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Vô C, Dib N, Bartoletti S, Gonzalez CM, Mondésert B, Gagnon MH, Fournier A, Khairy P. Navigating Arrhythmias in Tetralogy of Fallot Throughout the Lifespan: A Case-based Review. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:404-413. [PMID: 38161682 PMCID: PMC10755829 DOI: 10.1016/j.cjcpc.2023.09.006] [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: 07/28/2023] [Accepted: 09/12/2023] [Indexed: 01/03/2024]
Abstract
Arrhythmias are a common complication associated with tetralogy of Fallot (ToF), one of the most prevalent forms of congenital heart disease. As illustrated by this case-based review, various forms of arrhythmias can be encountered across the lifespan of patients with ToF, from infancy to older adulthood. These include atrioventricular block, junctional ectopic tachycardia, and atrial and ventricular arrhythmias. Arrhythmias have important implications on the health and quality of life of patients with ToF and require treatment by caregivers with dedicated expertise. The choice of pharmacologic and/or interventional therapies to alleviate symptoms, avoid complications, and mitigate risks depends in part on the type, severity, and frequency of the arrhythmia, as well as on the particularities of individual clinical scenarios. Preventing, monitoring for, and managing arrhythmias are an integral component of the care of patients with ToF throughout their lifespan that is critical to optimizing health outcomes.
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Affiliation(s)
- Christophe Vô
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Nabil Dib
- Division of Pediatric Cardiac Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Stefano Bartoletti
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Cecilia M. Gonzalez
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Blandine Mondésert
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Marie-Hélène Gagnon
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Anne Fournier
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Paul Khairy
- Division of Pediatric Cardiology, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montreal, Québec, Canada
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
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2
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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3
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Lee J, Adeola O, Garan H, Stevenson WG, Yarmohammadi H. Electrocardiographic recognition of benign and malignant right ventricular arrhythmias. Europace 2021; 23:1338-1349. [PMID: 33864080 DOI: 10.1093/europace/euab047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/17/2021] [Indexed: 11/12/2022] Open
Abstract
Ventricular arrhythmias (VAs) can originate from different anatomical locations of the right ventricle. Ventricular arrhythmias originating from right ventricle have unique electrocardiographic (ECG) characteristics that can be utilized to localize the origin of the arrhythmia. This is crucial in pre-procedural planning particularly for ablation treatments. Moreover, non-ischaemic structural heart diseases, such as infiltrative and congenital heart diseases, are associated with the VAs that exhibit particular ECG findings. This article comprehensively reviews discriminatory ECG characteristics of VAs in the right ventricle with and without structural right ventricular diseases.
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Affiliation(s)
- John Lee
- Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Oluwaseun Adeola
- Division of Cardiology, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
| | - Hasan Garan
- Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Avenue, Room 637, New York, NY 10032, USA
| | - William G Stevenson
- Division of Cardiology, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
| | - Hirad Yarmohammadi
- Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 177 Fort Washington Avenue, Room 637, New York, NY 10032, USA
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Le Bloa M, Abadir S, Nair K, Mondésert B, Khairy P. New developments in catheter ablation for patients with congenital heart disease. Expert Rev Cardiovasc Ther 2020; 19:15-26. [PMID: 33153326 DOI: 10.1080/14779072.2021.1847082] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Introduction: There are numerous challenges to catheter ablation in patients with congenital heart disease (CHD), including access to cardiac chambers, distorted anatomies, displaced conduction systems, multiple and/or complex arrhythmia substrates, and excessively thickened walls, or interposed material. Areas covered: Herein, we review recent developments in catheter ablation strategies for patients with CHD that are helpful in addressing these challenges. Expert opinion: Remote magnetic navigation overcomes many challenges associated with vascular obstructions, chamber access, and catheter contact. Patients with CHD may benefit from a range of ablation catheter technologies, including irrigated-tip and contact-force radiofrequency ablation and focal and balloon cryoablation. High-density mapping, along with advances in multipolar catheters and interpolation algorithms, is contributing to new mechanistic insights into complex arrhythmias. Ripple mapping allows the activation wave front to be tracked visually without prior assignment of local activation times or window of interest, and without interpolations of unmapped regions. There is growing interest in measuring conduction velocities to identify arrhythmogenic substrates. Noninvasive mapping with a multielectrode-embedded vest allows prolonged bedside monitoring, which is of particular interest in those with non-sustained or multiple arrhythmias. Further studies are required to assess the role of radiofrequency needle catheters and stereotactic radiotherapy in patients with CHD.
