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Kimura Y, Wallet J, Bouyer B, Jongbloed MRM, Bertels R, Hazekamp MG, Thambo JB, Iriart X, Cochet H, Sacher F, Lamb HJ, Blom NA, Zeppenfeld K. Three-dimensional cardiac magnetic resonance allows the identification of slow-conducting anatomical isthmuses in tetralogy of Fallot. Eur Heart J 2024; 45:2079-2094. [PMID: 38748258 DOI: 10.1093/eurheartj/ehae268] [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: 09/14/2023] [Revised: 03/14/2024] [Accepted: 04/15/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND AND AIMS Patients with repaired tetralogy of Fallot remain at risk of life-threatening ventricular tachycardia related to slow-conducting anatomical isthmuses (SCAIs). Preventive ablation of SCAI identified by invasive electroanatomical mapping is increasingly performed. This study aimed to non-invasively identify SCAI using 3D late gadolinium enhancement cardiac magnetic resonance (3D-LGE-CMR). METHODS Consecutive tetralogy of Fallot patients who underwent right ventricular electroanatomical mapping (RV-EAM) and 3D-LGE-CMR were included. High signal intensity threshold for abnormal myocardium was determined based on direct comparison of bipolar voltages and signal intensity by co-registration of RV-EAM with 3D-LGE-CMR. The diagnostic performance of 3D-LGE-CMR to non-invasively identify SCAI was determined, validated in a second cohort, and compared with the discriminative ability of proposed risk scores. RESULTS The derivation cohort consisted of 48 (34 ± 16 years) and the validation cohort of 53 patients (36 ± 18 years). In the derivation cohort, 78 of 107 anatomical isthmuses (AIs) identified by EAM were normal-conducting AI, 22 were SCAI, and 7 blocked AI. High signal intensity threshold was 42% of the maximal signal intensity. The sensitivity and specificity of 3D-LGE-CMR for identifying SCAI or blocked AI were 100% and 90%, respectively. In the validation cohort, 85 of 124 AIs were normal-conducting AI, 36 were SCAI, and 3 blocked AI. The sensitivity and specificity of 3D-LGE-CMR were 95% and 91%, respectively. All risk scores showed an at best modest performance to identify SCAI (area under the curve ≤ .68). CONCLUSIONS 3D late gadolinium enhancement cardiac magnetic resonance can identify SCAI with excellent accuracy and may refine non-invasive risk stratification and patient selection for invasive EAM in tetralogy of Fallot.
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Affiliation(s)
- Yoshitaka Kimura
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center (LUMC), P.O. Box 9600, Leiden 2300 RC, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands, and Aarhus, Denmark
| | - Justin Wallet
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center (LUMC), P.O. Box 9600, Leiden 2300 RC, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands, and Aarhus, Denmark
| | - Benjamin Bouyer
- Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Monique R M Jongbloed
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center (LUMC), P.O. Box 9600, Leiden 2300 RC, The Netherlands
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robin Bertels
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean-Benoit Thambo
- Department of Congenital Heart Disease, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Iriart
- Department of Congenital Heart Disease, Bordeaux University Hospital, Bordeaux, France
| | - Hubert Cochet
- Department of Radiology, Bordeaux University Hospital, Bordeaux, France
| | - Frederic Sacher
- Department of Cardiac Pacing and Electrophysiology, IHU Liryc, Electrophysiology and Heart Modeling Institute, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A Blom
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Leiden, The Netherlands
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Heart-Lung-Center, Leiden University Medical Center (LUMC), P.O. Box 9600, Leiden 2300 RC, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management (WECAM), Leiden, The Netherlands, and Aarhus, Denmark
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Moore JP, Su J, Shannon KM, Perens GS, Newlon C, Bradfield JS, Shivkumar K. Multidetector Computed Tomography Assessment of Anatomical Ventricular Tachycardia Isthmuses in Repaired Tetralogy of Fallot. JACC Clin Electrophysiol 2024; 10:857-866. [PMID: 38456860 DOI: 10.1016/j.jacep.2024.102333] [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] [Received: 11/01/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Tetralogy of Fallot (TOF) is associated with risk for sustained monomorphic ventricular tachycardia (VT). Preemptive electrophysiology study before transcatheter pulmonary valve placement is increasing, but the value of MDCT for anatomical VT isthmus assessment is unknown. OBJECTIVES The purpose of this study was to determine the impact of multidetector computed tomography (MDCT) in the evaluation of sustained monomorphic VT for repaired TOF. METHODS Consecutive pre-transcatheter pulmonary valve MDCT studies were identified, and anatomical isthmus dimensions were measured. For a subset of patients with preemptive electrophysiology study, MDCT features were compared with electroanatomical maps. RESULTS A total of 61 repaired TOFs with MDCT were identified (mean 35 ± 14 years, 58% men) with MDCT electroanatomical map pairs in 35 (57%). Calcification corresponding to patch material was present in 46 (75%) and was used to measure anatomical VT isthmuses. MDCT wall thickness correlated positively with number of ablation lesions and varied with functional isthmus properties (blocked isthmus 2.6 mm [Q1, Q3: 2.1, 4.0 mm], slow conduction 4.8 mm [Q1, Q3: 3.3, 6.0 mm], and normal conduction 5.6 mm [Q1, Q3: 3.9, 8.3 mm]; P < 0.001). A large conal branch was present in 6 (10%) and a major coronary anomaly was discovered in 3 (5%). Median ablation lesion distance was closer to the right vs the left coronary artery (10 mm vs 15 mm; P = 0.01) with lesion-to-coronary distance <5 mm in 3 patients. CONCLUSIONS MDCT identifies anatomical structures relevant to catheter ablation for repaired TOF. Wall thickness at commonly targeted anatomical VT isthmuses is associated with functional isthmus properties and increased thermal energy delivery.
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Affiliation(s)
- Jeremy P Moore
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California, USA; Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA; Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA.
| | - Jonathan Su
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Kevin M Shannon
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Gregory S Perens
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Claire Newlon
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Jason S Bradfield
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California, USA
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Moore JP. Preventing ventricular arrhythmia after transcatheter pulmonary valve placement for repaired tetralogy of Fallot. Heart Rhythm 2024; 21:239-240. [PMID: 38296458 DOI: 10.1016/j.hrthm.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 02/08/2024]
Affiliation(s)
- Jeremy P Moore
- Cardiac Arrhythmia Center, University of California Los Angeles (UCLA), Los Angeles, California; Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, UCLA Health System, Los Angeles, California.
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Ramdat Misier NL, de Groot NMS. ECG, the old kid around the block who betrays conduction secrets in patients with tetralogy of Fallot. Heart Rhythm 2023; 20:1697-1698. [PMID: 37678494 DOI: 10.1016/j.hrthm.2023.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
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