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Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
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Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
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Fürniss HE, Wülfers EM, Iaconianni P, Ravens U, Kroll J, Stiller B, Kohl P, Rog-Zielinska EA, Peyronnet R. Disease severity, arrhythmogenesis, and fibrosis are related to longer action potentials in tetralogy of Fallot. Clin Res Cardiol 2024; 113:716-727. [PMID: 37725108 PMCID: PMC11026253 DOI: 10.1007/s00392-023-02288-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 08/16/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Arrhythmias may originate from surgically unaffected right ventricular (RV) regions in patients with tetralogy of Fallot (TOF). We aimed to investigate action potential (AP) remodelling and arrhythmia susceptibility in RV myocardium of patients with repaired and with unrepaired TOF, identify possible correlations with clinical phenotype and myocardial fibrosis, and compare findings with data from patients with atrial septal defect (ASD), a less severe congenital heart disease. METHODS Intracellular AP were recorded ex vivo in RV outflow tract samples from 22 TOF and three ASD patients. Arrhythmias were provoked by superfusion with solutions containing reduced potassium and barium chloride, or isoprenaline. Myocardial fibrosis was quantified histologically and associations between clinical phenotype, AP shape, tissue arrhythmia propensity, and fibrosis were examined. RESULTS Electrophysiological abnormalities (arrhythmias, AP duration [APD] alternans, impaired APD shortening at increased stimulation frequencies) were generally present in TOF tissue, even from infants, but rare or absent in ASD samples. More severely diseased and acyanotic patients, pronounced tissue susceptibility to arrhythmogenesis, and greater fibrosis extent were associated with longer APD. In contrast, APD was shorter in tissue from patients with pre-operative cyanosis. Increased fibrosis and repaired-TOF status were linked to tissue arrhythmia inducibility. CONCLUSIONS Functional and structural tissue remodelling may explain arrhythmic activity in TOF patients, even at a very young age. Surprisingly, clinical acyanosis appears to be associated with more severe arrhythmogenic remodelling. Further research into the clinical drivers of structural and electrical myocardial alterations, and the relation between them, is needed to identify predictive factors for patients at risk.
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Affiliation(s)
- Hannah E Fürniss
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany.
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany.
| | - Eike M Wülfers
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Pia Iaconianni
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Ursula Ravens
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Peter Kohl
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
- Signaling Research Centers BIOSS and CIBSS, University of Freiburg, Freiburg, Germany
| | - Eva A Rog-Zielinska
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Rémi Peyronnet
- Institute for Experimental Cardiovascular Medicine, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
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Ramdat Misier NL, Moore JP, Nguyen HH, Lloyd MS, Dubin AM, Mah DY, Czosek RJ, Khairy P, Chang PM, Nielsen JC, Aydin A, Pilcher TA, O'Leary ET, Shivkumar K, de Groot NMS. Long-Term Outcomes of Cardiac Resynchronization Therapy in Patients With Repaired Tetralogy of Fallot: A Multicenter Study. Circ Arrhythm Electrophysiol 2024; 17:e012363. [PMID: 38344811 DOI: 10.1161/circep.123.012363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND A growing number of patients with tetralogy of Fallot develop left ventricular systolic dysfunction and heart failure, in addition to right ventricular dysfunction. Although cardiac resynchronization therapy (CRT) is an established treatment option, the effect of CRT in this population is still not well defined. This study aimed to investigate the early and late efficacy, survival, and safety of CRT in patients with tetralogy of Fallot. METHODS Data were analyzed from an observational, retrospective, multicenter cohort, initiated jointly by the Pediatric and Congenital Electrophysiology Society and the International Society of Adult Congenital Heart Disease. Twelve centers contributed baseline and longitudinal data, including vital status, left ventricular ejection fraction (LVEF), QRS duration, and NYHA functional class. Outcomes were analyzed at early (3 months), intermediate (1 year), and late follow-up (≥2 years) after CRT implantation. RESULTS A total of 44 patients (40.3±19.2 years) with tetralogy of Fallot and CRT were enrolled. Twenty-nine (65.9%) patients had right ventricular pacing before CRT upgrade. The left ventricular ejection fraction improved from 32% [24%-44%] at baseline to 42% [32%-50%] at early follow-up (P<0.001) and remained improved from baseline thereafter (P≤0.002). The QRS duration decreased from 180 [160-205] ms at baseline to 152 [133-182] ms at early follow-up (P<0.001) and remained decreased at intermediate and late follow-up (P≤0.001). Patients with upgraded CRT had consistent improvement in left ventricular ejection fraction and QRS duration at each time point (P≤0.004). Patients had a significantly improved New York Heart Association functional class after CRT implantation at each time point compared with baseline (P≤0.002). The transplant-free survival rates at 3, 5, and 8 years after CRT implantation were 85%, 79%, and 73%. CONCLUSIONS In patients with tetralogy of Fallot treated with CRT consistent improvement in QRS duration, left ventricular ejection fraction, New York Heart Association functional class, and reasonable long-term survival were observed. The findings from this multicenter study support the consideration of CRT in this unique population.
