Echocardiography means the ultrasonography of heart. The echo image is obtained by the reflection of stroking high-frequency sound waves (ultrasound) from heart walls, which are sent to heart through probe.

Echocardiography shows the structure (anatomy) of heart, its contractions (functions) and structural anomalies, if any, by means of, 1 (M-mode), 2 and 3 dimensional images. The defects (holes) between heart cavities and large blood vessels, the obstructions and deficiencies of cardiac valves can be detected by conventional Doppler and color Doppler echocardiography.

In which conditions is echo performed?
It is performed when a cardiovascular disease and/or murmur and alteration in heart sounds are detected during examination, as it is a noninvasive (harmless), easy applicable and secure method.

By whom is it performed?
It is performed by pediatric and adult cardiologists.

Does echo cause pain or harm?
It is a secure, harmless and painless test, however, sometimes children may cry. Patients should remain in lying position approximately for half an hour, in order to perform an optimum test. Toys, various colorful objects and cartoon videos are used to calm the anxious and crying children. The children who cannot be calmed, are given sedative medications (midazolam, for instance) orally. Patients who may be required to be given sedatives must not eat or drink (even water) for 4 hours.

ECHOCARDIOGRAPHY METHODS
Transthoracic echocardiography
Transthoracic echo is performed by panning the gel covered probe on the front-left side of the chest wall, directing it to heart from above and below the chest wall bone.

The image quality can be corrupted in patients with excessive overweight and with increased aerations in lungs (bronchiolitis, emphysema).

Transesophageal echocardiography
Transesophageal echocardiography is an echocardiographic method, which is performed by placing the probe in esophagus through mouth, in order to obtain a clearer image of the heart in certain circumstances. This procedure is performed in an environment (such as operating room, catheterization room), where the heart rate, blood pressure and respiration of the patient can be evaluated. General anesthesia is required in order to let the the probe through the throat and perform the test accurately. The procedure takes approximately 30- 60 minutes. It can be performed on both inpatients and outpatients. Outpatients are allowed to leave after they are followed up for 2-3 hours and completely wake up after the procedure.

The test is used for determination of aortic (carotid) dissections, formation of thrombus (clot) on spaces of heart and heart valves, and vegetation (infected clot), and to help surgeons during cardiac surgeries in which the vessels have been recovered. Furthermore, it is used in closure of transcatheter atrial septal defect or ventricular septal defect and to determine the size of the defect or whether the position of the device placed placed into the defect is appropriate.

Patients may feel throat ache for a few hours after the procedure. Although it is a safe method, there is a very low risk of esophageal trauma and perforation.

Intraoperative echocardiography
Intraoperative echo is performed by placing the probe directly on heart or moving it forward through the mouth to esophagus, in sterilized conditions, during surgery. The surgery practice and heart functions are evaluated with this method. Itimmediately allows to overcome the problem occurred during surgery.

Stress echocardiography
It is used to determine whether partial obstruction (that does not show indication during rest, but interrupts feeding the cardiac muscle during exercise or stress) exists in the coronary arteries, which provide blood supply to cardiac muscle. The systoles of the heart are evaluated during rest and under stress with this method. Stress can be created with exercises or with various medications (such as dobutamin or dipyridamole) that increase the heart rate or cause reduction in coronary blood flow. When it is performed with medications, It is called pharmacologic stress echocardiography when performed with medications. Pharmacologic stress is preferred since performing echocardiography is difficult during the exercise.

Fetal echocardiography
The heart of an unborn baby (fetus) can be evaluated withfatal echo. This is the most practical and safe method. It is performed by panning the gel covered probe on the abdomen of the mother. It is suggested to perform the first fetal echo between the 18th and 20th weeks of pregnancy, but it can also be performed on the following weeks. It does not cause any harm in mother and in fetus.

Fetal echocardiography is performed if suspicious conditions related with the hearts of the babies occur during the routine ultrasonography, in case of problems of mothers and/or families that may effect the babies' heart health or it is performed upon request of the families.