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Affiliation(s)
- Mathieu Le Bloa
- Montreal Heart Institute, Université De Montréal , Montreal, Canada.,Electrophysiology Service, Centre Hospitalier Universitaire Vaudois , Lausanne, Switzerland
| | - Sylvia Abadir
- Montreal Heart Institute, Université De Montréal , Montreal, Canada
| | - Krishnakumar Nair
- University Health Network, Toronto General Hospital , Toronto, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université De Montréal , Montreal, Canada
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5
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Le Bloa M, Pham M, Mongeon FP, Mondésert B, Khairy P. Right Ventricular Basal Aneurysm as a Substrate for Ventricular Tachycardia in Tetralogy of Fallot. JACC Clin Electrophysiol 2020; 6:743-744. [PMID: 32553228 DOI: 10.1016/j.jacep.2020.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | - Magali Pham
- Montreal Heart Institute, Montreal, Quebec, Canada
| | | | | | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada.
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6
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Hernández-Madrid A, Paul T, Abrams D, Aziz PF, Blom NA, Chen J, Chessa M, Combes N, Dagres N, Diller G, Ernst S, Giamberti A, Hebe J, Janousek J, Kriebel T, Moltedo J, Moreno J, Peinado R, Pison L, Rosenthal E, Skinner JR, Zeppenfeld K, Sticherling C, Kautzner J, Wissner E, Sommer P, Gupta D, Szili-Torok T, Tateno S, Alfaro A, Budts W, Gallego P, Schwerzmann M, Milanesi O, Sarquella-Brugada G, Kornyei L, Sreeram N, Drago F, Dubin A. Arrhythmias in congenital heart disease: a position paper of the European Heart Rhythm Association (EHRA), Association for European Paediatric and Congenital Cardiology (AEPC), and the European Society of Cardiology (ESC) Working Group on Grown-up Congenital heart disease, endorsed by HRS, PACES, APHRS, and SOLAECE. Europace 2018; 20:1719-1753. [DOI: 10.1093/europace/eux380] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Antonio Hernández-Madrid
- Department of Cardiology, Arrhythmia Unit, Ramón y Cajal Hospital, Alcalá University, Carretera Colmenar Viejo, km 9, 100, Madrid, Spain
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University Medical Center, Robert-Koch-Str. 40, Göttingen, Germany
| | - Dominic Abrams
- PACES (Pediatric and Congenital Electrophysiology Society) Representative, Department of Cardiology, Boston Childreńs Hospital, Boston, MA, USA
| | - Peter F Aziz
- HRS Representative, Pediatric Electrophysiology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Academical Medical Center, Amsterdam, The Netherlands
| | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Massimo Chessa
- Pediatric and Adult Congenital Heart Centre-University Hospital, IRCCS Policlinico San Donato, Milan, Italy
| | - Nicolas Combes
- Arrhythmia Unit, Department of Pediatric and Adult Congenital Heart Disease, Clinique Pasteur, Toulouse, France
| | - Nikolaos Dagres
- Department of Electrophysiology, University Leipzig Heart Center, Leipzig, Germany
| | | | - Sabine Ernst
- Royal Brompton and Harefield Hospital, London, UK
| | - Alessandro Giamberti
- Congenital Cardiac Surgery Unit, Policlinico San Donato, University and Research Hospital, Milan, Italy
| | - Joachim Hebe
- Center for Electrophysiology at Heart Center Bremen, Bremen, Germany
| | - Jan Janousek
- 2nd Faculty of Medicine, Children's Heart Centre, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Thomas Kriebel
- Westpfalz-Klinikum Kaiserslautern, Children’s Hospital, Kaiserslautern, Germany
| | - Jose Moltedo
- SOLAECE Representative, Head Pediatric Electrophysiology, Section of Pediatric Cardiology Clinica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | - Javier Moreno
- Department of Cardiology, Arrhythmia Unit, Ramón y Cajal Hospital, Alcalá University, Carretera Colmenar Viejo, km 9, 100, Madrid, Spain
| | - Rafael Peinado
- Department of Cardiology, Arrhythmia Unit, Hospital la Paz, Madrid, Spain