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Affiliation(s)
- Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
| | - Jeremy P Moore
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Hoang H Nguyen
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (H.H.N.)
| | - Michael S Lloyd
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (M.S.L.)
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto CA (A.M.D.)
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Richard J Czosek
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati OH (R.J.C.)
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal Quebec, Canada (P.K.)
| | - Philip M Chang
- Congenital Heart Center, University of Florida Health, Gainesville, FL (P.M.C.)
| | - Jens C Nielsen
- Department of Clinical Medicine, Aarhus University, Aarhus Denmark (J.C.N.)
- Department of Cardiology, Aarhus University Hospital, Aarhus Denmark (J.C.N.)
| | - Alper Aydin
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario Canada (A.A.)
| | - Thomas A Pilcher
- Division of Pediatric Cardiology, Department of Internal Medicine, University of Utah, Salt Lake City UT (T.A.P.)
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Kalyanam Shivkumar
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
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Habib E, Srivasthan K, El Masry H. Evaluation and Management of Sudden Death Risk in Repaired Tetralogy of Fallot. J Pers Med 2023; 13:1715. [PMID: 38138942 PMCID: PMC10744881 DOI: 10.3390/jpm13121715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/01/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Although substantial progress has been made to prevent sudden cardiac death in repaired tetralogy of Fallot patients, ventricular arrhythmia and sudden death continue to be major causes of morbidity and mortality in these patients. Greater survival in contemporary cohorts has been attributed to enhanced surgical techniques, more effective management of heart failure, and increased efforts in risk stratification and management of ventricular arrhythmias. More recently, our understanding of predictive risk factors has evolved into personalized risk prediction tools that rely on comprehensive demographic, imaging, functional, and electrophysiological data. However, the universal applicability of these different scoring systems is limited due to differences between study cohorts, types of anatomic repair, imaging modalities, and disease complexity. Noninvasive risk stratification is critical to identify those who may derive benefit from catheter ablation or cardioverter defibrillator implantation for primary prevention. Ultimately, assessment and risk stratification by a multidisciplinary team is crucial to analyze the various complex factors for every individual patient and discuss further options with patients and their families.
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Affiliation(s)
- Eiad Habib
- Division of Internal Medicine, Mayo Clinic, Scottsdale, AZ 85259, USA;
| | | | - Hicham El Masry
- Division of Cardiology, Mayo Clinic, Scottsdale, AZ 85259, USA;
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Kakarla J, Denham NC, Ishikita A, Oechslin E, Alonso-Gonzalez R, Nair K. Risk Stratification for Sudden Cardiac Death in Repaired Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:414-425. [PMID: 38161672 PMCID: PMC10755789 DOI: 10.1016/j.cjcpc.2023.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 01/03/2024]
Abstract
There has been significant progress in the prevention of sudden cardiac death in repaired tetralogy of Fallot. Contemporary cohorts report greater survival attributable to improved surgical techniques, heart failure management, and proactive strategies for risk stratification and management of ventricular arrhythmias including defibrillator implantation and ablation technology. Over the last 25 years, our understanding of predictive risk factors has also improved from invasive and more limited measures to individualized risk prediction scores based on extensive demographic, imaging, electrophysiological, and functional data. Although each of these contemporary scoring systems improves prediction, there are important differences between the study cohorts, included risk factors, and imaging modalities that can significantly affect interpretation and implementation for the individual patient. In addition, accurate phenotyping of disease complexity and anatomic repair substantially modulates this risk and the mechanism of sudden death. Routine implementation of risk stratification within repaired tetralogy of Fallot management is important and directly informs primary prevention defibrillator implantation as well as consideration for proactive invasive strategies including ventricular tachycardia ablation and pulmonary valve replacement. Assessment and risk stratification by a multidisciplinary team of experts in adult congenital heart disease are crucial and critical. Although we have increased understanding, reconciliation of these complex factors for the individual patient remains challenging and often requires careful consideration and discussion with multidisciplinary teams, patients, and their families.