USAGE AREAS OF FETAL ECHOCARDIOGRAPHY

• Definition of cardiovascular system morphology

• Evaluation of heart rhythm, rate and function disorder

• Monitoring of arrhythmias and fetal cardiac functions

• Follow-up of treatments of arrhythmia and heart failure

• Observation of adverse effects of treatment in fetus which will be applied to mother

• In case of patient being in severe cardiac diseases group during intrauterine period it can give an idea to gynecologists to determine the birth time and method when there is an apparent cardiac disease (that can be completely recovered with surgical treatment after delivery) or when the pregnancy cannot be terminated due to advanced maternal age, or the family do not prefer to terminate the pregnancy. In such a case it is suggested the birthing is performed in a center, where the required medical and surgical treatments can be performed for the newborn.

• If it will not be possible to recover completely with surgical methods after birthing, or if the fetus is in severe cardiac diseases group during intrauterine period, the family is informed that the pregnancy can be terminated before the 24th week (or before the legally specified time of period).

• It is provided that the family receives genetic consultancy. The family can be informed whether the pregnancy can be maintained or not, in accordance with the severity of the cardiac disease, if the termination is not an alternative genetically.

• It helps new treatment methods such as prenatal surgery and interventional catheter procedure, to be developed and performed.

• The pregnant that have fetus with severe or apparent cardiac diseases should be directed to tertiary centers which have newborn care unit, pediatric cardiology and cardiovascular surgery services.

Considerations before echo test
General anesthesia is required for only transesophageal echo among the echo tests, for this reason, patients should fast at least for 6-8 hours before this test. Fasting is not necessary for other echo tests. Since hunger causes unease and cry in little children, it is suggested for them to be with a slightly full stomach.

If additional preparations are required related with the features of the test, please comply with the instructions of your physician.

How is daily appointment queue of echo test determined?
Echo appointments are scheduled in two groups; morning and afternoon. Any patient in these groups may be tested in accordance with the busyness of test room and type of the test. As the patients should be quite and calm during test, PRIORITY IS GIVEN TO SLEEPING CHILDREN, EMERGENCY PATIENTS AND INPATIENTS IN DIFFICULT SITUATION. Thus, patients should allocate approximately 2-3 hours of their time for the test, and they should not hurry about queue.

When will you receive your echo result?
Echo results are submitted immediately after the test. By means of clearness of echo images, several patients can be referred to surgeries without the need of advanced tests (e.g. cardiac catheterization). On the COUNCIL MEETING to be held on the first Wednesday after the echocardiographic test, such patients are discussed based on their histories, physical examinations and test results physical examinations and test results and after the meeting the defined treatment plans are immediately submitted to the families of patients.

After historical, physical, ECG and echocardiographic examinations there are two main reasons to perform cardiac catheterization- angiography on patients. Firstly, it is performed to obtain detailed information on the anatomies and functions of hearts of children with congenital or acquired cardiac diseases (diagnostic cardiac catheterization). Secondly, treatment of certain cardiac anomalies is aimed with interventional cardiac catheterization (therapeutic interventional cardiac catheterization).

What is diagnostic cardiac catheterization-angiography?
It is a test performed for obtaining detailed information on the structure of heart and on how it works. In this procedure, thin and small plastic tubes (catheters) are moved to heart through the blood vessels or arteries in inguinal or neck regions, the blood pressure in all heart cavities and in large vessels are measured and blood samples are collected. Furthermore, images of heart are obtained by injecting contrast agents (dye can be displayed on X-ray) to heart cavities and blood vessels with catheters. By means of this, the complex cardiac anomalies can be diagnosed and the type of surgery can be planned.

In most of the patients, general anesthesia is not required during diagnostic cardiac catheterization. The procedure can be performed by reducing the anxiety and pain with a sedative medication. It takes approximately 1-3 hours. After the procedure, the patients are monitored by being hospitalized for a day. The patients can continue their daily lives on the following day.

What is therapeutic interventional cardiac catheterization-angiography?
As in diagnostic cardiac catheterization, the procedure is performed by moving the catheters to heart with the help of a needle through the blood vessels in inguinal or neck regions. By means of this, the congenital or acquired cardiac disease can be treated without surgery. Closure of heart defects, recovery of valve or vessel stenosis are the most common procedures. The major heart defects that can be closured with interventional cardiac catheterization are patent ductus arteriosus (PDA), atrial septal defects (ASD), patent foramen ovale (PFO) and ventricular septal defects. In the department Amplatzer devices, Cook and pfm coils are frequently used in closure of these defects. Major stenoses that can be treated with interventional cardiac catheterization are pulmonary valve stenosis, aortic valve stenosis, peripheral pulmonary artery stenosis and aortic coarctation. Normally, balloon catheters are used during these procedures.

