1
|
Ganni E, Ho SY, Reddy S, Therrien J, Kearney K, Roche SL, Dimopoulos K, Mertens LL, Bitterman Y, Friedberg MK, Saraf A, Marelli A, Alonso-Gonzalez R. Tetralogy of Fallot Across the Lifespan: A Focus on the Right Ventricle. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:283-300. [PMID: 38161676 PMCID: PMC10755834 DOI: 10.1016/j.cjcpc.2023.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Abstract
Tetralogy of Fallot is a cyanotic congenital heart disease, for which various surgical techniques allow patients to survive to adulthood. Currently, the natural history of corrected tetralogy of Fallot is underlined by progressive right ventricular (RV) failure due to pulmonic regurgitation and other residual lesions. The underlying cellular mechanisms that lead to RV failure from chronic volume overload are characterized by microvascular and mitochondrial dysfunction through various regulatory molecules. On a clinical level, these cardiac alterations are commonly manifested as exercise intolerance. The degree of exercise intolerance can be objectified and aid in prognostication through cardiopulmonary exercise testing. The timing for reintervention on residual lesions contributing to RV volume overload remains controversial; however, interval assessment of cardiac function and volumes by echocardiography and magnetic resonance imaging may be helpful. In patients who develop clinically important RV failure, clinicians should aim to maintain a euvolemic state through the use of diuretics while paying particular attention to preload and kidney function. In patients who develop signs of cardiogenic shock from right heart failure, stabilization through the use of inotropes and pressor is indicated. In special circumstances, the use of mechanical support may be appropriate. However, cardiologists should pay particular attention to residual lesions that may impact the efficacy of the selected device.
Collapse
Affiliation(s)
- Elie Ganni
- McGill Adult Unit for Congenital Heart Disease, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Sushma Reddy
- Division of Cardiology, Lucile Packard Children’s Hospital, Stanford University, Stanford, California, USA
| | - Judith Therrien
- McGill Adult Unit for Congenital Heart Disease, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Katherine Kearney
- Toronto ACHD Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - S. Lucy Roche
- Toronto ACHD Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Department of Pediatrics, the Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Konstantinos Dimopoulos
- Division of Cardiology, Royal Brompton Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, London, United Kingdom
| | - Luc L. Mertens
- Department of Pediatrics, the Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yuval Bitterman
- Department of Pediatrics, the Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark K. Friedberg
- Department of Pediatrics, the Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anita Saraf
- Division of Cardiology, Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Rafael Alonso-Gonzalez
- Toronto ACHD Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Bou Chaaya RG, Barron E, Herrmann JL, Brown JW, Ephrem G. QRS Duration After Pulmonary Valve Replacement in Adults with Repaired Tetralogy of Fallot: Association with Ventricular Arrhythmia and Correlation with Right Ventricular Size. Pediatr Cardiol 2023; 44:1658-1666. [PMID: 37624409 DOI: 10.1007/s00246-023-03272-0] [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: 05/13/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023]
Abstract
The aim of this study is to analyze the relationship between QRS duration after pulmonary valve replacement (PVR) and ventricular arrhythmias (VA) in patients with repaired tetralogy of Fallot (ToF). ToF patients may face complications such as heart failure and VA after primary repair, often mitigated by PVR. Prior studies have shown a decrease in QRS duration and right ventricular (RV) size following PVR. It remains unclear whether a lack of QRS duration reduction identifies patients at risk of VA. We retrospectively identified adult patients with repaired ToF who underwent surgical or transcatheter PVR. EKG data (pre-PVR, 30 days to 1-year post-PVR, and closest to CMR) was collected. The primary endpoint was sustained ventricular tachycardia (VT), ICD shock for sustained VT, or inducible VT on EP study. 85 patients were included (median follow-up 3.6 years; median age 34 years; 51% females). The primary outcome was noted in 8 patients. Mean QRS duration decreased by 5 ms following PVR (p = 0.0001). Increased age at PVR, QRS ≥ 180 ms post-PVR, no reduction in QRS after PVR, and a history of VT were associated with higher risk of the primary endpoint. The change in QRS was linearly correlated with the change in RVEDVi (R = 0.66). Adults with repaired ToF experience a reduction in QRS duration post-PVR that correlates with the change of the RV size. Patients with QRS ≥ 180 ms post-PVR, no reduction in QRS, increased age at repair, and a history of VT are at risk for recurrent VT and warrant closer monitoring/ICD consideration.