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Affiliation(s)
- Jayant Kakarla
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Nathan C. Denham
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Ayako Ishikita
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Erwin Oechslin
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
| | - Krishnakumar Nair
- University Health Network Toronto, Peter Munk Cardiac Centre, Toronto Adult Congenital Heart Disease Program, and University of Toronto, Toronto, Ontario, Canada
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Bitterman Y, Hui W, Fan CPS, Kiss A, Mertens L, Wald RM, Friedberg MK. Electromechanical Dyssynchrony Is Associated With Right Ventricular Remodeling and Dysfunction Independently of Pulmonary Regurgitation Late After Tetralogy of Fallot Repair. J Am Soc Echocardiogr 2023; 36:1315-1323. [PMID: 37356675 DOI: 10.1016/j.echo.2023.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND The aim of this study was to investigate the relationship among right ventricular (RV) dilatation, dysfunction, and electromechanical dyssynchrony (EMD) in patients with repaired tetralogy of Fallot (rTOF). METHODS Data from a prospective rTOF registry of subjects with moderate or greater pulmonary regurgitation (PR) and contemporary imaging were analyzed. Electrocardiograms and echocardiograms were analyzed for EMD (prolonged QRS duration [QRSd], echocardiographic septal flash, and mechanical delay) and mechanical dispersion. The relationship among these, RV measurements on cardiac magnetic resonance, exercise capacity, and incident arrhythmia or death was analyzed with adjustment for PR. RESULTS In total, 271 patients with rTOF (42% women; median age, 32 years; interquartile range [IQR], 23-34 years) were included. Patients had moderate to severe PR (median PR fraction, 38%; IQR, 30%-47%), moderate to severe RV enlargement (median RV end-diastolic volume index, 161 mL/m2; IQR, 138-186 mL/m2) and mild RV systolic dysfunction (median RV ejection fraction [RVEF], 44%; IQR, 38%-48%). Eleven patients (4%) experienced ventricular arrhythmia or death. Presence of EMD was associated with larger RV size (RV end-diastolic volume index and RV end-systolic volume index, P = .006 and P < .001, respectively) and lower RVEF (P < .001). A sharp inflection in the relation among QRSd, RV size, and RVEF was observed when QRSd exceeded 150 msec (3.1% decrease in RVEF for every 20-msec increase in QRSd between 160 and 200 msec). Similar inflection points were observed for the mechanical delay between the RV basal-lateral and midseptal segments. The mechanical delay was higher in patients with vs without incident atrial arrhythmia (371 vs 276 msec, P = .014). CONCLUSIONS In adults with rTOF, EMD is independently associated with larger RV size, lower RVEF, and incident atrial arrhythmias.
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Affiliation(s)
- Yuval Bitterman
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Hui
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Center for Heart Research, The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Andreea Kiss
- Toronto General Hospital/University Health Network, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto General Hospital/University Health Network, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Labatt Family Heart Centre, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
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Leonardi B, Cifra B. The Role of Cardiopulmonary Testing to Risk Stratify Tetralogy of Fallot Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:314-321. [PMID: 38161674 PMCID: PMC10755826 DOI: 10.1016/j.cjcpc.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024]
Abstract
Neonatal repair has completely changed the clinical history of patients with tetralogy of Fallot (ToF); however, these patients carry a significant risk of severe arrhythmias and sudden cardiac death in the long term. The exact mechanism for late sudden cardiac death is multifactorial and still not well defined, and the risk stratification for primary prophylaxis in these patients remains challenging. Cardiopulmonary exercise testing (CPET) is a well-established and safe method to assess cardiopulmonary function in children and adults with congenital heart disease. Several parameters obtained with CPET have been identified as potential prognostic of major adverse cardiovascular events in congenital heart disease. CPET is routinely used to assess functional capacity also in patients with ToF, and there is some evidence showing its usefulness in predicting the cardiac adverse events in patients with repaired ToF. Current guidelines recognize the importance of CPET in the evaluation and management of patients with ToF, but there is no clear consensus on which the CPET parameter or level of exercise intolerance, as measured by CPET, is truly predictive of an increased risk of arrhythmia and major adverse cardiovascular events in this population. Therefore, the aim of this narrative review is to describe the current evidence on the potential use of CPET in the risk stratification of patients with repaired ToF.
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Affiliation(s)
- Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Hospital, IRCCS, Rome, Italy
| | - Barbara Cifra
- Division of Cardiology, Labatt Family Heart Centre, the Hospital for Sick Children, Toronto, Ontario, Canada
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Kumthekar R, Webster G. Prediction of Sudden Death Risk in Patients with Congenital Heart Diseases. Card Electrophysiol Clin 2023; 15:493-503. [PMID: 37865522 DOI: 10.1016/j.ccep.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Risk stratification for sudden death should be discussed with patients with congenital heart disease at each stage of personal and cardiac development. For most patients, risk is low through teenage years and the critical factors to consider are anatomy, ventricular function, and symptoms. By adulthood, these are supplemented by screening for atrial arrhythmias, ventricular arrhythmias, and pulmonary hypertension. Therapies include medication, ablation, and defibrillator placement.