During interventional cardiac catheterization general anesthesia is administered to most of the patients for the safety of procedures and patients. Patients are discharged from hospital after being monitored for a day, following the procedure. They continue their daily lives immediately after they are discharged.

In where is cardiac catheterization-angiography performed?
It is performed in digital catheterization room which is recently renewed, in Pediatric Cardiology Unit. Recently purchased angiography device is two-armed and images from different sides can be displayed simultaneously. Thus, more images can be obtained with less amount of contrast agent. With this feature, the pediatric cardiac catheterization room is one of the few centers in Turkey.

By whom is the cardiac catheterization-angiography performed?
It is performed by Pediatric Cardiologists with the supports of assistant health personnel such as technician, nurse. When patient require general anesthesia an Anesthesiologist also participates in the procedure.

What are the considerations before the cardiac catheterization appointment?

• • Beginning from the night before, older children should fast for at least 8-12 hours and younger children should fast for 4-6 hours.

• • You should bring the medications that you use constantly with you.

• • You should ask your physician whether there are medications to be terminated prior to your appointment.

• • Patients with other chronic diseases (e.g. diabetes) should receive permission from related departments regarding cardiac catheterization.. Particularly, patients with diabetes should not take their diabetes medications (insulin or pill) on the morning of appointment day. Otherwise, your blood glucose may decrease to undesired levels, since you are hungry.

• • Please bring all documents related with your health coverage, private life insurance card or institution referral with you.

• • Please learn whether your official documents such as referral papers are expired or not.

• • You should bring your hospital file with you, if it is at home.

• • Please definitely bring the angiography film and report with you, if your patient had angiography before.

• • If your patient had a surgery in another center, please definitely bring the surgery report with you.

• • Please bring all blood test results, films and reports, if any, related with your disease.

How is daily appointment queue of cardiac catheterization-angiography test determined?
Patients are taken to cardiac catheterization test IN ACCORDANCE WITH THE APPOINTMENT QUEUE. However, the priority is of infants and younger children in cardiac catheterization test. Also, patients in case of emergency and inpatients who are in difficutl situation will HAVE PRIORITY FOR THE TEST

When will you receive the cardiac catheterization-angiography result?
The results of cardiac catheterization are evaluated soon after the test and submitted to family of the patient. However, final report is generally submitted after the COUNCIL meeting on the following Wednesday, after the catheter procedure. The defined further plans (when and how the patient will be operated if required, when the patient will come to control examination if she/he is needed to be observed clinically) are submitted along with the final report.

In the unit, conventional treadmill exercise test is practiced.

What is the aim of exercise test?

• It can be determined that whether the patient has coronary artery disease.

• Valve diseases can be evaluated and their effects on heart functions can be defined.

• By defining the exercise performance of heart, treatment of the cardiac disease can be planned or the anxiety of the patient can be removed if the heart is normal.

• With the exercise, it can be determined whether a rhythm abnormality has occurred.

• While several heart diseases do not indicate symptoms during rest, they indicate during exercise. To give an example, mild or moderate aortic valve stenoses or cardiomyopathies (cardiac muscle diseases) can be types of such pathologies.

How does exercise test detect heart diseases?
Cardiac muscle need more blood during exercise to meet increased work load. Adequate blood flow to heart muscle cannot be supplied due to a coronary artery stenosis and specific changes reveal in ECG. These changes can be revealed with ECG records acquired before, during and after the exercise. In addition, for patients with aortic valve stenosis or cardiac muscle contraction, heavy exercises cannot be tolerated as adequate blood cannot be pumped.

What are the considerations before the test?
As the patient will quickstep and run and also will sweat during the test, it is suggested to bring comfortable trainers and extra clothing.

How is the test performed?
During the exercise test, the ECG and blood pressure are recorded periodically while the patient is on a treadmill of which speed and slope are increased periodically.

