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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is an exceptional arrhythmia in the pediatric age group in the absence of complex congenital heart defects or previous cardiac surgery&#46; We present 2 cases of paroxysmal AF in childhood&#44; both in patients without a known history of cardiac disease&#44; triggered by intense physical activity and that responded well to treatment&#46; We also reviewed the literature on this disease in the pediatric age group&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Case 1 corresponded to a male adolescent aged 14 years that presented to the emergency department with palpitations and a sensation of difficulty breathing with onset a few hours prior after performance of physical activity &#40;martial arts&#44; a sport with a high static component and a moderate dynamic component&#41;&#46; He had no medical history of interest and was not receiving any ongoing pharmacological treatment&#46; The father had idiopathic AF&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Several diagnostic tests were performed&#44; among which the most relevant was an electrocardiogram &#40;ECG&#41; that showed an irregular rhythm with narrow QRS complexes and a heart rate of 80 beats per minute with multiple low-amplitude F-waves&#44; compatible with AF &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The arterial blood pressure was 122&#47;71<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The body mass index &#40;BMI&#41; was under the 95th percentile&#46; The results of blood chemistry tests were normal&#44; with no abnormalities in electrolyte levels and negative results of drug testing in urine&#59; thyroid hormone levels were normal&#46; A Doppler ultrasound scan ruled out structural heart defects&#44; revealing normal atria and ventricular function both in systole and diastole and absence of intracardiac thrombi&#46; The scan detected the presence of persistent left superior vena cava with moderate dilatation of the coronary sinus&#44; which was confirmed by a saline contrast study performed by injection of shaken physiological saline in the left cephalic vein&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was given a dose of oral flecainide &#40;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#44; which achieved restoration of the sinus rhythm&#46; This was followed by initiation of maintenance therapy with flecainide&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At 12 months of follow-up the patient had experienced no recurrences&#44; and the antiarrhythmic drug therapy was discontinued&#46; A subsequent cardiac stress test revealed a normal heart rhythm and blood pressure&#44; both at peak exertion and during recovery&#44; with no associated vagal symptoms&#46; The patient remained asymptomatic 9 months later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Case 2 corresponded to a male adolescent aged 17 years referred to the emergency department due to syncope following exertion &#40;bodybuilding a sport with a high static component and a moderate dynamic component&#41; that exhibited complete neurologic recovery in a few seconds with immediate development of palpitations and the sensation of tachycardia&#46; The patient was put under observation with performance of a full ECG&#44; which revealed atrial fibrillation with ventricular contractions occurring at 110&#8211;120 beats per minute &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was given an oral dose of 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of flecainide&#44; which achieved restoration of the sinus rhythm&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The physical examination revealed a mild systolic ejection murmur best heard over the aortic valve&#46; The BMI was below the 95th percentile&#46; The Doppler ultrasound scan revealed a bicuspid aortic valve with two raphes of mild severity&#44; a disorder that had not been diagnosed previously&#46; The atria had normal morphology and were not enlarged&#46; There was no evidence of thrombi in the heart&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient had no personal or family history of interest and was not undergoing chronic pharmacological treatment&#46; The urine drug test was negative and the levels of serum electrolytes and thyroid hormones were normal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient remained under pharmacological treatment with flecainide for 12 months&#44; without recurrence of arrhythmia at 5 months of follow-up&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Isolated atrial fibrillation is an infrequent arrhythmia in the pediatric population&#44; especially in the absence of organic heart disease of a probably multifactorial etiology&#46; Both of the cases we present here corresponded to a first episode of AF that was haemodynamically insignificant in patients with no known history of heart disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Persistent left superior vena cava&#44; diagnosed in case 1&#44; has been associated with the development of supraventricular arrhythmias&#44; including AF&#46; Radiofrequency catheter ablation of these connections can prevent their recurrence&#46; Hsu et al&#46; described 5 cases of AF where electrophysiology testing identified persistent left superior vena cava as the source arrhythmia&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To our knowledge&#44; an association between AF and bicuspid aortic valve&#44; a defect detected in case 2&#44; has not been previously reported&#44; and therefore the coexistence of these 