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Eric Rosenthal
- Consultant Paediatric and Adult Congenital Cardiologist, Evelina London Children's Hospital, Guy's and St Thomas' Hospital Trust, London, UK
| | - Jonathan R Skinner
- APHRS Representative, Paediatric and Congenital Cardiac Services Starship Childreńs Hospital, Grafton, Auckland, New Zealand
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Joseph Kautzner
- Institute For Clinical and Experimental Medicine, Prague, Czech Republic
| | - Erik Wissner
- University of Illinois at Chicago, 840 S. Wood St., 905 S (MC715), Chicago, IL, USA
| | - Philipp Sommer
- Heart Center Leipzig, Struempellstr. 39, Leipzig, Germany
| | - Dhiraj Gupta
- Consultant Electrophysiologist Liverpool Heart and Chest Hospital, Honorary Senior Lecturer Imperial College London and University of Liverpool, Liverpool, UK
| | | | - Shigeru Tateno
- Chiba Cerebral and Cardiovascular Center, Tsurumai, Ichihara, Chiba, Japan
| | | | - Werner Budts
- UZ Leuven, Campus Gasthuisberg, Herestraat 49, Leuven, Belgium
| | | | - Markus Schwerzmann
- INSELSPITAL, Universitätsspital Bern, Universitätsklinik für Kardiologie, Zentrum für angeborene Herzfehler ZAH, Bern, Switzerland
| | - Ornella Milanesi
- Department of Woman and Child's Health, University of Padua, Padua Italy
| | - Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Electrophysiology and Sudden Death Unit, Department of Cardiology, Hospital Sant Joan de Déu, Barcelona - Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues, Barcelona, Catalunya, Spain
| | - Laszlo Kornyei
- Gottsegen Gyorgy Orszagos Kardiologiai, Pediatric, Haller U. 29, Budapest, Hungary
| | - Narayanswami Sreeram
- Department of Pediatric Cardiology, University Hospital Of Cologne, Kerpenerstrasse 62, Cologne, Germany
| | - Fabrizio Drago
- IRCCS Ospedale Pediatrico Bambino Gesù, Piazza Sant'Onofrio 4, Roma
| | - Anne Dubin
- Division of Pediatric Cardiology, 750 Welch Rd, Suite 321, Palo Alto, CA, USA
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7
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Ramdjan TT, Mouws EM, Teuwen CP, Sitorus GD, Houck CA, Bogers AJ, de Groot NM. Progression of late postoperative atrial fibrillation in patients with tetralogy of Fallot. J Cardiovasc Electrophysiol 2017; 29:30-37. [DOI: 10.1111/jce.13369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 08/31/2017] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - Elisabeth M.J.P. Mouws
- Department of Cardiology; Erasmus University Medical Center; Rotterdam The Netherlands
- Department of Cardiothoracic Surgery; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Christophe P. Teuwen
- Department of Cardiology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Gustaf D.S. Sitorus
- Department of Cardiology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Charlotte A. Houck
- Department of Cardiology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Natasja M.S. de Groot
- Department of Cardiology; Erasmus University Medical Center; Rotterdam The Netherlands
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8
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Sathananthan G, Harris L, Nair K. Ventricular Arrhythmias in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects. Card Electrophysiol Clin 2017; 9:213-223. [PMID: 28457236 DOI: 10.1016/j.ccep.2017.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The risk of ventricular arrhythmias in the adult congenital heart disease population increases with age. The mechanism, type, and frequency vary depending on the complexity of the defect, whether it has been repaired, and the type and timing of repair. Risk stratification for sudden death in patients with congenital heart disease is often challenging. Current recommendations provide a useful guide for management of these patients and risk stratification continues to evolve. Internal cardiac defibrillator implantation is often challenging due to limited transvenous access, often resulting in the need for epicardial or subcutaneous devices.