While the patient is resting the blood pressure is measured and ECG is recorded and the treadmill is switched on once more and the patient is asked to walk on it. The speed and slope of the treadmill is increased in every 3 minutes. ECG and blood pressure are followed up continuously. If the patient gets tired as much as not to continue the test, if severe chest pain occurs at the moment and if ECG and blood pressure shows any evidence of pathological findings, the test is terminated.

Is exercise test reliable?
The test results may be normal for patients with coronary artery diseases sometimes, and abnormal for healthy patients. During the exercise, cardiac muscle perfusion scintigraphy may be performed with a radioactive material (Thallium or Technetium). Stress echocardiography can be performed.

What are the risks and disadvantages of exercise test?
It is the safest and most common one of cardiologic tests. Death risk is extremely low. However, it may seldom cause cardiac rhythm problems and heart attacks. The physician that performs the exercise test and the substructure of the department have features to cope with the potential problems.

When is exercise test performed?
It is performed every day of the week. As the test takes approximately 15 minutes, appointments are scheduled for a specific number of patients every day.

Definitive diagnoses and treatments of all types of heart rhythm disorders (heart rate disorder, arrhythmia) are conducted at Electrophysiology Laboratory of Pediatric Cardiology Subdivision of Hacettepe University Faculty of Medicine.

• Normal heart conduction system and normal cardiac rhythm Arrhythmias (abnormal rhythms)

• Electrophysiology Laboratory- Tests used in diagnosis of Arrhythmia (rhythm disorder)

• Electrocardiogram (ECG)

• Heart rate variability (HRV)

• Ambulatory ECG (Holter monitoring)

• Event recorder

• Transesophageal electrophysiological study

• Tilt testing

• Intracardiac electrophysiological study

• Arrhythmia treatment

• Pacemaker

• Implantable cardiac defibrillator

• Radiofrequency Catheter Ablation (RFA), Cold Ablation

Normal heart conduction system and normal cardiac rhythm
A normal heart is a strong pump composed of four heart chambers; two atria (right and left atrium) and two ventricles (right and left ventricle). The upper two atria collect blood from the body and lungs and pump it to the ventricles below. Ventricles pump the blood back to the lungs and the body. The blood flows in one direction due to the opening and closing movements of several valves within the heart

Each heart beat begins with a small electrical impulse produced by a special tissue (sinus node) at the right atrium. This impulse spreads to muscle tissue composing the atria after coming outside of the sinus node, and causes atrial contraction. Then, the same electrical impulse reaches another special tissue (atrioventricular node, AV node) which is located between the atria and ventricles. AV node takes the electrical impulse coming from the atria and keeps it for a while, and then transmits it to the ventricular muscles through special ways and ventricles contract rapidly. The waiting period in AV node, allows the ventricles to be filled with blood. If the heart is working normally, these specialized cells make impulses about 70-110 times in older children. This rate increases as the age decreases.

Arrhythmias
An arrhythmia is an abnormal heart rhythm. These can be either irregular heartbeats or faster (tachycardia) and slower (bradycardia) heart rhythms.

What are the reasons of arrhythmia?
A large part of arrhythmias occur in children who have healthy hearts. However, it is known that arrhythmias in children are related with heart abnormalities. Therefore, children with arrhythmia complaint should be examined in terms of heart abnormality. Furthermore, medication use, excessive caffeine intake, smoking and stress factors that can lead to arrhythmias must be questioned.

Do arrhythmias have familial (genetic) types?
Some certain types of arrhythmias and heart diseases may be hereditary and may occur in the same family more frequently. In addition, it is known that, certain genetic diseases cause certain arrhythmias and heart diseases. When such diseases occur, the whole family is screened in order to identify the disease and if needed they can be researched by a center performing genetical tests. Long term QT syndrome can be given as an example of such diseases.

What kind of complaints do arrhythmias cause and what are the syptoms?
Arrhythmias may cause fast heartbeats, fluttering in the chest, weakness, dizziness, blackout, fainting or chest pain.

What are the normal and abnormal heart rhythms?

Normal sinus rhythm: It is a impulse-generating heart rhythm coming from the sinoatrial node on the upper part of right atrium. While the node generates 70-110 impulse per minute in older children, the heart rate increases as the age increases.

Sinus arrhythmia: These are the variations in heart rate, caused by respiration. It is observed in younger children more frequent. It is thought to be normal.