Collapse
Affiliation(s)
- Rody G Bou Chaaya
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA.
| | - Emily Barron
- Cardiovascular Institute, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Section of Pediatric Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - John W Brown
- Section of Pediatric Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Georges Ephrem
- University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
3
|
Slouha E, Trygg G, Tariq AH, La A, Shay A, Gorantla VR. Pulmonary Valve Replacement Timing Following Initial Tetralogy of Fallot Repair: A Systematic Review. Cureus 2023; 15:e49577. [PMID: 38156158 PMCID: PMC10754298 DOI: 10.7759/cureus.49577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Pulmonary valve replacement (PVR) is a critical aspect of surgical management for patients with tetralogy of Fallot (ToF). Determining an optimal timeframe for intervention is imperative, as it directly impacts long-term outcomes and the risk of complications in ToF patients. Ventriculotomy with the transannular patch is currently indicated for right ventricular outflow tract obstruction, but the patch itself can lead to pulmonary regurgitation (PR), dyspnea, and cyanosis, among other complications. This investigation seeks to establish an evidence-based timeline to enhance the overall quality of care for individuals with this congenital heart condition. From 2002 to 2022, 21,935 articles regarding the PVR timing for ToF were examined and filtered. The publications were screened using PRISMA guidelines, and 32 studies were included for analysis and review. Among the studies, PVR was strongly indicated for patients who had developed severe PR, especially in asymptomatic patients and those experiencing fatigue and exercise intolerance. Severe PR was associated with arrhythmias such as right bundle branch block, atrioventricular block, and prolonged QRS intervals, in which male sex and high right ventricular end-diastolic volume (RVEDV) were significant predictors of long preoperative QRS duration. Most physicians found RVEDV necessary for making surgical referrals despite a lack of correlation between PR severity and RVEDV or indexed right ventricular end-systolic volume (RVESVi). However, asymptomatic ToF patients with preoperative RVESVi benefited from PVR. Except for some variations in QRS intervals among studies, arrhythmias tended to persist post-op, yet NYHA functional class and RV size improved significantly following PVR. Older age at PVR was found to be associated with adverse cardiac events, whereas early PVR presented with appropriately short QRS intervals. Cardiac function tended to be significantly worse in patients undergoing late PVR versus early PVR, with timelines ranging from one to three decades following initial ToF repair. Choosing the best timeline for PVR largely depends on the patient's baseline cardiopulmonary presentation, and additional quantitative deformation analysis can help predict an appropriate timeline for ToF patients.
Collapse
Affiliation(s)
- Ethan Slouha
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Genevieve Trygg
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Abdul Hadi Tariq
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Anthony La
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Allison Shay
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| |
Collapse
|
4
|
Cocomello L, Sinha S, Gonzalez Corcia MC, Baquedano M, Benedetto U, Caputo M. Determinants of QRS duration in patients with tetralogy of Fallot after pulmonary valve replacement. J Card Surg 2021; 36:1958-1968. [PMID: 33651426 DOI: 10.1111/jocs.15469] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Following the repair of TOF patients may be left with pulmonary regurgitation and a dilated right ventricle (RV), which in turn can lead to ventricular arrhythmias and sudden death. A prolonged QRS is a predictor of ventricular arrhythmias. However, whether subsequent pulmonary valve replacement (PVR) can reverse QRS-prolongation is controversial. We hypothesized that changes in QRS duration following PVR are determined by preoperative QRS-duration and RV volumes METHODS: A retrospective single-center cohort study was conducted on 142 post-TOF repair patients (mean age 25 ± 13 years) who underwent PVR between 1995 and 2019. Information on QRS duration and RV volumes measured by cardiac MRI (available in 83 patients) were collected. A linear mixed model was used to investigate the association between the preoperative QRS duration and RV volumes and the postoperative QRS duration. RESULTS The QRS-duration following PVR continued to increase in all subjects with a prolonged preoperative QRS-duration(>160 ms, rate of increase of 0.87 msec ± 0.33 per year; p = .01), markedly raised RV end-diastolic volume (RVEDV; ≥166 ml/m2, rate of increase of 2.0 msec ± 0.37 per year; p < .01) or RV end-systolic volume (RVESV; ≥89 ml/m2 , rate of increase of 1.25 msec ± 0.43 per year; p = .01). In contrast, in patients with preoperative QRS-duration <160 msec (p = .16), RVEDV <166 ml/m2 (p = .14), or RVESV < 89 ml/m2 (p = .37), the QRS-duration did not change significantly when compared to preoperative values. CONCLUSIONS In subjects with shorter QRS and smaller RV volumes, QRS duration did not show further prolongation following PVR. While markedly prolonged QRS and increased RV volumes were associated with a small but constant increase in QRS duration despite PVR.