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Affiliation(s)
- Rohan Kumthekar
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH, USA
| | - Gregory Webster
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL 60611, USA.
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Ganea G, Cinteză EE, Filip C, Iancu MA, Balta MD, Vătășescu R, Vasile CM, Cîrstoveanu C, Bălgrădean M. Postoperative Cardiac Arrhythmias in Pediatric and Neonatal Patients with Congenital Heart Disease-A Narrative Review. Life (Basel) 2023; 13:2278. [PMID: 38137879 PMCID: PMC10744555 DOI: 10.3390/life13122278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/14/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
Cardiac arrhythmias are a frequent complication in the evolution of patients with congenital heart disease. Corrective surgery for these malformations is an additional predisposition to the appearance of arrhythmias. Several factors related to the patient, as well as to the therapeutic management, are involved in the etiopathogenesis of cardiac arrhythmias occurring post-operatively. The risk of arrhythmias in the immediate postoperative period is correlated with the patient's young age and low weight at surgery. The change in heart geometry, hemodynamic stress, and post-surgical scars represent the main etiopathogenic factors that can contribute to the occurrence of cardiac arrhythmias in the population of patients with operated-on congenital heart malformations. Clinical manifestations differ depending on the duration of the arrhythmia, underlying structural defects, hemodynamic conditions, and comorbidities. The accurate diagnosis and the establishment of specific management options strongly influence the morbidity and mortality associated with arrhythmias. As such, identifying the risk factors for the occurrence of cardiac arrhythmias in the case of each patient is essential to establish a specific follow-up and management plan to improve the life expectancy and quality of life of children.
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Affiliation(s)
- Gabriela Ganea
- Department of Pediatrics, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.G.); (E.E.C.); (C.F.); (M.B.)
- “Marie Skolodowska Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania
| | - Eliza Elena Cinteză
- Department of Pediatrics, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.G.); (E.E.C.); (C.F.); (M.B.)
- “Marie Skolodowska Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania
| | - Cristina Filip
- Department of Pediatrics, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.G.); (E.E.C.); (C.F.); (M.B.)
- “Marie Skolodowska Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania
| | - Mihaela Adela Iancu
- Department of Internal Medicine, Family Medicine and Labor Medicine, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- “Alessandrescu-Rusescu” National Institute for Mother and Child Health, 20382 Bucharest, Romania
| | - Mihaela Daniela Balta
- Department of Internal Medicine, Family Medicine and Labor Medicine, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- “Alessandrescu-Rusescu” National Institute for Mother and Child Health, 20382 Bucharest, Romania
| | - Radu Vătășescu
- Emergency Clinical Hospital, 014461 Bucharest, Romania
- Cardio-Thoracic Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Corina Maria Vasile
- Pediatric and Adult Congenital Cardiology Department, Centre Hospitalier Universitaire de Bordeaux, 33000 Bordeaux, France;
| | - Cătălin Cîrstoveanu
- Department of Neonatal Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Neonatal Intensive Care Unit, M.S. Curie Children’s Clinical Hospital, 041451 Bucharest, Romania
| | - Mihaela Bălgrădean
- Department of Pediatrics, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.G.); (E.E.C.); (C.F.); (M.B.)
- “Marie Skolodowska Curie” Emergency Children’s Hospital, 041451 Bucharest, Romania
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Bessière F, Waldmann V, Combes N, Metton O, Dib N, Mondésert B, O'Leary E, De Witt E, Carreon CK, Sanders SP, Moore JP, Triedman J, Khairy P. Ventricular Arrhythmias in Adults With Congenital Heart Disease, Part I: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1108-1120. [PMID: 37673512 DOI: 10.1016/j.jacc.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/08/2023] [Accepted: 06/05/2023] [Indexed: 09/08/2023]
Abstract
Patients with congenital heart disease associated with a higher risk for ventricular arrhythmias (VA) and sudden cardiac death (SCD) can be divided conceptually into those with discrete mechanisms for reentrant monomorphic ventricular tachycardia (VT) (Group A) and those with more diffuse substrates (Group B). Part I of this review addresses Group A lesions, which predominantly consist of tetralogy of Fallot and related variants. Well-defined anatomic isthmuses for reentrant monomorphic VT are interposed between surgical scars and the pulmonary or tricuspid annulus. The most commonly implicated critical isthmus for VT is the conal septum that divides subpulmonary from subaortic outlets. Programmed ventricular stimulation can be helpful in risk stratification. Although catheter ablation is not generally considered an alternative to the implantable cardioverter-defibrillator (ICD) for prevention of SCD, emerging data suggest that there is a subset of carefully selected patients who may not require ICDs after successful monomorphic VT ablation.