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Affiliation(s)
- Gnalini Sathananthan
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Louise Harris
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Krishnakumar Nair
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada.
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9
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Philip Saul J, Kanter RJ, Abrams D, Asirvatham S, Bar-Cohen Y, Blaufox AD, Cannon B, Clark J, Dick M, Freter A, Kertesz NJ, Kirsh JA, Kugler J, LaPage M, McGowan FX, Miyake CY, Nathan A, Papagiannis J, Paul T, Pflaumer A, Skanes AC, Stevenson WG, Von Bergen N, Zimmerman F. PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease. Heart Rhythm 2016; 13:e251-89. [DOI: 10.1016/j.hrthm.2016.02.009] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 11/15/2022]
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10
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Can J Cardiol 2014; 30:e1-e63. [PMID: 25262867 DOI: 10.1016/j.cjca.2014.09.002] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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11
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Abstract
Late after surgical repair of complex congenital heart disease, atrial arrhythmias are a major cause of morbidity, and ventricular arrhythmias and sudden cardiac death are a major cause of mortality. The six cases in this article highlight common challenges in the management of arrhythmias in the adult congenital heart disease population.
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Affiliation(s)
- Robert M Hayward
- Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Zian H Tseng
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
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12
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Chinushi M, Saitou O, Furushima H. Radiofrequency catheter ablation of macroreentrant ventricular tachycardia after corrective surgery for tetralogy of Fallot. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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13
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Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot ND, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA. PACES/HRS Expert Consensus Statement on the Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 2014; 11:e102-65. [PMID: 24814377 DOI: 10.1016/j.hrthm.2014.05.009] [Citation(s) in RCA: 371] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 02/07/2023]
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14
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Chubb H, Williams SE, Wright M, Rosenthal E, O'Neill M. Tachyarrhythmias and catheter ablation in adult congenital heart disease. Expert Rev Cardiovasc Ther 2014; 12:751-70. [PMID: 24783943 DOI: 10.1586/14779072.2014.914434] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advances in surgical technique have had an immense impact on longevity and quality of life in patients with congenital heart disease. However, an inevitable consequence of these surgical successes is the creation of a unique patient population whose anatomy, surgical history and haemodynamics result in the development of a challenging and complex arrhythmia substrate. Furthermore, this patient group remains susceptible to the arrhythmias seen in the general adult population. It is through a thorough appreciation of the cardiac structural defect, the surgical corrective approach, and haemodynamic impact that the most effective arrhythmia care can be delivered. Catheter ablation techniques offer a highly effective management option but require a meticulous attention to the real-time integration of anatomical and electrophysiological information to identify and eliminate the culprit arrhythmia substrate. This review describes the current approach to the interventional management of patients with tachyarrhythmias in the context of congenital heart disease.
