QRS PROLONGATION DOES NOT PREDICT MALIGNANT VENTRICULAR ARRHYTHMIAS AND SUDDEN DEATH IN PATIENTS FOLLOWING NEONATAL TETRALOGY OF FALLOT REPAIR

Abstract OBJECTIVES The long-term outcome of tetralogy of Fallot (TOF) is determined by progressive right ventricular (RV) dysfunction through pulmonary regurgitation (PR) and the risk of malignant arrhythmia. Although mechano-electrical coupling in TOF is well-known, its time effect on the inducibility of arrhythmia remains ill-defined. The goal of this study was to investigate the mechano-electrical properties at different times in animals with chronic PR. METHODS PR was induced by a transannular patch with limited RV scarring in infant pigs. Haemodynamic assessment included biventricular pressure–volume loops after 3 (n = 8) and 6 months (n = 7) compared to controls (n = 5). The electrophysiological study included endocardial monophasic action potential registration, intraventricular conduction velocity and induction of ventricular arrhythmia by burst pacing. RESULTS Progressive RV dilation was achieved at 6 months (RV end-diastolic volume 143 ± 13 ml/m2—RV end-systolic volume 96 ± 7 ml/m2; P < 0.001), in association with depressed RV contractility (preload recruitable stroke work-slope: 19 ± 1 and 11 ± 3 Mw.ml−1.s−1 for control and 6 m; P < 0.001) and left ventricular contractility (preload recruitable stroke work-slope: 60 ± 13 and 40 ± 11 Mw.ml−1.s−1 for control and 6 m; P = 0.005). Concomitant to QRS prolongation, monophasic action potential90-duration and dispersion at the RV and left ventricle were increased at 6 months. Intraventricular conduction was delayed only in the RV at 6 months (1.8 ± 0.2 and 2.4 ± 0.6 m/s for group 6M and the control group; P = 0.035). Sustained ventricular arrhythmias were not inducible. CONCLUSIONS In animals yielding the sequelae of a contemporary operation for TOF, mechano-electrical alterations are progressive and affect predominantly the RV after midterm exposure of PR. Because ventricular arrhythmias were not inducible despite significant RV dilation, the data suggest that the haemodynamic RV deterioration effectively precedes the risk of inducing sustained arrhythmia after TOF repair and opens a window for renewed stratification of contemporary risk factors of ventricular arrhythmias in patients operated on with currently used pulmonary valve- and RV-related techniques.

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QRS Complex Enlargement as a Predictor of Ventricular Arrhythmias in Patients Affected by Surgically Treated Tetralogy of Fallot: A Comprehensive Literature Review and Historical Overview

ISRN Cardiology ◽

10.1155/2013/782508 ◽

2013 ◽

Vol 2013 ◽

pp. 1-8 ◽

Cited By ~ 8

Author(s):

Pier Paolo Bassareo ◽

Giuseppe Mercuro

Keyword(s):

Tetralogy Of Fallot ◽

Ventricular Arrhythmias ◽

Surgical Repair ◽

Strong Predictor ◽

Term Survival ◽

Qrs Prolongation ◽

Life Threatening ◽

Qrs Duration ◽

The Impact

Tetralogy of Fallot (TOF) is a congenital heart disease frequently treated by surgical repair to relieve symptoms and improve survival. However, despite the performing of an optimal surgical repair, TOF patients are at times characterized by a poor long-term survival rate, likely due to cardiac causes such as ventricular arrhythmias, with subsequent sudden death. In the 80s it was irrefutably demonstrated that QRS prolongation ≥180 msec at basal electrocardiogram is a strong predictor for refining risk stratification for ventricular tachycardia in these patients. The aim of this research was to undertake a review of all studies conducted to assess the impact of QRS duration on the development of life-threatening ventricular arrhythmias in repaired TOF subjects.

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Predicting Sudden Death in Patients Who Have Undergone Tetralogy of Fallot Repair:.

Journal of Cardiovascular Electrophysiology ◽

10.1111/j.1540-8167.1998.tb00873.x ◽

1998 ◽

Vol 9 (1) ◽

pp. 103-106 ◽

Cited By ~ 18

Author(s):

JOHN D. KUGLER

Keyword(s):

Sudden Death ◽

Tetralogy Of Fallot ◽

Tetralogy Of Fallot Repair

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Ventricular arrhythmias after repair of congenital heart disease: Who needs treatment?

Cardiology in the Young ◽

10.1017/s1047951100000342 ◽

1991 ◽

Vol 1 (3) ◽

pp. 177-181 ◽

Cited By ~ 27

Author(s):

Arthur Garson

Keyword(s):

At Risk ◽

Congenital Heart Disease ◽

Heart Disease ◽

Ventricular Tachycardia ◽

Sudden Death ◽

Tetralogy Of Fallot ◽

Ventricular Arrhythmias ◽

Congenital Heart ◽

Antiarrhythmic Drugs ◽

Premature Ventricular Contractions

Sudden death occurs in patients after repair of congenital heart disease. In those with tetralogy of Fallot, or a similar lesion, ventricular tachycardia has been hypothesized as the major arrhythmic mechanism for sudden death. It would be desirable to identify individuals at risk for sudden death, to determine which arrhythmia would be likely to cause sudden death, and to treat those individuals with an appropriate antiarrhythmic to prevent sudden death. For the last 10 years, physicians have been treating patients with antiarrhythmic drugs, based on a number of criteria, the most common of which is the presence of premature ventricular contractions.1,2 The practice has recently been called into question by the CAST trial. It is the purpose of this paper to review the evidence that repair causes ventricular arrhythmias, that ventricular arrhythmias cause sudden death, and that ventricular arrhythmias should be treated prophylactically.