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MESH Headings
- Humans
- Adult
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/therapy
- Catheter Ablation
- Defibrillators, Implantable
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Affiliation(s)
- Francis Bessière
- Electrophysiology Unit, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France; Pediatric and Congenital Heart Disease Medico-Surgical Unit, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, LabTau, INSERM, Lyon, France.
| | - Victor Waldmann
- Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, Paris, France; Pediatric and Congenital Medico-Surgical Unit, Necker Hospital, Paris, France; Electrophysiology Unit, European Georges Pompidou Hospital, Paris, France; Université de Paris Cité, PARCC, INSERM, Paris, France
| | - Nicolas Combes
- Clinique Pasteur, Toulouse, France; Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olivier Metton
- Pediatric and Congenital Heart Disease Medico-Surgical Unit, Hôpital cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Nabil Dib
- Division of Electrophysiology, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Blandine Mondésert
- Division of Electrophysiology, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Edward O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth De Witt
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Chrystalle Katte Carreon
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen P Sanders
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA; UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - John Triedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Khairy
- Division of Electrophysiology, Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
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11
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Celermajer DS, Baker DW, Cordina RL, Gatzoulis M, Broberg CS. Common diagnostic errors in adults with congenital heart disease. Eur Heart J 2023; 44:3217-3227. [PMID: 36527303 DOI: 10.1093/eurheartj/ehac717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 09/08/2023] Open
Abstract
Owing to the great advances in the care for children with congenital heart disease by paediatric cardiac surgeons and cardiologists, there are ever increasing numbers of patients with congenital heart disease who reach adult life. At some stage during the late teenage years or soon after, these patients 'transition' from paediatric cardiac care to surveillance by cardiologists who look after adults. Many such specialists, however, are more familiar with commoner acquired heart problems such as coronary disease, heart failure, and arrhythmia in structurally normal hearts and less familiar with congenital heart disease. For this reason, international guidelines have suggested that the care of young adults with congenital heart disease take place in designated specialist adult congenital heart disease centres. It remains very important, however, for general cardiologists to have a good understanding of many aspects of adult congenital heart disease, including common pitfalls to avoid and, importantly, when to refer on, to a specialist centre. To help healthcare providers across the spectrum of cardiology practice to address common themes in adult congenital heart disease, this state-of-the-art review provides a series of case vignettes to illustrate frequent diagnostic problems that we have seen in our tertiary-level adult congenital heart disease centres, which are sometimes encountered in general cardiology settings. These include commonly 'missed' diagnoses, or errors with diagnosis or management, in these often very complex patients.
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Affiliation(s)
- David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - David W Baker
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Rachael L Cordina
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
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12
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Wallet J, Kimura Y, Blom NA, Man S, Jongbloed MRM, Zeppenfeld K. The R″ wave in V1 and the negative terminal QRS vector in aVF combine to a novel 12-lead ECG algorithm to identify slow conducting anatomical isthmus 3 in patients with tetralogy of Fallot. Europace 2023; 25:euad139. [PMID: 37314194 PMCID: PMC10265971 DOI: 10.1093/europace/euad139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
AIMS Patients with repaired tetralogy of Fallot (rTOF) have an increased risk of ventricular tachycardia (VT), with slow conducting anatomical isthmus (SCAI) 3 as dominant VT substrate. In patients with right bundle branch block (RBBB), SCAI 3 leads to local activation delay with a shift of terminal RV activation towards the lateral RV outflow tract which may be detected by terminal QRS vector changes on sinus rhythm electrocardiogram (ECG). METHODS AND RESULTS Consecutive rTOF patients aged ≥16 years with RBBB who underwent electroanatomical mapping at our institution between 2017-2022 and 2010-2016 comprised the derivation and validation cohort, respectively. Forty-six patients were included in the derivation cohort (aged 40±15 years, QRS duration 165±23 ms). Among patients with SCAI 3 (n = 31, 67%), 17 (55%) had an R″ in V1, 18 (58%) had a negative terminal QRS portion (NTP) ≥80 ms in aVF, and 12 (39%) had both ECG characteristics, compared to only 1 (7%), 1 (7%), and 0 patient without SCAI, respectively.Combining R″ in V1 and/or NTP ≥80 ms in aVF into a diagnostic algorithm resulted in a sensitivity of 74% and specificity of 87% in detecting SCAI 3. The inter-observer agreement for the diagnostic algorithm was 0.875. In the validation cohort [n = 33, 18 (55%) with SCAI 3], the diagnostic algorithm had a sensitivity of 83% and specificity of 80% for identifying SCAI 3. CONCLUSION A sinus rhythm ECG-based algorithm including R″ in V1 and/or NTP ≥80 ms in aVF can identify rTOF patients with a SCAI 3 and may contribute to non-invasive risk stratification for VT.
