Qrs duration predicts life-threatening ventricular arrhythmia and death in adults with a systemic right ventricle

Introduction: Patients with D-TGA palliated with atrial switch operations have the morphologic right ventricle in the systemic position. There is increased risk of atrial arrhythmias and systemic right ventricle (SRV) failure. We sought to analyze the long term outcomes of these patients. Methods: All patients with D-TGA and SRV followed in the Adult Congenital Heart Disease Clinic of a large tertiary care institution were reviewed. A comprehensive retrospective analysis of the medical record was performed, including consult notes, ECGs, echocardiograms and electrophysiology reports. Results: A total of 154 patients (63% male) aged 29±11 years were followed for a mean of 10±9 years (range 0-51). During follow-up, 3 patients underwent cardiac transplantation and 15 died; 5 had sudden death, 2 had cardiogenic shock, 5 had non-cardiac death (i.e., infective endocarditis, sepsis) and 3 had unknown causes of death. Heart failure symptoms were present in 53(34%) patients. Severe SRV systolic dysfunction occurred in 37(24%) patients, with a mean EF of 23±5.5%; moderate SRV dysfunction occurred in 67(44%) patients, mean EF 35±4%. Sinus node dysfunction was present in 75(49%) patients, complete AV block in 9(5%) patients, and a pacemaker placed in 60(39%) patients, with cardiac resynchronization therapy in 5. Atrial arrhythmias occurred in 94(61%) patients and ablations were performed in 47(31%) patients. An ICD was implanted in 37 patients; 5 patients had appropriate shocks, but 7 had inappropriate shocks due to atrial arrhythmias. Age (HR 1.07, p=001), heart failure symptoms (HR 4.9, p= 0.007), severe SRV enlargement (HR 3.7, p=0.03), severe systolic dysfunction (HR 5.4, p=0.003), severe systemic AV valve regurgitation (HR 5.2, p=0.002) and a QRS duration> 122ms (HR 3.7, p=0.02) were significant predictors of mortality. The 15 year probability of sudden death was 3.2%(95% CI 0-6.9%). Conclusions: Atrial arrhythmias are common after atrial switch operations secondary to atriotomy scars. Further studies will need to determine whether restoration of sinus rhythm or cardiac synchrony may prevent further deterioration of the systemic right ventricle. Severe SRV dysfunction and prolonged QRS duration >122ms were significantly correlated with mortality.

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Commentary: Creating a Systemic Right Ventricle – Are You Crazy?

Seminars in Thoracic and Cardiovascular Surgery ◽

10.1053/j.semtcvs.2020.09.033 ◽

2020 ◽

Author(s):

David J. Barron

Keyword(s):

Right Ventricle ◽

Systemic Right Ventricle

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Emerging Treatment Options for the Systemic Right Ventricle: A Single Centre Experience of Sacubitril/Valsartan in Transposition of Great Arteries

Heart Lung and Circulation ◽

10.1016/j.hlc.2021.06.067 ◽

2021 ◽

Vol 30 ◽

pp. S122

Author(s):

A. Challa ◽

L. Hayward ◽

R. Maxwell ◽

K. Burns ◽

V. Wijesekera ◽

...

Keyword(s):

Right Ventricle ◽

Treatment Options ◽

Single Centre ◽

Transposition Of Great Arteries ◽

Systemic Right Ventricle ◽

Single Centre Experience

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Durable ventricular assist device implantation for systemic right ventricle: a case series

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa359 ◽

2020 ◽

Author(s):

Naoki Tadokoro ◽

Satsuki Fukushima ◽

Takaya Hoashi ◽

Shin Yajima ◽

Takura Taguchi ◽

...

Keyword(s):

Right Ventricle ◽

Ventricular Assist Device ◽

Case Series ◽

Transoesophageal Echocardiography ◽

Class Iii ◽

Assist Device ◽

Ventricular Assist ◽

Systemic Right Ventricle ◽

Computed Tomography Images ◽

Atrial Switch

Abstract Background A systemic right ventricle (RV) after atrial switch in transposition of the great arteries (TGA) or congenitally corrected TGA (ccTGA) often results in advanced heart failure in adulthood. Case summary Four patients with INTERMACS Class III underwent durable ventricular assist device (VAD) implantation for a systemic RV. Two patients were diagnosed with ccTGA and underwent tricuspid valve replacement, and two were diagnosed with TGA in childhood and underwent Mustard repair. The two patients with ccTGA received an EVAHEART (Sun Medical, Nagano, Japan) and HeartMate 3 (Abbott Laboratories, Abbott Park, IL, USA) at the age of 56 years and 34 years, respectively. Of the patients with TGA, one received a Heartmate II at age 40 years, and one received a HeartMate 3 at age 40 years. All patients were weaned from cardiopulmonary bypass without subpulmonic VAD support and transferred to the intensive care unit with optimum VAD support. No in-hospital deaths, cerebrovascular accidents, or other major complications occurred. The post-VAD right heart catheter study showed a remarkable reduction in pulmonary capillary wedge pressure in all patients. Discussion The indications for and surgical technique of durable VAD implantation for a systemic RV after atrial switch of TGA or ccTGA have not been fully established. A durable VAD, including the HeartMate 3, was successfully implanted in four such patients in this study. Pre-operative three-dimensional computed tomography images and intraoperative transoesophageal echocardiography guidance helped to determine the positions of the inflow and pump.

