]. Some of 

the risk factors for developing postoperative JET that 

have been elucidated in recent studies include young age, 

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low weight, longer cardiopulmonary bypass and aortic 

cross clamp times, and hypothermic circulatory arrest [2, 3, 

7, 12, 14]. More recently, a genetic polymorphism in the 

angiotensin-converting enzyme gene has been found to be 

a possible risk factor [5]. In our institutional experience, 

younger patients appear to be at greater risk for developing 

JET, which is perhaps related to specific anatomic defects 

and surgical procedures. A few studies have attempted to 

determine if certain cardiac lesions or operations have a 

higher association with JET, but the data are often contradictory, 

likely due to single-center study design and the 

small amount of patients in each individual study [3, 5, 8, 

11, 12, 14]. What is better appreciated is that patients who 

develop JET have increased morbidity as assessed by 

longer duration of mechanical ventilation and increased 

intensive care unit (ICU) stay [2, 8, 12, 14] and, in one 

study, JET increased the risk of mortality [2]. No study has 

systematically examined a potential relation between JET 

and other well-described postoperative morbidities, such as 

cardiopulmonary resuscitation or the need for extracorporeal 

membrane oxygenation (ECMO) support. Furthermore, 

previous studies examining a potential relation 

between JET and mortality have not focused on high-risk 

populations, such as infants, in which the occurrence of 

JET may be more frequent and may have a more dramatic 

impact on survival. In addition, previous studies have not 

used well-matched controls, so there may be an underappreciated 

association of JET with mortality. 

The specific aims of this study were to estimate the 

incidence of postoperative JET focusing on an infant 

patient population and in this group to identify patient- and 

procedure-related risk factors for developing JET. Furthermore, 

this study aimed to assess if an association 

between JET and postoperative morbidity and mortality in 

infants after cardiac surgery exists and, if so, to what 

extent. Infants \1 year old were studied because JET is 

more common in this age group, and the clinical implications 

of JET are potentially greater in this population based 

on previous studies and our own institutional experience 

[2, 3, 7, 12, 14]. 

Methods 

After obtaining approval from our Institutional Review 

Board, using our internal surgical database, all patients 

who underwent cardiopulmonary bypass surgery at The 

University of Michigan Congenital Heart Center between 

July 1, 2005, and June 30, 2010, and who were \1 year of 

age at the time of surgery were identified. To identify 

patients who developed JET after surgery, three overlapping 

databases were queried, and an electronic medical 

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record search engine was used. The databases used were 

our internal surgical database (LUMEDX; LUMEDX 

Corporation, Oakland, CA), VPS (a commercially available 

database cooperative formerly known as the Virtual 

PICU System; VPS, LLC; Alexandria, VA), and our 

institution’s pharmacy database (WORx; Mediware Information 

Systems, Lenexa, KS). The internal surgical and 

VPS databases were queried for arrhythmias. The pharmacy 

database was queried for all patients who were prescribed 

amiodarone, either as a bolus or continuous 

infusion, during admission to our pediatric cardiothoracic 

ICU. Amiodarone was chosen because it is the treatment 

medication most commonly used for JET in our pediatric 

cardiothoracic ICU. Next, all free-text documents of 

patients’ medical records in our health system were 

reviewed by way of a back-end database search to identify 

documents that mentioned the terms ‘‘junctional ectopic,’’ 

‘‘accelerated junctional,’’ or ‘‘JET.’’ These patients were 

then cross-matched to the list of patients obtained from the 

internal surgical database who underwent surgery during 

the dates of our study. The Electronic Medical Record 

Search Engine was then used to conduct a chart review of 

all cases to ensure that the cases were valid and met our 

inclusion criteria. Among the remaining valid patients, a 

full chart review was conducted to abstract other clinically 

relevant outcomes data. 