2 disorders could be coincidental and unrelated to the disease process&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Intense physical activity may cause electrical and structural changes in the atria that would promote the development of an episode of AF&#46; In both our patients&#44; AF was associated with physical activity&#46; There is also evidence of an association between chest trauma with commotio cordis and AF&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Cases of isolated familial AF have been reported in the literature in association with genetic mutations affecting multiple ion channels and circulating hormones such as atrial natriuretic peptide&#46; However&#44; the diagnostic yield of genetic testing for this type of arrhythmia is currently not known&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#44;5</span></a> In this regard&#44; the presence of idiopathic AF in the father of case 1 may have increased the risk of AF in our patient&#46; In addition&#44; consumption of some recreational substances&#44; such as cannabis&#44; can trigger AF&#46; In the cases presented here&#44; we ruled out the consumption of arrhythmogenic substance use&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In a series of 1750 cases of isolated AF in children&#44; the only risk factors identified were obesity with a BMI above the 95th percentile&#44; male sex and age greater than 14 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">At present there is no consensus regarding the first-line antiarrhythmic drug for treatment of AF in the pediatric age group&#46; However&#44; drugs used to control heart rate &#40;such as beta blockers&#41; are the most widely used agents&#46; In the 2 cases presented here&#44; treatment with flecainide was chosen with the aim of achieving cardioversion&#46; In cases refractory to pharmacotherapy&#44; electrical cardioversion and radiofrequency ablation of the sources of atrial arrhythmia are effective alternatives&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Lastly&#44; the use of anticoagulant therapy was ruled out in both cases due to the low risk of thrombosis and the early recovery of the sinus rhythm&#46; In any case&#44; there are no guidelines providing the indication of prophylactic treatment for prevention of stroke in this population&#46;</p></span>"
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Scientific Letter
Atrial fibrillation. A presentation of 2 cases
Fibrilación auricular. A propósito de 2 casos
Marc Roguera Sopena
Corresponding author
, Laura Sabidó Sánchez, Roger Villuendas Sabaté, Ricardo del Alcázar Muñoz
Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
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    "titulo" => "Atrial fibrillation&#46; A presentation of 2 cases"
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        "titulo" => "Fibrilaci&#243;n auricular&#46; A prop&#243;sito de 2 casos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; is an exceptional arrhythmia in the pediatric age group in the absence of complex congenital heart defects or previous cardiac surgery&#46; We present 2 cases of paroxysmal AF in childhood&#44; both in patients without a known history of cardiac disease&#44; triggered by intense physical activity and that responded well to treatment&#46; We also reviewed the literature on this disease in the pediatric age group&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Case 1 corresponded to a male adolescent aged 14 years that presented to the emergency department with palpitations and a sensation of difficulty breathing with onset a few hours prior after performance of physical activity &#40;martial arts&#44; a sport with a high static component and a moderate dynamic component&#41;&#46; He had no medical history of interest and was not receiving any ongoing pharmacological treatment&#46; The father had idiopathic AF&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Several diagnostic tests were performed&#44; among which the most relevant was an electrocardiogram &#40;ECG&#41; that showed an irregular rhythm with narrow QRS complexes and a heart rate of 80 beats per minute with multiple low-amplitude F-waves&#44; compatible with AF &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The arterial blood pressure was 122&#47;71<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The body mass index &#40;BMI&#41; was under the 95th percentile&#46; The results of blood chemistry tests were normal&#44; with no abnormalities in electrolyte levels and negative results of drug testing in urine&#59; thyroid hormone levels were normal&#46; A Doppler ultrasound scan ruled out structural heart defects&#44; revealing normal atria and ventricular function both in systole and diastole and absence of intracardiac thrombi&#46; The scan detected the presence of persistent left superior vena cava with moderate dilatation of the coronary sinus&#44; which was confirmed by a saline contrast study performed by injection of shaken physiological saline in the left cephalic vein&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was given a dose of oral flecainide &#40;2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#44; which achieved restoration of the sinus rhythm&#46; This was followed by initiation of maintenance therapy with flecainide&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">At 12 months of follow-up the patient had experienced no recurrences&#44; and the antiarrhythmic drug therapy was discontinued&#46; A subsequent cardiac stress test revealed a normal heart rhythm and blood pressure&#44; both at peak exertion and