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Affiliation(s)
- Justin Wallet
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Willem Einthoven Centre of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
| | - Yoshitaka Kimura
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Willem Einthoven Centre of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
| | - Nico A Blom
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sumche Man
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Willem Einthoven Centre of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Willem Einthoven Centre of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands
- Centre for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
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13
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Gunsaulus M, Bueno A, Bright C, Snyder K, Das N, Dobson C, DeBrunner M, Christopher A, Hoskoppal A, Follansbee C, Arora G, Olivieri L, Alsaied T. The Use of Automated Atrial CMR Measures and a Novel Atrioventricular Coupling Index for Predicting Risk in Repaired Tetralogy of Fallot. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020400. [PMID: 36832529 PMCID: PMC9955804 DOI: 10.3390/children10020400] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
Atrial size and function have been recognized as markers of diastolic function, and diastolic dysfunction has been identified as a predictor of adverse outcomes in repaired tetralogy of Fallot (rTOF). This was a retrospective single-center study with the objective of investigating the use of atrial measurements obtained via CMR for predicting outcomes in rTOF patients. Automated contours of the left and right atria (LA and RA) were performed. A novel parameter, termed the Right Atrioventricular Coupling Index (RACI), was defined as the ratio of RA end-diastolic volume to right ventricle (RV) end-diastolic volume. Patients were risk-stratified using a previously validated Importance Factor Score for the prediction of life-threatening arrhythmias in rTOF. Patients with a high-risk Importance Factor Score (>2) had a significantly larger minimum RA volume (p = 0.04) and RACI (p = 0.03) compared to those with scores ≤2. ROC analysis demonstrated RACI to be the best overall predictor of a high-risk Importance Factor Score (AUC 0.73, p = 0.03). Older age at the time of repair and a diagnosis of pulmonary atresia were associated with a larger RACI. Automated atrial CMR measurements are easily obtained from standard CMRs and have the potential to serve as noninvasive predictors of adverse outcomes in rTOF.
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14
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Massarella D, Alonso-Gonzalez R. Updates in the management of congenital heart disease in adult patients. Expert Rev Cardiovasc Ther 2022; 20:719-732. [PMID: 36128784 DOI: 10.1080/14779072.2022.2125870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Adults with congenital heart disease represent a highly diverse, ever-growing population. Optimal approaches to management of problems such as arrhythmia, sudden cardiac death, heart failure, transplant, application of advanced therapies and unrepaired shunt lesions are incompletely established. Efforts to strengthen our understanding of these complex clinical challenges and inform evidence-based practices are ongoing. AREAS COVERED This narrative review summarizes evidence underpinning current approaches to congenital heart disease management while highlighting areas requiring further investigation. A search of literature published in 'Medline,' 'EMBASE,' and 'PubMed' using search terms 'congenital heart disease,' 'arrhythmia,' 'sudden cardiac death,' 'heart failure,' 'heart transplant,' 'advanced heart failure therapy,' 'ventricular assist device (VAD),' 'mechanical circulatory support (MSC),' 'intracardiac shunt' and combinations thereof was undertaken. EXPERT OPINION Application of novel technologies in the diagnosis and management of arrhythmia has and will continue to improve outcomes in this population. Sudden death remains a prevalent problem with many persistent unknowns. Heart failure is a leading cause of morbidity and mortality. Improved access to specialist care, advanced therapies and cardiac transplant is needed. The emerging field of cardio-obstetrics will continue to define state-of-the-art care for the reproductive health of women with heart disease.