JET was defined, using our institutional consensus definition, 

as a narrow QRS morphology tachycardia with 

atrio-ventricular dissociation or ventriculo-atrial association 

with retrograde P waves as determine either by review 

of atrial and ventricular electrograms on telemetry at the 

bedside, examining the atrial pressure tracings from central 

lines, or by obtaining a 12-lead electrocardiogram with an 

atrial electrogram. Given the retrospective nature of this 

study, to be diagnosed with JET, there needed to be documentation 

of the arrhythmia in the medical record made 

by a pediatric cardiac intensivist during the patient’s 

pediatric cardiothoracic ICU stay. Patients identified as 

having JET by any other person or means were not considered 

to have JET for this study. The only exclusion 

criterion was a documented preoperative arrhythmia 

requiring either antiarrhythmic medications or placement 

of a pacemaker before or at the time of surgery. 

After identifying the patients who developed JET during 

the postoperative period, we employed a nested case-control 

study design to analyze potential risk factors for JET 

and clinical outcomes. We randomly selected an equivalent 

number of control subjects (those who did not develop JET 

during their ICU stay) from the larger cohort of infants who 

underwent cardiopulmonary surgery during the 5-year time 

frame of our study. Because all patients were \1 year of 

age at the time of surgery, the cases and controls were agematched. 

Multiple patients had more than one surgery


before 1 year of age, so only the data for the surgery in 

which JET first occurred was analyzed. For control patients 

with more than one surgery, just as the individual patient 

was selected randomly, the surgery that was used for 

analysis was also selected randomly. 

The primary outcome measure of this study was the 

incidence of JET. Secondary outcomes included (1) 

potential patient- and procedure-related risk factors for 

developing JET (e.g., patient demographics, age, weight 

and body surface area, cardiac diagnosis, cardiac operation 

performed and surgical factors, including length of cardiopulmonary 

bypass, aortic cross clamp duration, and 

whether circulatory arrest was performed), and (2) the 

potential relationship between JET and patient post-operative 

outcomes (e.g., length of initial intubation, ICU 

length of stay, hospital length of stay, cardiac arrest, need 

for ECMO support, and death including while in the ICU, 

prior to hospital discharge, and within 30 days of hospital 

discharge). These secondary outcomes were compared 

between the cases and the randomly selected controls. 

Because of the heterogeneity of specific cardiac diagnoses 

in our patients, patients were grouped into 1 of 13 diagnostic 

categories a priori, which attempted to take into 

account both the cardiac anatomy and physiology as well 

as the surgical repair required. 

Length of ICU stay was defined as the date of surgery to 

the date of transfer out of the ICU. Duration of intubation 

was defined as the date of surgery to the date of first 

extubation. Cardiac arrest was defined as the need for chest 

compressions and resuscitation medications. Only outcome 

measures that occurred while the patient was in the ICU 

were analyzed except for death (30-day mortality from 

hospital discharge). 

Table 1 Incidence of JET in 

infants after surgery for CHD 

PAPVR partial anomalous 

pulmonary venous return, 

TAPVR total anomalous 

pulmonary venous return 

Data were presented as frequencies with percentage or 

median with interquartile range (IQR). Group comparisons 

on patient- and procedure-related characteristics, as well as 

outcomes, were made using chi-square test for categorical 

variables and Wilcoxon rank sum test for continuous 

variables. Unadjusted and adjusted odds ratio (AOR) and 

their 95 % confidence intervals (CIs) were estimated using 

univariate and multivariate logistic regression, respectively, 

to examine the association between possible risk 

factors and developing JET. To avoid multicollinearity in 

the multivariate analysis, we evaluated the correlation 

matrix of all continuous variables and excluded variables 

with a high correlation (r [ 0.8). Similarly, for the diagnosis 

groups with a greater incidence than the total incidence 

of JET in the overall cohort, separate logistic 

regression was used to evaluate the relation of each diagnosis 

group with JET. All analyses were performed using 

SAS version 9.2 software (SAS, Cary, NC), and statistical 

significance was set at p \ 0.05 using two-sided tests. 