during recovery&#44; with no associated vagal symptoms&#46; The patient remained asymptomatic 9 months later&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Case 2 corresponded to a male adolescent aged 17 years referred to the emergency department due to syncope following exertion &#40;bodybuilding a sport with a high static component and a moderate dynamic component&#41; that exhibited complete neurologic recovery in a few seconds with immediate development of palpitations and the sensation of tachycardia&#46; The patient was put under observation with performance of a full ECG&#44; which revealed atrial fibrillation with ventricular contractions occurring at 110&#8211;120 beats per minute &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was given an oral dose of 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of flecainide&#44; which achieved restoration of the sinus rhythm&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The physical examination revealed a mild systolic ejection murmur best heard over the aortic valve&#46; The BMI was below the 95th percentile&#46; The Doppler ultrasound scan revealed a bicuspid aortic valve with two raphes of mild severity&#44; a disorder that had not been diagnosed previously&#46; The atria had normal morphology and were not enlarged&#46; There was no evidence of thrombi in the heart&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient had no personal or family history of interest and was not undergoing chronic pharmacological treatment&#46; The urine drug test was negative and the levels of serum electrolytes and thyroid hormones were normal&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient remained under pharmacological treatment with flecainide for 12 months&#44; without recurrence of arrhythmia at 5 months of follow-up&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Isolated atrial fibrillation is an infrequent arrhythmia in the pediatric population&#44; especially in the absence of organic heart disease of a probably multifactorial etiology&#46; Both of the cases we present here corresponded to a first episode of AF that was haemodynamically insignificant in patients with no known history of heart disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Persistent left superior vena cava&#44; diagnosed in case 1&#44; has been associated with the development of supraventricular arrhythmias&#44; including AF&#46; Radiofrequency catheter ablation of these connections can prevent their recurrence&#46; Hsu et al&#46; described 5 cases of AF where electrophysiology testing identified persistent left superior vena cava as the source arrhythmia&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">To our knowledge&#44; an association between AF and bicuspid aortic valve&#44; a defect detected in case 2&#44; has not been previously reported&#44; and therefore the coexistence of these 2 disorders could be coincidental and unrelated to the disease process&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Intense physical activity may cause electrical and structural changes in the atria that would promote the development of an episode of AF&#46; In both our patients&#44; AF was associated with physical activity&#46; There is also evidence of an association between chest trauma with commotio cordis and AF&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Cases of isolated familial AF have been reported in the literature in association with genetic mutations affecting multiple ion channels and circulating hormones such as atrial natriuretic peptide&#46; However&#44; the diagnostic yield of genetic testing for this type of arrhythmia is currently not known&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#44;5</span></a> In this regard&#44; the presence of idiopathic AF in the father of case 1 may have increased the risk of AF in our patient&#46; In addition&#44; consumption of some recreational substances&#44; such as cannabis&#44; can trigger AF&#46; In the cases presented here&#44; we ruled out the consumption of arrhythmogenic substance use&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In a series of 1750 cases of isolated AF in children&#44; the only risk factors identified were obesity with a BMI above the 95th percentile&#44; male sex and age greater than 14 years&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">At present there is no consensus regarding the first-line antiarrhythmic drug for treatment of AF in the pediatric age group&#46; However&#44; drugs used to control heart rate &#40;such as beta blockers&#41; are the most widely used agents&#46; In the 2 cases presented here&#44; treatment with flecainide was chosen with the aim of achieving cardioversion&#46; In cases refractory to pharmacotherapy&#44; electrical cardioversion and radiofrequency ablation of the sources of atrial arrhythmia are effective alternatives&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Lastly&#44; the use of anticoagulant therapy was ruled out in both cases due to the low risk of thrombosis and the early recovery of the sinus rhythm&#46; In any case&#44; there are no guidelines providing the indication of prophylactic treatment for prevention of stroke in this population&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Roguera Sopena M&#44; Sabid&#243; S&#225;nchez L&#44; Villuendas Sabat&#233; R&#44; del Alc&#225;zar Mu&#241;oz R&#46; Fibrilaci&#243;n auricular&#46; A prop&#243;sito de 2 casos&#46; Arch Bronconeumol&#46; 2020&#59;92&#58;47&#8211;49&#46;</p>"
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ISSN: 23412879
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