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Ventricular Assist Devices in Adults with Failing Systemic Right Ventricle: The Importance of Concomitant Tricuspid Valve Replacement

The Journal of Heart and Lung Transplantation ◽

10.1016/j.healun.2021.01.321 ◽

2021 ◽

Vol 40 (4) ◽

pp. S96-S97

Author(s):

O. Gonzalez Fernandez ◽

F. De Rita ◽

L. Coats ◽

D. Crossland ◽

M. Nassar ◽

...

Keyword(s):

Right Ventricle ◽

Valve Replacement ◽

Tricuspid Valve ◽

Ventricular Assist Devices ◽

Tricuspid Valve Replacement ◽

Ventricular Assist ◽

Assist Devices ◽

Systemic Right Ventricle

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Cathodic-anodal left ventricular stimulation during cardiac resynchronization therapy: haemodynamic evaluation and electrocardiographic analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0799 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Gravellone ◽

G Dell' Era ◽

F De Vecchi ◽

E Boggio ◽

E Prenna ◽

...

Keyword(s):

Ejection Fraction ◽

Arterial Pressure ◽

Cardiac Resynchronization Therapy ◽

Right Ventricle ◽

Single Point ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Biventricular Stimulation ◽

Qrs Duration

Abstract Background Cardiac resynchronization therapy (CRT) is an established treatment for heart failure with reduced ejection fraction (HFrEF). However, one third of patients are “non responders”. Cathodic-anodal (CA) left ventricle (LV) capture is a multisite pacing occurring during CRT using both bipolar and quadripolar LV lead. It allows depolarization to arise simultaneously from the cathode and the anode of the bipole located on the LV epicardium, activating a larger volume of myocardium than cathodal pacing alone, thus potentially improving electromechanical synchrony (figure 1). We have previously proven that CA-LV stimulation is feasible and similar to bicathodic multipoint pacing (MPP) in terms of QRS wavefront activation. Purpose We aimed to evaluate both the acute intraprocedural haemodynamic and electrical effects of CA biventricular stimulation (CA-BS), comparing it with right-ventricle only pacing (Right Ventricle-Stimulation: RV-S), single-point CRT (Single Point-Biventricular Stimulation: SP-BS) and multipoint bicathodic biventricular stimulation (Multi Point-Biventricular Stimulation:MP-BS) in de novo CRT implants. Methods Ten patients candidates to CRT (LV ejection fraction ≤35% and left bundle branch block) received a quadripolar LV lead. Four pacing configurations were tested: RV-S, SP-BS, MP-BS and CA-BS, where cathode and the anode were the same electrodes used as cathodes in MP-BS. QRS duration by 12-lead ECG was defined as the time from the earliest ventricular deflection until the return to the isoelectric line. Haemodynamic assessment by radial artery catheterization using Pressure Recording Analytical Method processed the following parameters: dP/dT max (mmHg/msec), systolic arterial pressure (aPsys, mmHg), diastolic arterial pressure (aPdia, mmHg), mean arterial pressure (aPmean, mmHg), Cardiac Index (CI, l/min/m2), Stroke Volume Index (SVI, ml/min/m2). Results dP/dT max and aPmean increased significantly from RV-S to SP-BS (mean dP/dT max 0,82±0,28 versus 0,87±0,29 mmHg/msec, p=0,02; mean aPmean 89±19 versus 93±20 mmHg, p=0,01), but not from RV-S to MP-BS. Comparing RV-S to CA-BS, only aPmean exhibited a significant increase (mean aPmean 89±19 versus 92±20 mmHg, p=0,01). There were no haemodynamic differences between SP-BS, MP-BS and CA-BS. QRS duration reduced significantly from RV-S (167±10 msec) to each biventricular stimulation (135±14 msec, p=0,0002 for SP-BS; 130±17 msec, p=0,0001 for MP-BS; 129±18 msec, p=0,0002 for CA-BS) and from SP-BS to MP-BS and CA-BS (p=0,03 for both), whereas there were no difference comparing MP-BS and CA-BS. Conclusions CA-LV stimulation is not superior to single-point CRT in terms of acute haemodynamic performance, whereas it reduces the duration of ventricular electrical activation, showing an electrohaemodynamic mismatch. Long-term studies are needed to evaluate if acute electrical benefits of CA stimulation can predict chronic benefits, in terms of reverse cardiac remodelling. Cathodic-anodal left ventricular capture Funding Acknowledgement Type of funding source: None

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