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Ventricular extrasystole in children
Last reviewed: 05.07.2025

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Extrasystole is an unscheduled, premature heartbeat. This is the most common type of cardiac arrhythmia, occurring in all age groups and also observed in practically healthy people. In childhood, extrasystolic arrhythmia accounts for 75% of all arrhythmias.
A common feature of all types of extrasystoles is their premature occurrence. The coupling interval (R~R) before the extrasystole is shorter than the RR interval of the sinus rhythm. Only an esophageal ECG recording can provide an accurate topical diagnosis of extrasystole.
Ventricular extrasystole is a premature excitation in relation to the main rhythm, originating from the ventricular myocardium. Ventricular extrasystole disrupts the correctness of the heart rhythm due to the premature contractions of the ventricles, post-extrasystolic pauses and the associated asynchrony of myocardial excitation. Ventricular extrasystole is often hemodynamically ineffective or accompanied by a decrease in cardiac output. The prognosis of ventricular extrasystole depends on the presence or absence of organic heart pathology, electrophysiological characteristics of extrasystole (frequency, degree of prematurity, localization), as well as the ability of ventricular extrasystole to have a negative effect on blood circulation - the hemodynamic effectiveness of ventricular extrasystole.
Epidemiology
The frequency of ventricular extrasystoles depends on the method of their detection. With ECG, single ventricular extrasystoles are detected in 0.8% of newborns and 2.2% of adolescents, and with Holter monitoring - in 18% of newborns and 50% of adolescents without organic heart disease.
Causes of ventricular extrasystole in children
The causes of extrasystole are different, but in the vast majority of cases these are neurogenic disorders of extracardiac origin. Under the influence of the parasympathetic system, membrane permeability, the level of intra- and extracellular potassium and sodium change, the intensity of transmembrane ion currents changes, which results in disturbances of excitability, automatism, conductivity with the occurrence of extrasystole. An important pre-exposure factor in the genesis of extrasystolic arrhythmia is often the migration of rhythm between the sinus and atrioventricular nodes - a consequence of vagotonia, less often intoxication in organic pathology of the heart.
Extrasystole may be the result of increased automatism of some cells of the conduction system outside the sinus node.
Diagnostic electrocardiographic criteria are not always sufficient to distinguish between nodal and atrial extrasystoles, so the physician has the right to use the general term “supraventricular extrasystoles”.
Another type of extrasystole - ventricular - has long been considered the most common type of rhythm disturbance in children. But recently it has been established that many extrasystoles previously considered ventricular are in fact supraventricular with an aberrant QRS complex. In healthy children, single, single-focus, usually right-ventricular extrasystoles are more common. This extrasystole is based on vegetative dystonia.
Symptoms and diagnosis of ventricular extrasystole
In most cases, idiopathic ventricular extrasystole is asymptomatic. About 15% of older children with frequent ventricular extrasystole describe "interruptions" or "gaps", "skipped beats" in the heart rhythm. Other symptoms include asthenovegetative complaints reflecting dysfunction of the sympathetic or parasympathetic division of the autonomic nervous system (rapid fatigue, sleep disturbances, headaches, sudden attacks of weakness, dizziness, poor tolerance of transport, cardialgia). In ventricular extrasystole that develops against the background of organic heart pathology, the severity of clinical symptoms depends on the underlying disease. Electrocardiographic criteria of ventricular extrasystole are the presence of premature ventricular contractions with a deformed wide QRS complex (more than 60 ms in children under 1 year, more than 90 ms in children from 1 year to 3 years, more than 100 ms in children 3-10 years, more than 120 ms in children over 10 years), which sharply differs in morphology from the main sinus rhythm. The P waves are absent or inverted and are recorded after the ventricular complex, the ST segment and the G wave are discordant with the extrasystolic QRS complex, and fusion complexes are possible. Ventricular complexes may be almost not expanded or expanded slightly with ventricular extrasystole from the base of the high posteroinferior branching of the left bundle branch of His or with the participation of macro-re-entry along the bundle branches of His.
Topical noninvasive diagnostics of ventricular extrasystole based on ECG data is performed based on a number of algorithms. Right ventricular extrasystoles are characterized by the ventricular complex morphology of the left bundle branch block type, left ventricular extrasystoles are characterized by the right bundle branch block type. This rule has exceptions due to the fact that ECG data reflect subepicardial electrophysiological processes to a greater extent, and extrasystoles originating from endocardial zones can change their morphology. Overcoming a significant distance from the endocardium to the epicardium. The most unfavorable are load (sympathetic-dependent), as well as early and very early ventricular extrasystoles superimposed on the descending knee of the T wave, its apex or ascending knee, sometimes on the end of the ST segment of the preceding normal QRS complex.