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Ventricular arrhythmias and sudden death in tetralogy of Fallot

Archives of Cardiovascular Diseases ◽

10.1016/j.acvd.2016.12.006 ◽

2017 ◽

Vol 110 (5) ◽

pp. 354-362 ◽

Cited By ~ 8

Author(s):

Philippe Maury ◽

Frederic Sacher ◽

Anne Rollin ◽

Pierre Mondoly ◽

Alexandre Duparc ◽

...

Keyword(s):

Sudden Death ◽

Tetralogy Of Fallot ◽

Ventricular Arrhythmias

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Arrhythmias and Sudden Death among Older Children and Young Adults Following Tetralogy of Fallot Repair in the Current Era: Are Previously Reported Risk Factors Still Applicable?

Congenital Heart Disease ◽

10.1111/chd.12153 ◽

2013 ◽

Vol 9 (5) ◽

pp. 407-414 ◽

Cited By ~ 15

Author(s):

Swati Arya ◽

Julie Kovach ◽

Harinder Singh ◽

Peter P. Karpawich

Keyword(s):

Risk Factors ◽

Young Adults ◽

Sudden Death ◽

Tetralogy Of Fallot ◽

Older Children ◽

Children And Young Adults ◽

Tetralogy Of Fallot Repair

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Management of arrhythmias in patients with a tetralogy of Fallot

Cardiology in the Young ◽

10.1017/s1047951113001789 ◽

2013 ◽

Vol 23 (6) ◽

pp. 888-895 ◽

Cited By ~ 3

Author(s):

Jamie A. Decker ◽

Jeffrey J. Kim

Keyword(s):

Sudden Death ◽

Tetralogy Of Fallot ◽

Congenital Heart ◽

Surgical Repair ◽

Treatment Strategies ◽

Late Development ◽

Significant Percentage ◽

Different Types ◽

Life Threatening ◽

Tetralogy Of Fallot Repair

AbstractAlthough arrhythmias are commonly found in patients with all different types of congenital heart disease, perhaps no patient is at higher risk of late development of arrhythmias that may result in sudden death than in the patient following tetralogy of Fallot repair. Despite major improvement in the surgical repair of this disease, a significant percentage of these patients continue to remain at risk for the late development of arrhythmias, and a small percentage will develop life-threatening arrhythmias and sudden death. Which patients remain at highest risk is still not clearly delineated. Diligent arrhythmia surveillance and aggressive treatment strategies are necessary to minimise this risk. This article highlights important strategies to manage arrhythmia development and prevention in this patient population.

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Does transatrial-transpulmonary approach improve outcomes compared with transventricular approach in non-neonatal patients undergoing tetralogy of Fallot repair?

Interactive CardioVascular and Thoracic Surgery ◽

10.1093/icvts/ivz204 ◽

2019 ◽

Vol 29 (6) ◽

pp. 960-966

Author(s):

Xin Tao Ye ◽

Edward Buratto ◽

Igor E Konstantinov ◽

Yves d’Udekem

Keyword(s):

Tetralogy Of Fallot ◽

Valve Replacement ◽

Exercise Capacity ◽

Ventricular Arrhythmias ◽

Observational Studies ◽

Pulmonary Valve ◽

Pulmonary Valve Replacement ◽

Outflow Tract ◽

Rv Function ◽

Tetralogy Of Fallot Repair

AbstractA best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the transatrial-transpulmonary approach to tetralogy of Fallot repair in non-neonatal patients provides superior outcomes compared with the transventricular approach. Altogether, 175 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. Two randomized controlled trials (RCTs) and 3 observational studies showed that the transatrial approach resulted in better preservation of right ventricular (RV) function, whereas 4 observational studies showed no significant difference. Three observational studies showed better attenuation of RV dilatation, whereas 3 showed no difference. One RCT and 2 observational studies showed lower incidence of postoperative ventricular arrhythmias, while 1 RCT and 4 observational studies showed no difference. Two observational studies demonstrated greater freedom from reoperation, 1 RCT and 2 observational studies showed no difference, while 1 retrospective study observed a higher incidence of residual RV outflow tract obstruction and lower freedom from reoperation in infants. Two observational studies reported lower risk of requiring pulmonary valve replacement, whereas 2 reported no difference. Three observational studies reported superior exercise capacity, while 1 reported no difference. No difference in long-term survival was demonstrated. The results presented suggest that transatrial repair of tetralogy of Fallot confers superior or equivalent outcomes in terms of preservation of RV function and volume, ventricular arrhythmias, need for pulmonary valve replacement, and exercise capacity compared with transventricular repair. However, the incidence of residual RV outflow tract obstruction may be higher in infants undergoing transatrial repair.

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