Sinus tachycardia: It is the faster heart rate than normal heart rate originating from sinotrical node in comparison with the determined age.
Sinus bradycardia: It is the lower heart rate than normal heart rate originating from sinotrical node in comparison with the determined age.
premature electrical impulse in the heart, generated above the level of theventricle.

Supraventricular extrasystole: These are the premature heart contractions originating from atria. It is frequently seen in healthy children. It rarely shows symptoms.

Supraventricular tachycardia (SVT): It is the fast heartbeat attack originating from the heart's upper chambers (atria).It can last as short as seconds or it can continue for days. Normally, during this period, the heart rate is over 150 beats/min.

Wolff–Parkinson–White syndrome (WPW): It is the most common reason of STVs in children. It occurs due to the presence of additional electrical conduction pathway,accessory pathway, between the atria and ventricles. Accessory pathway can be detected by ECG. While it can disappear by itself during infancy, after this period it can rarely recover by itself.

AV nodal reentrant tachycardia: It occurs in adults more commonly. It is seen in infants rarely. It occurs due to the presence of an extra pathway in AV node. It occurs and terminates suddenly.

Atrial flutter: It rarely occurs in children. It is caused by an abnormal electrical circulation in atria. It generally occurs in patients at increased ages, who had surgeries due to complex cardiac anomalies.

Atrial fibrillation: It rarely occurs in children. It is the irregular SVT due to multiple irregular electrical impulses origining from atria. It is rarely familial. I may also occur after the cardiac surgeries.

Ventricular extrasystole (VES, premature heartbeats due to ventricles): While it occurs in children with healthy heart, it may be an indication of an abnormality, thus it should be examined.

Ventricular tachycardia: These are the regular and fast heartbeats caused by ventricles. While it can last for minutes- hours (long duration), it may also take less than 30 seconds. Generally, it may occur along with an underlying heart disease.

Ventricular fibrillation: It is the irregular and critically too fast heart rhythm originating from ventricles. In this case, as the heart does not contract sufficiently, it cannot pump blood.

Heart block: The electrical impulse which begins from the upper chamber of heart (right atrium), passes through certain pathways until arriving in lower ventricles. The electrical impulse coming from the upper part cannot be conducted to lower ventricles, due to the blockage in any of those pathways. Therefore, the concordance between atria and ventricles is corrupted. In this case, lower ventricles contracts in lower rates than upper atria.

Sick sinus syndrome: It is the occurrence of excessive deceleration and pause of electrical impulse origining from sinoatrial node due to the damage in sinoatrial node because of a certain heart disease or a surgery. It may cause abnormal low heart rates.

Tests used in electrophysiology
Electrocardiogram (ECG)
It is a procedure of recording the electrical activities of heart on a paper by affixing electrodes to certain parts of the body. Patients do not feel anything during recording. If it is requested by the physician, ECG can be recorded and evaluated within the same day.

Heart rate variability (HRV)
It is obtained with examining the short-term (5 min.) or long-term (24 hours) ECG records. It gives information on autonomic control of heart by the examination of variations (oscillations) in heart rate.

Ambulatory electrocardiogram (Holter monitoring)
Similar to ECG, it is a procedure of recording heart’s electrical activities on a tape or on a disk for 24-48 hours with electrodes connected to body and a small device, then examining the records with a computer. The patient is allowed to go home after the device is affixed to the body of the patient between 09:00-11:00 in the morning , then is told to come back for the device to be removed 24-48 hours later, at 09:00 at the latest. So, the changes on ECG that may indicate ischemia can be detected in addition to the abnormal rhythms and extra heart beats, and the effectiveness of the treatment can be defined.

Holter appointment
At most 5 appointments can be scheduled per day, as there are 5 recording devices in the department. The appointments are scheduled at Holter room in Pediatric Cardiology Subdivision by telephone or by applying in person within working hours.

When are Holter results submitted?
The results are given to patients in the afternoon of the same daythat devices are delivered back.

What are the considerations before Holter test?
You should bring 2 ‘’DURACELL’’ alkaline batteries of 1.5 volts with you. You can get them from the canteen by the entrance of gate 7. As the devices will be affixed to other patients after you it is necessary to deliver the devices on time.