Results 

Characteristics No. of patients 

with JET 

There were 1,134 patients[1 year of age who underwent a 

total of 1,451 cardiopulmonary bypass surgeries between 

July 1, 2005, and June 30, 2010. Four patients were 

excluded from analysis due to pacemaker implantation 

secondary to congenital complete heart block (n = 3) and 

preoperative ventricular ectopy on propranolol therapy 

(n = 1). One hundred sixty-two patients were determined 

to have had JET during the postoperative period. Thus, the 

total incidence of JET in infants undergoing cardiopulmonary 

bypass surgery was 14.3 % (Table 1). 

No. of patients in 

diagnostic class 

Incidence 

(%) 

Overall 

Diagnosis class 

162 1,130 14.3 

Single ventricle 27 283 9.5 

TOF and variants 42 208 20.2 

VSD 15 135 11.1 

Aortic arch repair with VSD closure 15 75 20.0 

Aortic arch repair without VSD closure 3 49 6.1 

dTGA with VSD closure 20 78 25.6 

dTGA without VSD closure 2 48 4.2 

ASD (isolated) 1 19 5.3 

Primary AV valve (AV) 1 14 7.1 

Primary semilunar valve anomaly 3 33 9.1 

AVSD 23 136 20.4 

Anomalous pulmonary venous return 6 36 16.7 

Other 4 39 10.3 

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Regarding risk factors for developing JET, there were no 

statistical differences in race, sex, previous bypass surgery, 

weight, or BSA between the cases and age-matched controls, 

and the use of circulatory arrest was also not associated 

with JET (Table 2). Risk factors for JET found on 

univariate analysis were longer cardiopulmonary bypass 

(p = 0.03) and aortic cross-clamp times (p = 0.0002) 

(Tables 2, 3). However, only longer aortic cross-clamp 

time remained an independent risk factor associated with 

JET on multivariate analysis [AOR 1.02, 95 % CI 

1.01–1.03, p = 0.001 (Table 3)]. This indicated that the 

odds of having JET increase by 2 % for every 1-min 

increase in aortic cross-clamp time while controlling for 

other possible risk factors. Five congenital heart lesions 

had higher individual incidences of JET compared with the 

Table 2 Patient- and procedure-related characteristics in infants with JET after surgery for CHD 


overall cohort and accounted for 65 % of the patients with 

JET. These lesions included tetralogy of Fallot (TOF) and 

variants (20.2 %), aortic arch repair with ventricular septal 

defect (VSD) closure (20 %), d-transposition of the great 

arteries (dTGA) with VSD closure (25.6 %), atrioventricular 

septal defect (AVSD) (20.4 %), and anomalous pulmonary 

venous return (16.7 %) (Table 1). However, only 

patients who underwent complete repair of TOF were at 

greater risk of developing JET on both univariate and 

multivariate analysis (Table 4). 

Compared with age-matched controls, patients with JET 

had longer length of intubation (4 vs. 3 days), length of 

ICU stay (7 vs. 5 days), and length of hospitalization (18 

vs. 13 days) (all p = \0.0001). In addition, JET patients 

had a greater chance of requiring ECMO support during 

Characteristics All JET (n = 162) Control (n = 162) p* 

Male sex 180 (55.6) a 

Race 

85 (52.5) 95 (58.6) 0.26 

White 214 (66.1) 110 (67.9) 104 (64.2) 0.74 

African American 29 (9.0) 13 (8.0) 16 (9.9) 

Other/unknown 81 (25.0) 39 (24.1) 42 (25.9) 

Age at surgery (days) 

Diagnosis 

64.5 (9.0–137.5) 65.5 (11.0–129.0) 61.5 (8.0–142.0) 0.63 

Single ventricle 62 (19.1) 27 (43.5) 35 (56.5) N/A 

TOF and variants 74 (22.8) 42 (56.8) 32 (43.2) 

VSD 29 (9.0) 15 (51.7) 14 (48.3) 

Aortic arch repair with VSD closure 29 (9.0) 15 (51.7) 14 (48.3) 

Aortic arch repair without VSD closure 12 (3.7) 3 (25.0) 9 (75.0) 

dTGA with VSD closure 32 (9.9) 20 (62.5) 12 (37.5) 

dTGA without VSD closure 14 (4.3) 2 (14.3) 12 (85.7) 