Considering the fact that not every type of extrasystole indicates vegetative dystonia, all patients with extrasystole should undergo ECG recording at rest and under load with consultation with a cardiologist. In clinical practice, extrasystole is usually detected accidentally - during examination during a respiratory disease or soon after it. Apparently, this is due to the hyperactivity of trophotropic devices in the early period of recovalescence, when the vagus tone prevails, against the background of decreased activity of sympathoadrenal mechanisms. Sometimes children themselves actively complain of "blows" in the chest, note heart rhythm disturbances, but this applies to a greater extent to the older age group. In general, complaints associated with extrasystole or manifestations of hemodynamic disorders are absent. Such manifestations as dizziness, weakness are noted only with extrasystolic arrhythmia against the background of severe heart damage with a disorder of general hemodynamics.
Children with extrasystole in the structure of vegetative dystonia present complaints of a traditional nature - increased fatigue, irritability, dizziness, periodic headache, etc. Analysis of the life history of these children shows that 2/3 of children with extrasystole had pathology of the pre- and perinatal period. The role of foci of chronic infection, in particular chronic tonsillitis, in the genesis of extrasystole, as shown in recent years, is clearly exaggerated. Even tonsillectomy does not relieve children of this arrhythmia, which confirms only the predispositional role of this type of pathology. In terms of their physical development, children with extrasystole do not differ from their peers. Therefore, clinical assessment of extrasystole must be carried out comprehensively, taking into account complaints, anamnesis, the state of the cardiovascular, central and vegetative nervous systems.
An important feature of extrasystole in vegetative dystonia is a decrease in the frequency of extrasystoles in the orthostatic position, during physical exertion (bicycle ergometry), during a test with atropine, which confirms the dependence of arrhythmia on the state of the parasympathetic division of the ANS (the so-called labile extrasystoles of rest). Cardiologists divide extrasystoles into rare (up to 5 per 1 min), medium frequency (6-15 per 1 min), frequent (more than 15 extrasystolic complexes per 1 min). It is customary to count extrasystoles per 100 QRS complexes; frequent are those that make up more than 10%. When using daily heart rhythm monitoring, a clear connection is noted between the frequency of extrasystoles and the functional states of the child's body - a decrease in the frequency of extrasystoles during the period of maximum activity, play; an increase in frequency - during a period of relative rest, in the deep stages of sleep.
In the autonomic nervous system, assessed on the basis of traditional criteria, children with extrasystole have a predominance of the parasympathetic section - vagotonia - or dystonia with prevalence of vagotonic signs (marbling of the skin, increased sweating, diffuse, red, elevated dermographism, etc.). These children often suffer from vestibulopathy, increased meteosensitivity and meteotropism. They have other viscerovegetative manifestations - nocturnal enuresis, biliary dyskinesia, gastroduodenitis.
Vegetative reactivity is increased in most cases - hypersympathicotonic. Children with vegetative dystonia and extrasystole, as a rule, have insufficient vegetative support for activity (hyperdiastolic, asympathicotonic variants of the clinoorthotest are recorded in 2/3 of children). Carrying out a bicycle ergometric load confirms the inadequacy of the reactions of the cardiovascular system, which is manifested by an increase in pulse rate with an insufficient increase in blood pressure (in healthy people, systolic blood pressure increases proportionally to the increase in heart rate), in patients, physical performance and tolerance to stress are reduced. These data confirm the functional insufficiency of the ergotropic devices of the autonomic nervous system, manifested by maladaptive reactions of the sympathetic department.
The study of the central nervous system of children with extrasystole reveals mild residual symptoms in the form of individual microorganic signs. Their combination with hypertensive-hydrocephalic syndrome diagnosed by craniograms and echoencephaloscopy indicates a residual nature of organic cerebral insufficiency resulting from an unfavorable course of pregnancy and childbirth. Analysis of the state of nonspecific systems of the brain of children with extrasystole, conducted by the polygraphic method in different functional states, shows dysfunction of the structures of the limbic-reticular complex, manifested by insufficiency of activating and predominance of deactivating (inhibitory) apparatuses. Cerebral changes are more pronounced in right ventricular extrasystoles with an aberrant QRS complex. Local epileptic activity on the electroencephalogram in patients with extrasystole was not noted.
In the psychological aspect, this category of patients was largely similar to children with arterial hypotension. At the same time, anxiety and depressive disorders with extrasystole were expressed much more mildly, hypochondriacal fixation on the state of one's own health was less. It should be noted that, despite emotional lability and a high level of neuroticism, children with extrasystole did well at school, the number of interpersonal conflicts they had was significantly less than with other types of arrhythmia.
