Single- and dual-site ventricular pacing entirely through the coronary sinus for patients with prior tricuspid valve surgery

Abstract Background Patients with transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA (ccTGA) are prone to systemic right ventricular (sRV) failure. Atrioventricular (AV)-conduction disturbances and tricuspid regurgitation aggravate the course of sRV dysfunction. Timely tricuspid valve (TV) surgery stabilizes sRV function. However, TV surgery is an independent risk for AV-block and ventricular pacing in non-congenital cardiothoracic surgery patients. Chronic subpulmonary ventricular pacing-induced dyssynchrony further contributes to sRV failure, potentially reducing the beneficial effects of the tricuspid valve surgery. Purpose The aim of this study is to explore the incidence, timing and functional consequences of AV-conduction block requiring ventricular pacing after TV surgery in sRV patients. Methods Consecutive adolescent and adult patients with a sRV who underwent TV surgery in the period 1989–2020 and follow-up at our tertiary care center were included in this observational cohort study. Patients who were <10 years of age at the time of operation and/or died in perioperative, in-hospital, setting were excluded from analysis (n=5). Demographic and clinical data was collected from the patient records. Results Data of 28 patients (54% female, 57% ccTGA) was analysed (Figure). The mean age at surgery was 38±13 years, 5 patients (18%) received chronic ventricular pacing preoperatively. Mean follow-up was 9.7±6.8 years, during which 7 patients (25%) died and 3 (11%) underwent ventricular assist device implantation (VAD). Two patients died awaiting VAD/HTx, one patient died awaiting CRT upgrade. Seven (25%) patients underwent a re-operation, of which 3 (11%) TV replacement, 3 (11%) VAD and 1 (4%) pulmonary valve replacement. Of the 23 patients at risk of developing AV-block, 11 (48%) developed an indication for chronic ventricular pacing, of which 6 within 24 months postoperatively (4 before hospital discharge). Of the 21 patients with a device, 7 (25%) had successful resynchronization therapy (2 before TV surgery). Patients with chronic ventricular pacing had a wider QRS-duration (mean 121 ms vs 194 ms in those without pacing, p<0.001) and 43% had a severely reduced sRV function (vs 36% in those without pacing) at latest follow-up. Conclusions Patients with a failing sRV who undergo TV surgery are prone to AV-conduction abnormalities with 48% of this group developing an indication for chronic ventricular pacing during follow-up. Pacing-induced dyssynchrony can further contribute to sRV dysfunction. Implantation of an epicardial sRV lead at the time of TV surgery for future CRT may be considered to attenuate the detrimental effects of subpulmonary ventricular pacing in this heart failure prone patient group with complex anatomy, limiting transvenous possibilities. FUNDunding Acknowledgement Type of funding sources: None.

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P1012Radiofrequency catheter ablation of accessory pathways at the site of prior valve surgery

European Heart Journal ◽

10.1093/eurheartj/ehz747.0604 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J S Uhm ◽

J Kim ◽

M N Jin ◽

I S Kim ◽

H J Bae ◽

...

Keyword(s):

Catheter Ablation ◽

Tricuspid Valve ◽

Coronary Sinus ◽

Case Reports ◽

Valve Surgery ◽

Radiofrequency Energy ◽

Stepwise Approach ◽

Accessory Pathways ◽

Tricuspid Valve Surgery ◽

Bipolar Ablation

Abstract Background Radiofrequency catheter ablation (RFCA) for accessory pathways (APs) at the site of prior valve surgery remains challenging. We aimed to clarify the factors associated with successful RFCA for such APs. Methods Upon reviewing a RFCA registry and previous case reports, we included nine patients who underwent RFCA of APs at the site of prior valve surgery (total-VS group; age, 34.0 [24.5–45.0] years; men, 4/9) and 196 patients who underwent RFCA of APs with no history of valve surgery (no-VS group; age, 40.5 [23.0–54.0] years; men, 114/196). Electrophysiological features, procedural details, and outcomes were examined. Results AP exhibited decremental conduction in four of nine patients in the total-VS group. The number of RFCA attempts was significantly higher in the total-VS group than in the no-VS group (10.0 [4.5–14.5] vs 2.0 [1.0–3.0]; p<0.001). In four patients who underwent mitral valve surgery, successful RFCA was achieved using the transaortic approach, coronary sinus approach, or bipolar ablation. In three patients who underwent tricuspid valve surgery, successful RFCA was achieved using the above-prosthetics or trans-prosthetics approach. In two patients, RFCA failed. The trans-prosthetics approach and bipolar ablation technique were effective. The transaortic and coronary sinus approaches were occasionally effective. The transseptal approach was ineffective. Based on the success rate and accessibility, we suggest a stepwise approach to RFCA of APs at the site of prior mitral or tricuspid valve surgery (Figure). Stepwise approach to AP at valve surgery Conclusions Successful RFCA of APs at the site of prior valve surgery can be achieved by detailed mapping of the areas both above and below the prosthetic valve, as well as by ensuring effective radiofrequency energy delivery using various catheter approaches and RFCA techniques.

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