ASD (isolated) 3 (0.9) 1 (33.3) 2 (66.7) 

Primary AV valve anomaly 3 (0.9) 1 (33.3) 2 (66.7) 

Primary semilunar valve anomaly 7 (2.2) 3 (42.9) 4 (57.1) 

AVSD 36 (11.1) 23 (63.9) 13 (36.1) 

Anomalous pulmonary venous return 13 (4.0) 6 (46.1) 7 (53.9) 

Other 10 (3.1) 4 (40.0) 6 (60.0) 

Previous surgery requiring bypass 34 (10.5) 19 (11.7) 15 (9.3) 0.47 

Weight at surgery (kg) 4.1 (3.3–5.6) 4.0 (3.3–5.7) 4.2 (3.2–5.6) 0.92 

Length at surgery (cm) 54.1 (50.0–61.4) 54.1 (50.0–61.0) 54.1 (50.0–62.0) 0.83 

Body mass index at surgery (kg/m 2 ) 13.7 (12.3–15.6) 13.9 (12.3–15.7) 13.6 (12.3–15.2) 0.38 

BSA (m 2 ) 0.24 (0.21–0.31) 0.24 (0.21–0.31) 0.25 (0.21–0.31) 0.89 

ACC time (min) 46 (30–71) 51 (35–78) 40 (26–63) 0.001 

CPB time (min) 99 (75–136) 106 (80–145) 92 (70–130) 0.01 

Hypothermic cardiac arrest 84 (25.9) 36 (22.2) 48 (29.6) 0.14 

N/A not applicable, ACC aortic cross-clamp, CPB cardiopulmonary bypass 

a 

Data are presented as N (%) for categorical variables and median (IQR) for continuous variables 

* p-value from chi-square test for categorical variables and from Wilcoxon rank sum test for continuous variables based on comparison of each 

characteristic between patients with and without JET 

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Table 3 Odds of developing JET after surgery for CHD 

Characteristics Unadjusted Adjusted a 

OR 95 % CI of OR 

(lower, upper) 

their ICU stay (13 vs. 4.3 %). There was no difference in 

need for cardiopulmonary resuscitation (CPR) (11.7 vs. 

7.4 %) or 30-day mortality (13 vs. 11.1 %) between 

patients who developed JET compared with control subjects 

(Table 5). 

p* AOR 95 % CI of AOR 


Sex 

Male 0.78 0.50, 1.21 0.26 0.77 0.48, 1.22 0.27 

Female 

Age at surgery (days) 

Ref Ref 

B30 0.84 0.54, 1.30 0.43 0.87 0.45, 1.68 0.69 

[30 Ref Ref 

Weight at surgery (kg) 1.01 0.88, 1.15 0.93 0.92 0.77, 1.10 0.35 

Length at surgery (cm) 1.00 0.97, 1.02 0.72 N/A 

BMI at surgery (kg/m 2 ) 1.02 0.94, 1.11 0.63 

BSA at surgery (m 2 ) 0.84 0.03, 23.0 0.92 

ACC time (min) 1.01 1.005, 1.02 0.0002 1.02 1.01, 1.03 0.001 

CPB time (min) 

Hypothermic cardiac arrest 

1.004 1.00, 1.01 0.03 0.997 0.99, 1.003 0.31 

Yes 0.68 0.41, 1.13 0.14 0.55 0.30, 1.03 0.06 

No Ref Ref 

OR (unadjusted) odds ratio, Ref reference category, N/A not applicable, ACC aortic cross-clamp, CPB cardiopulmonary bypass, BMI body mass 

index 

a 

Excluded continuous variables involved in multicollinearity with a high correlation (correlation coefficient r [ 0.8) 