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Affiliation(s)
- Henry Chubb
- Division of Imaging Sciences and Biomedical Engineering and Division of Cardiovascular Medicine, King's College London, 4th Floor, North Wing, St Thomas' Hospital, Westminster Bridge Road, London, UK
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15
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Le Gloan L, Guerin P, Mercier LA, Abbey S, Dore A, Marcotte F, Ibrahim R, Poirier NC, Khairy P. Clinical assessment of arrhythmias in tetralogy of Fallot. Expert Rev Cardiovasc Ther 2014; 8:189-97. [DOI: 10.1586/erc.09.156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Motonaga KS, Khairy P, Dubin AM. Electrophysiologic Therapeutics in Heart Failure in Adult Congenital Heart Disease. Heart Fail Clin 2014; 10:69-89. [DOI: 10.1016/j.hfc.2013.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brugada J, Blom N, Sarquella-Brugada G, Blomstrom-Lundqvist C, Deanfield J, Janousek J, Abrams D, Bauersfeld U, Brugada R, Drago F, de Groot N, Happonen JM, Hebe J, Yen Ho S, Marijon E, Paul T, Pfammatter JP, Rosenthal E. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement. ACTA ACUST UNITED AC 2013; 15:1337-82. [DOI: 10.1093/europace/eut082] [Citation(s) in RCA: 217] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Escudero C, Khairy P, Sanatani S. Electrophysiologic Considerations in Congenital Heart Disease and Their Relationship to Heart Failure. Can J Cardiol 2013; 29:821-9. [DOI: 10.1016/j.cjca.2013.02.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/14/2013] [Accepted: 02/20/2013] [Indexed: 10/26/2022] Open
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de Groot NMS, Lukac P, Schalij MJ, Makowski K, Szili-Torok T, Jordaens L, Nielsen JC, Jensen HK, Gerdes JC, Delacretaz E. Long-term outcome of ablative therapy of post-operative atrial tachyarrhythmias in patients with tetralogy of Fallot: a European multi-centre study. Europace 2011; 14:522-7. [DOI: 10.1093/europace/eur313] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Le Gloan L, Mercier LA, Dore A, Marcotte F, Ibrahim R, Mongeon FP, Asgar A, Miro J, Poirier N, Khairy P. Recent advances in adult congenital heart disease. Circ J 2011; 75:2287-95. [PMID: 21881245 DOI: 10.1253/circj.cj-11-0601] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As a result of major achievements in pediatric cardiac care, a growing number of patients with congenital heart disease (CHD) are flourishing well into adulthood. This heterogeneous and aging population of patients, many of whom represent the first generation of middle-age survivors, faces unique issues and challenges. As a field, adult CHD has evolved markedly during the past decade on several fronts, including imaging, arrhythmia management, percutaneous interventions, surgical techniques, research, and multidisciplinary care that extends beyond the cardiac realm. This review highlights recent advances across the wide spectrum of key issues encountered by adults with CHD.
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Affiliation(s)
- Laurianne Le Gloan
- Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montréal, Canada
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Diller GP, Breithardt G, Baumgartner H. Congenital heart defects in adulthood. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:452-9. [PMID: 21776319 PMCID: PMC3139408 DOI: 10.3238/arztebl.2011.0452] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 06/28/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND More than 90% of children with congenital heart defects now survive into adulthood; just a few decades ago, survival was rare, particularly among patients with complex defects. The new population of adults with congenital heart disease presents a special challenge to physicians from all of the involved specialties. METHODS Selective literature review. RESULTS AND CONCLUSION A complete cure of the congenital heart defect in childhood is exceptional, and most adult patients continue to suffer from residual problems and sequelae. Further surgery or catheter interventions may be needed. Potential late complications include arrhythmias, heart failure, pulmonary hypertension, endocarditis, and thromboembolic events. The management of these patients during pregnancy or non-cardiac surgery remains a challenge. If this evolving patient population is to receive the best possible care, the adequate provision of specialized medical services is a necessary, but not sufficient, condition: patients and their referring physicians will also need to be aware that these services are available, and then actually make use of them. Moreover, optimal communication among all of the involved physicians is essential.
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Affiliation(s)
- Gerhard-Paul Diller
- Kardiologisches Zentrum für Erwachsene mit angeborenen und erworbenen Herzfehlern (EMAH), Münster, Germany.
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Meyer C, Martinek M, Winter S, Nesser HJ, Pürerfellner H. [Arrhythmias in patients with surgically corrected tetralogy of Fallot]. Herzschrittmacherther Elektrophysiol 2011; 21:189-95. [PMID: 20734055 DOI: 10.1007/s00399-010-0103-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The population of adults with surgically corrected tetralogy of Fallot (TOF) is increasing. Atrial and ventricular arrhythmias are prevalent, and therapeutical approaches including implantable cardioverter-defibrillators and radiofrequency catheter ablation need to be considered carefully for the prevention of hemodynamic deterioration and sudden cardiac death. Complex anatomy, myocardial hypertrophy, and broad channels of slow conduction may in part explain some challenges regarding risk stratification, and identification/modification of the arrhythmogenic substrate in these patients. The aim of this brief review is 2-fold: (1.) To present insights into characteristics of typical TOF related arrhythmias and (2.) to reflect therapeutical concepts targeting tachyarrhythmias in these patients by focusing on catheter ablation.