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Classification of ventricular extrasystole
Ventricular extrasystoles are divided depending on their location into right ventricular (most often from the outflow tract in children) and left ventricular. According to the frequency of occurrence, ventricular extrasystoles are divided as follows: less than 30 per hour, 30-100 per hour, 100-600 per hour, more than 600 per hour (or up to 5 per minute), 5-10 per minute, more than 10 per minute; or up to 15,000 per 24 hours and more than 15,000 per 24 hours. Ventricular extrasystoles with a frequency of occurrence of more than 5 per minute (according to ECG data) or more than 300 per hour (according to Holter monitoring data) are considered frequent. Ventricular extrasystole with a registration frequency of more than 15,000 per day according to Holter monitoring data is considered critical from the point of view of assessing the probability of developing secondary arrhythmogenic changes in the myocardium in children.
By morphology, there are monomorphic ventricular extrasystoles (one morphology of the ventricular complex) and polymorphic (more than one morphology of the ventricular complex); by density of extrasystoles - single ventricular extrasystoles and paired (paired); by periodicity - sporadic and regular; by time of occurrence and degree of prematurity - early, late and interpolated. Taking into account the circadian representation, ventricular extrasystoles are classified as daytime, nighttime and mixed.
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Treatment of ventricular extrasystole in children
The issues of treating extrasystole have not been developed sufficiently to date, they contain many controversial issues, apparently due to different assessments of the degree of organic involvement of the heart in extrasystole. Children usually do not have to be prescribed antiarrhythmic drugs. Therapy should be complex and long-term. The issues of drug treatment of extrasystole are described in sufficient detail in special guidelines on pediatric cardiology. It is necessary to conduct the main treatment according to the rules of therapy of the corresponding form of vegetative dystonia using the entire arsenal of non-drug means (acupuncture, physiotherapy, etc.), psychotropic and general tonic drugs, psychotherapy.
Children with ventricular extrasystoles, as a rule, do not require emergency therapy. Children with rare ventricular extrasystoles in the absence of data for organic heart disease, central hemodynamic disturbances do not require treatment. They need dynamic observation at least once a year, and in the presence of clinical symptoms, Holter monitoring is recommended once a year. Interventional treatment is not indicated.
In case of frequent idiopathic ventricular extrasystole, it is necessary to monitor the state of central hemodynamics, a change in which in the form of a decrease in the ejection fraction and an increase in dilation of the heart cavities is considered an indication for interventional treatment.
Drug treatment of vagal-dependent ventricular extrasystoles includes correction of neurovegetative disorders. If signs of diastolic dysfunction of the myocardium are detected according to echocardiography data, disorders of the repolarization process according to ECG or stress tests, metabolic and antioxidant therapy is recommended. Children with ventricular extrasystoles against the background of heart diseases are shown treatment of the underlying disease, correction of metabolic disorders in the myocardium, hypokalemia and hypomagnesemia.
Indication for interventional treatment (radiofrequency catheter ablation) or antiarrhythmic therapy (if radiofrequency catheter ablation is impossible) in children with ventricular extrasystoles is frequent (more than 15,000 ventricular extrasystoles per day) extrasystole, accompanied by the development of arrhythmogenic dysfunction. It is important to use the most gentle protocol of radiofrequency effects in children. In the immediate postoperative period, it is recommended to conduct a control echocardiographic study, Holter monitoring. Preference in prescribing antiarrhythmic therapy is given to beta-blockers, they reduce the risk of ventricular tachycardia and ventricular fibrillation, do not worsen myocardial function in case of circulatory failure. Selection of antiarrhythmic drugs is carried out under the control of ECG data and Holter monitoring, taking into account the saturation doses and the circadian nature of the arrhythmia. It is advisable to calculate the maximum therapeutic effect of the drug taking into account the periods of the day in which ventricular extrasystole is most pronounced. The exceptions are long-acting drugs and amiodarone. If there are indications in the anamnesis of a possible connection between arrhythmia and an infectious disease, a single course of treatment with NSAIDs is administered. In the case of the addition of symptoms of circulatory failure, ACE inhibitors are prescribed.
The prognosis in children with ventricular extrasystoles against the background of organic heart disease depends on the effectiveness of treatment of the underlying disease and the degree of arrhythmia control. Criteria for a favorable prognosis: monomorphic ventricular extrasystole, suppressed by physical exertion, hemodynamically stable (effective), not associated with organic heart disease.
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