* p-value from (unadjusted) logistic regression 

** p-value from a multivariate logistic regression 

Table 4 Association between diagnosis and risk of JET after surgery for CHD 

Diagnosis Unadjusted Adjusted 

OR 95 % CI of OR 


Discussion 

p c 

AOR 95 % CI of AOR 


TOF and variants 1.42 0.84, 2.40 0.19 1.63 0.95, 2.80 0.08 

VSD 1.08 0.50, 2.31 0.85 1.27 0.57, 2.81 0.55 

Aortic arch repair with VSD closure 1.08 0.50, 2.31 0.85 0.91 0.42, 1.99 0.81 

dTGA with VSD closure 1.76 0.83, 3.73 0.14 1.05 0.45, 2.49 0.91 

AVSD 1.90 0.93, 3.89 0.08 1.38 0.65, 2.96 0.40 

Arterial arch repair or dTGA with VSD closure a 

5.65 1.88, 16.97 0.001 2.94 0.89, 9.67 0.08 

TOF complete repair b 

1.92 1.08, 3.39 0.02 2.00 1.12, 3.57 0.02 

OR (unadjusted) odds ratio, CI confidence interval 

a 

Reference group comprised patients undergoing aortic arch repair without VSD closure or dTGA without VSD closure [thus, a comparison was 

made with 61 patients diagnosed by aortic arch repair with VSD closure or dTGA with VSD closure (35 in JET group and 26 in control group) 

versus 26 patients diagnosed by aortic arch repair without VSD closure or dTGA without VSD closure (5 in JET group and 21 in control group)] 

b 

Diagnosed with TOF and variants, and surgery performed was complete repair 

* p-value from (unadjusted) logistic regression 

** p-value from a multivariate logistic regression controlling for aortic cross-clamp time and cardiopulmonary bypass time (which were found to 

be significant predictors from univariate analyses) 

p** 

In this nested case-control study, we found that the overall 

incidence of JET in infants undergoing cardiac surgery 

with cardiopulmonary bypass at a tertiary care referral 

p d 

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Table 5 Outcomes in infants with JET after surgery for CHD 

Outcomes All JET (n = 162) Control (n = 162) p* 

Length of initial intubation (d) 4 (2–6) a 

4 (3–8) 3 (2–5) \0.0001 

ICU length of stay (d) 6 (4–10) 7 (5–12) 5 (3–9) \0.0001 

Hospital length of stay (d) 15 (9–26) 18 (11–31) 13 (7–21) \0.0001 

Cardiac arrest requiring CPR 31 (9.6) 19 (11.7) 12 (7.4) 0.19 

Need for ECMO 28 (8.6) 21 (13.0) 7 (4.3) 0.01 

Length of time on ECMO (d) 7 (4.5–12) 7 (5–14) 5 (1–11) 0.25 

Death during ICU stay 26 (8.0) 12 (7.4) 14 (8.6) 0.68 

Hospital death 36 (11.1) 20 (12.4) 16 (9.9) 0.48 

Died in hospital or within 30 days of hospital discharge 39 (12.0) 21 (13.0) 18 (11.1) 0.61 

Current patient status dead 49 (15.1) 25 (15.4) 24 (14.8) 0.88 

CPR cardiopulmonary resuscitation 

a 

Data are presented as N (%) for categorical variables and median (IQR) for continuous variables 

* p-value from chi-square test for categorical variables and from Wilcoxon rank sum test for continuous variables on comparison of each 

characteristic between patients with/without JET 

center was 14.3 %. Only patients with TOF and TOF 

variants undergoing a complete repair and longer aortic 

cross-clamp times were found to be significant independent 

risk factors for JET. Patients with JET had longer length of 

intubation, longer ICU stay, and longer total length of 

hospitalization and were more likely to require ECMO 

compared with infants who did not develop JET. There was 

no statistical difference in perioperative mortality between 

the JET and control subjects. 

With respect to risk factors for JET, the only diagnosis 

significantly associated with JET in our study was complete 

repair of TOF. This is in accordance with what previous 

studies have found [7, 8, 11]. However, we did not 

see the same strong association of JET with some other 

cardiac lesions, such as anomalous pulmonary venous 

return, or cardiac surgeries, such as arterial switch surgery, 

which have been previously published [3, 7, 11, 14]. 