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Affiliation(s)
- C Meyer
- Abteilung für Innere Medizin II/Kardiologie, Krankenhaus der Elisabethinen, Linz, Osterreich.
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Khairy P, Aboulhosn J, Gurvitz MZ, Opotowsky AR, Mongeon FP, Kay J, Valente AM, Earing MG, Lui G, Gersony DR, Cook S, Ting JG, Nickolaus MJ, Webb G, Landzberg MJ, Broberg CS. Arrhythmia Burden in Adults With Surgically Repaired Tetralogy of Fallot. Circulation 2010; 122:868-75. [DOI: 10.1161/circulationaha.109.928481] [Citation(s) in RCA: 382] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background—
The arrhythmia burden in tetralogy of Fallot, types of arrhythmias encountered, and risk profile may change as the population ages.
Methods and Results—
The Alliance for Adult Research in Congenital Cardiology (AARCC) conducted a multicenter cross-sectional study to quantify the arrhythmia burden in tetralogy of Fallot, to characterize age-related trends, and to identify associated factors. A total of 556 patients, 54.0% female, 36.8±12.0 years of age were recruited from 11 centers. Overall, 43.3% had a sustained arrhythmia or arrhythmia intervention. Prevalence of atrial tachyarrhythmias was 20.1%. Factors associated with intraatrial reentrant tachycardia in multivariable analyses were right atrial enlargement (odds ratio [OR], 6.2; 95% confidence interval [CI], 2.8 to 13.6), hypertension (OR, 2.3; 95% CI, 1.1 to 4.6), and number of cardiac surgeries (OR, 1.4; 95% CI, 1.2 to 1.6). Older age (OR, 1.09 per year; 95% CI, 1.05 to 1.12), lower left ventricular ejection fraction (OR, 0.93 per unit; 95% CI, 0.89 to 0.96), left atrial dilation (OR, 3.2; 95% CI, 1.5 to 6.8), and number of cardiac surgeries (OR, 1.5; 95% CI, 1.2 to 1.9) were jointly associated with atrial fibrillation. Ventricular arrhythmias were prevalent in 14.6% and jointly associated with number of cardiac surgeries (OR, 1.3; 95% CI, 1.1 to 1.6), QRS duration (OR, 1.02 per 1 ms; 95% CI, 1.01 to 1.03), and left ventricular diastolic dysfunction (OR, 3.3; 95% CI, 1.5 to 7.1). Prevalence of atrial fibrillation and ventricular arrhythmias markedly increased after 45 years of age.
Conclusions—
The arrhythmia burden in adults with tetralogy of Fallot is considerable, with various subtypes characterized by different profiles. Atrial fibrillation and ventricular arrhythmias appear to be influenced more by left- than right-sided heart disease.
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Affiliation(s)
- Paul Khairy
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Jamil Aboulhosn
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Michelle Z. Gurvitz
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Alexander R. Opotowsky
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - François-Pierre Mongeon
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Joseph Kay
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Anne Marie Valente
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Michael G. Earing
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - George Lui
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Deborah R. Gersony
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Stephen Cook
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Jennifer Grando Ting
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Michelle J. Nickolaus
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Gary Webb
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Michael J. Landzberg
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
| | - Craig S. Broberg
- From the Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada (P.K., F.P.M.); University of California, Los Angeles (J.A.); University of Washington, Seattle (M.Z.G.); Boston Adult Congenital Heart Service, Children’s Hospital Boston, Boston, Mass (P.K., A.R.O., A.M.V., M.J.L.); University of Colorado, Denver (J.K.); Medical College of Wisconsin, Milwaukee (M.G.E.); Columbia University Medical Center, New York, NY (G.L., D.R.G.); Ohio State University, Columbus (S.C.); Hershey
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