Event recorder: It is a beeper-sized device that enables defining the arrhythmias which could not be defined with Holter test and it remains on patients for 15 days. Thus, the appointments are scheduled for every 15 days. There are 2 event recorder devices in the department. When the patient has discomfort she/he presses the button on the device, then the device begins recording and it records during the time it is programmed. Afterwards, the records are examined on computer.

How is an event recorder appointment scheduled?
It can be scheduled at the same place of Holter appointment by phone or by applying in person.

What are the considerations before the event recorder appointment?
You should bring an alkaline battery with you.

When are the results submitted? After patient’s records are delivered to the department, the results are submitted on the very same day.

Transesophageal electrophysiologic study (TEEPS)
It is a semi-invasive method and can be used to determine the causes of fast heart beats (tachycardia) or to treat (transforming fast heart beats to normal sinus rhythm) it. TEEPS is used in order to record the electrical activity in atria, to impulse atria temporarily, to evaluate function of conduction, to clarify the mechanism of arrhythmia and to terminate tachycardia. It can be performed for all age groups and it takes approximately 15-30 minutes.

How is TEEPS performed?
In this method, a catheter (a thin, soft and flexible plastic tube) with a metal tail end is placed on the back part of atria from nostril through alimentary canal (esophagus) by establishing vascular access in electrophysiology laboratory after 3 hours of fasting and giving a sedative medication to the patient. Since the alimentary canal is just near the atria, the ECG records acquired from there provide more precise information than the surface ECG. Tachycardia is tried to be stimulated by giving electric current to the catheter inserted to the alimentary canal of the child through nose and by transfusing medications, for a certain time and in a certain intensity which is, then the type of stimulated tachycardia is defined and necessary treatment is decided.

TEEPS method is used for stimulating tachycardia, determining the mechanism of tachycardia, identifying the patient in risk of Wolff–Parkinson–White syndrome, specifying the effectiveness of medication treatment used, terminating tachycardia and in controlling the patients who are subjected to tachycardia treatments with ablation methods. This method is insufficient in detecting ventricular tachycardia.

It is also safe for infants. Although it is a low-risk method, it may cause resistant arrhythmia and tachycardia and also slight scratchiness in alimentary canal. Therefore, t is good for the patients to take liquid foods which are not very hot or cold, for 12 hours after the procedure.

When is the result submitted?
The test is evaluated and submitted to the family immediately after the procedure.

When is the patient allowed to leave after the procedure?
Hospitalizing the patient after the procedure is not necessary. The patient is observed for 1 hour following the procedure and allowed to go home after recovering oneself.

Tilt testing (Tilt table test)
The procedure is performed by monitoring (tracing the heart beats on the display) the patient and establishing the vascular access in an environment where all kinds of interventions can be practiced in case of emergency. The patient is laid down on a moving table. Patient is tied to the table with special belts to prevent falling in case of fainting during the test. Table is tilted 60-80 degrees and the patient is observed approximately for 45 minutes, tension and pulse are controlled in every 5 minutes. In case of severe decreases of blood pressure and slow down of pulsation, or fainting, the test is immediately terminated. It is used to determine the cause and definitive diagnosis of the fainting. Since the test takes more than 1 hour with the preparation and resting periods, tilt testing is performed to one patient per day. Tests are performed after 15:00 on appointment date. Patients can go home after the test.

What are the considerations before the test?
Unless indicated otherwise by your physician, you should fast for 2-3 hours before the test.

Intracardiac (through the heart) electrophysiological study (IEPS)
Intracardiac electrophysiological study may be necessary to determine the features of electric conduction system of heart, to define and treat the causes of abnormal rapid heartbeats (tachycardia). In this procedure, a catheter (a thin, soft and flexible plastic tube) which has one or more metal tile ends, is moved from inguinal to heart through large vessels and placed in certain regions within heart. The recorded electric signals in the heart , provide more certain information than surface ECG. During the test, heart can be stimulated to beat fastly or irregularly. The response of heart against this impulse enables the cardiologist to identify the features of rhythm disorders better and to detect the pathway of the activity during tachycardia. Therapeutic interventional method can only be performed in older children. Test is performed in Electrophysiology Laboratory, located in Cardiac Catheterization room of Pediatric Cardiology, and it takes approximately 2-4 hours. After the patients are taken to the laboratory, vascular access is established and a blood pressure measuring device is inserted in order to measure the blood pressure automatically at certain intervals. Electrodes are connected to the body for following the heart rhythm (ECG) on the display. Test can be performed on easy going older children by giving only sedative medication (midazolam). To perform the test, general anesthesia (e.g. intravascular ketamine) may be required in naughty and restless children.. Patient is suggested not to eat or drink for 4 hours after the test. The patients are discharged from the hospital after being followed up for a night. It is suggested to keep away from movements that may damage inguinal region for a week after the test.