However, in all of these studies, the total patient population 

studied was well less than half of that in our study and 

included much older patients. Furthermore, whereas we 

had 162 cases of JET, the other studies had far fewer cases 

(33, 57, and 27, respectively). Therefore, the differences 

found in the association of certain cardiac lesions with JET 

are likely related to the combination of our more homogenous 

patient population (i.e., \1 year of age) and our 

relatively large number of patients in the study. 

Similarly, our incidence of JET is different than that in 

previous studies because we chose to focus on a more 

homogeneous population of infants\1 year old who are at 

a greater risk for worse outcomes related to JET [2, 3, 7, 

11, 14]. Although there is the potential that the results 

found in previous studies differed from our results due to 

differing study eras, we believe it is unlikely. The previous 

studies were completed on patients who underwent surgery 

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between 1997 and 2005 compared with our more contemporary 

study group between 2005 and 2010. We do not 

believe the surgical repair of the majority of cardiac lesions 

discussed has changed significantly during the last 

10–15 years. Furthermore, even the previous studies 

completed within 1–2 years of each other have disparate 

conclusions regarding incidence and effect of cardiac 

diagnosis on the risk of developing JET. 

Although aortic arch repair and dTGA were not found to 

be associated with JET, when VSD closure was a part of 

the surgery, the likelihood that JET occurred was 5.65 

times greater compared with VSD closure not being performed 

(Table 4). Given this and the finding that TOF 

repair presents the highest occurrence of JET, one might 

surmise that VSD closure places the patient at risk for JET. 

This same conclusion has been drawn in previous studies 

[8, 12]. However, if this were the case, we would have 

expected to see patients with isolated VSD to have a 

greater rate of JET, which we did not find. Thus, developing 

JET is likely more complex than a purely surgical or 

purely anatomic problem, perhaps resulting from an 

interaction between the two. There may also be a genetic 

propensity to developing postoperative arrhythmias such as 

JET. Recently, a common genetic polymorphism in the 

angiotensin-converting enzyme (ACE) gene was found to 

have an association with JET independent of several of the 

risk factors identified in our study [5]. As more is learned 

about the genetic basis for specific conditions, the complex 

interplay of various patient-related ‘‘risk factors’’ may be 

better elucidated, and further studies with these patient 

factors might help to assess risk and provide for more 

targeted prevention and treatment of JET. 

The only other independent risk factor significantly 

associated with JET in our study was longer aortic


cross-clamp time, which has also been reported by other 

studies [3, 14]. We believe this could be explained by the 

relation between low cardiac output syndrome (LCOS) and 

JET. Recent studies have shown a relationship between 

LCOS and increased patient morbidity and mortality, and 

others have shown a possible relationship between LCOS 

and prolonged aortic cross-clamp time [1, 4, 13]. Although 

no study that we are aware of has defined whether JET is a 

risk factor versus outcome of LCOS, our study, which 

showed an association between prolonged aortic crossclamp 

time and JET as well as JET and poorer patient outcomes, 

does support the presence of a relationship between 

JET and LCOS. The study by Hoffman et al. [11] showed 

that dopamine administration was an independent predictor 

of developing JET and concluded that JET might be secondary 

to the catecholaminergic properties of dopamine, 

which is why milrinone administration was not a predictor of 

JET. An alternate explanation for their findings is that 

patients with LCOS after surgery require more vasoactive 

support, such as dopamine, and so it is the relationship 

between LCOS and JET, rather than a direct relationship 

between dopamine and JET, which is important. Again, JET 

may only be an outcome of LCOS and have no causative 

relationship, but as future studies attempt to elucidate the 

clinical factors that define LCOS, the occurrence of 

arrhythmias such as JET might become a part of that clinical 

diagnosis because JET primarily occurs during the postoperative 

period and, as we have shown in this study, is more 

commonly seen after the repair of certain types of cardiac 

lesions and with longer aortic cross-clamp times. 

As was found in other studies, developing JET is associated 

with worse clinical outcomes, specifically length of 

intubation and length of ICU stay. We also found that JET 

is associated with longer total hospitalization course. 