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Affiliation(s)
- Danielle Massarella
- Department of Cardiology, University Health Network, Peter Munk Cardiac Centre, Toronto ACHD program, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Department of Cardiology, University Health Network, Peter Munk Cardiac Centre, Toronto ACHD program, Toronto, Ontario, Canada
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15
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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16
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QRS fragmentation versus QRS prolongation in predicting right ventricular enlargement and dysfunction in children and adults with repaired Tetralogy of Fallot. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Majeed A, Geva T, Sleeper LA, Graf JA, Lu M, Babu-Narayan SV, Wald RM, Mulder BJM, Valente AM. Cardiac MRI predictors of good long-term outcomes in patients with repaired TOF. Am Heart J 2022; 245:70-77. [PMID: 34875276 DOI: 10.1016/j.ahj.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/20/2021] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Risk stratification in patients with repaired tetralogy of Fallot (rTOF) have focused on poor clinical outcomes while predictors of a benign clinical course have not been characterized. OBJECTIVE The goal of this study was to Identify cardiac magnetic resonance (CMR) markers of a good clinical course late after TOF repair. METHODS Clinical and CMR data from the International Multicenter TOF Registry (INDICATOR) were analyzed. The primary outcome was time to the earliest occurrence of a composite of death, aborted sudden death, and sustained ventricular tachycardia (VT). The secondary outcome was time to the earliest occurrence of atrial arrhythmia, nonsustained VT, and NYHA class >II. Multinomial regression was used to identify predictors of the 3-category outcome: (a) good outcome, defined as freedom from the primary AND secondary outcomes at age 50 years; (b) poor outcome, defined as presence of the primary outcome before age 50 years; and (c) intermediate outcome, defined as not fulfilling criteria for good or poor outcomes. RESULTS Among 1088 eligible patients, 96 had good outcome, 60 experienced poor outcome, and 932 had intermediate outcome. Patients were age 25.8±10.8 years at the time of the index CMR. Median follow-up was 5.8 years (IQR 3.0, 9.9) after CMR in event-free patients. By univariate analysis, smaller right ventricular (RV) end-systolic and end-diastolic volume index, smaller left ventricular end-systolic volume index, higher right and left ventricular ejection fraction, lower right and left ventricular mass index, and lower left ventricular mass/volume ratio were associated with good outcome. Multivariable modeling identified higher RV ejection fraction (OR 2.38 per 10% increase, P = .002) and lower RV mass index (OR 1.72, per 10 g/m2 decrease, P = .002) as independently associated with good outcome after adjusting for age at CMR. Classification and regression tree analysis identified important thresholds associated with good outcome that were specific to patients age ≥37 years at the time of CMR; these were RV ejection fraction ≥42% and RV mass index <39 g/m2. CONCLUSIONS Adults with rTOF and no more than mild RV dysfunction combined with no significant RV hypertrophy are likely to be free from serious adverse clinical events into their sixth decade of life and may require less frequent cardiac testing.
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Affiliation(s)
- Amara Majeed
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Julia A Graf
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Sonya V Babu-Narayan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust London, United Kingdom; and National Heart Lung Institute, Imperial College London, United Kingdom
| | - Rachel M Wald
- University of Toronto, Toronto, ON, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto ON, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, NH, The Netherlands; Academic Medical Center, Amsterdam, NH, The Netherlands
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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18
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Pinsker BL, Serfas JD, Krasuski RA. Burden and Impact of Arrhythmias in Repaired Tetralogy of Fallot. Curr Cardiol Rep 2022; 24:225-234. [PMID: 35138576 DOI: 10.1007/s11886-022-01638-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Arrhythmias are a leading cause of morbidity and mortality following repair of tetralogy of Fallot (TOF). This review will highlight current understanding of arrhythmia pathogenesis in this patient population and review novel therapeutic options. RECENT FINDINGS Risk factors for developing ventricular arrhythmias in repaired TOF have thus far been better defined than for atrial arrhythmias. Growing understanding of the pathophysiology of arrhythmias, development of risk stratification models, and novel techniques such as electrophysiologic ultrahigh-density mapping should help to better identify patients that benefit from advanced therapies such as ablation and implantable cardioverter defibrillators. Atrial and ventricular arrhythmias are common in TOF patients. Methods of risk stratification and therapeutic approaches are rapidly evolving, leading to ever improving clinical outcomes in this patient population.
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Affiliation(s)
| | - John D Serfas
- Section of Adult Congenital Heart Disease, Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Box 3012, Durham, NC, 27710, USA
| | - Richard A Krasuski
- Duke University School of Medicine, Durham, NC, USA. .,Section of Adult Congenital Heart Disease, Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Box 3012, Durham, NC, 27710, USA.
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19
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Grosse-Wortmann L, Madriago EJ. Getting Closer to Predicting SCD in TOF. JACC Cardiovasc Imaging 2021; 15:269-270. [PMID: 34801450 DOI: 10.1016/j.jcmg.2021.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/15/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Lars Grosse-Wortmann
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA.