Arrhythmia treatment
There have been several options in treating rhythm disorders in children.
Common types of arrhythmia such as supraventricular and ventricular extrasystoles are usually not dangerous, thus treatment is not required. Several things without treatment can be done to terminate supraventricular tachycardias (SVT) in older children like like retching, straining. This kind of events are followed up clinically without treating. Treatment is considered if severe symptoms like dizziness, blackout and fainting are observed during fluttering (tachycardia). Treatment differs in accordance with the type of arrhythmia and whether there is an underlying heart disease. Most of the rhythm disorders, especially tachycardia are responsive to medication treatment.

Medication Treatment
Antiarrhythmic medications cannot fully treat the rhythm disorder. However, they may decrease symptoms, prevent it to begin, decrease heart rate and duration of rhythm disorder. Selection of medications may be difficult and sometimes the right medication can be found by trying various medications. All medications have adverse effects, therefore, children may be hospitalized while medication treatment with certain medications is started. During follow-up, the medication level in blood should be measured, blood tests and organ examinations should be performed due to the effects of medication on organs.

What is pacemaker?
Rhythm disorders that cause slow heart rhythm, such as heart blocks, sick sinus syndrome are the most common reasons of pacemaker usage. Apart from that, in the event of tachycardia that cause fast heart rhythms, pacemakers or implantable cardiac defibrillators can be inserted along with medication treatment. It is a small metal battery-powered device weighs 15-30 gr, and is 3.5X3.5 cm in diameter. It is placed under the chest or abdominal walls and the thin electrode is placed into the heart. it sends small electrical impulses to the heart to avoid pain.
The implantation process of pacemaker takes approximately 2 hours. Patients should fast before the operation. Then, they are discharged from the hospital after being followed-up and the chek-up process is done.

What is implantable cardiac defibrillator (ICD)?
It is used to treat fast or irregular heart rhythms and to restore heart's normal rhythm.The appearance of ICD is similar with pacemaker, but it is a little bigger. It has a role of preventing particularly resistant ventricular tachycardia. In addition to this qualification, it has cardioversion and defibrillation performing features. Implantation of the device is similar to pacemaker. Procedure takes approximately 2 hours. Patients should fast before the procedure.

How is monitoring pacemaker or ICD performed?
Patients implanted with pacemakers or ICDs should be examined with particular devices at certain intervals. Generally, batteries can be used for many years; however they should be changed at certain intervals during the lifetime of user. The battery life, electrode resistances, conductance and threshold tests are checked with a particular device placed on the permanent pacemaker or ICD. At first, after pacemaker or ICD is implanted, patients get examined at short intervals, but after 6 months if there is not a problem; patients are followed up once a 6 month. Controls of patients and batteries are performed in our division.

What is Radiofrequency Catheter Ablation (RFA), Cold Ablation?
More permanent treatment methods may require in certain types of tachycardia (fast heart rhythm) that threaten lives or interrupt the daily activities of children. The definitive treatment of tachycardia in older children is provided with RFA method, by destroying the pathways of abnormal electrical activity which generate SVT and VT.

This method may be used in tachycardia treatment if medication treatment is unsuccessful or on children older than 4 years. By means of this, patients get free from lifelong medication use.

RFA or cold ablation is a method practiced by inserting a catheter to heart. The catheter is replaced on the region that causes tachycardia, by using one of heating or cooling methods the region is destroyed and conduction of electrical current is prevented Although it is rare, there is the risk of complete heart block during the operation. Patients should fast before the operation and it may take as long as 4-6 hours. The patient is suggested to take 1 low dose of aspirin per day during 3-4 months to prevent blood clottingin the proceeded region.