Because a longer length of intubation would rationally 

lengthen both ICU stay and therefore total duration of 

hospitalization, the key outcome affected may be duration 

of intubation. Because patients are often not extubated until 

they are clinically stable, it is plausible that the clinical 

instability caused by JET prolongs intubation course. 

Future studies that look at other more subtle measures of 

clinical instability, such as vasoactive inotrope scores, 

might be helpful to delineate this association. Furthermore, 

whereas patient postoperative outcomes are likely related 

to a host of factors, further studies aimed to determine a 

causative effect of JET on postoperative clinical outcomes 

is necessary to build on the associations found in this study. 

We did not find an association between JET and 

increased mortality, and previous publications have had 

conflicting results regarding this association. However, we 

did find a significant association between JET and need for 

ECMO support during the postoperative period. We would 

have expected this to translate to an increased mortality 

because studies have shown a high mortality rate in 

patients who require ECMO support [10]. This again might 

come back to the relationship between JET and LCOS. 

Although in our series need for ECMO support did not 

translate to increased mortality, increased ECMO requirement 

likely contributes to increased morbidity because 

ECMO is associated with various secondary outcomes (risk 

of bleeding, infection, neurologic dysfunction, renal failure, 

etc. [10]), which we did not study. We found that 

patients who were placed on ECMO had prolonged ICU 

stays and that this was independent of developing JET. 

Limitations 

There are several limitations to this study. First, previous 

studies have used electrophysiologic criteria for JET and 

whether performed prospectively or retrospectively, none 

used a retrospective database approach to ascertain which 

patients developed JET [2, 3, 7, 11, 12, 14, 15]. This makes 

it difficult to compare the incidence of JET in our study 

with that in previous studies. Here, we used a clinical 

definition for JET, and because of the retrospective nature 

of the study, we did not have the data necessary to confirm 

that patients had JET based on electrocardiogram or Holter 

monitor data. In our institution, it is not standard of care to 

obtain a 12-lead electrocardiogram to document arrhythmias. 

It is the standard of care to obtain a 12-lead electrocardiogram 

on all patients during the early postoperative 

period, but because of the nature of JET, this electrocardiogram 

often does not capture patients who may have 

been in or will go into JET. We do not believe that this 

methodology is a limitation but rather an alternative and 

clinically important way to determine which patients 

developed JET. 

Another limitation of this study is how CHDs were 

grouped. This problem is not unique to this study, and 

classification of heart diseases can vary based on school of 

thought. We attempted to place patients into broad diagnostic 

categories that took their anatomy, physiology, and 

surgery into consideration, but this is not without flaw. 

Although this did allow us to make groups large enough for 

statistical analysis, it may have limited the applicability of 

the results to individual patients because we only determined 

the incidence of JET for groups of lesions and not 

for specific lesions. Of note, these groupings were made 

a priori and were not created after data collection for statistical 

purposes. 

Conclusion 

In infants who undergo open cardiac surgery, JET is a 

relatively common postoperative arrhythmia, occurring in 

123

14.3 % of surgeries. When it occurs, JET is associated with 

negative outcomes and a worse clinical course compared 

with patients who do not develop JET. The results of this 

study add to the current published data on postoperative 

JET in CHD for several reasons. First, by only studying 

infants, it focuses on the highest-risk patient population. 

Second, the patient sample size was larger than that of all 

previously reported single-center studies. And third, 

although it was retrospective in nature, the unique multiple 

database search strategy facilitated as close to complete 

case capture as possible in a retrospective study without 

confirmatory tests, such as electrocardiograms or Holter 

monitor recordings, available for review. The information 

gained from this study will allow us to design future prospective 

studies to better treat and/or prevent JET from 

occurring in the infant population. In addition, this study 

confirms and adds to what was known about the clinical 

impact of JET and thus gives insight into what outcome 

measures to target in assessing treatment effectiveness in 

the future. 

Acknowledgments All work was performed at the University of 

Michigan, Ann Arbor, MI. Financial support came from an $8000 

internal grant (Griese-Hutchinson-Woodson Champions for Children 

Heart Award). 

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Junctional Ectopic Tachycardia After Infant Heart ... - David Hanauer

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