Collapse
Affiliation(s)
- Lucia Cocomello
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom
| | - Shubhra Sinha
- Department of Translational Health Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Mai Baquedano
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, UK
| |
Collapse
|
5
|
Alkashkari W, Albugami S, Abbadi M, Niyazi A, Alsubei A, Hijazi ZM. Transcatheter pulmonary valve replacement in pediatric patients. Expert Rev Med Devices 2020; 17:541-554. [PMID: 32459512 DOI: 10.1080/17434440.2020.1775578] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Right ventricular outflow tract (RVOT) dysfunction is common among individuals with congenital heart disease (CHD). Surgical intervention often carries prohibitive risks due to the need for sequential pulmonary valve (PV) replacements throughout their life in the majority of cases. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with RVOT dysfunction. AREAS COVERED In this review, we examine the pathophysiology of RVOT dysfunction, indications for tPVR, and the procedural aspect. Advancements in clinical application and valve technology will also be covered. EXPERT OPINION tPVR is widely accepted as an alternative to surgery to address RVOT dysfunction, but still significant numbers of patients with complex RVOT morphology deemed not suitable for tPVR. As the technology continues to evolve, new percutaneous valves will allow such complex RVOT patient to benefit from tPVR.
Collapse
Affiliation(s)
- Wail Alkashkari
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affair , Jeddah, Saudi Arabia.,Medical Research Department, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia.,Medical Research Department, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Saad Albugami
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affair , Jeddah, Saudi Arabia.,Medical Research Department, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia.,Medical Research Department, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Mosa Abbadi
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affair , Jeddah, Saudi Arabia.,Medical Research Department, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia.,Medical Research Department, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Akram Niyazi
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affair , Jeddah, Saudi Arabia.,Medical Research Department, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia.,Medical Research Department, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Amani Alsubei
- Department of Cardiology, King Faisal Cardiac Center, Ministry of National Guard Health Affair , Jeddah, Saudi Arabia.,Medical Research Department, King Abdullah International Medical Research Center , Jeddah, Saudi Arabia.,Medical Research Department, King Saud Bin Abdulaziz University for Health Science , Jeddah, Saudi Arabia
| | - Ziyadi M Hijazi
- Sidra Heart Center, Sidra Medicine , Doha, Qatar.,Medical Research Department, Weill Cornell Medicine , New York, NY, USA
| |
Collapse
|
6
|
Abstract
PURPOSE OF REVIEW We aim to review select literature pertaining to congenital heart disease (CHD)-induced right ventricular (RV) function and failure. RECENT FINDINGS We review recent findings pertaining to children and adults with repaired tetralogy of Fallot (rTOF), systemic RV and hypoplastic left heart syndrome (HLHS). We emphasize pathophysiological mechanisms contributing to RV dysfunction in these conditions, the risk factors for adverse outcomes and the continuing challenges in treating these patients. We discuss how recent pathology findings, as well as developments in imaging and computer modeling have broadened our understanding of the pathophysiology of these conditions. We further review developments in the molecular and cellular basis of RV failure; and in particular, the RV molecular response to stress in repaired tetralogy of Fallot (rTOF). We highlight some of the genetic complexities in HLHS and how these may influence the long-term outcomes in these patients. SUMMARY Recent literature has led to new understandings in the pathology, pathophysiology, risk factors for adverse outcomes, molecular and genetic basis for RV dysfunction and failure in CHD. Although these findings provide new therapeutic targets, the treatment of RV failure at this time remains limited.
Collapse
|