| | - Erin J Madriago
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
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20
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Zormpas C, Silber-Peest AS, Eiringhaus J, Hillmann HAK, Hohmann S, Müller-Leisse J, Westhoff-Bleck M, Veltmann C, Duncker D. Eligibility for subcutaneous implantable cardioverter-defibrillator in adults with congenital heart disease. ESC Heart Fail 2021; 8:1502-1508. [PMID: 33538124 PMCID: PMC8006645 DOI: 10.1002/ehf2.13243] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/30/2020] [Accepted: 01/19/2021] [Indexed: 01/06/2023] Open
Abstract
Aims Patients with adult congenital heart disease (ACHD) carry an increased risk for sudden cardiac death. Implantable cardioverter‐defibrillator (ICD) therapy may be challenging in these patients due to anatomical barriers, repeated cardiac surgery, or complicated transvenous access. Thus, the subcutaneous ICD (S‐ICD) can be a promising alternative in this patient population. Patients with ACHD show significant electrocardiogram (ECG) abnormalities, which could affect S‐ICD sensing because it depends on surface ECG. Methods and results One hundred patients with ACHD were screened for S‐ICD eligibility. Standard ECG‐based screening test and automated S‐ICD screening test were performed in all patients. Sixty‐six patients (66%) were male. Underlying congenital heart disease (CHD) was mainly CHD of great complexity (71%) and moderate complexity (29%), including repaired tetralogy of Fallot (20%), which was the most common entity. Thirty‐seven patients (37%) already had a pacemaker (23%) or ICD (14%) implanted. Automated screening test identified 83 patients (83%) eligible for S‐ICD implantation in either left parasternal position (78%) or right parasternal position (75%). Absence of sinus rhythm, QRS duration, and a paced QRS complex were associated with S‐ICD screening failure in univariate analysis. Receiver operating characteristic curve and multivariate analysis revealed a QRS duration ≥148 ms as the only independent predictor for S‐ICD screening failure. Conclusions Patients with ACHD show satisfactory eligibility rates (83%) for S‐ICD implantation utilizing the automated screening test, including patients with CHD of high complexity. S‐ICD therapy should be considered with caution in ACHD patients with a QRS duration ≥148 ms and/or need for ventricular pacing.
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Affiliation(s)
- Christos Zormpas
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Jörg Eiringhaus
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Henrike A K Hillmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johanna Müller-Leisse
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover, D-30625, Germany.,Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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21
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Cohen MI, Khairy P, Zeppenfeld K, Van Hare GF, Lakkireddy DR, Triedman JK. Preventing Arrhythmic Death in Patients With Tetralogy of Fallot: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 77:761-771. [PMID: 33573746 DOI: 10.1016/j.jacc.2020.12.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/03/2020] [Accepted: 12/07/2020] [Indexed: 01/18/2023]
Abstract
Patients with tetralogy of Fallot are at risk for ventricular arrhythmias and sudden cardiac death. These abnormalities are associated with pulmonary regurgitation, right ventricular enlargement, and a substrate of discrete, slowly-conducting isthmuses. Although these arrhythmic events are rare, their prediction is challenging. This review will address contemporary risk assessment and prevention strategies. Numerous variables have been proposed to predict who would benefit from an implantable cardioverter-defibrillator. Current risk stratification models combine independently associated factors into risk scores. Cardiac magnetic resonance imaging, QRS fragmentation assessment, and electrophysiology testing in selected patients may refine some of these models. Interaction between right and left ventricular function is emerging as a critical factor in our understanding of disease progression and risk assessment. Multicenter studies evaluating risk factors and risk mitigating strategies such as pulmonary valve replacement, ablative strategies, and use of implantable cardiac-defibrillators are needed moving forward.
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Affiliation(s)
- Mitchell I Cohen
- Division of Cardiology, Inova Children's Hospital, Falls Church, Virginia, USA.
| | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - George F Van Hare
- Department of Pediatrics, Washington University in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | | | - John K Triedman
- Electrophysiology Division, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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22
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Alsaied T. From Other Journals: A Review of Recent Articles in Pediatric Cardiology. Pediatr Cardiol 2020; 41:1532-1537. [PMID: 32813029 PMCID: PMC7434847 DOI: 10.1007/s00246-020-02438-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/10/2020] [Indexed: 11/30/2022]
Abstract
In this review, we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. Our aim is to provide a summary of the latest articles published recently in other journals in our field. The articles address (1) cardiac resynchronization in children with symptomatic ventricular dysfunction and dyssynchrony which seems to result in higher transplant-free survival, (2) outcomes of aortic leaflet reconstruction including Ozaki procedure to repair aortic valve disease in adolescents, (3) meta-analysis for risk factors of ventricular tachycardia and death after repaired tetralogy of Fallot which reiterates the known risk factors and showed that the severity of pulmonary regurgitation is not in itself associated with outcomes although the ventricular response to regurgitation (dilation and dysfunction) is, (4) preschool promotion of healthy life style did not associate with sustained effect when evaluated later in childhood although repeated intervention seems to have a dose-related effect to promote healthy life style, (5) the lack of beneficial effects of angiotensin-converting enzyme inhibitors in the interstage period, and (6) a new phenomenon of acute heart failure and multisystem inflammatory syndrome in children temporarily related to the COVID-19 pandemic.
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Affiliation(s)
- Tarek Alsaied
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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